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87<br />
July–August 2012<br />
Unmanned aircraft | a civil discussion<br />
Sneaky leaks | pinhole corrosion<br />
a civil discussion<br />
Unmanned<br />
aircraft
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Kay McLaglen T: +61 (0) 3 5282 0502 M: +61 (0) 411 147 882 E: kmclaglen@amda.com.au
CONTENTS<br />
Issue 87 | July–August 2012<br />
08<br />
62<br />
20<br />
FEATURES<br />
08 Unmanned aircraft<br />
The realities and challenges of<br />
a rapidly growing aviation sector –<br />
and they aren’t drones!<br />
20 A hard-headed look<br />
at helmets<br />
If you don’t need a head, you<br />
don’t need a helmet?<br />
22 Aerodrome safety survey<br />
The results are in<br />
25 A hands-on approach<br />
Never give up flying the aircraft<br />
28 In plane sight – hazard<br />
ID and SMS<br />
The vital connection between<br />
the two<br />
31 Sneaky leaks<br />
The problem of pinhole corrosion<br />
40 A game of many parts<br />
Technology, reporting and safety<br />
44 Sharing the sky … gliders<br />
Part three of this series looks at<br />
the joys of soaring like an eagle<br />
58 Pride before a fall<br />
The fatal combination of a confused<br />
captain and a timid first officer<br />
62 Watch out, whales about!<br />
Flying neighbourly during the<br />
migration season<br />
44<br />
REGULARS<br />
02 Air mail<br />
Letters to the editor<br />
03 Flight bytes<br />
Aviation safety news<br />
16 ATC Notes<br />
News from Airservices Australia<br />
18 Accident reports<br />
18 International accidents<br />
19 Australian accidents<br />
31 Airworthiness section<br />
34 SDRs<br />
39 Directives<br />
46 Close calls<br />
46 Hot and shaky<br />
48 Live, learn, survive and be happy<br />
50 Taking control<br />
52 ATSB supplement<br />
News from the Australian Transport<br />
Safety Bureau<br />
66 Av Quiz<br />
Flying ops | Maintenance<br />
IFR operations<br />
70 Calendar<br />
Upcoming aviation events<br />
71 Quiz answers<br />
72 Coming next issue<br />
72 Product review<br />
CASA’s new Maintenance Guide<br />
for Owners/Operators
02<br />
AIR MAIL / FLIGHT BYTES<br />
Aviation safety news<br />
AIR MAIL<br />
Dear Editor<br />
I enjoy reading and digesting Flight Safety Australia, a most<br />
informative and professional journal. Besides the useful<br />
safety information contained, I appreciate the culture of open<br />
communication fostered by the editors.<br />
I read with interest the article on cabin crew training (‘The cabin<br />
connection’) in the March-April issue, and present a dilemma<br />
for consideration by all cabin crews of commercial airlines.<br />
As far as I can recall, every time I choose to travel on a large<br />
passenger aircraft I am frustrated by loud, inattentive passengers<br />
who ignore the emergency procedures briefing before takeoff.<br />
While I can accept that not every passenger views this as<br />
important to them, their inconsiderate actions can limit others<br />
from hearing and understanding this information.<br />
As a passenger I feel uncomfortable in asking these people to<br />
refrain from talking during this important presentation by the<br />
cabin crew. I have yet to witness any of the cabin crew make<br />
an attempt to advise passengers of their inconsiderate<br />
behaviours, which could, in rare circumstances, lead to unsafe<br />
actions during an in-flight emergency.<br />
I believe that strategies for addressing this issue could usefully<br />
be incorporated into cabin crew training in the near future.<br />
Gary Allan<br />
Several callers responded to the story Pad not paper, in issue 86,<br />
May-June 2012. All approved of using tablet computers as an<br />
aid to conventional flight planning, but those from tropical parts<br />
of Australia pointed out that tablet computers and smartphones,<br />
such as the Apple iPad and iPhone, often black out when left in<br />
a hot aircraft cockpit. They remain blank until they cool down,<br />
which can take up to half an hour. Apple lists 0 to 35 degrees C<br />
as the operating air temperature range for iPhones and iPads and<br />
says other symptoms of overheating include the display going<br />
dim, the mobile signal strength fading and the device stopping<br />
charging. ‘It’s nice to have, but that’s why I don’t rely on it, ‘said<br />
one caller.<br />
Director of Aviation Safety, CASA | John F McCormick<br />
Manager Safety Promotion | Gail Sambidge-Mitchell<br />
Editor, Flight Safety Australia | Margo Marchbank<br />
Writer, Flight Safety Australia | Robert Wilson<br />
Sub-editor, Flight Safety Australia | Joanna Pagan<br />
Designer, Flight Safety Australia | Fiona Scheidel<br />
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© Copyright 2012, Civil Aviation Safety Authority Australia.<br />
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ISSN 1325-5002.<br />
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Flight Safety Australia<br />
Issue 87 July–August 2012<br />
03<br />
FLIGHT BYTES<br />
Correction<br />
In the May–June issue of FSA the date listed for the free<br />
‘Aviation access all information areas’ aviation safety education<br />
forum at the University of NSW in Sydney was unfortunately<br />
incorrect. The forum will be on 22 August from 0900 to 1630<br />
and prospective attendees need to register as soon as possible<br />
on www.casa.gov.au/avsafety<br />
Book now for the Brisbane safety forum!<br />
The free ‘aviation - access all areas’ forums are a joint<br />
venture between CASA, Airservices, the ATSB, the BoM and<br />
the RAAF to share vital aviation safety information with all<br />
interested parties, with an emphasis on human factors,<br />
as well as on accessing information on tablets and<br />
smartphones. The Brisbane seminar is on 28 July, and you<br />
can register for it, or for future seminars around Australia,<br />
at www.casa.gov.au/avsafety<br />
Having trouble finding<br />
aviation information<br />
www.casa.gov.au/avsafety<br />
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04<br />
FLIGHT BYTES<br />
Aviation safety news<br />
Centralising carriage and discharge of<br />
firearms approvals<br />
If you are one of the small number of pilots or aircrew (such<br />
as police, or those who fly over crocodile-infested swamps)<br />
who need to carry a firearm on an aircraft, or the even smaller<br />
group of people (professional shooters) who have a legitimate<br />
reason to shoot from an aircraft, this one is for you. CASA<br />
is centralising its application and approval process for the<br />
carriage in, and discharge of firearms from, aircraft.<br />
Two permits will be available, one to carry a firearm on an<br />
aircraft, and the other to carry and discharge a firearm from<br />
an aircraft, for feral animal shooting. The permits apply to,<br />
and are required for, both fixed- and rotary-wing aircraft.<br />
The new permits cover all firearms, making no distinction<br />
between handguns, rifles and shotguns<br />
The permits will be valid for three years, or until the applicant’s<br />
firearms licence expires, whichever is soonest.<br />
An online application form will be available on the CASA<br />
website in July.<br />
ADS-B rolling out over the U.S.A.<br />
More than 60 per cent of the required ground stations for the<br />
satellite-based automatic dependent surveillance-broadcast<br />
(ADS-B) network have now been completed in the U.S.A., with<br />
428 ADS-B radio stations already built. The current plan is for<br />
700 stations to be deployed: 647 in the continental U.S., 41 in<br />
Alaska, nine in Hawaii and one each in Guam, Puerto Rico and<br />
the U.S. Virgin Islands.<br />
The FAA initially plans to use the network to provide ADS-Bin<br />
data to its air traffic control facilities. This means ADS-B<br />
eventually can replace radar as a surveillance source for<br />
controllers. Aircraft operators must equip for ADS-B-in by<br />
2020. The ADS-B-out service, which provides surveillance and<br />
other data to aircraft cockpits, will be rolled out later.<br />
The FAA has been using ADS-B for traffic control at four initial<br />
sites and this year plans to begin using the ADS-B feed at up to<br />
a dozen additional facilities.<br />
Interestingly, in Australia, all operators of aircraft flying above<br />
FL290 will have ADS-B equipment installed and operating<br />
correctly by 12 December 2013, with over 70 per cent of<br />
international flights in our FIR currently using it.<br />
After December 2013, non-ADS-B-equipped aircraft will have<br />
to operate below FL290 in Australian airspace, and risk any<br />
resultant delays and reduced flexibilty.<br />
Sources: Aviation Week and Flight Safety Australia<br />
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Flight Safety Australia<br />
Issue 87 July–August 2012<br />
05<br />
Easier process for small aviation businesses<br />
Small aviation organisations will be able to use a new<br />
simplified and streamlined process to comply with important<br />
drug and alcohol management requirements.<br />
CASA is introducing the simplified drug and alcohol<br />
management processes for aviation organisations with seven<br />
or fewer employees engaged in safety sensitive activities.<br />
The new simplified processes do not apply to any aviation<br />
organisation engaged in or providing services to regular public<br />
transport operations.<br />
Aviation organisations eligible to use the new drug and alcohol<br />
compliance processes will use a standard drug and alcohol<br />
management plan provided by CASA. Full details of eligibility<br />
requirements are on CASA’s web site.<br />
Organisations will also use a CASA e-learning package<br />
to educate and train their employees in drug and alcohol<br />
responsibilities.<br />
Director of Aviation Safety, John McCormick, said the<br />
new drug and alcohol compliance processes for small<br />
organisations recognised that the existing requirements could<br />
be unnecessarily onerous for these operations.<br />
‘We are making life easier for small aviation organisations by<br />
streamlining the process of drug and alcohol management<br />
while maintaining high safety standards,’ McCormick said.<br />
‘Small aviation organisations will no longer have to develop<br />
their own drug and alcohol management plans.’<br />
‘By using CASA’s new drug and alcohol management plan and<br />
new on-line training small aviation organisations will save time<br />
and resources and still be confident they are meeting all the<br />
regulatory requirements.<br />
“CASA has listened to the concerns of the aviation industry<br />
about the impact of drug and alcohol management plans on<br />
small organisations and found a solution that is simpler and<br />
protects safety.’<br />
Small aviation organisations using the new processes will still<br />
be required to report to CASA every six months on their drug<br />
and alcohol management performance and CASA will continue<br />
to check on compliance.
06<br />
FLIGHT BYTES<br />
Aviation safety news<br />
A caffeine gum hit<br />
The Israeli army is supplying aviators and special operations<br />
forces with a caffeine-charged chewing gum that dramatically<br />
enhances their ability to cope with fatigue on missions lasting<br />
more than 48 consecutive hours.<br />
The food supplement gum is part of ongoing efforts to curb<br />
fatigue-related injuries and deaths and is also included, along<br />
with other foodstuffs designed to increase vigilance and<br />
endurance, in the ‘First Strike Rations’ issued to U.S. field units<br />
on high-intensity combat operations in Iraq and Afghanistan.<br />
Before introduction of the gum, soldiers often chewed on<br />
freeze-dried coffee to stay awake during night operations.<br />
A standard pack holds five cinnamon-flavoured pieces that<br />
contain 100 milligrams of caffeine each. This is absorbed from<br />
the circulatory system five times faster than caffeine in coffee.<br />
‘There are no side effects, except for the disgusting taste.<br />
It improves the soldiers’ alertness and their cognitive<br />
performance. The pilots are amazed to discover that it simply<br />
works’, said a senior Israel Air Force officer.<br />
Despite their satisfaction with the gum’s performance, the<br />
Israelis are not taking any chances. Troops sent on 72-hour<br />
missions are also issued with Modafinil, a prescription drug for<br />
treating an assortment of sleep disorders.<br />
Source: Yedioth Ahronoth<br />
No in-flight calls please – we’re British<br />
According to a recent poll, 86 per cent of British travellers<br />
are opposed to the use of mobile phones on flights. The poll<br />
follows Virgin Atlantic’s announcement that it will become the<br />
first British airline to allow passengers to make calls on their<br />
own mobiles.<br />
Respondents said they would object to passengers making<br />
voice calls, mainly because ‘it’s annoying to listen to other<br />
people’s conversations’.<br />
Almost half said they would use the service, but only to send<br />
text messages. A further 10 per cent said they would send<br />
emails, but only six per cent said they would make or receive<br />
voice calls.<br />
Sam Baldwin, Skyscanner’s travel editor, said: ‘In a world<br />
where we are now almost always on call, it seems people<br />
don’t want to say goodbye to their last sanctuary of nonconnectivity.<br />
Flying allows us to switch off for a few hours,<br />
both from our own calls, and other people’s. However, Virgin’s<br />
move is the beginning of the end of the no-phone zone.’<br />
Virgin will launch the service on flights between London and<br />
New York, but wants to make it available on at least nine more<br />
routes before the end of the year. Calls are still not permitted<br />
during take-off or landing, and American laws mean it has to<br />
be turned off 250 miles from U.S. airspace.<br />
Source: Daily Telegraph U.K.<br />
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Flight Safety Australia<br />
Issue 87 July–August 2012<br />
07<br />
Non-destructive testing seminar<br />
The National Aerospace NDT Board will hold a Quality and<br />
Testing in Aircraft Maintenance seminar in Sydney on<br />
14-15 November 2012. The themes include NDT but extend<br />
beyond it to capture the quality and compliance issues that<br />
underpin any effective inspection and quality program in<br />
aircraft maintenance.<br />
Australian and international presenters will cover subjects<br />
such as quality management, SMS, human factors, regulatory<br />
compliance (including CASR Part 145), training, NDT<br />
inspections, composites, ageing aircraft and much more.<br />
This event is targeted at the aircraft maintenance professionals<br />
from general aviation, executive transport, regional operators<br />
and the airlines who are responsible for quality, inspection,<br />
maintenance, audit, NDT and compliance. There will also be<br />
an inspection equipment and services exhibition.<br />
As an incentive to join them in Sydney, the board will<br />
maximise the value to attendees and their employers by<br />
generously subsidising registration costs. Seminar and<br />
registration details can be found www.ndtboard.com<br />
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Oxygen bottle fire forces diversion<br />
An OLT Express Poland Airbus A320 made an emergency<br />
landing in Sofia, Bulgaria on May 17 after suffering cabin<br />
decompression and, subsequently, a fire in the cabin.<br />
The aircraft was en route from Warsaw to Hurghada, Egypt<br />
when cabin pressure was lost at cruising altitude and the<br />
oxygen masks deployed. The cause of the decompression<br />
has not yet been determined.<br />
The fire was caused by a short circuit in an oxygen generator,<br />
which then fell onto the cabin carpet during the oxygen<br />
mask deployment. It ignited the carpet, but the cabin crew<br />
immediately extinguished the fire.<br />
The captain decided to make an emergency landing in Sofia.<br />
The aircraft landed around noon, and all 147 passengers and<br />
eight crew evacuated via the escape slides with no injuries.<br />
Source: Flightglobal<br />
Go East cabin crew<br />
As China’s major airlines expand flights across the globe<br />
they are looking for foreign cabin crew in a bid to become<br />
more international. The main reason for this, they say, is that<br />
international passengers prefer to be served by cabin crew<br />
from their own countries, and more foreigners than ever are<br />
now working, living and travelling in the People’s Republic<br />
of China.<br />
Ryan Cornish, a British expat who regularly flies between<br />
Europe and China, said: ‘While I don’t mind Chinese-speaking<br />
attendants, if there’s ever a problem on board it helps to have<br />
a native English speaker. For foreign cabin crew, working for a<br />
Chinese airline is likely to provide very valuable experience.’<br />
However, applicants may also need to be fluent in Mandarin,<br />
plus at least one of the other major spoken languages of China.<br />
Major carriers Air China, China Southern Airlines and China<br />
Eastern Airlines have all said they plan to increase their<br />
recruitment of foreign cabin crew.<br />
Industry figures show that Chinese airlines are flying more<br />
foreign passengers as they expand their international reach.<br />
According to Air China’s annual report, it carried more than<br />
seven million international passengers last year. It also added<br />
eight new international and regional routes.<br />
China Southern Airlines recently flew its maiden voyage<br />
from the city of Guangzhou in south China to London, and is<br />
targeting passengers wanting to travel between Europe and<br />
Australasia. There will be three flights on the new route a week,<br />
with the flights also expected to benefit Asian passengers<br />
heading to the Olympic Games this summer.<br />
Source: The Telegraph
08<br />
FEATURE<br />
Unmanned aircraft<br />
Flight Safety Australia, in light of the recent media<br />
buzz on UAVs, looks at what is arguably one of the<br />
fastest growing sectors of aviation<br />
Unmanned<br />
aircraft<br />
a civil discussion
‘They’re being used now,’ she<br />
explains, ‘and in certain situations<br />
are the mainstay’.<br />
Flight Safety Australia<br />
Issue 87 July–August 2012 09<br />
Scan any newspaper today, and you’re likely to find reports of<br />
activity by ‘drones’, a term unmanned aircraft systems (UAS)<br />
insiders decry as negative, with its connotations of monotony,<br />
menace and inflexibility. (The word drone is said to have<br />
derived from the name of one of the first unmanned aircraft,<br />
the de Havilland Queen Bee, a radio-controlled variant of the<br />
Tiger Moth biplane.)<br />
Even the most respected media take a melodramatic tone.<br />
When The Wall Street Journal visited the subject, the headline<br />
asked ‘Could we trust killer robots?’ Likewise The Australian<br />
in a recent feature summed up the subject as ‘Drones, lives<br />
and liberties’, and declared ‘as civilian use of unmanned<br />
aerial vehicles (UAVs) grows, so does the risk to our privacy’.<br />
The story invoked George Orwell’s 1984 in its discussion of<br />
how police use of ‘drones’ may affect civil liberties. It did not<br />
mention the potential uses for UAS until the sixth of its eight<br />
columns, nor, for that matter, the ubiquitous ground-based<br />
CCTV cameras increasingly watching over urban dwellers.<br />
Hollywood can take much of the credit, or blame, for this<br />
sinister image of what are more accurately, and less emotively,<br />
known as remotely piloted aircraft (a part of unmanned aircraft<br />
systems [UAS] or UAV, to use the older term). Reece Clothier,<br />
senior research fellow at the Australian Research Centre for<br />
Aerospace Automation (ARCAA) also points a finger at the<br />
silver screen. ‘What most people know about UAS is what<br />
they’ve seen in movies like Stealth, the Terminator series,<br />
Eagle Eye and Mission Impossible. The movie images are of<br />
killing machines rather than machines that can make aviation<br />
safer,’ he laments.<br />
The reliance on such vehicles for military surveillance and<br />
intelligence gathering, and increasingly as weapons platforms,<br />
in war zones such as Afghanistan (since 2001), Iraq (since<br />
2002), Yemen (since 2002), Pakistan (since 2004) and Gaza<br />
(since 2008) also contributes to a public misapprehension<br />
about the benefits, purpose and safety of UAVs in civil use.<br />
While civilian UAVs (also classified by the International<br />
Civil Aviation Organization [ICAO] as remotely-piloted aircraft<br />
[RPAs], to emphasise the fact that there is a human pilot in<br />
control) have obviously benefited from military research and<br />
development, they have also been described in the same dark<br />
and often inaccurate terms.<br />
This frightening portrayal is emerging as a challenge for<br />
what is arguably the fastest-growing and most dynamic<br />
sector of aviation.<br />
CASA’s UAS specialist, Phil Presgrave, says there are now<br />
19 certified UAS operators/organisations (UOC holders) in<br />
Australia, comprising a mix of fixed-wing (8), rotary (6) and<br />
multi-wing (4), and one airship, with 30 anticipated by the<br />
end of 2012, and enquiries growing daily.<br />
It is a technology which is ‘not coming, but here’ says<br />
Peggy MacTavish, the Executive Director of the Association<br />
of Unmanned Vehicle Systems Australia (AUVSA). ‘She<br />
describes UAS in a memorable phrase, they’re ‘not the<br />
leading edge any more, but the bleeding edge’. They have<br />
moved well beyond the incubator of academic research and<br />
into mainstream aviation use. ‘They’re being used now,’<br />
she explains, ‘and in certain situations are the mainstay’.<br />
Peter Smith, vice-president of AUVS-Australia, says ‘in three<br />
years we will almost routinely be flying UAVs in selected<br />
situations to provide information about the position, movement<br />
and severity of bushfires. It will be done at night, at low<br />
altitude, using sensors like synthetic aperture radar to look<br />
through the smoke.’<br />
A paper presented at a recent UAS conference identified<br />
over 650 applications for UAS.
10<br />
FEATURE<br />
Unmanned aircraft<br />
UAS—the safety case<br />
But the payoff is huge: they do dull,<br />
dirty, dangerous and demanding jobs<br />
without putting the pilot at risk<br />
Some Australian<br />
examples of UAS use<br />
Surveillance – fishing<br />
Law enforcement<br />
Noxious weed identification; for example,<br />
Siam weed in northern Queensland<br />
Aerial photography<br />
Powerline monitoring<br />
Animal population monitoring – counts of<br />
migratory whales; feral animals in northern<br />
Australia<br />
Crop monitoring<br />
Crop and noxious weed spraying<br />
Search and rescue<br />
Customs/border surveillance<br />
Meteorology<br />
Emergency services support – firefighting.<br />
Paul Martin, a CASA-licensed UAS operator, as well as a<br />
manned helicopter pilot, has been using UAVs in his aerial<br />
photography business since 2008. ‘I think UAS will have<br />
a huge effect on safety. At the moment they’re incorrectly<br />
categorised as being a safety risk. But the payoff is huge:<br />
they do dull, dirty, dangerous and demanding jobs without<br />
putting the pilot at risk,’ he says.<br />
Peter Smith says UAS can take the risk, and the corresponding<br />
moral dilemma, out of scientific research and mercy missions.<br />
By using UAS, the question of scientific breakthrough versus<br />
loss of human life no longer arises. ‘Nobody in their right<br />
mind would go into a hurricane and fly below 1000 feet, but<br />
we flew an Aerosonde into a hurricane and got down to below<br />
100 feet,’ he says.<br />
‘The result was to confirm what science had suspected—<br />
that there are surface friction and low-level atmospheric<br />
effects. We got the aeroplane out of that one. You can do<br />
stuff that morally you could not expose a flight crew to.’<br />
Smith says UAS can benefit from 100 years of safety<br />
development in manned aviation. ‘UAVs are different but<br />
they’re not unique,’ he says. ‘They’re part of a spectrum of<br />
air vehicles and need to be put into context. We don’t have<br />
to invent a brand new wheel: there are elements of existing<br />
systems that can be used.<br />
There are a huge number of issues about privacy, safety<br />
and other aspects but none of them seem to me to be more<br />
demanding than those surrounding manned aircraft.’<br />
After a government employee was killed in a helicopter crash,<br />
the Queensland Government has decided to use UAS more<br />
widely to avoid placing employees at risk. A trial to monitor<br />
fishing off North Stradbroke Island (illegal fishing costs<br />
the industry hundreds of thousands of dollars) using UAS<br />
was the first known flight of a UAS in class C airspace, and<br />
demonstrated that UAS could do the job at least as well as a<br />
manned aircraft, while collecting terabytes of valuable data.
Flight Safety Australia<br />
Issue 87 July–August 2012<br />
11<br />
Sharing the skies<br />
Currently, Australian UAS operations are limited to visual<br />
line-of-sight operations in visual meteorological conditions<br />
(VMC) below 400ft AGL. However, CASA’s Phil Presgrave<br />
says the long-term goal, based on the growing competence<br />
and sophistication of the UAS industry, is to allow routine<br />
operations beyond visual line of sight in VMC/IMC in all<br />
classes of airspace by the end of 2017.<br />
To do this safely, UAS will need reliable and increasingly<br />
sophisticated safety systems. Dr Duncan Campbell, who<br />
heads the Australian Research Centre for Aerospace<br />
Automation (ARCAA) says ARCAA is working with global<br />
industry partners on four main areas around this broad theme.<br />
The first focuses on the development of advanced systems<br />
for navigation, automating airspace management, and<br />
importantly, on dynamic and static ‘detect and avoid’. There<br />
will be a progression towards greater onboard computational<br />
intelligence and autonomous mission replanning, dynamic path<br />
planning, and as the highest priority, an automated emergency<br />
landing system. Secondly, another research area focuses on<br />
developing aviation risk management frameworks and tools<br />
relating to UAS, and appropriate regulation. (Australia led the<br />
way in UAS regulation with its Civil Aviation Safety Regulation<br />
[CASR] Part 101, which is ten years old this year. Only one<br />
other country, the Czech Republic, has formal UAS regulation,<br />
since last year.)<br />
A third research area is focusing on multidisciplinary design<br />
and optimisation, especially human-machine interaction<br />
around multi-UAV mission command. ARCAA is working<br />
with Telecom Bretagne in France and Thales on several<br />
related projects.<br />
And finally, ARCAA is working on advanced sensing for<br />
specific UAS applications.<br />
Peter Smith sees particular potential in the development of<br />
sensors for UAS. He says that as an IT-based technology<br />
UAS have benefited from Moore’s law—the rule of thumb<br />
that says computing power (defined by the number of<br />
transistors on a chip) roughly doubles every two years, with<br />
corresponding benefits in size and cost. ‘It’s happened with<br />
the military already and when civil volume is added, I think<br />
we will get to the point where Moore’s law really shows us<br />
what can be done.<br />
CASA has a full program of planned<br />
training, licensing, certification changes<br />
and education over the short-, mediumand<br />
long-term, from now to 2030:<br />
Integrating remotely-piloted aircraft (RPA)<br />
into airspace<br />
Further developing the rule set—reviewing and<br />
updating CASR part 101, and releasing a suite of<br />
eight advisory circulars: general UAS, training and<br />
licensing, operations, manufacturing and initial<br />
airworthiness, and continuing airworthiness<br />
Regulatory oversight—for CASA, flying RPA safely<br />
is paramount. Illegal operations will be penalised<br />
Education: of the UAS sector, the aviation industry<br />
and the general public.<br />
‘When I first came into the industry ten years ago, the only<br />
sensors were lipstick cameras like the ones fitted to Formula<br />
One cars—they cost a few thousand dollars each and you<br />
could just about see something on the ground from 3000<br />
feet. Then there were infrared sensors, and all you could<br />
see with them was a white blob on the ground. Since then<br />
the resolution of those sensors has roughly doubled every<br />
18 months, to the point where you can carry a useful suite<br />
of sensors in a small UAV. The latest Aerosonde for the US<br />
military allows the operator to differentiate between a shovel<br />
and a weapon in a person’s hand.
12<br />
FEATURE<br />
Unmanned aircraft<br />
UAS enablers<br />
Although UAS are not new, having precedents from<br />
before the Wright Brothers, such as the pilotless<br />
balloons used in the Austrian bombardment of<br />
Venice in 1849, a number of factors have enabled<br />
their increasing take-up in aviation. These include:<br />
The widespread civilian use of GPS, following<br />
the U.S. decision to end selective availability of<br />
the system in 2000<br />
Powerful lithium ion batteries have made<br />
practical small RPAs possible, particularly in<br />
conjunction with brushless electric motors<br />
Development of microelectronics made<br />
sophisticated flight control systems and<br />
lightweight sensors possible<br />
Advances in robotics, which brought artificial<br />
intelligence and self-learning computer software.<br />
Some RPAs can now analyse their previous flight<br />
paths and fly more accurately on their next pass<br />
Development and commercialisation of strong<br />
lightweight materials, including carbon-fibre<br />
composites.<br />
At the same time, the weight of the system has halved every<br />
18 months. Now on a 35kg aeroplane you can have daylight<br />
video, nighttime video and probably low-light TV as an<br />
intermediate. All of that in a six-degree-of-freedom gimbal<br />
mount. Prices have remained quite high, but bang for buck has<br />
gone asymptotic (exponential).’<br />
ARCAA is working on the next level of UAS ‘detect and avoid’<br />
technology—dynamic detect and avoid, which encompasses<br />
a seamless automated process of threat detection, evaluation<br />
and avoidance. In recent trials with a vision-based system<br />
fitted to a Cessna 172, the sensor was able to ‘see’ a small<br />
RPA at 10km, far beyond human visual range.<br />
Peter Smith says when it comes to the avoid part of ‘detect<br />
and avoid’ even experienced engineers, himself included, have<br />
fallen into the trap of thinking that a UAV must behave like a<br />
manned aircraft. He realised his error in what he describes as<br />
an Isaac Newton moment.<br />
‘What you need to create is a system on the aircraft that<br />
can detect something unusual, and in a very few seconds,<br />
calculate the likelihood of a collision and take action to avoid.<br />
‘I was driving and drove towards some piping shrikes. One of<br />
them wasn’t looking and I almost got him, but he just threw<br />
himself sideways. This bird was thinking, “forget the laws of<br />
aerodynamics—I’ll recover later”. I suddenly thought, “That’s<br />
it”. The Aerosonde is designed to take 25 G because it is<br />
recovered in a net. You could never subject human beings to<br />
that sort of force, but with a UAV you don’t have to. You can<br />
do the tightest turn that the good Lord ever saw, and get out of<br />
the way. As soon as I mentioned it to one of our researchers<br />
he said, “of course”.<br />
‘We have the potential to give the aircraft a considerable ability<br />
to protect not just itself, but other aircraft’, Smith says.
Flight Safety Australia<br />
Issue 87 July–August 2012<br />
13<br />
‘You have to think of communication<br />
on several levels when you operate<br />
a UAV: how you control your vehicle,<br />
how you talk to the world and how<br />
you talk to your ground crew’<br />
But technology is only one aspect of safe operations.<br />
The importance of communications emerges as a common<br />
theme among UAS developers.<br />
‘You have to think of communication on several levels when<br />
you operate a UAV: how you control your vehicle, how you talk<br />
to the world and how you talk to your ground crew’, says BAE<br />
Systems’ technology and development program engineering<br />
manager, Nelson Evans.<br />
‘We decided to speak openly about what we were doing so<br />
there were no surprises for any parties’, he says.<br />
BAE Systems operates the Kingfisher unmanned aircraft<br />
system at its flight test and development centre in West Sale in<br />
Victoria, within RAAF East Sale’s airspace. ‘We operate under<br />
a CASA agreement, during daylight hours in a pre-defined flight<br />
zone, NOTAMed when we operate. We’ve operated with mixed<br />
traffic without issue; that is among RAAF training, general<br />
aviation, trike operators and the like,’ Evans says.<br />
‘One of the early lessons was that communication with the<br />
broader community was highly valuable. We talked to all<br />
the operators, the council and the farmers about what we<br />
were doing. Eight years ago, UAVs were rare and not always<br />
discussed in positive terms.’<br />
Future challenges<br />
What particularly worries the UAS sector of aviation is<br />
what happens when the reality of RPA operation and its<br />
public image literally collide.<br />
UAS operators emphasise the operational discipline and<br />
technological redundancy they must have in order to fly,<br />
but several say this is not always reciprocated by manned<br />
aviation. One researcher said that ‘although UAS operations<br />
must advise their presence with a NOTAM, in practice many<br />
general aviation and recreational pilots either do not read the<br />
NOTAM, or having read it, on several occasions decided to<br />
fly into UAS operating areas “to have a look”.’<br />
Another explains what he described as the ‘Florida problem’<br />
put to them by the U.S. Federal Aviation Administration.<br />
An Australian UAS operator had to walk away from a lucrative<br />
contract for highway surveillance in the southern state.<br />
‘The problem is the state is full of rich retirees and a significant<br />
number of airport condominium developments. You have<br />
80-year-olds with their 40-year-old Piper Cherokees parked<br />
outside their houses. Your danger with a UAV in Florida is<br />
somebody like that is going to whack into our aircraft one day.’<br />
A third UAS insider was brutally succinct: ‘We have triple<br />
redundancy in our systems—they have the mark one eyeball.’<br />
There are also some specific, and immediate, technological<br />
challenges for UAS.<br />
Peter Smith says: ‘The reliability level of UAVs is not yet<br />
as high as CASA would want for completely autonomous<br />
operations in densely populated areas.’<br />
Malcolm (Mac) Robertson, technical airworthiness manager<br />
with BAE Systems, sees two distinct challenges. ‘GPS or any<br />
satellite-based system is not reliable enough for use in UAS.<br />
The response in military research is to look at navigation<br />
through feature-recognition systems, revisiting the technology<br />
of inertial navigation and using magnetic field detection.’
14<br />
FEATURE<br />
Unmanned aircraft<br />
Another challenge is radio frequency spectrum allocation.<br />
‘The radio frequencies allocated to UAS need to be secure.<br />
It’s a question of bandwidth, which will increase as UAVs and<br />
their sensors become more sophisticated, and of integrity.<br />
There needs to be sufficient bandwidth for future operations,<br />
and that part of the spectrum needs to be free from<br />
interference by other radio users.’<br />
‘We can check every engine’s power<br />
usage at any time ... Every single<br />
flight you do is recorded and can’t<br />
be deleted.’<br />
Recently, BAE Systems successfully demonstrated a UAV<br />
recovery to an airfield unfamiliar to the aircraft’s mission<br />
system and without GPS. This was achieved exclusively<br />
through on-board sensors and a single geographic location of<br />
the airfield.<br />
The intermittent reliability of GPS navigation systems for UAS,<br />
and the threat of their communication links being jammed,<br />
could result in catastrophic consequences, regardless of<br />
built-in redundancies and INS (inertial navigation system)<br />
back-up. BAE Systems has developed technology that would<br />
improve the safety of UAS missions and negate the reliance on<br />
GPS for safe, accurate navigation. According to Brad Yelland,<br />
BAE Systems’ head of strategy and business development:<br />
‘This new technology … provides that extra capability for<br />
UAV operators to make emergency landings to non-surveyed<br />
airfields, especially in high-impact airspace where the<br />
operational situation changes continuously.’<br />
Security and potential misuse are concerns Yamaha takes on<br />
with usage restrictions on the R-Max unmanned helicopter<br />
they plan to use for aerial applications in Australia. Yamaha<br />
Sky Division pIans to introduce the R-Max into Australia<br />
early next year, with projections for 36 R-Max to be in<br />
operation in the first 12 months. But the UAV helicopter will<br />
only be allowed to be leased, not bought outright, and only<br />
to approved and licensed operators. Yamaha Sky Division<br />
business development manager, Liam Quigley, says its GPS<br />
system incorporates a geo-fence, which disables the R-Max<br />
if any attempt is made to operate it outside a pre-agreed area.<br />
Even within the agreed zone, any attempt to tamper with the<br />
R-Max’s digital flight recorder will prompt its flight control<br />
computer to shut down, rendering the aircraft inoperable.<br />
However, not all RPAs are as sophisticated. Some operators<br />
look with dismay at what has been referred to as ‘the toy-shop<br />
end of the industry’.<br />
‘There’s a lot happening that’s literally under the radar,’<br />
Clothier says. Unlicensed operators are using recreational<br />
model aircraft to take pictures and video, blurring the line<br />
between UAS and model aircraft in the public mind. Again,<br />
the mainstream media are no help. A recent feature in<br />
The Australian Financial Review carried the standfirst: ‘Get<br />
ready for some adrenalin-pumping fun with a drone of your<br />
own’, and went on to describe how the writer blithely lost<br />
a $349 iPhone-controlled quadcopter ‘drone’ and ‘found<br />
it dangling from a branch hanging perilously out over the<br />
freeway below’.<br />
Stories like these infuriate commercial quadcopter operator,<br />
Paul Martin. His German-made Microdrones Systems aircraft<br />
use the same grades of carbon fibre as military aircraft<br />
(because they were originally military aircraft) and cost up to<br />
$100,000. For a working helicopter that can earn an income<br />
from aerial photography and survey that’s not as expensive as<br />
it sounds, he explains.<br />
The MD-4 400 and MD-4 1000 aircraft incorporate safety<br />
and flight-recording systems more sophisticated than airline
Flight Safety Australia<br />
Issue 87 July–August 2012<br />
15<br />
transport aircraft, he says. ‘We can check every engine’s<br />
power usage at any time, its rpm, vibrations, efficiency, thrust<br />
percentage of load—that’s just the motors. It even plots<br />
your flight plan on Google Earth. Every single flight you do is<br />
recorded and can’t be deleted.’<br />
But Martin is dismayed that other operators, with much less<br />
sophisticated equipment, and a less conscientious attitude to<br />
regulations are devaluing his investment, damaging the image<br />
of the industry and putting the public at risk.<br />
‘We are deeply concerned that our ability to expand the<br />
envelope of what we can do in future will be inhibited<br />
significantly by those who don’t do the right thing and cause<br />
problems. It happens in many industries, I suppose, where<br />
the few wreck it for the many.’<br />
‘I have had to knock back jobs that could not be done in<br />
compliance with the regulations, only to find out other<br />
operators have taken them on,’ he says.<br />
‘The problem is that cheap equipment, almost overnight, has<br />
become readily available. While it sort of works most of the<br />
time it’s only a matter of time before these components fail.<br />
Internet operator forums for these machines tell the real story,<br />
he says. ‘They’re full of comments like “ it just crashed”<br />
or “it flew away, I couldn’t control it”, and “it just does massive<br />
circles in the sky”. Everyone’s asking everyone else how<br />
to fix it.<br />
‘Our machine is almost self-governing. It uses GPS to hover<br />
automatically within a cubic metre. If anything goes wrong<br />
we have the information to show what was happening,<br />
and that information is generated by the machine not by us.<br />
It’s impartial data.’<br />
Aviation requires the best, he says. ‘When you go to the<br />
airport you don’t see anything other than a Boeing or Airbus.<br />
You don’t see half-price or quarter-price Chinese copies.<br />
That’s not because airlines don’t want to save money—they<br />
would buy them in a heartbeat. It’s because people’s lives are<br />
at stake and only the best will do. I think that’s an appropriate<br />
standard for all aviation.’<br />
BOOK EARLY, LIMITED AVAILABILITY!
ATC notes<br />
ICAO flight<br />
notification changes<br />
The changes to provisions for flight planning triggered by ICAO Amendment 1<br />
to the PANS-ATM will soon be implemented.<br />
When filing a flight plan, you will need to<br />
understand the NEW format descriptors used in<br />
Item 10 and the allowable indicators for Item 18.<br />
The most noticeable change will be an<br />
upgrade of the NAIPS web interface and<br />
back-end processing as well as to the Flight<br />
Notification Form. This will result in flight plans<br />
and flight movement messages being created<br />
and generated in the NEW format. Note that<br />
NAIPS will be configured to accept only NEW<br />
format descriptors.<br />
Some of the key changes are as follows:<br />
• Ability to file detailed communication,<br />
navigation and surveillance capabilities by<br />
use of new alphanumeric descriptors<br />
• Filing an ‘S’ in Item 10a will indicate<br />
carriage of VHF, VOR and ILS but will no<br />
longer include ADF. An ‘F’ will need to be<br />
filed separately to indicate carriage of ADF<br />
• Only certain indicators will be allowed in<br />
Item 18 STS/. This means that some of<br />
the commonly used indicators like MED1,<br />
MED2, SARTIME, VIP, etc will be invalid.<br />
Alternative indicators and/or procedures will<br />
be notified in AIP<br />
• SARTIME details will be submitted in the<br />
same format but in RMK/ rather than in STS/<br />
Flight plans will be accepted up to five days in<br />
advance but must include a ‘Date of Flight’ in<br />
Item 18 (in format DOF/YYMMDD) if filing more<br />
than 24 hours in advance.<br />
Further information and links to key ICAO<br />
documents can be found at<br />
www.airservicesaustralia.com/projects<br />
Information will also be made available through<br />
AICs and AIP Supplements.
Check your flight notifications<br />
The lodgement of a flight notification is<br />
a critical step in safety of the airways<br />
system. Whether you are planning a<br />
multi leg IFR commuter flight or a weekend<br />
getaway with a SARTIME notification,<br />
completeness and accuracy of the notification<br />
is crucial.<br />
Lodging flight notifications via computer<br />
or mobile devices has added a level of<br />
convenience and safety that was not previously<br />
available. However, as with many software<br />
applications, what the operator thinks they<br />
have input may not necessarily be what is<br />
transmitted. For example, there have been<br />
instances of pilots believing they have filed a<br />
SARTIME, but because of the software on the<br />
device they were using, the SARTIME field was<br />
depopulated prior to sending.<br />
The user interface of small devices can also<br />
contribute to incorrect data being entered.<br />
Remember, small screens and big fingers do<br />
not go well together.<br />
When a notification is submitted, NAIPS<br />
replies to the originator with a copy of what<br />
was received. Always check that the flight<br />
notification NAIPS sends back to you is<br />
correct, and is what you intended to submit. If<br />
in doubt, call Airservices national briefing office<br />
on 1800 805 150 or 07 3866 3517. This simple<br />
cross check could save you time, money, or<br />
even your life
18<br />
Accident reports<br />
International accidents | Australian accidents<br />
International accidents/incidents 20 April – 3 June 2012<br />
Date Aircraft Location Fatalities Damage Description<br />
20 Apr Boeing 737-236 2.5km SW of Benazir<br />
Bhutto Int. Airport,<br />
Pakistan<br />
21 Apr Curtiss C-46F-I-CU Santa Cruz Viru-Viru Int.<br />
Airport, Bolivia<br />
127 Destroyed Passenger aircraft (first flight 1984) destroyed on approach<br />
to Islamabad, after a Bhoja Air inaugural flight from Karachi.<br />
The plane crashed, broke up and burned in a rural area,<br />
killing all on board, in weather described as poor, with limited<br />
visibility, thunderstorms, rain and the possibility of wind shear<br />
or a microburst.<br />
3 Written off Cargo plane (first flight 1945) crashed about 200m from the<br />
northern end of the runway during a go-around shortly after<br />
take-off. Three crew members were killed, one survived.<br />
25 Apr Pilatus PC-6 30km from Muara, Borneo 2 Destroyed Aircraft crashed at the edge of a ravine a few minutes after<br />
the passenger sent a text message reporting a fuel problem<br />
and anticipating an emergency landing. Both the passenger<br />
(an aerial photographer) and the pilot were killed.<br />
28 Apr Antonov 24 Galkayo Airport, Somalia 0 Written off Passenger aircraft sustained substantial damage in a landing<br />
accident. A witness said that ‘its tyres blew out, then it leaned<br />
to the right side until it broke into two pieces’. Fortunately,<br />
there were no fatalities.<br />
30 Apr ATR-72-212A Dhaka-Shajalal Int. Airport,<br />
Bangladesh<br />
2 May Cessna 208B<br />
Grand Caravan<br />
9 May Sukhoi Superjet<br />
100-95<br />
10 May Super Puma<br />
EC225<br />
0 Substantial A Royal Thai Air Force aircraft sustained damage in a<br />
runway excursion while landing. It came to rest against a<br />
concrete barrier, causing substantial damage to the RH wing.<br />
Two passengers reportedly suffered minor injuries.<br />
Yambio Airport, S. Sudan 0 Substantial UN World Food Programme aircraft (first flight 1992) hit a<br />
drainage channel on landing and flipped over. One pilot<br />
and a passenger suffered non life-threatening injuries.<br />
75km S of Jakarta,<br />
Indonesia<br />
40km off the coast of<br />
Aberdeen, UK<br />
14 May Dornier 228-212 5km SW of Jomsom<br />
Airport, Nepal<br />
45 Destroyed New aircraft on a demonstration flight destroyed when it hit<br />
the side of a mountain in poor weather. It is suspected that<br />
the aircraft had deviated from its planned flight path and lost<br />
altitude before crashing. The manufacturer says that there<br />
have so far been no indications of any failure of the aircraft’s<br />
systems and components.<br />
0 Unknown Helicopter carrying workers to two offshore oil rigs ditched<br />
after an oil pressure warning light came on. Investigations<br />
revealed a crack in the bevel gear shaft, and suggested a<br />
possible ‘manufacturing defect’. All 12 passengers and two<br />
crew were rescued, with no major injuries.<br />
15 Destroyed Passenger aircraft (first flight 1997), on a flight from Pokhara<br />
destroyed when it struck the side of a mountain, killing two<br />
pilots and 13 passengers. Five passengers and the flight<br />
attendant survived. The pilot had apparently told ATC that he<br />
was returning to Pokhara moments before the crash.<br />
17 May ATR-72-212A Munich Airport, Germany 0 Substantial Shortly after take-off the pilot of a passenger aircraft (first flight<br />
2001) reported smoke in the cabin and decided to return to<br />
Munich. On approach the pilot reported engine problems and<br />
feathered no. 2 prop. After landing, the aircraft ran into the<br />
grass and its nose gear collapsed. One passenger suffered<br />
minor injuries.<br />
18 May Antonov 2T Gödöllõ Airfield, Hungary 0 Substantial Biplane (first flight 1980) damaged in a fire on the ground.<br />
Flames spewed from the engine during a test run and the RH<br />
lower wing caught fire and burned out.<br />
2 Jun Boeing 727-221F Accra-Kotoka Airport,<br />
Ghana<br />
3 Jun McDonnell Douglas<br />
MD-83<br />
near Lagos Int. Airport,<br />
Nigeria<br />
12 Destroyed Cargo aircraft (first flight 1982) suffered a runway excursion on<br />
landing. All four crew members survived, but 12 people were<br />
reported killed when the aircraft hit a minivan and a taxi. The<br />
aircraft had been cleared to land during a thunderstorm but,<br />
after landing in a pool of water, ran off the end of the single<br />
runway, through a perimeter fence and into the vehicles.<br />
~153+10 Destroyed Passenger aircraft (first flight 1990) destroyed when it crashed<br />
into a residential area of Lagos, killing everyone on board<br />
and at least 10 people on the ground. Just after take-off the<br />
crew reported that they had lost power in both engines before<br />
the plane clipped a power line and crashed into a two-storey<br />
building north of the runway.
Australian accidents/incidents 01 April – 28 May 2012<br />
Date Aircraft Location Injuries Damage Description<br />
01 Apr PZL - Bielsko<br />
50-3 Puchaz<br />
11 Apr Ayres S2R-G10<br />
Thrush<br />
Flight Safety Australia<br />
Issue 87 July–August 2012<br />
Ararat Aerodrome, Vic Fatal Destroyed During initial climb, the tow line broke and the glider collided<br />
with terrain. The two people on board were killed.<br />
Moree Aerodrome, 313°<br />
T 36km, NSW<br />
Fatal Destroyed While conducting a ferry flight from St George, Queensland to<br />
Moree, NSW the aircraft collided with terrain and burnt.<br />
The investigation is continuing.<br />
12 Apr Cessna 310R Marlgawo (ALA), NT Minor Substantial On final approach, at about 50ft AGL, the aircraft encountered severe<br />
windshear and landed heavily. The investigation is continuing.<br />
13 Apr Mooney M20J Yarrawonga Aerodrome,<br />
Vic<br />
Nil Substantial The aircraft landed with the landing gear retracted.<br />
13 Apr Helicopteres<br />
Guimbal Cabri G2<br />
18 Apr Cessna 210M<br />
Centurion<br />
21 Apr Cessna 172R<br />
Skyhawk<br />
Camden Aerodrome,<br />
NSW<br />
29 Apr Cessna 150M Bourke Aerodrome, 047°<br />
M 55km, NSW<br />
01 May Piper PA-25-235/<br />
A9 Pawnee<br />
03 May Cessna 172R<br />
Skyhawk<br />
20 May Amateur-built<br />
Hornet AG<br />
Minor Substantial During jammed pedal recovery practice, the helicopter collided<br />
with the ground and rolled over. The investigation is continuing.<br />
Nyirripi (ALA), NT Serious Substantial On approach, the aircraft encountered gusting winds resulting in<br />
loss of control. The crew were unable to regain control and the aircraft<br />
collided with terrain. One of the two crew members onboard was<br />
seriously injured. The investigation is continuing.<br />
Archerfield Aerodrome, Nil Substantial During landing, the aircraft ran off the runway.<br />
Qld<br />
Leongatha Aerodrome,<br />
018° T 13km, Vic<br />
Camden Aerodrome,<br />
NSW<br />
near Gloucester (ALA),<br />
NSW<br />
28 May Cessna 172 Wentworth Aerodrome,<br />
WSW M 10km, NSW<br />
Fatal Destroyed During mustering the aircraft collided with terrain.<br />
The investigation is continuing.<br />
Fatal Destroyed It was reported that the aircraft collided with terrain.<br />
The investigation is continuing.<br />
Nil Substantial The aircraft landed hard, resulting in substantial damage.<br />
Minor Substantial During cruise, the engine lost power and subsequently failed<br />
during the return to Gloucester. An engineering inspection revealed<br />
that the reduction drive gear box had failed.<br />
Fatal Substantial The aircraft collided with terrain, killing the pilot.<br />
The investigation is continuing.<br />
19<br />
Australian accidents<br />
Compiled from the Australian Transport Safety Bureau (ATSB).<br />
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<br />
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<br />
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.<br />
International accidents<br />
Compiled from information supplied by the Aviation Safety Network (see www.aviation-safety.net/database/) and reproduced with permission.<br />
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<br />
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<br />
FEATURE<br />
Helmets in aviation<br />
A hard-headed look<br />
at helmets<br />
The law says you need a<br />
helmet to ride a bicycle<br />
in Australia—and a life<br />
jacket if you board a<br />
boat—but you are free to<br />
fly in any type of aircraft<br />
with a bare head.<br />
That’s not going to change; CASA is not<br />
planning to make helmets compulsory. To<br />
wear a helmet, or not, is every individual’s<br />
decision. But that decision should be an<br />
informed one.<br />
Most research and documentation on<br />
the usefulness of helmets comes from<br />
military helicopter aviation. The results<br />
are unambiguous.<br />
When the US Army evaluated the<br />
effectiveness of its SPH-4 flight helmet,<br />
it found unhelmeted helicopter cockpit<br />
occupants were 6.3 times more likely to<br />
suffer a fatal head injury and 3.8 times<br />
more likely to have a severe head injury<br />
than helmet wearers. The analysis looked<br />
at severe accidents that were at least<br />
partially survivable. Unhelmeted occupants<br />
in the passenger or freight area of the<br />
helicopter were even more likely to be<br />
injured if not wearing a helmet.<br />
They were 5.3 times more likely to suffer a<br />
severe injury and 7.5 times more likely to<br />
have a fatal head injury.<br />
The author of the US study, John S.<br />
Crowley, extended his conclusions<br />
to civilian flying. ‘Although much civil<br />
helicopter flying is obviously different<br />
from tactical military aviation (controlled<br />
airspace, high altitude, busy airports),<br />
some civilian flying is very similar … it<br />
does appear reasonable to apply these<br />
military data to civilian helicopter scenarios<br />
with similar flight profiles,’ he wrote.<br />
A guide for US government employees<br />
quotes some impressive examples of<br />
helmeted occupants of helicopters who<br />
escaped serious injury. They include an<br />
occupant who suffered two rotor blade<br />
strikes to the helmet but escaped without<br />
permanent head injury. In another case, a<br />
helicopter hit the ground inverted and the<br />
seatbelt failed: the survivor had no head
Flight Safety Australia<br />
Issue 87 July–August 2012<br />
21<br />
injuries. Another helicopter came<br />
down on its left side after a 100-foot<br />
fall—without serious head injuries to<br />
the helmeted survivors.<br />
In 2009, an agricultural helicopter pilot<br />
wearing a helmet and a four-point harness<br />
survived a wirestrike near Albury, NSW that<br />
destroyed the Bell 206 he was flying.<br />
Some types of aviation obviously carry<br />
elevated risk. Agricultural flying, aerial<br />
firefighting, powerline work and mustering<br />
come to mind. But for helicopters in<br />
particular, activities often thought of<br />
as fairly safe are prominent in accident<br />
statistics. When the Australian Transport<br />
Safety Bureau looked at light utility<br />
helicopter safety, it identified private flying<br />
and flying training as the second and third<br />
largest categories of accident flights after<br />
aerial work, (which included mustering).<br />
For Australia’s most popular helicopter, the<br />
Robinson R22, private flying and training<br />
each produced about six times as many<br />
accidents as aerial agriculture. In short:<br />
elevated risk does not always announce<br />
itself by being high-G and low-level.<br />
By keeping you conscious and allowing<br />
you to escape from the cockpit of a<br />
crashed aircraft, a helmet can save you<br />
from burning to death or drowning—there<br />
are many examples of this—and many<br />
other cases where incapacitated aircrew<br />
died who might have lived had they been<br />
wearing helmets.<br />
A less well-known safety benefit of helmets<br />
comes from how their visors protect the<br />
face. The US Army found that in 25 per<br />
cent of accidents to helmeted aircrew, it<br />
was the visor that prevented or reduced<br />
injury. In 22.2 per cent of accidents the<br />
visor prevented injury. The study found:<br />
‘crewmembers who wore their visors<br />
down sustained minor injuries—caused by<br />
the visor in many cases (often due to the<br />
visor edge striking the cheek)—but there<br />
were fewer fatalities among them.’<br />
The ATSB noted in its report into a 2006<br />
helicopter crash, where both the pilot and<br />
feral animal shooter were wearing helmets,<br />
and survived, that the pilot might have<br />
been protected from facial and eye injuries<br />
had his visor been down.<br />
While not demanding it, CASA encourages<br />
helmet wearing. For example, advisory<br />
circular 21-47(0) on flight-test safety, of<br />
April 2012, says: ‘For the early flights of<br />
an experimental or major developmental<br />
program, and for any flight in which there<br />
is a chance that the aircraft may be subject<br />
to a loss of control near or on the ground,<br />
or may have to be abandoned while<br />
airborne, a protective helmet should also<br />
be worn.’<br />
Some sectors of aviation have<br />
unreservedly adopted helmets.<br />
‘The Aerial Agriculture Association<br />
of Australia strongly recommends all<br />
application pilots wear helmets during<br />
operations,’ says AAAA chief executive<br />
Phil Hurst. ‘We have been teaching this<br />
for years, it is included in the Aerial<br />
Application Pilots Manual—and has almost<br />
universal adoption within the industry.’<br />
In Hurst’s opinion, the relevance of helmets<br />
to the wider GA community depends on<br />
the risk and the nature of the operation.<br />
‘As a helmet or protective clothing is<br />
classified as “PPE” —personal protection<br />
equipment—it is on the bottom rung of<br />
risk management. The highest order of risk<br />
management is of course not to be there—<br />
to eliminate the risk,’ he says.<br />
‘While this is not possible in many ops—<br />
and therefore the need for other mitigation<br />
measures—it is certainly the case for<br />
any GA pilot who might be tempted to<br />
undertake low flying “for the fun of it”.<br />
They simply shouldn’t put themselves in<br />
the hostile, low-level environment.’<br />
‘Of course, helmets and other PPE are just<br />
another means of trying to get the odds on<br />
your side for a favourable (safe) outcome<br />
to every flight.’<br />
Like most things in aviation, flight<br />
helmets are not cheap. They can cost<br />
up to $2000, although a small financial<br />
mercy is that they can be inspected and<br />
refurbished for further use, unlike, for<br />
example, motorcycle helmets, which can<br />
be equally expensive but are recommended<br />
for destruction after a certain lifespan.<br />
Sport aviation helmets are available for<br />
hang glider, trike and three-axis ultralight<br />
occupants.<br />
Nobody plans to have an accident: nobody<br />
wants to have an accident. All sensible<br />
pilots take precautions with their aircraft<br />
and how they fly it, so they do not have an<br />
accident, or minimise its effects. Wearing<br />
a helmet is one such precaution that has<br />
been shown to work. The decision to wear<br />
one is yours. On your head be it.<br />
Further reading<br />
1991 US Army helicopter crew helmets study<br />
www.ncbi.nlm.nih.gov/pubmed/1890485<br />
Helmet use: What message are we sending to<br />
patients? Ted Ryan, Beth L. Studebaker, Gary<br />
D. Brennan Air Medical Journal Volume 13,<br />
Issue 9, September 1994, Pages 346–348<br />
Helicopter Safety Vol. 24 No. 6 November-<br />
December 1998 Flight Safety Foundation,<br />
Alexandria, VA, USA<br />
ATSB investigation reports: 2006—<br />
200606510, and 2009 B206 Albury wirestrike
22<br />
FEATURE<br />
Aerodrome safety<br />
A big thank you to the 242 certified and registered aerodrome operators<br />
who completed the Aerodrome Safety Questionnaire in September 2011.<br />
This valuable feedback equated to a 76 per cent response rate.<br />
The 2011 survey provided a picture of the scope and size of<br />
certified and registered aerodrome operations. Close to one fifth<br />
of all aerodromes see only one flight or less on average per day,<br />
while 50 per cent have between 10 and 100 flights per week.<br />
The majority of aerodromes (68 per cent) are operated by<br />
local government organisations. Twenty per cent of the aerodrome<br />
operators are private enterprises for profit.<br />
Almost half of all aerodromes reported employing only one<br />
or no full-time staff to run the aerodrome. The largest<br />
aerodromes, representing five per cent of the total, employ<br />
60 per cent of all full-time airport operator staff.<br />
10% 2%<br />
The survey collected information regarding aerodrome<br />
operations such as:<br />
the turnover of key personnel<br />
the ability to hire staff for key positions<br />
20%<br />
Responsibility for<br />
daily operations<br />
68%<br />
changing workload conditions across the industry.<br />
This sort of information regarding industry stability<br />
provides important insights into potentially increased risk<br />
associated with change.<br />
Turnover rates for the aerodrome manager, head of operations<br />
and head of safety are all relatively similar, with around 25 per<br />
cent of current managers holding their positions for less than<br />
a year. The head of airfield maintenance position seems to be the<br />
most stable, with 60 per cent having held their role for more than<br />
five years.<br />
Other<br />
Private enterprise not-for-profit<br />
Private enterprise for profit<br />
Local government
Flight Safety Australia<br />
Issue 87 July–August 2012<br />
23<br />
Threat species by climate zone<br />
4<br />
6<br />
te zone<br />
Number of aerodromes<br />
One third of the respondents stated that foreign object damage<br />
(FOD) control is the sole responsibility of airport operators<br />
or local council personnel, whilst 25 per cent see FOD as the<br />
responsibility of everyone working airside.<br />
Just under half of the responding aerodromes have a runway<br />
safety program in place.<br />
Airport runway safety program<br />
45<br />
40<br />
35<br />
30<br />
25<br />
20<br />
15<br />
10<br />
5<br />
0<br />
Very small<br />
0–1000<br />
annual movements<br />
Small<br />
1000–5000<br />
Medium<br />
5000–20,000<br />
Yes<br />
No<br />
Unknown<br />
Large<br />
more than<br />
20,000<br />
34<br />
30<br />
20<br />
14<br />
28<br />
Kangaroo/Wallaby<br />
5<br />
7<br />
11<br />
21<br />
Galah<br />
8<br />
18<br />
13<br />
11<br />
2<br />
5<br />
9<br />
Lapwing/Plover<br />
3<br />
7<br />
8<br />
Flying Fox/Bat<br />
1<br />
4<br />
Kite<br />
10<br />
25 30 35<br />
One section in the questionnaire was dedicated to wildlife<br />
unt of eight or more management. The majority of respondents indicated that their<br />
aerodrome has a wildlife hazard management plan. Around 30 per<br />
cent of the smaller airports (those with fewer than 5000 annual<br />
aircraft movements) do not have such a plan. When these figures<br />
are ranked according to aerodrome type—registered versus<br />
certified—only 20 per cent of registered aerodromes have a wildlife<br />
hazard management plan, as opposed to 80 per cent of the certified<br />
aerodromes. Almost 80 per cent of aerodromes that carried out a<br />
risk assessment said they had a wildlife hazard management plan.<br />
Most respondents rated the risk of wildlife on their airport as<br />
low, with the larger aerodromes often reporting a medium risk<br />
(46 per cent). Generally, tropical and subtropical area aerodromes<br />
rated their wildlife risk as higher than the operators in more<br />
temperate regions.<br />
Respondents who rated the risk of wildlife as medium or high were<br />
asked to indicate the specific species that posed the highest risk on<br />
their aerodrome. A maximum of three species could be selected.<br />
The results are shown opposite, broken down by climate zones.<br />
13<br />
Ibis<br />
1<br />
4<br />
6<br />
9<br />
Duck<br />
Magpie<br />
Note: flying-fox/bat–only species with a count of eight or more<br />
are displayed<br />
Tropical and Equatorial<br />
Subtropical<br />
Desert and Grassland – hot<br />
Desert and Grassland – temperate<br />
Temperate and Alpine<br />
2<br />
7<br />
4
24<br />
FEATURE<br />
Aerodrome safety<br />
Most aerodrome operators selected kangaroos and wallabies<br />
as problematic species throughout all climate zones.<br />
Although the actual number of animal strikes is low, there is<br />
a relatively high possibility of aircraft damage arising from<br />
animal/marsupial strikes compared to bird strikes.<br />
While the lapwing/plover and flying-fox/bat species are the<br />
most common bird/mammal types struck in Australia, they<br />
only come fourth and fifth respectively in the ranking of<br />
risk species as identified by the aerodrome operators. The<br />
highest single bird species struck is the galah, making up a<br />
significant proportion of bird strikes in New South Wales, the<br />
Australian Capital Territory and South Australia. The survey<br />
results support this finding; the majority of aerodromes rated<br />
the galah as the highest-risk bird type, in all climate zones.<br />
Galahs are known to have flocking tendencies, which may<br />
lead to multiple bird strikes. Flocking behaviour may also<br />
explain why ten aerodromes rated ducks as a hazard.<br />
There are some significant differences in problematic<br />
species by climate region. In the hot desert and tropical<br />
areas, kite species pose the most significant wildlife risk for<br />
aerodromes, whereas temperate areas face most difficulties<br />
with galahs and ibis.<br />
Operators were asked to rate a list of possible risks to<br />
aviation safety as high, medium or low. The majority of<br />
aerodromes rated the presented risks as low or no risk.<br />
Certified and registered aerodromes showed a very<br />
similar pattern in their risk rating.<br />
Aerodrome operators were more likely to rate<br />
organisational risks as high or medium than operational<br />
risks. A lack of funds, closely followed by the inability<br />
to attract skilled staff and the age of facilities were most<br />
often identified as medium- to high-risk issues.<br />
The Aerodrome Safety Questionnaire also gave operators<br />
the opportunity for feedback about their perception of<br />
CASA. Almost 70 per cent of participants reported that<br />
CASA had been helpful, or very helpful, in identifying<br />
important safety issues that their organisations had not<br />
previously been aware of. Similarly, over 80 per cent of<br />
aerodrome operators found the CASA website helpful.<br />
Operators’ responses have given CASA a wealth of<br />
valuable information relating to many potential aviation<br />
safety issues.<br />
Operational risks<br />
Wildlife<br />
Emergency<br />
Fuelling safety<br />
Runway safety<br />
Inadequate maintenance of airfield<br />
Vehicular safety<br />
Transport/storage of dangerous goods<br />
Debris in operational area<br />
Use of alcohol and other drugs<br />
Signs and markings<br />
%<br />
0 10 20 30 40 50 60 70 80 90 100<br />
No risk<br />
Low risk Medium risk High risk
Flight Safety Australia<br />
Issue 87 July–August 2012<br />
25<br />
A Hands-on Approach<br />
Two flights, more than sixty years apart, have much to<br />
teach about the importance of pilots staying involved and<br />
never giving up, as an airline pilot reveals<br />
Long before it was given a name, crew resource management<br />
and the flying skills of First Lieutenant Lawrence M. DeLancey<br />
brought a B-17 bomber back to Nuthampstead air base, in<br />
England. It was November 1944 and flak over Germany had<br />
blown the B-17’s nose off and damaged its hydraulic system.<br />
The bombardier was killed by the flak burst, but ‘Larry’<br />
DeLancey and his co-pilot Phil Stahlman saved the rest of the<br />
aircraft’s crew. Their reward was life. DeLancey lived until 1995<br />
and Stahlman went on to a 40-year career as an airline pilot.<br />
A report on the landing described how the pilots sat stunned<br />
in the cockpit afterwards and how DeLancey was able to walk<br />
only a few paces before ‘he sat down with knees drawn up,<br />
arms crossed and head down.’<br />
Decades later, in a peaceful European sky, Turkish Airlines flight<br />
TK1951 began its approach to Schiphol airport, Amsterdam.<br />
Within a minute of touchdown the approach became a<br />
disaster—in still, clear air, the Boeing 737-800 stalled and<br />
crashed. The links in this accident chain have been disclosed<br />
in the Dutch Safety Board report, in exquisite detail. I have no<br />
new revelations, but merely pose some questions to give pilots<br />
something to think about.<br />
With 20/20 hindsight, the proper actions are obvious—they<br />
always are. Why did the captain, who was a senior instructor,<br />
not take over manually and hand-fly the approach? He had<br />
already identified that the aircraft had diminished functionality<br />
with impaired and defective systems.
26<br />
FEATURE<br />
Flying operatiions<br />
If not then, why did he not take over when the<br />
localiser was intercepted, late, at a tight 5.5nm<br />
and 2000 feet?<br />
When I flew into Schiphol, I recall that the<br />
approach controllers preferred a quiet, idle<br />
thrust, constant descent, approach with little<br />
or no chance for a level period to comfortably<br />
capture the glide slope, especially approaching<br />
from the north and east of the airport. That’s<br />
how it was more than ten years ago.<br />
It is a common occurrence around the world<br />
for an aircraft to be vectored too close and too<br />
high to the runway, forcing the glide slope to<br />
be captured from above. The steep descent,<br />
on a non-precision approach, adds to a crew’s<br />
already high workload.<br />
Automatic flight systems, such as autopilot<br />
and autothrottle, increase fuel savings, reduce<br />
crew workload, and give more opportunity<br />
for situational awareness, but may also make<br />
pilots too complacent, too comfortable, lazyminded,<br />
and out of practice when hand-flying<br />
becomes necessary. Underlying systems<br />
malfunctions could be masked, especially when<br />
the crew lacks a complete understanding of the<br />
automated systems’ interactions. Automation<br />
can set deadly traps for a crew not on top of<br />
their game.<br />
To this add training that is perfunctory and<br />
uninspiring, that is inadequate, outdated, and<br />
lacking standardisation between one instructor<br />
and the next. Combine it with non-existent<br />
or poor CRM, and watch the problems in the<br />
cockpit swell.<br />
Turkish Airlines TK1951 crash site<br />
We know from the accident report that the radio altimeter gave the autopilot<br />
false information. This forced idle thrust and, uncorrected, led to the stall. But<br />
this accident was completely preventable, had the captain taken control and<br />
manually flown the approach.<br />
At what point would it have been prudent for the captain to take physical<br />
control of the aircraft? In the performance of his pilot monitoring duties, the<br />
captain was not proactive in his support of the first officer, who was pilot<br />
flying. Was the captain too comfortable with his first officer’s handling of<br />
the aircraft, the fact the weather was not too threatening and that the aircraft<br />
was being flown on autopilot? Did he just assume, because the approach<br />
procedure was one he had done a hundred times before, that there would<br />
be no drama that day? We have all fallen into that trap, regardless of how<br />
disciplined and professional we think we are.<br />
Had the captain been vigilant, as he was supposed to be as pilot monitoring,<br />
had he been calling out the flight mode annunciations on the primary flight<br />
display (PFD), and monitoring engine instruments, such as abnormally low<br />
N1 (low-pressure compressor rpm) and fuel flow, he would have immediately<br />
realised that there was something abnormal about the profile and the aircraft’s<br />
automation. (Editor’s note: See the feature article in Flight Safety Australia<br />
March-April 2012 for a discussion on the difficulties and poor definition of the<br />
pilot monitoring role.)<br />
Typically, when I was flying the Boeing 737NG, on final approach, after gear<br />
down and flaps 15, I would call for ‘flaps 30 - landing checklist’ at about 1300<br />
feet. I would let the aircraft re-stabilise, disengage the autothrottle, checking<br />
that N1 was approximately 57 per cent, then disengage the autopilot and<br />
hand-fly the approach from 1000 feet to landing rollout. Maybe this technique<br />
allowed me to dodge the bullet that brought down TK1951. Maybe I was<br />
just lucky.<br />
As a pilot, I would like to get something out of every flying day that reminds<br />
me I am still a pilot. Taking manual control of the aircraft to hand-fly is a rare<br />
opportunity that I really enjoy, whether as captain or first officer. It is also<br />
an opportunity to refresh my hand-flying skills, which I may still need for<br />
a visual circuit when the autopilots have failed, or if I have a simulator<br />
proficiency check.
Flight Safety Australia<br />
Issue 87 July–August 2012<br />
27<br />
Loss of control has become one of the largest contributors to aircraft<br />
accidents, and it is not just a problem for commercial transport-category jets.<br />
It affects every category and class—agricultural pilots making uncoordinated<br />
turns, seaplanes attempting take-off on glassy water, helicopters that lose tail<br />
rotor authority from a steep downwind approach, or from extreme manoeuvres<br />
(cowboying the aircraft) during cattle mustering. Helicopters self-destructing<br />
due to ground resonance, a medium twin in severe turbulence, a turboprop<br />
airline crew that failed to recognise icing, a corporate jet hitting wake<br />
turbulence from a Boeing 757, (surprise, surprise), a transport category jet<br />
with a rudder hard over––all loss of control.<br />
1st Lt. Lawrence DeLancey’s crippled B-17 at Nuthampstead<br />
October 15, 1944<br />
In all preventable loss-of-control aircraft accidents<br />
the common denominator is the crew’s response—<br />
or lack of response—to an event.<br />
The solutions are well known, but easier to list<br />
than implement. Meaningful initial and recurrent<br />
training (this means more than playing ‘stump<br />
the dummy’ in the simulator), crew vigilance,<br />
discipline and professionalism are the keys to<br />
preventing future loss of control accidents.<br />
For the pilot all this boils down<br />
to two principles: always stay<br />
mentally engaged and never give<br />
up flying the aircraft.<br />
I learned this from a personal experience on the<br />
simulator. During a recurrent training session a<br />
few years ago, I was paired with a captain who<br />
had been trained by a large Asian airline. Both<br />
of us were captains for the same airline, on<br />
the same fleet. I was in a supporting and pilot<br />
monitoring role, in the right-hand seat. While<br />
flying upwind, the aircraft ended up inverted.<br />
The captain said, ‘That’s it, we’re dead’, to<br />
which I replied, ‘*** **** ** ***!’ I took<br />
control, immediately applied full thrust and<br />
pushed forward on the yoke, to climb while<br />
inverted. I rolled the aircraft shiny-side-up at<br />
about 3000 feet. Then I asked him, ‘Are we<br />
dead?’ I transferred control and said, ‘Never<br />
give up flying the aircraft!’<br />
I flatter myself to think that Larry DeLancey,<br />
who was 25 when he made his epic flight,<br />
would have approved.<br />
Extra 500 Turboprop<br />
luxury business tourer<br />
– Carries more<br />
– Flies farther<br />
– Costs less<br />
– Compare for yourself<br />
For more information on a demonstration flight in your region please contact<br />
John Rayner on 0418 311 686 or john.rayner@aviaaircraft.com.au<br />
www.aviaaircraft.com.au
28<br />
FEATURE<br />
Hazard ID<br />
In plane sight –<br />
hazard ID and SMS<br />
PASSENGER<br />
CITIZEN / JOHN MR<br />
DATE<br />
JULY 2012<br />
CARRIER<br />
CITY AIR<br />
CASA safety systems<br />
inspector, Leanne<br />
Findlay, and ground<br />
operations inspector,<br />
David Heilbron, look at<br />
the vital role hazard-<br />
ID plays in safety<br />
management systems<br />
Operational safety<br />
Aviation companies have different safety-related procedures. A ‘keeping-it-simple’<br />
approach assumes a basic understanding by all staff (including subcontractors),<br />
across all areas of the operation, of the hazard identification processes and<br />
procedures available to them.<br />
You can use The SHEL model (sometimes referred to as the SHEL[L] model) to help<br />
visualise the relationships between the various parts of an aviation system. This model<br />
emphasises individual human interfaces with the other parts of the aviation system, in<br />
line with International Civil Aviation Organization (ICAO) standards.<br />
The process of hazard identification never stops. Every flight is different, every<br />
passenger and combination of passengers is different, and new technology and its<br />
effects on the various combinations of interfaces can create new hazards and, in turn,<br />
risks. Many organisations are now developing safety management systems, which<br />
ideally reflect an ability to continually review and improve processes and procedures<br />
to adapt to change.<br />
Introducing any change to an operation should elicit more safety reports, and this<br />
additional data can be analysed, acted upon and monitored to mitigate risk. Change<br />
might include the fine-tuning of procedures, new equipment, a reduction or increase in<br />
personnel, or turnover of personnel. During these changes, everyone with the ability to<br />
report hazards and identify their potential risks needs to understand the many forms<br />
hazards can take.
Flight Safety Australia<br />
Issue 87 July–August 2012<br />
29<br />
CANBERRA ² BRISBANE<br />
CBR ² BNE<br />
FLIGHT<br />
FSA87<br />
BOARDING TIME<br />
2030<br />
GATE<br />
8<br />
SEAT NO.<br />
12B<br />
PASSENGER<br />
CITIZEN / JOHN MR<br />
FLIGHT<br />
FSA87<br />
When designing training, consider the target audience:<br />
What do staff need to know?<br />
What do staff need to look for? (e.g. baggage size and weight, able-bodied<br />
passengers, oxygen bottle types, medical requirements.)<br />
Why are these identified as hazards, or potential hazards?<br />
Why do staff need to report hazards?<br />
Will operational staff know what a hazard is if they do not understand the concept?<br />
Why are identification and reporting important, even if the hazard does not cause<br />
an incident or accident?<br />
Anything noticed (smelt, seen, heard) and identified as a hazard has to be reported<br />
to someone who can address the issue and prevent a possible incident or accident.<br />
Operational staff need to know that their contributions to the safety reporting system<br />
will be used to strengthen systems, in the spirit of a ‘just’ safety culture.<br />
CASA safety systems inspector, Leanne Findlay, and ground operations inspector,<br />
David Heilbron, recognise the importance of operational safety personnel<br />
understanding what to report. Training of new staff, combining the use of theory,<br />
role-plays and formal on-the-job experience of hazard identification, can consolidate<br />
awareness of hazards and risks. Training records should document all forms of initial<br />
and recurrent training. Asking experienced staff to mentor newer staff helps them to<br />
recognise potential hazards in the workplace. Each event can have different variables,<br />
and situations will not necessarily follow a scenario that the staff have seen before, or<br />
read about in a textbook.<br />
continued on page 64
30<br />
FEATURE<br />
Text here<br />
advertisement<br />
AA&S 2012<br />
24 - 26 26 July July<br />
The AA&S (Australia) Conference is for the benefit of all those<br />
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Structures and Corrosion, NDT, Avionics and Wiring Systems,<br />
Obsolescence, Propulsion, Logistics and Supply Chain, Cost of<br />
Ownership, Workforce Capability and Unmanned Aerial Systems.<br />
Kindly sponsored by CASA and the RAAF, the event seeks to<br />
maximise interaction between the military and civilian aviation<br />
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we’ve learned in the past translate to safer fleets for the future.<br />
When and Where:<br />
Brisbane Convention and Exhibition Centre (BCEC) over 24-26 July 2012.<br />
Please see website for further details.<br />
www.ageingaircraft.com.au/aasc
Flight Safety Australia<br />
Issue 87 July–August 2012<br />
31<br />
Sneaky leaks<br />
The problem of pinhole corrosion<br />
When we think about corrosion in aircraft, most of us probably think of airframe structures.<br />
However, there are plenty of unsettling examples of an insidious corrosion infecting the<br />
network of aircraft aluminium plumbing, as fact-finding investigations for CASA’s ageing<br />
aircraft management plan have discovered.<br />
Corrosion is not just a problem for airframes. It’s also a<br />
cancer for aircraft systems. A small but disturbing number<br />
of the many service difficulty reports sent to CASA concern<br />
pinhole corrosion in the aluminium tubing used in aircraft fuel,<br />
hydraulic, oxygen and instrument systems.<br />
Pinhole corrosion starts when moisture gets inside the<br />
aluminium tubing that is embedded throughout the structure of<br />
almost every aircraft. It collects into a pool at the low point, sits<br />
virtually on one spot and provides the catalyst for corrosion<br />
to start. Aluminium tubing can be found in the powered flight<br />
control system, undercarriage brake system, the instrument<br />
system and the fuel system. Moisture also collects in deactivated<br />
oxygen system lines, but is usually only discovered<br />
when the system is operated.<br />
Little information is available on pinhole corrosion in aircraft.<br />
It is, however, a known issue in household plumbing, where<br />
it is attributed to age, water quality and sometimes, cavitation<br />
induced by sharp bends. But there are sufficient reports<br />
of pinhole corrosion reaching CASA for it to be<br />
something every LAME should be aware of.<br />
Not all pinhole corrosion requires liquid in a<br />
pipe. One event known to CASA described<br />
an AS350 helicopter with gross pinhole<br />
corrosion in the engine compressor bleed<br />
air line required for the windscreen de-icer/<br />
demister.<br />
pinhole<br />
corrosion in the<br />
aluminium tubing<br />
used in aircraft fuel,<br />
hydraulic, oxygen<br />
and instrument<br />
systems.<br />
Such was the pressure loss though the corrosion holes that<br />
the demister system, important for helicopter flight in cold or<br />
humid weather, was inoperative.<br />
One of the most disturbing incidents was recently reported to<br />
CASA by an engineer doing an engine run after a scheduled<br />
inspection. Concerned by the smell of fuel in the cabin, the<br />
engineer immediately shut down the engine and eventually<br />
found the cabin trim fabric and the aircraft’s rear seat cushions<br />
were saturated in avgas.<br />
‘This raised the distinct possibility of flight crew incapacitation<br />
due to the fumes, or even fire or explosion in flight, which, of<br />
course, makes a pinhole in a pipe a major defect,’ CASA senior<br />
maintenance engineer, Roger Alder, notes drily.<br />
‘Over the years, we’ve been receiving defect reports on pinholes<br />
in hydraulic lines and fuel system lines, which can be attributed<br />
to water precipitating out of either the fuel and/or the mineral<br />
hydraulic oil and pooling in the low points of the system.<br />
Airborne moisture typically enters the engine<br />
oil, hydraulic oil, and fuel systems via the<br />
vent systems (just by sitting on the ground<br />
“breathing” due to normal atmospheric<br />
changes) where it will later condense and<br />
form small pools.’<br />
‘Although the numbers involved are small,<br />
there has been a recent increase in this type<br />
of report,’ Alder adds.
32<br />
AIRWORTHINESS<br />
Pinhole corrosion<br />
‘Pinhole corrosion in one section of the system can be a warning sign of more<br />
extensive internal corrosion in other sections of the system and therefore may<br />
require replacement of the entire tubing network.’<br />
As any LAME knows, inspecting corrosion in an airframe<br />
is exacting work; inspecting for corrosion on the inside of a<br />
small bore aluminium line as it meanders through the wing<br />
and fuselage is bordering on impossible, without hi-tech<br />
equipment.<br />
‘The key issue is, how do you inspect for this? It is truly<br />
insidious, and inspecting for it requires technology at the<br />
cutting edge of inspection techniques. Very small borescopes,<br />
capable of operating over long distances and special electronic<br />
metal thickness detectors would be required. Then comes the<br />
question as to what data to be used,’ Alder says.<br />
‘It would seem that pinhole corrosion could be mainly due to<br />
aircraft having low utilisation over many years. But there’s<br />
no telling when it could occur—a slight flaw in the anodising<br />
inside a pipe could be enough to precipitate it.<br />
It affects older aircraft more than newer ones, because the<br />
corrosion takes some years to bite its way from the inside to<br />
the outside of a pipe. On the basis of the number of reports<br />
received by CASA, pinhole corrosion appears to be age- rather<br />
than hours-related; although an aircraft which has been used<br />
regularly over a long time might still have the problem. Using<br />
an aircraft infrequently gives water time to collect and sit<br />
between flights. It also gives the special additives added to<br />
avgas at the time of manufacture time to evaporate.<br />
‘While many aluminium pipes are rejected for a number of<br />
reasons, including external corrosion, these pipes can look<br />
perfectly normal on the outside until breached by pinhole<br />
corrosion from the inside,’ Alder says. ‘Remember that the<br />
pipe has been corroding from the inside out. The spot where<br />
the pinhole occurred is just the first place at which it broke<br />
through. You must also look at the matching component or<br />
section of tubing on the other side of the aircraft—it may have<br />
similar problems and be the next item to go.’<br />
Alder says that considering existing manufacturers’<br />
maintenance schedules, particularly those for light aircraft,<br />
which rarely (if ever) include an inspection for internal<br />
corrosion of the aluminium tubing, plus current inspection<br />
techniques and technology, pinhole corrosion in aircraft is<br />
looming as a potentially expensive problem to first of all find,<br />
and then fix. ‘Pinhole corrosion in one section of the system<br />
can be a warning sign of more extensive internal corrosion<br />
in other sections of the system and therefore may require<br />
replacement of the entire tubing network.<br />
‘Some manufacturers permit splicing a replacement section<br />
into a pipe but others do not, citing changes to fluid flow and<br />
the creation of weak points where the splice is joined into<br />
the pipe.’<br />
What can aircraft owners do?<br />
Store your aircraft in the best possible conditions—under<br />
cover in as dry an environment as possible. The major<br />
enemy is ingress of moisture and the main culprit appears<br />
to be moisture in the low points of the system.<br />
Replace tubing that has external corrosion.<br />
Go flying. In other words: use your aircraft. Every flight<br />
that generates heat from the engine, gets fuel and fluid<br />
flowing through the aircraft’s network of pipes, and puts<br />
the aircraft in a variety of attitudes, helps to reduce the<br />
likelihood of pinhole corrosion forming.<br />
Stay informed: If you hear of a case of pinhole corrosion<br />
in a similar aircraft to yours, then you should inspect<br />
or replace the corresponding part on your aircraft. You<br />
can email sdr@casa.gov.au to check pinhole corrosion<br />
occurrences for your aircraft type.<br />
The reports<br />
SDR510014540<br />
Rigid hydraulic tubing located between LH wing root and<br />
engine nacelle-contained corrosion pitting through wall<br />
thickness resulting in loss of hydraulic fluid. Suspect caused<br />
by tubing contacting flexible hose in wing channel.<br />
Gulfstream 500S<br />
SDR510014546<br />
Rigid aluminium fuel line from LH tank to fuel cock contained<br />
pinhole corrosion allowing fuel leakage into cockpit.<br />
Pilot returned to land after smelling avgas in cockpit.<br />
Investigation found corroded and leaking fuel gauge pressure<br />
tube assembly. Tube corroded in area of contact with black<br />
scat hose. Cessna 150<br />
SDR 2011144<br />
Defect description: Very difficult to determine exact cause.<br />
The defect was noted and rectified while the aircraft airconditioning<br />
system was being overhauled. When the cabin<br />
floor panels were removed to carry out reinstallation of
Flight Safety Australia<br />
Issue 87 July–August 2012<br />
33<br />
condensers it was noted that the insulation surrounding the<br />
cross feed tube was fuel soaked and causing a slow drip of<br />
avgas. The insulation was removed, exposing a very small<br />
pinhole leak. Component then removed and replaced. Fuel tube<br />
cut open to determine cause of leak. Corrosion (internal) found<br />
to be the cause.<br />
Opinion as to the cause of the defect: Corrosion and possible<br />
introduction of water to flush fuel system during EDA<br />
(ethylenediamine) cleaning. If water was introduced to fuel<br />
system by any means it would, during periods of non use,<br />
be liable to settle in the cross-feed tube and create the right<br />
environment to start the corrosion process.<br />
SDR 510010841<br />
While performing engine ground runs strong smell of avgas<br />
evident in cabin. On removal of interior trim, soundproofing<br />
found saturated with fuel.<br />
Investigation results: Fuel feed line from R/H source found to<br />
be weeping avgas at the entry into the fuselage.<br />
The solid aluminium tube was holed at this point due<br />
corrosion. Replacement line installed and scoured, fuel<br />
replenished. No leaks evident.<br />
SDR 20020830<br />
Defect description: corrosion due to water contamination.<br />
(Solid aluminium tube was leaking/pinhole.) Opinion as to the<br />
cause of the defect: corrosion and human factors.<br />
SDR 510009700<br />
Pilot returned to land after smelling avgas in cockpit.<br />
Investigation found corroded and leaking fuel gauge pressure<br />
tube assembly. Tube corroded in area of contact with black<br />
scat hose.<br />
SDR 20020090<br />
Defect description: Aircraft was found to leak while in our<br />
hangar for other defects. On further inspection the leak was<br />
found to be coming from the R/H inboard transfer line. This<br />
line was replaced. Inspection of the leaking tube revealed<br />
pitting in the walls due to corrosion.<br />
SDR 20000474<br />
Fuel cross-feed RH tank to LH engine lower outboard fuel line<br />
at the rear of engine firewall corroded approximately one third<br />
of the way in from the end, causing fuel to leak into area rear<br />
of engine firewall.<br />
Hyd line assy left P/N: 31527-00 on flap operation system at sta 74.75<br />
just forward of spar, inside of cabin
34<br />
AIRWORTHINESS<br />
Pull-out section<br />
SELECTED SERVICE DIFFICULTY REPORTS<br />
29 March – 16 May 2012<br />
Note: Similar occurrence figures not included<br />
in this edition<br />
AIRCRAFT ABOVE 5700kg<br />
Aerospatiale ATR42300 Aileron fitting corroded.<br />
SDR 510014684<br />
LH and RH aileron T-pick-up fittings in ribs 4, 11<br />
and 12 corroded.<br />
Aerospatiale ATR42300 Cabin cooling system<br />
check valve broken. SDR 510014678<br />
RH heat exchanger check valve broken. P/No: CT140A<br />
Aerospatiale ATR42300 DC system wire broken.<br />
SDR 510014677<br />
Broken wire on negative stud of 22 PA battery shunt.<br />
Aerospatiale ATR42300 Fuselage stiffener<br />
cracked. SDR 510014683<br />
Outboard aft wing pressure deck angle stiffener<br />
cracked in area adjacent to wire support bracket<br />
aft of frame 27.<br />
Aerospatiale ATR42300 Landing gear actuator<br />
corroded. SDR 510014685<br />
LH and RH landing gear retraction actuators P/Nos:<br />
D22898000-3 and D22897000-3 heavily corroded.<br />
Aerospatiale ATR42320 Elevator stiff.<br />
SDR 510014746<br />
Elevator control system jammed/stiff in operation<br />
– numerous bolts, bearings and bushes corroded/<br />
deteriorated.<br />
Airbus A320-232 Aileron control system<br />
ELAC failed. SDR 510014812<br />
No.1 elevator and aileron computer (ELAC) failed.<br />
P/No: 3945128209<br />
Airbus A320-232 APU smoke/fumes.<br />
SDR 510014536<br />
Strong smell in cabin affecting cabin crew.<br />
APU replaced – no further unusual odours.<br />
Airbus A320-232 APU oil system overfilled.<br />
SDR 510014732<br />
Strong oil fumes in rear of cabin. Investigation found<br />
APU oil system overfull.<br />
Airbus A320-232 Autopilot FMGC failed.<br />
SDR 510014733<br />
No.1 flight management guidance computer<br />
(FMGC) failed.<br />
P/No: 21SN04298A<br />
Airbus A320-232 Door insulation odour.<br />
SDR 510014598<br />
After take-off an unusual smell reported from rear<br />
galley. Crew identified a musty/mouldy smell from<br />
L2 door. Engineer found wet insulation blankets.<br />
Airbus A320-232 Exterior landing light missing.<br />
SDR 510014521<br />
RH landing light missing. Suspect light separated<br />
during previous flight.<br />
Airbus A320-232 Hydraulic pipe worn and<br />
damaged. SDR 510014741<br />
Rigid hydraulic pipe chafed by blue electric hydraulic<br />
pump flexible supply line. Pipe failed, causing loss of<br />
hydraulic fluid. Flexible pipe slipped in P clip and was<br />
resting on the rigid pipe. P/No: D2777022306200<br />
Airbus A330-202 IDG leaking. SDR 510014799<br />
No.1 engine integrated drive generator (IDG) leaking<br />
oil. Initial investigation found the input drive shaft<br />
dislodged, with considerable damage done to the<br />
QAD ring adapter and gearbox drive cup assembly.<br />
Gearbox carbon seal and IDG seal O-ring damaged.<br />
Investigation continuing. P/No: 75216B<br />
Airbus A330-202 Fuselage floor panel melted.<br />
SDR 510014581<br />
Heated floor panel at D4L hot to touch (melted), with<br />
smoke coming from panel. Investigation continuing.<br />
P/No: F5367233300200<br />
Airbus A330-202 Pneumatic distribution system<br />
valve faulty. SDR 510014509<br />
Dual bleed air system failure after fitment of<br />
improved pressure transducer. Maintenance<br />
investigation unable to find any fault with bleed<br />
air system. P/No: 6764B040000<br />
Airbus A380-842 Aircraft fuel distribution<br />
system coupling leaking. SDR 510014749<br />
Fuel leaking from No. 4 engine strut cavity.<br />
Fuel coupling loose and not lockwired. During<br />
disassembly, forward coupling connector P/No:<br />
ABS0108-200 found to be chafed on the inner seal<br />
surface. Investigation continuing.<br />
Airbus A380-842 Fire detection system<br />
connector loose. SDR 510014507<br />
No. 4 engine fire detection system loops A and B<br />
suspected to be faulty. Investigation found a loose<br />
connector 5041VC that had been cross-threaded<br />
and was only held on by half a turn.<br />
Airbus A380-842 Passenger seat lock faulty.<br />
SDR 510014574<br />
First-class passenger seats (4off) had incorrectly<br />
functioning and out of calibration 16G locks.<br />
Investigation continuing.<br />
Airbus A380-842 Wing rib cracked.<br />
SDR 510014512<br />
Wing rib crack inspection carried out iaw EASA AD<br />
2012-0026<br />
ATR72212A Nose/tail landing gear strut/axle<br />
bobbin cracked. SDR 510014628 (photo below)<br />
Nose landing gear towbar bobbin cracked. Suspect<br />
caused by unknown pushback incident. NLG leg<br />
removed for further investigation.<br />
P/No: D56861. TSN: 1,260 hours/1,248 cycles<br />
BAC 146-200 APU smoke/fumes.<br />
SDR 510014690<br />
Fumes from APU during troubleshooting<br />
maintenance on ground.<br />
BAC 146RJ100 Nose/tail landing gear attach<br />
section bolt cracked. SDR 510014595<br />
While carrying out AD/BAE146/071 no cracking of<br />
nose gear actuator attachment diaphragm found.<br />
However, the nose gear actuator to diaphragm<br />
attachment bolt was cracked.<br />
Beech 1900C Aircraft wing structure corroded.<br />
SDR 510014814<br />
Numerous areas of corrosion, cracking and loose<br />
rivets in both wings.<br />
Beech 1900C Hydraulic hose ruptured.<br />
SDR 510014580<br />
Landing gear failed to fully retract then extend.<br />
Investigation found LH main landing gear extend hose<br />
to actuator ruptured at firewall. P/No: 1013880167<br />
Beech 1900C Landing gear position and warning<br />
system switch faulty. SDR 510014743<br />
Nil landing gear down indication. Investigation found<br />
all microswitches serviceable. Further investigation<br />
found a loose screw in the gear indicator switch<br />
preventing a proper connection. P/No: 3080843101<br />
Boeing 737376 Drag control system cable<br />
broken. SDR 510014813<br />
RH inboard flight spoiler control cable WSA2-4<br />
broken approximately 152.4mm (6in) from end fitting.<br />
Cable hanging from RH wing trailing edge.<br />
Boeing 737376 Fuselage frame cracked.<br />
SDR 510014547<br />
Forward cargo door cutout fore and aft frames cracked<br />
from outboard upper fastener hole at door stop<br />
No. 3. Crack length approximately 6.35mm (0.25in).<br />
Found during NDI inspection iaw EI 733-53-292R3.<br />
Boeing 737476 Flight compartment window<br />
delaminated. SDR 510014531<br />
LH No. 5 cockpit window delaminated for<br />
approximately 25.4mm (1in) in vinyl interlayer<br />
at fore lower corner and aft upper corner.<br />
Found during inspection iaw EI Gen56103R5.<br />
P/No: 58935841.<br />
TSN: 3,683 hours. TSO: 3,683 hours.<br />
Boeing 737476 Battery failed. SDR 510014579<br />
Main battery failed. Battery voltage had dropped to<br />
6VDC. Investigation continuing.<br />
P/No: 401767. TSO: 5 hours.<br />
Boeing 73776N Drag control switch out of<br />
adjustment. SDR 510014780<br />
Speed brake lever switch out of adjustment, causing<br />
take-off configuration warning.<br />
Boeing 73776N Fuselage bulkhead doubler<br />
faulty manufact. SDR 510014529<br />
Fuselage doubler installation at Section 46 Stn 727C<br />
to 747 had incorrect rivet pitch with the last row of<br />
rivets failing to reach the tear strap at Stn 747E.<br />
Found during incorporation of Boeing SB737-53-<br />
1304R1 (live TV de-modification).<br />
Boeing 7377Q8 Windscreen post cracked.<br />
SDR 510014656<br />
LH cockpit C-D windscreen post cracked beyond<br />
limits. Crack length 27.9mm (1.1in). Found during<br />
NDT inspection.<br />
TSN: 30,122 hours/21,493 cycles.<br />
Boeing 7377Q8 Pneumatic distribution system<br />
smoke/fumes. SDR 510014665<br />
Fumes reported in cabin after take-off. Engine ground<br />
runs carried out. Investigation could find no definitive<br />
cause for the smell.<br />
Boeing 737-838 Airconditioning system<br />
smoke/fumes. SDR 510014539<br />
During descent a strong smell was noticed by the<br />
flight crew in cockpit and cabin crew in the rear<br />
galley area. Smell was described as ‘electrical,<br />
metallic and burnt plastic’. It lasted for about two<br />
to three minutes then dissipated. Nil defects found.<br />
Aircraft released to service.<br />
Boeing 737-838 Power distribution system<br />
terminal block arced. SDR 510014571<br />
Nose landing gear wiring conduit for gear sensing<br />
and taxi light damaged at terminal modules 2 and 3<br />
due to arcing between pins G2 and H2.<br />
P/No: M817143DD1.<br />
Boeing 737-838 APU FCU failed. SDR 510014752<br />
APU fuel control unit faulty causing APU to shut<br />
down. P/No: 4419215.<br />
Boeing 737-838 EFB power cord damaged.<br />
SDR 510014754<br />
Electronic flight bag (EFB) power cord damaged.<br />
Smoke was seen to be coming from the damaged<br />
part of the cord.
Flight Safety Australia<br />
Issue 87 July–August 2012<br />
35<br />
SELECTED SERVICE DIFFICULTY REPORTS ... CONT.<br />
Boeing 737-838 Fuel indicating system loom<br />
failed test. SDR 510014808<br />
Centre fuel tank fuel quantity indicating system wire<br />
bundle W7580 failed shield loop resistance check.<br />
Resistance greater than maximum value.<br />
Found during inspection iaw EI N37-28-72 Issue C.<br />
Boeing 737-838 Trailing edge flap drive spline<br />
worn and damaged. SDR 510014559<br />
No. 7 flap transmission drive coupling splines on<br />
the outboard side of the transmission coupling were<br />
found to be excessively worn to the point of almost<br />
disengaging completely. Opposite position to<br />
No. 7 also found to be in a similar condition.<br />
P/No: 256A37411.<br />
Boeing 7378BK Rudder control system motor<br />
inoperative. SDR 510014517<br />
Standby rudder valve motor inoperative. Suspect<br />
caused by failure or short circuiting of internal limit<br />
switches. P/No: 106788A131.<br />
Boeing 7378FE Fuel transfer valve faulty.<br />
SDR 510014654<br />
Fuel crossfeed valve faulty.<br />
P/No: 125334D1. TSN: 31,857 hours/18,632 cycles.<br />
Boeing 7378FE Hydraulic pump unserviceable.<br />
SDR 510014692<br />
No. 2 (System B) electric hydraulic pump failed.<br />
Investigation found a faulty internal overheat switch.<br />
P/No: 5718610. TSN: 870 hours/255 cycles.<br />
Boeing 7378FE Bleed air system smoke/fumes.<br />
SDR 510014556<br />
Strong engine oil smell/fumes in cockpit.<br />
Investigation found No. 1 engine had had a<br />
compressor wash prior to its last sector.<br />
Boeing 747-438 Nacelle/pylon access<br />
panel missing. SDR 510014778<br />
No. 4 pylon outboard access panel missing.<br />
P/No: 484DR.<br />
Boeing 747-438 Passenger compartment<br />
lighting relay failed. SDR 510014769<br />
Cabin, toilet and mid galley lighting inoperative.<br />
Relay R1169 failed due to loose terminal posts A2<br />
and C2. P/No: HTC7N060.<br />
Boeing 747-438 Tyre failed. SDR 510014619<br />
Main landing gear tyre failed. Initial investigation<br />
found some panel damage. Investigation continuing.<br />
Boeing 747-438 Windshield wiper separated.<br />
SDR 510014673<br />
First officer’s windshield wiper separated from<br />
aircraft. Investigation could find no damage to the<br />
aircraft. Investigation continuing.<br />
Boeing 767-336 Aileron control gearbox faulty.<br />
SDR 510014621<br />
LH inboard aileron drooping. Investigation found<br />
the LH inboard aileron droop angle gearbox<br />
unserviceable. P/No: 256T34303.<br />
Boeing 767-336 Hydraulic power wiring worn<br />
and damaged. SDR 510014695<br />
Wiring located behind hydraulic control panel worn<br />
due to panel mount bolts being installed in reverse<br />
causing bolt shanks to chafe on wiring.<br />
Boeing 767-338ER Air conditioning smoke/<br />
fumes. SDR 510014755<br />
Strong engine/oil fumes smell. Suspect smell<br />
originated from residual cleaning fluid in the<br />
cargo areas.<br />
Boeing 767-338ER Flight compartment window<br />
damaged. SDR 510014591<br />
First officer’s No. 2 window very hot. Outer pane<br />
cracked and bubbled.<br />
Boeing 767-338ER Fuel boost pump eroded.<br />
SDR 510014725<br />
LH main fuel tank aft boost pump housing inlet area<br />
eroded beyond limits due to cavitation. Erosion also<br />
found on the forward boost pump shut-off sleeve<br />
and aft boost pump strut.<br />
Boeing 767-338ER Nacelle/pylon access<br />
panel missing. SDR 510014533<br />
RH engine strut access panel missing from<br />
inboard side.<br />
Boeing 7773ZGER Galley station oven odour.<br />
SDR 510014728<br />
Burning smell from mid galley No. 3 oven (M711).<br />
Oven removed for investigation.<br />
P/No: 820216000001. TSN: 12,632 hours/1,126<br />
cycles. TSO: 5,337 hours/401 cycles.<br />
Boeing 7773ZGER Galley station oven<br />
unserviceable. SDR 510014729<br />
Forward galley No. 4 oven (F108) unserviceable.<br />
Oven became extremely hot even after turned<br />
off accompanied by a strong burning smell.<br />
Investigation continuing.<br />
P/No: 820216000001. TSN: 14,602 hours/1,208<br />
cycles. TSO: 2,422 hours/182 cycles.<br />
Boeing 7773ZGER Horizontal stabiliser structure<br />
hose leaking. SDR 510014555<br />
During heavy maintenance inspection level 2 and<br />
3 corrosion damage was found in the horizontal<br />
stabiliser compartment aft of Stn 2344. Corrosion<br />
damage was caused by hydraulic fluid exposure to<br />
both skin and stringer 40R and 43R.<br />
P/No: 272W48201.<br />
Bombardier BD7001A10 AC power connector<br />
burnt. SDR 510014549 (photo below)<br />
Wiring and connector behind galley close-out burnt/<br />
melted. Investigation suspected that the wiring was<br />
not correctly secured causing a build-up of resistance<br />
and heat.<br />
TSN: 629 hours/269 cycles.<br />
Bombardier CL604 Pitot/static drain<br />
contaminated with-water. SDR 510014775<br />
Standby airspeed indicator (ASI) failed. Investigation<br />
found water contamination of the pitot drain line.<br />
Aircraft had been flying in heavy rain.<br />
Bombardier DHC8202 Landing gear sparking.<br />
SDR 510014791<br />
Passenger reported sparks from LH main landing<br />
gear in area between the tyres. Precautionary<br />
air turnback carried out. Investigation could find<br />
no defects and this is considered to be a normal<br />
occurrence for metal brakes.<br />
Bombardier DHC8202 Passenger compartment<br />
light fitting burnt. SDR 510014612<br />
Cabin RH side overhead fluorescent light fitting arced<br />
and burnt. Fitting third from front on RH side.<br />
Bombardier DHC8315 Hydraulic main check<br />
valve leaking. SDR 510014792<br />
No. 2 hydraulic system alternate rudder check valve<br />
leaking. Loss of hydraulic fluid.<br />
Bombardier DHC8315 Hydraulic pipe leaking.<br />
SDR 510014655<br />
Hydraulic pipe leaking. Pipe located on the inboard<br />
side of the LH wheel well above the return filter<br />
assembly and near the exhaust. P/No: 82970009279.<br />
Bombardier DHC8402 Pressure valve outflow<br />
valve malfunctioned. SDR 510014566<br />
Aft outflow valve failed. P/No: 88060B010103.<br />
TSN: 4,698 hours/4,939 cycles.<br />
Bombardier DHC8402 Prop/rotor anti-ice/<br />
de-ice system heater burnt. SDR 510014551<br />
(photo below)<br />
No. 1 propeller blade heater element burnt and<br />
blade holed. TSN: 5,486 hours/5,880 cycles.<br />
Embraer EMB120 Aircraft fuel tube worn and<br />
damaged. SDR 510014753 (photo below)<br />
LH fuel quantity indication harness inboard to<br />
outboard fuel tank interconnect tube rubbing on rib<br />
11 at Stn 2996.00. P/No: 12032086007.<br />
Embraer EMB120 Elevator, tab structure trim tab<br />
delaminated. SDR 510014565 (photo below)<br />
LH elevator trim tab delaminated over approximately<br />
75 per cent of upper and lower skin area.<br />
P/No: 12020120015.<br />
Embraer EMB120 Engine control wiring<br />
connector corroded. SDR 510014659<br />
(photo below)<br />
Engine control wiring connector P/No: J0318<br />
contaminated with water and severely corroded.<br />
Wire W608-0114-240R (28VDC) cut through by<br />
corroded connector.
36<br />
AIRWORTHINESS<br />
Pull-out section<br />
SELECTED SERVICE DIFFICULTY REPORTS ... CONT.<br />
Embraer EMB120 EHSI failed. SDR 510014578<br />
Co-pilot’s EHSI (electronic horizontal situation<br />
indicator) failed in cruise. Part replaced but unit failed<br />
again on next flight. The second unit has a history of<br />
premature failure and is to be removed from company<br />
inventory. P/No: 6226342022.<br />
Embraer EMB120 Landing gear retract/extension<br />
system faulty. SDR 510014694<br />
During landing gear retraction following take-off<br />
the RH main landing gear indicating lights failed to<br />
extinguish, accompanied by vibration from RH side of<br />
aircraft. Landing gear extended and vibration ceased,<br />
with the landing gear indicating down and locked.<br />
Embraer ERJ170100 APU silencer delaminated.<br />
SDR 510014623 (photo below)<br />
APU air inlet silencer damaged and delaminated.<br />
Investigation found large areas of delamination on<br />
two of the three splitter plates, with a portion of one<br />
splitter plate separated.<br />
P/No: 4952354. TSN: 5,520 hours/4,600 landings.<br />
Embraer ERJ190100 Escape slide incorrect fit.<br />
SDR 510014544<br />
During inspection of lens cover on L2 door,<br />
emergency evacuation slide found to be unattached.<br />
Investigation found hook brackets fitted correctly in<br />
the clevis brackets but top screw not attached.<br />
Embraer ERJ190100 Hydraulic union<br />
incorrect fit. SDR 510014522<br />
No. 2 engine hydraulic pressure line union incorrectly<br />
installed on incorrect side of false spar, causing<br />
misalignment and leaking from hydraulic pipe to<br />
union connection.<br />
Embraer ERJ190100 Passenger/crew door<br />
cable failed. SDR 510014676<br />
R1 forward service door flexball cable inner conduit<br />
broken preventing door from being fully closed.<br />
P/No: 17084031401.<br />
Fokker F27MK50 Airfoil anti-ice/de-ice system<br />
hose broken. SDR 510014713<br />
LH inner leading edge anti-icing system hose broken.<br />
Fokker F27MK50 Fuselage floor plate corroded.<br />
SDR 510014714<br />
No. 1 galley floor threshold plate badly corroded.<br />
Fokker F27MK50 Wing miscellaneous structure<br />
bolt loose. SDR 510014686<br />
LH and RH wing buttstrap bolts loose.<br />
Fokker F28MK0100 Fuel storage wire damaged.<br />
SDR 510014558<br />
LH and RH fuel collector tank bonding wires<br />
deteriorated/damaged.<br />
Fokker F28MK0100 Fuselage floor panel<br />
corroded. SDR 510014715<br />
Floor structure badly corroded at BL1127R and<br />
BL1127L between Stn 3845 and Stn 4875. Small<br />
spots of corrosion also found in floor beam structures<br />
between Stn 3845 and Stn 4875.<br />
Fokker F28MK0100 Drag control actuator<br />
cracked. SDR 510014527 (photo below)<br />
LH No. 1 and No. 2 lift dumper actuator cracked.<br />
P/No: 1090019. TSN: 38,946 hours/35,475 cycles.<br />
Fokker F28MK0100 Elevator control system<br />
bearing stiff. SDR 510014702<br />
LH and RH elevators heavy in operation.<br />
Fokker F28MK0100 Fuselage structure cracked.<br />
SDR 510014584<br />
RH airconditioning bay cracked. Crack length 53mm<br />
(2in). LH airconditioning bay cracked. Crack length<br />
61mm (2.4in). Found during inspection following<br />
removal of airconditioning units.<br />
Fokker F28MK0100 Landing gear door<br />
bolt sheared. SDR 510014711<br />
RH main landing gear door bolt head sheared off.<br />
Fokker F28MK0100 Landing gear door<br />
hinge worn. SDR 510014601<br />
LH main landing gear transit light remained on<br />
following retraction. Fault remained following gear<br />
recycling. Investigation found the LH main landing<br />
gear inner door contacting the rear structure due to<br />
wear in the door hinge.<br />
Fokker F28MK0100 Wing skin repair patch<br />
separated. SDR 510014618<br />
RH wing inboard upper skin partially disbanded,<br />
allowing composite repair patch to separate and<br />
enter the RH engine. FOD damage to the leading<br />
edge of one IPC blade, with a section of the rotor<br />
path lining missing.<br />
Gulfstream GIV Wing/fuselage attach fitting<br />
corroded. SDR 510014744 (photo below)<br />
LH forward wing link attachment fitting corroded.<br />
Fitting located in fuel tank. Found during investigation<br />
of a wing fuel leak and discovery of damaged sealant<br />
around the fitting.<br />
AIRCRAFT Below 5700kg<br />
Bellanca 8KCAB Fuel storage pipe cracked<br />
and leaking. SDR 510014674<br />
Aluminium fuel line cracked and leaking from flare<br />
at fuselage header tank.<br />
P/No: 714142. TSN: 4,125 hours/380 months.<br />
Beech 200 Fuselage skin cracked.<br />
SDR 510014788<br />
Fuselage pressure hull cracked. Crack only found<br />
following removal of paint. P/No: 1014302051.<br />
Beech 200C Rudder hinge bracket corroded.<br />
SDR 510014573<br />
Rudder hinge bracket corroded. Corrosion found<br />
during preparation for repainting.<br />
P/No: 10164001415. TSN: 11,267 hours.<br />
Beech 58 Elevator control cable corroded<br />
and frayed. SDR 510014708<br />
Forward elevator control cable corroded within<br />
strands. One strand also found to be broken.<br />
Found during inspection iaw AD/Beech55/98.<br />
P/No: 58524015.<br />
Beech 58 Power lever cable broken.<br />
SDR 510014658<br />
RH engine throttle cable failed. Investigation found<br />
cable broken in area of rod end/swage. Outer casing<br />
cracked approximately 12.7mm (0.75in) from rigid<br />
fixing point. P/No: 5038901219.<br />
Beech 95B55 Landing gear retract/extension<br />
system plunger seized. SDR 510014652<br />
RH main landing gear retraction rod floating plunger<br />
seized preventing correct rigging of the landing gear.<br />
P/No: 3581512512. TSN: 6,641 hours.<br />
Cessna 150L Aircraft fuel system pipe corroded.<br />
SDR 510014546<br />
Rigid aluminium fuel line from LH tank to fuel cock<br />
contained pinhole corrosion allowing fuel leakage into<br />
cockpit. P/No: 0400311113. TAN: 13,213 hours.<br />
Cessna 172M Exterior light unapproved part.<br />
SDR 510014639<br />
RH navigation light suspect unapproved (automotive)<br />
part. P/No: W129014.<br />
Cessna 172M Wheel bearing corroded.<br />
SDR 510014637<br />
Nose wheel bearings P/No LM4078 and P/<br />
No LM67010 corroded. Suspect bearings also<br />
unapproved parts. Bearings branded SKF and KOYO.<br />
P/No: LM67048. TSN: 181 hours.<br />
Cessna 210L Wing spar cap cracked.<br />
SDR 510014771<br />
Wing spar cap cracked. Four similar reports received<br />
for this period.<br />
Cessna 404 Elevator, spar corroded.<br />
SDR 510014501<br />
RH elevator spar corroded. Found during routine<br />
inspection of aircraft under Cessna customer care<br />
program. P/No: 5834120.<br />
TSN: 32,562 hours/62,858 landings.<br />
Cessna 404 Fuel shut-off valve incorrect<br />
assembly. SDR 510014597<br />
LH engine cutting out. Investigation found a newly<br />
installed fuel crossfeed shut-off valve incorrectly<br />
assembled internally, resulting in the valve working<br />
in the reverse sense. P/No: 9910204. TSN: 10 hours.<br />
Cessna 441 Fuselage bulkhead angle cracked.<br />
SDR 510014627<br />
Forward pressure bulkhead upper attachment angle<br />
cracked in two places. Crack lengths approximately<br />
60mm (2.36in. Found during SID inspection.<br />
P/No: 57116071.<br />
TSN: 137,230 hours/10,160 cycles/10,160 landings.<br />
Cessna P206B Mixture control cable failed.<br />
SDR 510014644<br />
Mixture control outer cable separated from<br />
lever housing.<br />
P/No: S12203A. TSN: 26 hours/1 month.<br />
Cessna TR182 Aileron control cable frayed.<br />
SDR 510014721<br />
Broken strand in aileron control cable.<br />
P/No: 12600785.
Flight Safety Australia<br />
Issue 87 July–August 2012<br />
37<br />
SELECTED SERVICE DIFFICULTY REPORTS ... CONT.<br />
Cessna TR182 Elevator cable frayed.<br />
SDR 510014722 (photo below)<br />
Broken strands in elevator trim cable.<br />
P/No: 0510105248. TSN: 967 hours.<br />
Socata TB10TOBAGO Wing spar cracked.<br />
SDR 510014561 (photo below)<br />
LH and RH forward wing attachment small spars<br />
cracked in area adjacent to lower inboard bolt.<br />
Fifteen similar reports submitted for this type of<br />
aircraft in reporting period. P/No: TB1011000101.<br />
TSN: 11,893 hours.<br />
Cessna U206F Landing gear attach fitting<br />
cracked. SDR 510014797 (photo below)<br />
LH main landing gear attachment fitting cracked.<br />
P/No: 1211601497. TSN: 8,766 hours.<br />
Cessna U206G Power lever cable binding.<br />
SDR 510014643<br />
Engine throttle cable binding. Cable was an almost<br />
new item with only 37 hours TSN.<br />
P/No: 986305313. TSN: 37 hours/1 month.<br />
Giplnd GA200C Wing spar cracked.<br />
SDR 510014765 (photo below)<br />
Wing front lower spar cap cracked in area between<br />
WS 0.00 and WS 4.50 in area of wing/fuselage<br />
attachment. Crack length approximately 114.3mm<br />
(4.5in). Found during inspection iaw SB GA200-<br />
2011-06 Issue1. Aircraft registered in New Zealand.<br />
P/No: GA2005710025.<br />
Giplnd GA8 Horizontal stabiliser spar cap<br />
cracked. SDR 510014800 (photo below)<br />
Horizontal stabiliser rear lower spar cap cracked.<br />
Found during inspection iaw SB GA8-2002-02<br />
Issue 6. P/No: GA855102115<br />
Giplnd GA8 Trailing edge fitting rusted.<br />
SDR 510014723 (photo following)<br />
LH and RH trailing edge flap torque tube outboard<br />
fittings corroded (rusted).<br />
P/No: GA82750121413. TSN: 3,072 hours.<br />
Gulfstream 500S Hydraulic tube corroded.<br />
SDR 510014540<br />
Rigid hydraulic tubing located between LH wing<br />
root and engine nacelle contained corrosion pitting<br />
through wall thickness resulting in loss of hydraulic<br />
fluid. Suspect caused by tubing contacting flexible<br />
hose in wing channel. P/No: 5052038.<br />
Gulfstream 500S Landing gear retract/extend<br />
system bolt failed. SDR 510014538<br />
Landing gear uplock pivot bolt failed in area<br />
covered by bearing inner face. Investigation indicates<br />
failure might have been propagating for some time.<br />
P/No: AN174C21A.<br />
Piper PA24 Horizontal stabiliser fitting cracked.<br />
SDR 510014796 (photo below)<br />
Stabiliser horn balance attachment cracked<br />
from stabiliser attachment holes to balance tube<br />
attachment. TSN: 2,679 hours.<br />
Piper PA32R301T Fuselage door sill corroded.<br />
SDR 510014593 (photo below)<br />
Rear cabin door had localised corrosion at screw<br />
holes. Interior upholstery stainless steel screws and<br />
moisture in upholstery contributed to the corrosion.<br />
P/No: 68334000. TSN: 1,372 hours/144 months.<br />
Piper PA44180 Emergency exit separated.<br />
SDR 510014704<br />
Emergency exit/window forward latch disengaged<br />
allowing airflow, causing window and frame<br />
to separate from fuselage. P/No: 8660202.<br />
TSN: 8,590 hours.<br />
Piper PA60601B Cabin door opened.<br />
SDR 510014767<br />
Top half of main cabin door opened following<br />
take-off. Investigation found no faults with the door<br />
and no structural damage.<br />
Swrngn SA227AC Nose landing gear shimmy.<br />
SDR 510014577 (photo below)<br />
Nose landing gear shimmy on landing. Initial<br />
investigation found broken bolts at the NLG<br />
steering actuator. P/No: 2752500001. TSN: 30,174<br />
hours/45,110 cycles.<br />
Swrngn SA227DC Brake leaking.<br />
SDR 510014761<br />
RH outboard brake unit leaking and tyre deflated.<br />
Loss of hydraulic fluid.<br />
Swrngn SA227DC Landing gear faulty.<br />
SDR 510014764<br />
Pilots felt a repetitive bump and noticed the hydraulic<br />
pressure fluctuating during landing gear retraction.<br />
Landing gear suspect faulty. Investigation continuing.<br />
TSN: 20,006 hours/22,141 cycles.<br />
Components<br />
Fuel injection system suspect unapproved part.<br />
SDR 510014803<br />
RSA and Silver Hawk EX fuel injection system may be<br />
suspect/counterfeit parts. Precision Airmotive are the<br />
only manufacturer and distributor of these systems.<br />
Balloon cable worn. SDR 510014545<br />
(photo below)<br />
Hot air balloon basket suspension cables worn in<br />
area of contact with burner frame nylon support pole.<br />
TSN: 1,981 hours/138 months.<br />
Balloon load frame cracked. SDR 510013682<br />
Balloon burner load frame had several hairline cracks<br />
along original welds.<br />
P/No: KLF201088. TSN: 1,423 hours/123 months.
38<br />
AIRWORTHINESS<br />
Pull-out section<br />
SELECTED SERVICE DIFFICULTY REPORTS ... CONT.<br />
Turbine Engine<br />
GE CF680C2 Thrust reverser shaft damaged.<br />
SDR 510013773<br />
No.1 engine thrust reverser LH side electromechanical<br />
brake flexible shaft sheared. P/No: 3278500X.<br />
GE CF680E1 Turbine engine compressor stator<br />
blade worn. SDR 510013797<br />
No.1 engine 13th stage high-pressure compressor<br />
variable stator blades (VSV) loose and worn<br />
beyond limits in root/platform area. Found during<br />
borescope inspection.<br />
IAE V2527A5 Engine fuel/oil cooler housing<br />
leaking. SDR 510013640<br />
No.1 engine leaking from fuel diverter return<br />
valve to fuel-cooled oil cooler tube seal housing<br />
P/No 5W8201. Leakage from between seal housing<br />
and pipe. P/No: 5W8201.<br />
IAE V2533A5 Fuel controlling system<br />
probe faulty. SDR 510013814<br />
RH engine low power. Investigation found no<br />
definitive fault. Further investigation found a faulty<br />
alternate N1 speed probe.<br />
PWA PW150A Engine fuel system O-ring leaking.<br />
SDR 510013740<br />
Fuel transfer tube to fuel/oil heat exchanger<br />
O-ring seals P/Nos M83461-1-116 and AS3209-126<br />
deteriorated and leaking.<br />
TSN: 4,372 hours/4,618 cycles.<br />
PWA PW150A Fuel control/turbine engines<br />
FADEC failed. SDR 510013723<br />
No. 2 engine full authority digital engine control<br />
(FADEC) failed. Investigation continuing.<br />
P/No: 8193007009. TSN: 7,013 hours/8,130 cycles.<br />
Rolls-Royce BR700715A130 Turbine blade<br />
failed. SDR 510013660<br />
RH engine high EGT (over 800 degrees during climb).<br />
Investigation found failed HPT1 blade.<br />
Rolls-Royce RB211524G Engine fuel distribution<br />
tube worn and damaged. SDR 510013843<br />
No. 2 engine main fuel delivery tube found with<br />
extensive chafing damage due to contact with<br />
adjacent oil vent tube. Wear approximately<br />
50 per cent of wall thickness (limit is 0.005in).<br />
P/No: UL37972.<br />
Rolls-Royce RB211524G Turbine engine<br />
compressor blade failed. SDR 510013718<br />
No. 3 engine exceeded EGT limits during take-off.<br />
Initial investigation found metal on the chip detector<br />
and in the tailpipe, one IPC stage 7 compressor blade<br />
missing and considerable damage to HPC stages 1<br />
and 2, with one HPC stage 1 blade missing.<br />
Rolls-Royce RB211524G Turbine engine<br />
compressor damaged. SDR 510013872<br />
No. 4 engine had sparks coming from exhaust during<br />
take-off. Engine operated normally during flight.<br />
Borescope inspection found major damage to IPC 6<br />
and HPC 1. Downstream blades also damaged.<br />
Rolls-Royce TRENT97284 Turbine engine oil<br />
system pipe loose. SDR 510013842<br />
No. 4 engine shut down in flight due to low oil<br />
pressure. Investigation found No. 4 engine oil<br />
feed pipe P/No FW48295 loose and leaking.<br />
Deflector lockwire also broken. Loss of engine oil.<br />
Further investigation found oil loss due to the loss<br />
of torque on the ‘B’ nut of the HP/IP turbine bearing<br />
support tube.<br />
Piston Engine<br />
Continental IO470C Reciprocating engine piston<br />
incorrect weight. SDR 510014781<br />
Engine running roughly. Caused by incorrect<br />
opposing piston weights and connecting rod weights.<br />
P/No: 642360. TSO: 500 hours.<br />
Continental IO520F Reciprocating engine<br />
damaged. SDR 510014646<br />
Engine failed due to loss of oil pressure.<br />
Investigation continuing.<br />
P/No: IO520F. TSO: 1,153 hours.<br />
Continental TSIO520M Reciprocating engine<br />
crankcase cracked. SDR 510014502<br />
Crack discovered adjacent to No. 5 cylinder base.<br />
P/No: 642135. TSO: 1,224 hours.<br />
Lycoming AEIO540D4A5 Reciprocating engine<br />
bearing worn and damaged. SDR 510014631<br />
No. 6 connecting rod P/No: LW11750 big end bearing<br />
worn with no bearing material left on bearing shell.<br />
Bearing shell spinning in the connecting rod, causing<br />
damage to rod and crankshaft. Big end bearings<br />
on the other connecting rods also beginning to<br />
delaminate. Metal contamination of oil system.<br />
P/No: 74309. TSN: 721 hours. TSO: 721 hours.<br />
Lycoming IO540AB1A5 Magneto/distributor<br />
points failed. SDR 510014615<br />
RH magneto contact points leaf spring failed at<br />
approximately mid point.<br />
P/No: M3081. TSN: 223 hours.<br />
Lycoming IO540AE1A5 Engine muffler collapsed.<br />
SDR 510014691<br />
Muffler assembly collapsed and exhaust collector<br />
cracked. P/No: C16932.<br />
Lycoming IO540AE1A5 Reciprocating engine<br />
cooling nozzle separated. SDR 510014825<br />
Engine cylinder-mounted piston cooling nozzle<br />
separated from cylinder causing damage to two<br />
pistons. Some camshaft damage also found but not<br />
attributed to the nozzle separation<br />
P/No: 73772. TSO: 1,385 hours.<br />
Lycoming LTIO540J2BD Exhaust turbocharger<br />
oil system contaminated by carbon.<br />
SDR 510014783<br />
RH engine turbocharger oil supply system<br />
contaminated. Flake of carbon obstructing the<br />
metered orifice at the 90-degree oil pressure<br />
supply fitting in the wastegate actuator, preventing<br />
oil pressure supply to the turbocharger controlling<br />
system. P/No: NA. TSO: 2 hours.<br />
Lycoming LTIO540J2BD Reciprocating engine<br />
tappet body cracked. SDR 510014768<br />
No.1 cylinder intake hydraulic tappet body cracked.<br />
Slight damage found to lifter bore.<br />
P/No: 15B26064. TSN: 396 hours.<br />
Lycoming O360A1F6 Reciprocating engine oil<br />
transfer tube loose. SDR 510014587<br />
Oil transfer tube loose in crankshaft.<br />
Tube found to be rotating in the crankshaft bore.<br />
Suspect faulty manufacture.<br />
P/No: 68484. TSN: 6,629 hours. TSO: 1,957 hours.<br />
Lycoming TIO540AH1A Engine fuel pump failed.<br />
SDR 510014647<br />
Engine-driven fuel pump driveshaft failed.<br />
Investigation found that pump was not seized.<br />
P/No: 200F5002. TSN: 723 hours.<br />
Lycoming TIO540AH1A Exhaust turbocharger<br />
bypass valve faulty. SDR 510014731<br />
Turbocharger bypass valve actuator had excessive<br />
play, causing engine hunting.<br />
P/No: 47J22459. TSN: 2,040 hours.<br />
Propeller<br />
Hamilton Standard 14SF9 Propeller hub helicoil<br />
faulty. SDR 510013690<br />
Propeller actuator to hub attachment bolt helicoils<br />
defective. Following removal of the installation tang,<br />
a small part of the tang was left attached to the<br />
helicoil preventing full installation of the bolts.<br />
P/No: MS124698.<br />
Rotol R3904123F27 Propeller hub cracked.<br />
SDR 510013591<br />
Propeller hub cracked from bolt holes. Found during<br />
ultrasonic inspection iaw Dowty SB SF340-61-95R7<br />
and AD/PR/33.<br />
Rotorcraft<br />
Agusta-Bell A109E Rotorcraft cooling fan worn.<br />
SDR 510014629<br />
No. 2 engine oil cooler blower fan output shaft drive<br />
pin wore into shaft, causing excessive backlash.<br />
P/No: 109045501101.<br />
Bell 206B3 Horizontal stabiliser tube corroded.<br />
SDR 510013680<br />
Horizontal stabiliser tube severely corroded.<br />
P/No: 206020120011.<br />
Bell 206B3 Main rotor transmission leaking.<br />
SDR 510013841<br />
Transmission leaking oil from oil filter area.<br />
Filter mounting bowed, causing leak. P/No:<br />
206040002025. TSN: 7,474 hours. TSO 1.597 hours<br />
Bell 206B Engine/transmission coupling worn.<br />
SDR 510013854<br />
Engine/transmission driveshaft inner couplings<br />
worn beyond limits. Outer couplings serviceable.<br />
Found during inspection following over-temperature<br />
indication.<br />
P/No: 206040117001. TSN: 5,532 hours.<br />
Bell 412 Main rotor gearbox contaminated<br />
by metal. SDR 510013608<br />
Transmission had minor vibration in cruise.<br />
After approximately 10 minutes, the vibration<br />
increased, followed by chip detector illumination.<br />
Investigation found metal contamination.<br />
P/No: 412040002103.<br />
TSN: 10,642 hours. TSO: 4,823 hours.<br />
EUROCG BK117C2 Tail rotor control rod cracked.<br />
SDR 510013636<br />
Yaw smart electro-mechanical actuator (SEMA)<br />
control rod cracked on upper end. Crack<br />
confirmed using x10 magnifying glass and<br />
subsequent dye penetrant inspection. Cracking<br />
caused by intercrystalline stress corrosion.<br />
P/No: B673M4004101.<br />
EUROCG BK117C2 Tail rotor gearbox damaged.<br />
SDR 510013786<br />
Tail rotor gearbox chip detector illuminated.<br />
Piece of metal missing from one tooth on the bevel<br />
gear. TSN: 1,931 hours. TSO: 130 hours.<br />
Eurocopter EC225LP AC generator-alternator<br />
drive pin sheared. SDR 510013890<br />
No.1 engine double alternator drive pin sheared,<br />
allowing rotor to spin on shaft. P/No: 9759150100.<br />
MDHC 369E Tail rotor blade debonded.<br />
SDR 510013769<br />
Tail rotor blade leading edge debonding in area near<br />
blade tip. P/No: 500P3100105. TSN: 1,522 hours.<br />
Robinson R44 Main rotor gearbox contaminated<br />
by metal. SDR 510013627<br />
Main rotor gearbox chip detector light illuminated.<br />
Metal contamination of chip detector plug. Chip<br />
detector cleaned and rechecked, finding more metal.<br />
Further investigation found the hard facing coming off<br />
the gears. P/No: C0065. TSN: 503 hours.<br />
Robinson R44 Bulkhead/firewall cracked.<br />
SDR 510013625<br />
Firewall cracked. TSN: 1,495 hours.<br />
SCHWZR 269C Main rotor blade debonded.<br />
SDR 510013851<br />
Main rotor blade outboard leading edge abrasion strip<br />
debonding. Small crack also found in the abrasion<br />
strip in debonded area.<br />
P/No: 269A11851. TSN: 2,742 hours.
Flight Safety Australia<br />
Issue 87 July–August 2012<br />
39<br />
APPROVED AIRWORTHINESS DIRECTIVES<br />
23 March – 5 April 2012<br />
Rotorcraft<br />
Agusta A119 series helicopters<br />
2012-0058 Windows – pilot and co-pilot door<br />
windows bonding – inspection<br />
Above 5700kg<br />
Airbus Industrie A319, A320 and A321<br />
series aeroplanes<br />
2012-0055 Chemical emergency oxygen<br />
containers – modification<br />
Airbus Industrie A380 series aeroplanes<br />
2011-0013R1 Fuselage – wing-to-body fairing<br />
support structure – inspection/replacement /repair<br />
2012-0052 Wings – leading edge shear cleats –<br />
inspection/replacement<br />
2012-0048 Fuselage – rivets at junction of stringer<br />
21 and frame 0 – replacement<br />
Airbus Industrie A330 series aeroplanes<br />
2011-0196 (correction) Fuel/main transfer<br />
system – rear and/or centre tank fuel pump control<br />
circuit – modification<br />
Airbus Industrie A330 series aeroplanes<br />
2012-0053 Landing gear – main and centre<br />
landing gear bogie pivot pins – inspection<br />
Boeing 737 series aeroplanes<br />
AD/B737/334 Amendment 1 – flight deck windows<br />
nos. 2, 4 and 5 – 2<br />
Bombardier (Canadair) CL-600 (Challenger)<br />
series aeroplanes<br />
CF-2012–11 Non-compliant cargo<br />
compartment liners<br />
Cessna 560 (Citation V) series aeroplanes<br />
2012-06-01 Stiff or jammed rudder control system<br />
Embraer ERJ-170 series aeroplanes<br />
2012-03-04 Replacement of tail cone<br />
firewall grommet<br />
Embraer ERJ-190 series aeroplanes<br />
2012-03-03 Replacement of tail cone<br />
firewall grommet<br />
Fokker F27 series aeroplanes<br />
2012-0050 Electrical power centre (EPC) and<br />
battery relay panel – inspection/adjustment<br />
Fokker F28 series aeroplanes<br />
2012-0050 Electrical power centre (EPC) and<br />
battery relay panel – inspection/adjustment<br />
Fokker F50 (F27 Mk 50) series aeroplanes<br />
2012-0050 Electrical power centre (EPC) and<br />
battery relay panel – inspection/adjustment<br />
Fokker F100 (F28 Mk 100) series aeroplanes<br />
2012-0002R1 Nose landing gear main fitting –<br />
inspection/modification/replacement<br />
2012-0049 Time limits/maintenance checks –<br />
maintenance requirements – implementation<br />
2012-0050 Electrical power centre (EPC) and<br />
battery relay panel – inspection/adjustment<br />
Turbine engines<br />
Pratt and Whitney turbine engines –<br />
PW4000 series<br />
2012-06-18 Clogging of no. 4 bearing compartment<br />
oil pressure and scavenge tubes<br />
Pratt and Whitney Canada turbine engines –<br />
PW100 series<br />
CF-2012-12 Propeller shaft crack<br />
Rolls Royce turbine engines – RB211 series<br />
AD/RB211/43 Engine – IP compressor rotor and<br />
IP turbine discs<br />
2012-0057 Engine – intermediate pressure shaft<br />
coupling – inspection/replacement<br />
Turbomeca turbine engines– Arriel series<br />
2012-0054 Engine – module M03 (gas generator) –<br />
turbine blade – modification<br />
6 – 19 April 2012<br />
Rotorcraft<br />
Bell Helicopter Textron 412 series helicopters<br />
CF-2012-14 Crosstubes – life limitation<br />
Eurocopter AS 332 (Super Puma)<br />
series helicopters<br />
2012-0059-E Rotorcraft flight manual – emergency<br />
procedures – rush revision<br />
Eurocopter EC 225 series helicopters<br />
2012-0059-E Rotorcraft flight manual – emergency<br />
procedures – rush revision<br />
Kawasaki BK 117 series helicopters<br />
TCD-8021-2012 Tail rotor head attaching<br />
hardware – inspection<br />
Sikorsky S-92 series helicopters<br />
2012-06-24 Tail rotor blade – inspection<br />
Above 5700kg<br />
Airbus Industrie A319, A320 and A321<br />
series aeroplanes<br />
2011-0069R1 Main landing gear (MLG) door<br />
actuator – monitoring/inspection<br />
Airbus Industrie A330 series aeroplanes<br />
2012-0061 (correction) Flight controls –<br />
trimmable horizontal stabiliser actuator ballscrew<br />
lower splines – inspection/replacement<br />
Airbus Industrie A380 series aeroplanes<br />
2012-0062 Wings – movable flap track fairing –<br />
inspection/repair/replacement<br />
Boeing 737 series aeroplanes<br />
2012-05-02 Engine exhaust – heat damage to the<br />
inner wall of the thrust reversers<br />
Boeing 747 series aeroplanes<br />
AD/B747/361 Amendment 1 – flight station<br />
windows nos. 2 and 3 – cancelled<br />
2012-07-07 Latch pins – lower sills – forward<br />
and aft lower lobe cargo door – inspection<br />
2012-02-16 Flight station windows nos. 2 and<br />
3 – inspection/replacement<br />
Boeing 777 series aeroplanes<br />
2012-07-06 Airworthiness limitations and<br />
certification maintenance requirements<br />
Bombardier (Canadair) CL-600<br />
(Challenger) series aeroplanes<br />
CF-2012-13 Airworthiness limitations and<br />
maintenance requirements<br />
Cessna 680 (Citation Sovereign)<br />
series aeroplanes<br />
2012-07-04 Fuel control cards<br />
Turbine engines<br />
Rolls-Royce turbine engines – RB211 series<br />
AD/RB211/44 Powerplant – fuel flow regulator<br />
adjustment test<br />
AD/RB211/45 Air – IP cabin air offtake ducting<br />
2012-0060 Engine – intermediate pressure turbine<br />
disc – identification/inspection/replacement<br />
Turbomeca turbine engines– Arriel series<br />
AD/Arriel/28 Fuel control unit 3-way union<br />
plug – cancelled<br />
2012-0063 Engine fuel and control – fuel control<br />
unit (FCU) 3-way union plug – inspection<br />
Equipment<br />
Emergency equipment<br />
AD/EMY/34 Amendment 1 – emergency evacuation<br />
slide/raft – pressure relief valves – cancelled<br />
2012-06-25 Emergency evacuation slide/raft –<br />
pressure relief valves<br />
Fire protection equipment<br />
74-08-09R3 Installation of No Smoking placards<br />
and ashtrays<br />
continued on page 42<br />
TO REPORT URGENT DEFECTS<br />
CALL: 131 757 FAX: 02 6217 1920<br />
or contact your local CASA Airworthiness Inspector [freepost]<br />
Service Difficulty Reports, Reply Paid 2005, CASA, Canberra, ACT 2601<br />
Online: www.casa.gov.au/airworth/sdr/
40<br />
AIRWORTHINESS<br />
A game of many parts<br />
‘If there is an issue in future with corrosion<br />
levels everyone will be on the same page.<br />
It reduces ambiguity in communication.’<br />
CAAP 51-1(2) addresses a mismatch between established<br />
service defect reporting practices and new technology that has<br />
emerged over the last decade.<br />
‘There are two reasons why we decided to amend the CAAP,’<br />
says Peter Nikolic, CASA acting principal engineer, propulsion<br />
and mechanical systems.<br />
A game of many parts:<br />
technology, reporting and safety<br />
One was that we noticed a significant number of major defects<br />
that had not been reported by the industry because some of<br />
the provisions of the CAAP were inadequate as a reference for<br />
modern technology aircraft.’<br />
Nikolic says a problem with major defect reporting had resulted<br />
from the high level of systems integration in modern aircraft.<br />
Like cricket, aviation safety is a fascinating<br />
subject because it is complex and simple at<br />
the same time. The object of aviation safety is<br />
simple—prevent harm—but in the real world<br />
it can only be achieved by a complex interplay<br />
of technology, practice and policy. Recent<br />
changes to CASA’s civil aviation advisory<br />
publication (CAAP) 51, on service difficulty<br />
reporting, illustrate this beautifully.<br />
‘There was a provision in the previous version of CAAP 51<br />
not to report items that were covered under the minimum<br />
equipment list (MEL),’ he says. ‘Operators did not have to<br />
report any defects that were deferrable according to the<br />
minimum equipment list.‘<br />
This was a sensible and safe policy for aircraft that had<br />
separate systems for separate functions, but has been out<br />
dated by the latest generation of aircraft with integrated<br />
modular avionics and highly integrated mechanical systems.<br />
At this point, let’s take a quick overview of avionics. Until<br />
recently, aircraft avionic components could be described as<br />
federated in the way they worked with each other.
Flight Safety Australia<br />
Issue 87 July–August 2012<br />
41<br />
Under the federated model of system architecture, the various<br />
computers in an aircraft could be thought of as like member<br />
states of the European Union (or any other federation,<br />
Australia even). They worked for a common purpose, but<br />
each component was unique. There was a ‘black box’ for the<br />
autopilot, and a separate black box for the inertial navigation<br />
system, for example. They were able to cooperate closely<br />
in some tasks, but not as closely in others. To stretch<br />
the metaphor: they all used the euro, but their individual<br />
economies were very different.<br />
In contrast, integrated modular avionics, as used on the latest<br />
generation of transport aircraft, including the Airbus A380<br />
and Boeing 787 do away with discrete black boxes. They are<br />
replaced by racks of computer modules, which are, in the<br />
words of an Airbus presentation on the A380, ‘non systemspecific’.<br />
It’s like the way a laptop computer can do duty as<br />
a DVD player. As long as the right peripherals (sensors and<br />
actuators in an aircraft) are in place, a computer can turn<br />
its hand to whatever its software allows. Moreover, multiple<br />
systems applications can be executed on the same computer.<br />
The aircraft’s computers speak to each other on a high-speed<br />
multiplexed network.<br />
Integrated modular avionics bring obvious advantages of<br />
system redundancy and robustness. But they also bring new<br />
and subtle hazards in the way they differ from the old federal<br />
architecture.<br />
The Airbus presentation notes: ‘Resource sharing has a direct<br />
impact on the way to design and implement systems since<br />
it creates new dependencies between them, both from a<br />
technical and a process point of view.’<br />
‘With modern aircraft there are more functions, but not items,<br />
included in the MEL’, Nikolic says. ‘Each of these functions<br />
may be carried out by more than one system, some of which<br />
could be critical systems in the aircraft. You might have a<br />
function that is MEL-able, and to repair that function you need<br />
to replace a critical component. However, we have noticed a<br />
significant number of events that were not reported because<br />
the function was MEL-able.’<br />
One example illustrates the potential hazard. An operator flying<br />
a new technology aircraft reported through the SDR system<br />
that its engineers had removed the thrust control quadrant—<br />
the thrust levers and mounting—twice.<br />
A subsequent audit of the operator revealed 17 removals<br />
over 14 months. ‘We asked “why didn’t you report the other<br />
events?” and they said “they were all MEL-able—we didn’t<br />
have to report them”,’ Nikolic says.<br />
Further reading<br />
Jean-Bernard Itier, Airbus presentation on A380 integrated<br />
modular architecture. http://tinyurl.com/bpn6edq<br />
‘Two removals of the quadrant signified nothing much, but<br />
17 was an unambiguous trend. Here was a serious reliability<br />
issue with a major component—and we didn’t know about it.’<br />
‘We realised from this how the MEL could hide potential<br />
defects. Many of these could be precursors to a major event.<br />
If we are not aware of these failures we are not aware of the<br />
reduced reliability of a critical component and we can’t act. ‘<br />
In modern aircraft everything is connected, Nikolic explains.<br />
‘Unless you do a thorough investigation into the<br />
causes, you cannot establish whether any small<br />
functional failure is related, or not, to a potential<br />
major defect that must be reported.’<br />
Under the revised CAAP 51, the MEL provision not to report<br />
a defect does not exist, and it is up to the operator to do a full<br />
investigation and establish whether a defect is major, after<br />
considering the root cause. If the root cause points towards<br />
the major defect, an SDR must be submitted.<br />
The other reason for redrafting CAAP 51 was a significant<br />
number of questions coming from the industry about<br />
corrosion levels.<br />
‘The previous version did not have specific corrosion level<br />
definitions, or details of the corrosion level that required<br />
reporting to CASA,’ Nikolic says. ‘The new draft provides<br />
specific corrosion level definitions and also explains what<br />
corrosion levels need to be reported through the SDR system.’<br />
One result, Nikolic says, is that aircraft makers will be able to<br />
coordinate their internal corrosion reporting systems with the<br />
new CASA one. ‘If there is an issue in future with corrosion<br />
levels everyone will be on the same page. It reduces ambiguity<br />
in communication.’<br />
Two other significant details have been changed. The revised<br />
CAAP 51 says that when a service difficulty investigation<br />
takes more than two months to complete the submitter should<br />
provide follow-up interim reports every two months.<br />
‘In other words: you need to report every two months, even if<br />
it is only to say you are still working on it,’ Nikolic adds.<br />
And a short but significant sentence, added as item (w) to<br />
appendix A, encourages operators not only to submit major<br />
defects that match examples listed in appendix A, but also any<br />
other information they consider to be important.<br />
To sum up: aviation safety in the age of the Reason model<br />
multi-factor accident depends on information. What information<br />
is reported depends on the reporting system. That has been<br />
fixed—for now—but the game will continue to evolve.
42<br />
AIRWORTHINESS<br />
Pull-out section<br />
APPROVED AIRWORTHINESS DIRECTIVES ... CONT.<br />
continued from page 39<br />
20 April – 3 May 2012<br />
Rotorcraft<br />
Agusta AB139 and AW139 series helicopters<br />
2012-0076 Tail rotor blades – inspection/<br />
replacement<br />
Eurocopter SA 360 and SA 365 (Dauphin)<br />
series helicopters<br />
AD/DAUPHIN/27 Amendment 6 – tail rotor<br />
blades – cancelled<br />
2012-0067 Tail rotor blade monitoring<br />
and limitations<br />
Sikorsky S-92 series helicopters<br />
2012-08-01 Engine – inaccurate abovespecification<br />
power margin data<br />
Below 5700kg<br />
Airparts (NZ) Ltd FU 24 series aeroplanes<br />
AD/FU24/67 Vertical stabiliser – cancelled<br />
DCA/FU24/178A Vertical stabiliser – replacement<br />
Pacific Aerospace Corporation Cresco<br />
series aeroplanes<br />
AD/CRESCO/13 Aileron pushrods – cancelled<br />
DCA/CRESCO/12A Aileron pushrods –<br />
inspection/replacement<br />
DCA/CRESCO/16A Vertical stabiliser – replacement<br />
DCA/CRESCO/18 Control column – inspection/<br />
replacement<br />
Robin Aviation series aeroplanes<br />
2012-0072 Power plant – air filter – inspection/<br />
replacement<br />
Above 5700kg<br />
Airbus Industrie A330 series aeroplanes<br />
2012-0069 Navigation – radio altimeter erroneous<br />
indication – operational procedure<br />
2012-0070 High-pressure manifold check valves –<br />
inspection/modification<br />
Avions de Transport Regional ATR 72<br />
series aeroplanes<br />
F-1999-015-040 R2 Icing conditions – revision<br />
to airplane flight manual (AFM)<br />
F-2004-164 Main landing gear – side brace<br />
assembly – secondary side brace upper arm<br />
F-2005-160 Fuel quantity indicators<br />
2006-0216-E Main landing gear – shock absorber –<br />
cross locking bolt of the attachment pin<br />
2006-0283 Electrical power – 120 VU electrical<br />
harness – inspection<br />
2006-0303 Stabilisers – vertical stabiliser fin tip –<br />
inspection/repair/modification<br />
2006-0376 Flight controls – aileron tab bellcrank<br />
assembly – inspection<br />
2007-0164 Equipment and furnishings – thermal/<br />
acoustic insulation blankets – replacement/removal<br />
2007-0179 Ice and rain protection – pitot probe<br />
resistance and low current sensor – inspection/<br />
replacement<br />
2008-0062 Electrical/electronic – rear pressure<br />
bulkhead area and wire chafing – inspection/<br />
modification<br />
2008-0137-E Flight controls – cotter pins and<br />
pitch uncoupling mechanism (PUM) – inspection/<br />
installation<br />
2008-0218 Electrical/electronic – wire bundles in<br />
rear baggage zone – protection/clamping<br />
2009-0159-E Cockpit forward side windows –<br />
inspection/replacement<br />
2009-0170 Indicating/recording systems – multi–<br />
purpose computer (MPC) with aircraft performance<br />
monitoring (APM) function – installation<br />
2007-0226R1 Fuel tank system wiring and sensors –<br />
modification/replacement – fuel tank safety<br />
2009-0242 Time limits/maintenance checks –<br />
certification maintenance requirements and<br />
critical design configuration control limitations<br />
(fuel tank safety)<br />
2010-0061 Fire protection – halon 1211 fire<br />
extinguishers – identification/replacement<br />
2010-0138 Stabilisers – elevator inboard hinge<br />
fitting lower stop angles – inspection/replacement<br />
Avions de Transport Regional ATR 42<br />
series aeroplanes<br />
2012-0064 Flight controls – rudder tab,<br />
rudder pedal and elevator control rods –<br />
inspection/replacement<br />
Avions de Transport Regional ATR 72<br />
series aeroplanes<br />
2012-0064 Flight controls – rudder tab,<br />
rudder pedal and elevator control rods –<br />
inspection/replacement<br />
Boeing 737 series aeroplanes<br />
2012–08–17 Goodrich analog transient<br />
suppression devices – corrosion<br />
Boeing 777 series aeroplanes<br />
2012-08-09 Wing centre section spanwise<br />
beams – inspection<br />
2012-08-13 Rudder bonding jumper brackets<br />
Boeing 767 series aeroplanes<br />
2012-08-14 – wing upper skin fastener<br />
holes – inspection<br />
Bombardier (Boeing Canada/De Havilland)<br />
DHC-8 series aeroplanes<br />
CF-2012-15 Chafing of the nacelle fire detection<br />
wire on the main landing gear yoke<br />
Fokker F27 series aeroplanes<br />
2012-0065 Fuel – wing main tanks – modification<br />
(fuel tank safety)<br />
Learjet 45 series aeroplanes<br />
2012-08-08 Airworthiness limitations and<br />
maintenance requirements<br />
Learjet 60 series aeroplanes<br />
2012-08-16 Engine fire protection wiring<br />
Piston engines<br />
SMA piston engines<br />
2012-0075-E Powerplant – turbocharger and<br />
intercooler hoses – replacement<br />
Turbine engines<br />
Turbomeca turbine engines– Arriel series<br />
AD/ARRIEL/6 Amendment 1 – erosive atmosphere<br />
maintenance – cancelled<br />
2012-0071 Engine – axial compressor, gas generator<br />
4 – 17 May 2012<br />
Rotorcraft<br />
Bell Helicopter Textron 412 series helicopters<br />
CF-2012-14R1 Crosstubes – life limitation<br />
2012-0077-E Equipment and furnishings – hoist<br />
hook – inspection<br />
Eurocopter AS 332 (Super Puma)<br />
series helicopters<br />
2012-0084 Equipment and furnishings –<br />
EADS SOGERMA flight crew seats –<br />
inspection/replacement<br />
Eurocopter EC 225 series helicopters<br />
2012-0084 Equipment and furnishings –<br />
EADS SOGERMA flight crew seats –<br />
inspection/replacement<br />
Eurocopter SA 360 and SA 365 (Dauphin)<br />
series helicopters<br />
2012-0084 Equipment and furnishings –<br />
EADS SOGERMA flight crew seats –<br />
inspection/replacement<br />
Below 5700kg<br />
De Havilland DHC–1 (Chipmunk)<br />
series aeroplanes<br />
G-2012-0001 Wings – recording and consumption<br />
of fatigue lives<br />
Above 5700kg<br />
Airbus Industrie A319, A320 and A321<br />
series aeroplanes<br />
2012-0083 Chemical emergency oxygen<br />
containers – identification/modification<br />
Airbus Industrie A380 series aeroplanes<br />
2012-0078 Nacelles/pylons – finger seals at<br />
interface with nacelle – inspection/replacement<br />
Airbus Industrie A330 series aeroplanes<br />
2012-0082 Flight controls – wing tip brakes –<br />
operational test/replacement<br />
Boeing 737 series aeroplanes<br />
2012-09-06 Seat attach structure<br />
Boeing 767 series aeroplanes<br />
AD/B767/201 Amendment 2 – body station 955<br />
fail-safe straps – cancelled<br />
2012-09-04 Fail-safe straps – rear spar<br />
bulkhead at body station 955 – inspection<br />
2012-09-08 Aft pressure bulkhead – inspection<br />
Bombardier (Canadair) CL–600<br />
(Challenger) series aeroplanes<br />
CF-2005-41R1 Shear pin failure in the pitch<br />
feel simulator unit<br />
Cessna 560 (Citation V) series aeroplanes<br />
2012-09-01 Torque lug – main wheel – inspection<br />
Dassault Aviation Falcon 2000 series<br />
aeroplanes<br />
2012-0081 Airplane flight manual – take-off under<br />
out-of-trim condition – operational limitation<br />
Piston engines<br />
SMA piston engines<br />
2012-0075-E (correction) Powerplant – turbocharger<br />
and intercooler hoses – replacement<br />
Turbine engines<br />
Pratt and Whitney Canada turbine engines –<br />
PT6A series<br />
2012-09-10 Reduction gearbox – first-stage sun<br />
and planet gear – replacement
Flight Safety Australia<br />
Issue 87 July–August 2012<br />
43<br />
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44<br />
FEATURE<br />
Sharing the skies – gliders<br />
Sharing the skies—gliders<br />
Pilots of powered aircraft who<br />
have watched wedge-tailed<br />
eagles effortlessly soaring<br />
may have wondered at their<br />
mastery, but glider pilots say<br />
they feel a kinship with the<br />
eagles. Both fly in the same<br />
way, by soaring on the warm<br />
rising air of thermals, meaning<br />
that both must instinctively<br />
know much more about the<br />
dynamics of the sky than the<br />
typical powered pilot.<br />
‘Formally’, gliders, or sailplanes as they are<br />
now known, have been flying in Australia<br />
for over 60 years, although gliding began<br />
earlier in the ‘20s and ‘30s with opencockpit<br />
trainer gliders launched from<br />
hilltops. The peak association, the Gliding<br />
Federation of Australia (GFA), began in<br />
1949, bringing together the various state<br />
and local bodies which then made up the<br />
gliding community in Australia. The GFA<br />
has a core membership of 2500 pilots,<br />
with short-term memberships catering for<br />
those wanting to give gliding a try swelling<br />
the number during summer.<br />
There are around 1200 sailplanes on<br />
the register (gliders are VH-registered).<br />
The bulk, around 1000, are conventional<br />
sailplanes, while the remaining 200-odd<br />
are powered. And because they are VHregistered<br />
aircraft, gliders are subject to<br />
the same airworthiness regime as other<br />
VH-aircraft, with regularly scheduled<br />
inspections. The GFA administers this<br />
ongoing airworthiness, with approved and<br />
certified inspectors.<br />
There are several methods of launching<br />
gliders, with the most commonly used in<br />
Australia being ground-based winch and<br />
aerotow, which uses a tug plane to take<br />
the glider to launch altitude, explains Chris<br />
Thorpe, GFA operations manager. Winch<br />
launching and aerotow each have unique<br />
characteristics.<br />
Bacchus Marsh airfield, for example,<br />
is home to three gliding clubs, and<br />
uses winches and tug planes. In winch<br />
operations, Thorpe says, ‘the glider goes<br />
up pretty quickly, at a 45-degree angle,<br />
and only takes about 30-40 seconds to<br />
get to release height (2000ft AGL).’ Since<br />
the winch cable ‘in Australia, in the main,<br />
is 3.5mm spring steel and can go up to<br />
3000 or 4000 feet in the right conditions’,<br />
Thorpe advises pilots to check the relevant<br />
world aeronautical chart (WAC) to look<br />
for a winch symbol for the area they are<br />
planning to fly over. ‘You don’t want to<br />
be flying over an aerodrome if it is doing<br />
winch operations,’ he says. ‘Crosswind<br />
joins are especially dangerous; in any<br />
case, pilots should give the circuit a bit<br />
of margin.’ For this reason, ‘the reporting<br />
point for the airfield has been moved to the<br />
Bacchus Marsh township, so that pilots<br />
don’t fly over the aerodrome’.<br />
‘Aerotow is fairly sedate,’ he says, but it<br />
has still some unique features powered<br />
pilots should be mindful of. The glider/<br />
tow plane combination is not very<br />
manouverable, and the tow plane, often<br />
flying nose-high, cannot see particularly<br />
well to the front, and cannot take<br />
significant evasive action without releasing<br />
the glider. So pilots of powered aircraft<br />
should be aware of the limited capacity of<br />
a glider under tow to get out of the way<br />
– ‘it’s basically formation flying’, Thorpe<br />
adds, ‘so give the glider plenty of room,<br />
and don’t fly too close’.<br />
Pilots of powered aircraft should be aware<br />
of the distinct flight characteristics of<br />
gliders, Thorpe says. Landing, in particular,<br />
is a phase of flight that is very different for<br />
unpowered aircraft.
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‘It’s very important that powered pilots understand that gliders<br />
only have one shot at landing, so it’s not a good idea to cut in front,<br />
or exercise a perceived right over a glider that’s set up for landing.<br />
‘Every landing we do is a forced landing,’<br />
he says. ‘We don’t have the luxury of<br />
having another go’.<br />
‘It’s very important that powered pilots<br />
understand that gliders only have one shot<br />
at landing, so it’s not a good idea to cut in<br />
front, or exercise a perceived right over a<br />
glider that’s set up for landing. In fairness,<br />
most powered pilots are good like that.’<br />
A nasty little detail for IFR powered pilots<br />
to remember is that for some aerodromes<br />
(Kingaroy, Queensland, for example)<br />
the missed approach procedure directs<br />
traffic through gliding areas. This is<br />
not an issue in actual IFR conditions,<br />
obviously, but could contribute to a<br />
major fright—or worse—should an IFR<br />
pilot in training, head-down, practise a<br />
missed approach without first reading the<br />
ERSA and NOTAMs, and broadcasting<br />
conscientiously on the correct frequency.<br />
In their ceaseless quest for lift, glider<br />
flightpaths differ from those of powered<br />
aircraft. Gliders rarely fly in a straight line<br />
for more than a few minutes at most, and<br />
their airspeed also varies, as pilots seek<br />
the optimum cross-country speed. ‘We<br />
go from A to B via C, D, E, F and G (in a<br />
saw-tooth profile of descending and then<br />
climbing in thermals),’ says Thorpe.<br />
Gliders generally fly in class G and class<br />
E (non-controlled for VFR) airspace, but<br />
can be found in class A airspace at up<br />
to 35,000ft. This is legal if the glider has<br />
received block clearance from ATC, usually<br />
by prior arrangement.<br />
The world glider altitude record is 50,679ft<br />
and VNE for most gliders is about 140kt.<br />
Circuit speeds are usually between 65kt<br />
and 45kt and speeds between thermal<br />
climbs can be anywhere from 60kt to<br />
120kt, depending on type. However, during<br />
competitions, high-performance gliders<br />
can sometimes return to the airfield at low<br />
level and at speeds of up to 150kt.<br />
A skilled glider pilot who finds a rising<br />
column of air will often exploit the glider’s<br />
efficient wings to stay inside it. Gliders in<br />
thermals will often turn much more steeply<br />
than most powered aircraft. Banks of 45<br />
degrees are common in this situation, with<br />
60-degree banks not unknown. Rates of<br />
climb in thermals can exceed 1000fpm on<br />
a hot summer day. On a day with cumulus<br />
clouds, thermalling gliders will be found<br />
close to the cloud base, their white wings<br />
blending all too effectively with the grey<br />
cloudbase.<br />
Three frequencies have been allocated<br />
for gliders to use. They are 122.5, 122.7<br />
and 122.9. Gliders flying in a common<br />
traffic advisory frequency (CTAF) area<br />
will use the CTAF frequency, but they<br />
have an exemption from monitoring area<br />
frequency, as gliders flying closely together<br />
cross-country and during competitions<br />
will usually communicate on one of the<br />
allocated glider frequencies. ‘We fly the<br />
same radio procedures as everybody else,<br />
except for that exemption,’ says Thorpe.<br />
Gliders are not currently required to carry<br />
transponders, but many use FLARM,<br />
a collision warning system similar in<br />
principle to ADS-B that provides proximity<br />
advice for gliders and tugs so equipped.<br />
FLARM, short for flight alarm, is an<br />
off-the shelf, low-cost proximity-warning<br />
system suited to relatively slow-moving<br />
aircraft such as gliders. FLARM does<br />
not communicate with other automatic<br />
dependent surveillance systems, but this<br />
function is being considered.<br />
Sample NOTAM for Bacchus Marsh<br />
1. Gliding OPS HJ - Aerotow and winch<br />
launched. Gliders and tugs normally<br />
operate inside and below standard<br />
1000ft circuit.<br />
2. All circuits left-hand. Unforseen<br />
circumstances may occasionally force<br />
a glider to fly a right-hand circuit.<br />
3. Gliders and tugs operate from righthand<br />
side of RWY short of displaced<br />
THR. Other ACFT must not make low/<br />
shallow approaches and must land<br />
beyond displaced THR.<br />
4. When gliding OPS in progress the duty<br />
RWY is the RWY in use by the gliding<br />
operation. All TKOFs to commence<br />
from the displaced THR.<br />
5. If wind is BLW 5KT and VRBL, RWY<br />
19 or 27 must be used by all ACFT.<br />
WInd ABV 5KT, operate on the most<br />
into wind RWY.<br />
6. Overflying the AD is discouraged.<br />
If operationally necessary, overfly at<br />
2,000FT AGL (2,500FT AMSL).<br />
7. When inbound it is suggested ACFT<br />
track via and call on the CTAF at<br />
one of the following points - Melton<br />
Reservoir, Merrimu Reservoir, Pykes<br />
Creek Reservoir or Mt. Anakie.
46<br />
CLOSE CALLS<br />
Hot and shaky<br />
Name withheld by request<br />
Turbulence is often associated with flying through clouds, wake turbulence in the<br />
vortexes of other aircraft, clear air turbulence when flying close to jetstreams, or mountain<br />
wave turbulence near high terrain; but have you ever experienced a ‘fake’ turbulence that comes<br />
in bursts of a few seconds, followed by complete calm?<br />
We were at FL350, on a smooth night flight from Kuala Lumpur<br />
to Johannesburg, on a B744, when the quiet of the ride was<br />
interrupted by a sudden shudder that felt as though we had just<br />
flown through a cloud top. Peering quickly out through the front<br />
windshield, I saw nothing. Then I strained my eyes through the<br />
side window towards the left wing, and again I saw nothing.<br />
It was a clear night. There were definitely no jetstreams.<br />
We were over the middle of the Indian Ocean. Some moonlight<br />
would have helped me to spot clouds without the aid of the<br />
radar, but there was not a cloud to be seen.<br />
‘What could it be?’ I asked myself, and so did my colleague,<br />
a captain acting as my first officer in the right-hand seat. The<br />
flight was a three-pilot operation. The other first officer was<br />
in the bunk resting. I looked around the cockpit to see if there<br />
was anything unusual. I held the speedbrake lever and assured<br />
myself that it was in the down detent. I saw that the flap lever<br />
was in the ‘up’ slot. Rudder and aileron trims were all at normal<br />
in-trim positions. The gear lever was in the ‘Off’ position. There<br />
was nothing on radar except for the normal returns of the sea at<br />
the edge of the navigation display.<br />
A few minutes elapsed, and my captain/first officer quipped<br />
‘Maybe we hit the wake turbulence of another aircraft?’ But<br />
there was no traffic within VHF range that could have escaped<br />
our awareness. The traffic collision avoidance system also<br />
showed nothing and it was a clear night.<br />
I resigned myself to accepting the fact that it had to be some kind<br />
of clear air turbulence, but then, again breaking the stillness of<br />
the night, there was a similar shake, this time more pronounced.<br />
It felt like moderate turbulence, but only lasted for a second.<br />
I had been in moderate turbulence before on numerous<br />
occasions, but it had never felt like this – this was too brief!<br />
Again, I checked the same controls and levers again, to ensure<br />
that I had not missed anything, but only felt more perplexed<br />
about what was going on.<br />
Suddenly, the intercom chimed and there was a loud knock on<br />
the cockpit door. My colleague answered and said in surprise,<br />
‘It’s the chief stewardess!’ I released the remote door latch<br />
and she rushed in. From the way she sounded, panting as she<br />
spoke, there was definitely something important happening.<br />
Almost hysterically, she described what she had observed from<br />
the cabin – ‘fire right side of aircraft!’<br />
I thanked her for the invaluable information and gave her what<br />
little reassurance I could muster. In the cockpit, no words were<br />
uttered from then on. I selected the engine parameters on<br />
the lower EICAS and we turned our attention to the starboard<br />
engines. Within seconds, the now familiar shake occurred<br />
again. However, this time, the shudder throughout the whole<br />
aircraft was followed by a rapid rise in No. 3 exhaust gas<br />
temperature (EGT) towards the red limit. Seeing that, my<br />
colleague and I confirmed No.3 engine and I quickly retarded<br />
the No. 3 thrust lever to idle position. The stillness that followed<br />
was so comforting that I sighed with great relief. Although the<br />
EGT had subsided somewhat, it was still higher than normal<br />
compared with the other engines. No noticeable vibration<br />
could be felt from the cockpit but the engine vibration indicator<br />
showed that some broadband (BB) vibration persisted. It was<br />
now obvious what had caused the ‘turbulence’. After a brief<br />
discussion with my colleague, the engine was shut down, using<br />
the quick reference handbook (QRH) checklist.
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Almost<br />
hysterically,<br />
she described<br />
what she had<br />
observed from the<br />
cabin – Fire right side<br />
of aircraft!’<br />
As we were just under three hours away from our<br />
destination, I decided to continue the flight to Johannesburg,<br />
after discussing weather and fuel with my crew. My rested<br />
first officer had just been awakened, not by the engine-induced<br />
turbulence, but by his internal alarm clock. When he realised<br />
what had happened, he wasted no time in resuming his duty,<br />
as this was also his first three-engine real-life landing ever.<br />
Close cabin crew collaboration<br />
Praise is due for the alertness of the chief stewardess (chief<br />
purser) in spotting the flames, despite the window shades being<br />
shut because the cabin was in ‘sleep’ mode. Her vigilance and<br />
situational awareness were a major factor in the successful<br />
handling of the situation, as they gave me a vital clue and a<br />
crucial advantage. Who knows what could have happened if<br />
there had been any delay in applying corrective action and the<br />
engine had continued to run erratically and unbalanced on fire<br />
and at high thrust? In hindsight, on all three shudders, there had<br />
been no yaw, only up and down motion, and the autopilot had<br />
remained engaged.<br />
Conclusions<br />
As conscientious pilots, we are the last line of defence, and if<br />
we are compelled by circumstances to fly an aircraft with an<br />
engine that had a previous surge-related problem, we should be<br />
aware that there could be extraordinary events throughout the<br />
flight, especially in the critical take-off phase when the engine is<br />
under greater stress.<br />
During less critical phases, it is important to remember that<br />
in addition to the warning and monitoring systems in the<br />
cockpit, we should be aware of unusual vibrations, noises and<br />
odours. These subtle indicators could be initial warnings of an<br />
impending engine failure.
48<br />
CLOSE CALLS<br />
Live, learn, survive and be happy<br />
Live, learn, survive<br />
and be happy<br />
Name withheld by request<br />
‘I’ve learned<br />
that feelings of<br />
invulnerability,<br />
hopelessness<br />
or resignation<br />
are recognised<br />
hazardous<br />
attitudes that can<br />
be overcome.’<br />
I hadn’t planned on writing yet another ‘close call’ story –<br />
after all, my experiences are probably similar to everyone<br />
else’s – but there really isn’t a better way of illustrating<br />
how my attitude to risk in flying has changed over time.<br />
So, I’ve included a few brief stories at the end of this<br />
article as examples of lessons learned or mistakes I wish<br />
I’d never made.<br />
Back in my bush flying days, it seemed the list of things<br />
that could kill me was almost endless – overloaded<br />
machines with barely adequate performance, lousy<br />
weather, the kind of territory where an engine failure<br />
inevitably meant disaster, dodgy maintenance, indifferent<br />
company management etc. etc.<br />
I eventually became inured to these everyday risks, and<br />
a fatalistic attitude set in. I used to think to myself: Well,<br />
if one thing doesn’t get me, something else probably will,<br />
so what’s the point of even trying to manage anything?<br />
Besides, I’m fireproof and it’ll never happen to me anyway,<br />
so why worry? Just press on and hope for the best.<br />
This went on for years and somehow I survived, but some<br />
of my colleagues didn’t. It gradually dawned on me that,<br />
if I wanted to live, I’d better start managing all the risks<br />
I possibly could. I mean, how long could my luck last?<br />
Sure, there were plenty of things I still had no control over,<br />
but (when I thought about it) I could influence a surprising<br />
number, for better or worse.<br />
So, when I was next faced with situations outside my<br />
comfort zone, I either adjusted things until I felt the odds<br />
were mostly in my favour, or I declined the task altogether.<br />
If pressured by my employer to continue unsafe or unduly<br />
risky practices, I quit. I lost a few jobs that way, but it<br />
didn’t do me any harm in the long run and, perhaps more<br />
importantly, I’m still around to talk about it.<br />
Since those days, I’ve learned that feelings of<br />
invulnerability, hopelessness or resignation are recognized<br />
hazardous attitudes that can be overcome. I wish I’d<br />
known that beforehand, instead of belatedly discovering<br />
them for myself, but better late than never, I suppose.<br />
The first story concerns fuel – or lack of it, to be precise.<br />
In the interest of satisfying my employer’s or my<br />
customer’s demands for max payload, I used to fly without<br />
legal and/or sensible alternate fuel for weather diversions.<br />
I figured I would always make it to my destination, either<br />
because I knew the area well and felt I could safely bust
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49<br />
the proper procedures (like scud run), or because I had<br />
some ‘homemade’ instrument approaches worked out if<br />
conditions were really bad. Actually, I always did manage<br />
to make it (although sometimes with only fumes in the<br />
tank and my heart in my mouth) but, looking back and<br />
thinking about the risks I ran in those days – for no good<br />
reason – now makes my blood run cold.<br />
Still on the subject of carrying max payloads to please the<br />
boss, I’ve lost count of the number of times I’ve squeezed<br />
out of tiny take-off areas and missed obstacles on climbout<br />
by the skin of my teeth. All in a day’s work, you might<br />
say, but the margin for error really shouldn’t be zero ...<br />
I recall one occasion when my task was to land a heavy<br />
load of passengers on a ridge-top pad. From prior<br />
experience, I knew the helicopter’s performance would be<br />
marginal at best, but I pressed on regardless, not bothering<br />
to carry out a detailed assessment of the approach, or<br />
to consider other options (such as landing elsewhere<br />
and making the passengers walk). The upshot was that<br />
I ran out of power on short final, exceeded engine and<br />
transmission limits and touched down rather firmly on the<br />
pad with the rotor low-rpm horn blaring and the collective<br />
up around my armpit. A narrow escape... but why did I<br />
do it?<br />
I think the three factors mentioned earlier could be relevant<br />
to these (probably no uncommon) incidents: invulnerability<br />
(‘I’ve done this before’), hopelessness (‘The passengers<br />
expect me to land there’) and resignation (‘My job is on the<br />
line if I don’t do this’).<br />
These days, I do my best to be consciously on guard<br />
against potentially hazardous feelings such as this, as part<br />
of my intention to live a long, happy and safe flying life.<br />
ever had a<br />
CLOSE CALL?<br />
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subject of a current official investigation. Submissions may be edited for clarity, length and reader focus.
50<br />
CLOSE CALLS<br />
Taking control<br />
Name withheld by request<br />
I was flying an international heavy jet to New Chitose, Japan,<br />
also known as Sapporo. It was May 2012, and the usual threats<br />
of cold weather, snowy conditions and contaminated runways<br />
which plague the airport early in the year were fortunately not<br />
in evidence this time. Our early afternoon arrival was in clear<br />
skies, with 25km visibility reported by ATIS and ATC suggesting<br />
a visual approach.<br />
Before descent, and after the approach briefing, the captain<br />
suggested that we should have an extra stage of flap out than<br />
normally specified when abeam the threshold. The descent<br />
was normal and radar vectors were given until in sight of the<br />
aerodrome, then a visual approach clearance was issued.<br />
By late downwind, I selected autopilot off and with everything<br />
normal I turned base leg.<br />
The captain commented about the military runway at the far side<br />
of the airport which, given our position, in my judgement, was<br />
not a threat or concern. I prefer to hand-fly visual approaches,<br />
and by manipulating the controls manually, I guarantee a tighter<br />
turn than one made with the autopilot, ensuring a shallow<br />
intercept onto final. I also do this as a preventative measure<br />
against overshooting, or straying onto a parallel runway area.<br />
The gear was selected down with the final stage of flap to go,<br />
and the landing checklist to be completed. This is always a<br />
busy time. The captain, focused on the navigation display,<br />
muttered something about the geometry of the turn and not<br />
going to intercept final correctly. I was now halfway through<br />
the base turn with the runway in sight. Everything looked as<br />
it should. The vertical deviation indicator showed the profile<br />
was good and I was happy to continue, seeing no need to<br />
modify anything.<br />
I noticed the captain becoming uncomfortable, even agitated.<br />
Suddenly, forcefully, and without warning, he took control of<br />
the thrust levers and control stick, saying ‘I have control’.<br />
Immediately, I changed to pilot-monitoring duties, and<br />
acknowledged: ‘you have control as per our SOPs’.<br />
I didn’t know the reason for his decision, but at this stage of<br />
the approach there was no discussion. From my situational<br />
awareness everything was within limits and normal, nothing<br />
had been breached. It had not occurred to me before, so I asked<br />
myself ‘was there something missed, or some information the<br />
captain knew which I didn’t, or hadn’t recognised?’ I had to<br />
be open-minded. We all make mistakes, but judging by the<br />
captain’s action, this was no small error.<br />
The captain took control and stopped the base turn. I did not<br />
understand why, but I did know that unless he corrected the new<br />
flight path he had established, it would be an unstable approach.<br />
An incursion of the adjacent runway’s airspace would quickly<br />
follow, and if allowed to continue, an infringement of military<br />
restricted airspace. And this would happen in seconds. I was<br />
not thrilled about control being taken away, without knowing<br />
why. The captain began manoeuvring towards the next runway.<br />
Only a second had passed since handing over control, and I<br />
noticed him focusing on the military runway, two runways away<br />
from ours, and adjusting track to land there. From our current<br />
position it would be difficult to achieve at best, even though the<br />
military runway seemed closer to us. It is located further north<br />
than the two civil runways, but from our position northeast<br />
of the airport, its lighter-coloured tarmac made it appear<br />
more obvious.<br />
I was astonished as the situation unfolded. My next thought was<br />
to take over from the captain, as per our procedures and crew<br />
resource management (CRM) principles. But would that be the<br />
best fix, considering where we were on the approach as well as<br />
our cultural differences? What if he didn’t surrender control?<br />
I knew clearly what had to be done in a very short time frame<br />
to make this a successful approach, but that window was<br />
closing fast.<br />
This captain and first officer were thinking two very different<br />
things. One of us was right, the other was wrong. Unfortunately,<br />
the one who was wrong had assumed command of the controls,<br />
but he did not know he was wrong, making it a dangerous<br />
situation. It was now up to me to prove his error—and quickly.<br />
His situational awareness was compromised when he<br />
tried matching the picture he had developed from the<br />
navigation display with the one he could see through<br />
the window.<br />
He believed he was making a bad situation better. In fact, he was<br />
doing the opposite: turning a normal, within-limits manoeuvre<br />
into something unsafe.
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military runway<br />
hand-fly visual approaches<br />
navigation display<br />
wrong situational awareness<br />
turned base leg<br />
01R/19L<br />
3,000m/9,843ft<br />
01L/19R<br />
3,000m/9,843ft<br />
18R/36L<br />
2,700m/8,858ft<br />
18L/36R<br />
3,000m/9,843ft<br />
I shouted at him very<br />
deliberately, so there would be<br />
no misunderstanding,<br />
‘No!’,<br />
pointed to the runway at our 10 o’clock<br />
position, and said,<br />
‘that’s our runway’.<br />
Finally, he turned the aircraft in the correct direction; I will<br />
never forget the lost and confused look on his face. He asked<br />
for landing flap and landing checklist, and we completed the<br />
landing normally within the stable approach parameters.<br />
So much went on in just a few seconds. At the time I don’t know<br />
what thinking made him arrive at his decision. But whatever<br />
the reason, he made a basic error. The situation could rapidly<br />
have escalated into something worse if I had failed to challenge<br />
him, or had passively accepted his wrong decision. To many<br />
this is obvious, but in some cultures they do not challenge and<br />
will accept a bad decision, even if they know it is wrong. Many<br />
aircraft accidents occur because of this, as we often read in<br />
FSA and other aviation magazines.<br />
A pilot taking over from a normal condition and unwittingly<br />
attempting to take it into an unsafe condition is not something<br />
you specifically train for in simulator exercises. Standard<br />
procedure is to back up the other pilot but offer assistance<br />
where necessary—that is to give a heads-up if you think an<br />
error will be made. This is part of CRM, but you have to adapt to<br />
different situations and respond accordingly: scenarios may not<br />
play out as described in quick reference handbooks, manuals,<br />
textbooks, or simulator exercises.
24 Hours<br />
1800 020 616<br />
Web<br />
www.atsb.gov.au<br />
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@ATSBinfo<br />
Email<br />
atsbinfo@atsb.gov.au<br />
How safe is<br />
Australian<br />
aviation?<br />
You may have seen some recent media<br />
coverage suggesting that the high number<br />
of aviation occurrences reported to the ATSB<br />
reflects a low standard of aviation safety in<br />
Australia. With a bit of context, you’ll see that<br />
the opposite is true.<br />
Australia has an extensive mandatory<br />
reporting scheme and a healthy reporting<br />
culture that sees a broad range of occurrences<br />
reported to the ATSB. These include reports<br />
from all sectors of aviation, ranging from<br />
sport and recreational flying in ultra-lights and<br />
gyrocopters, to private flying and commercial<br />
passenger operations.<br />
It’s important to remember that Australian<br />
aviation has many layers of defence to protect<br />
safety. If even one of these layers is breached,<br />
then the ATSB needs to know about it. We<br />
use the information from occurrence reports<br />
to determine whether to investigate an<br />
incident or accident and to make real practical<br />
improvements to the safety system.<br />
The large number of occurrences reported to<br />
the ATSB reflects a strong reporting culture.<br />
It does not represent a low standard of<br />
aviation safety in Australia. In fact, through our<br />
investigations and analysis of occurrence data,<br />
the ATSB has not seen any overall increase<br />
in risk or systemic safety issues in Australian<br />
aviation. If we did, we would immediately<br />
bring it to the attention of industry and the<br />
relevant safety authority.<br />
I encourage the Australian aviation industry to<br />
continue the great job of reporting incidents<br />
and accidents to the ATSB. Through your<br />
reports, we make flying safer.<br />
Martin Dolan<br />
Chief Commissioner<br />
General aviation:<br />
Continuing safety<br />
concern<br />
The ATSB has released its latest statistical report<br />
– Aviation Occurrence Statistics 2002 to 2011 –<br />
providing the most up-to-date portrait of aviation<br />
safety in Australia.<br />
There were 130 accidents, 121 serious incidents,<br />
and 6,823 incidents in 2011 involving VH-registered<br />
aircraft.<br />
General aviation operations continue to have an<br />
accident rate higher than commercial air transport<br />
operations—about four times higher for accidents,<br />
and nine times higher for fatal accidents in 2011.<br />
Most commercial air transport accidents and<br />
serious incidents were related to reduced aircraft<br />
separation, and engine issues.<br />
Charter operations accounted for most of the<br />
accidents, including two fatal accidents in 2011<br />
within air transport. Air transport incidents were<br />
more likely to involve birdstrikes or a failure to<br />
comply with air traffic control instructions or<br />
published information.<br />
For general aviation aircraft, accidents and serious<br />
incidents often involved terrain collisions, aircraft<br />
separation issues, or aircraft control problems.<br />
General aviation incidents commonly involved<br />
airspace incursions, failure to comply with air traffic<br />
control, and wildlife strikes.<br />
In most operation types, helicopters had a<br />
higher rate of accidents and fatal accidents than<br />
aeroplanes, except for in charter operations. Even<br />
though the fatal accident rate is generally higher,<br />
helicopter accidents are generally associated with<br />
fewer fatalities than fixed-wing aircraft.<br />
The figures and insights from the report are helping<br />
the ATSB concentrate its efforts on transport safety<br />
priorities. The report also reveals that many of the<br />
accident types are avoidable (especially for general<br />
aviation) and can be prevented through good flight<br />
management and preparation.<br />
Aviation Occurrence Statistics 2002 to 2011 is<br />
available for free at www.atsb.gov.au •
If in doubt, don’t take-off<br />
ATSB investigation AO-2011-016<br />
A fatal accident involving a Robinson<br />
Helicopter Company R44 helicopter is a<br />
powerful reminder to stay on the ground<br />
if something isn’t right with your aircraft.<br />
On 4 February 2011, a Robinson R44<br />
Astro helicopter, registered VH-HFH,<br />
crashed after part of the aircraft’s flight<br />
controls separated from the hydraulicboost<br />
system during circuit operations at<br />
Cessnock Aerodrome.<br />
Following a landing as part of a simulated<br />
failure of the hydraulic boost system<br />
for the helicopter’s flight controls,<br />
the flight instructor assessed that the<br />
hydraulic system had failed and elected<br />
to reposition the helicopter on the apron.<br />
As the helicopter became airborne, it<br />
became uncontrollable, collided with<br />
the runway and caught fire. The pilot<br />
survived, but the flight instructor and a<br />
passenger died in the accident.<br />
What caused the<br />
accident<br />
A number of factors—both human and<br />
mechanical—contributed to the accident.<br />
The ATSB’s investigation found that a<br />
flight control fastener had detached,<br />
making the aircraft uncontrollable. The<br />
ATSB was unable to determine the<br />
specific reason for the separation as a<br />
number of components could not be<br />
located in the wreckage.<br />
Testing conducted by the manufacturer<br />
showed that the ‘feel’ of the flight control<br />
fault mimicked a hydraulic system failure.<br />
That behaviour, together with the report<br />
that the hydraulic system had been<br />
leaking and the apparently unsuccessful<br />
attempts to re-engage the hydraulic<br />
boost system while on the ground,<br />
probably resulted in the misdiagnosis<br />
of a hydraulic system fault. The fault,<br />
however, was with the flight controls,<br />
not the hydraulic system and when<br />
the helicopter became airborne for<br />
repositioning, control was lost.<br />
Following the preliminary results of<br />
its investigation, in March last year<br />
the ATSB issued a Safety Advisory<br />
Notice encouraging all operators of R44<br />
hydraulic system-equipped helicopters<br />
to inspect and test the security of the<br />
flight control attachments on their R44<br />
helicopters, paying particular attention to<br />
the connections at the top and bottom of<br />
the servos.<br />
The risks of aluminium<br />
fuel tanks<br />
The fatal injuries sustained by the<br />
instructor and passenger were caused<br />
by the post-impact fire. The investigation<br />
identified that a large number of R44<br />
helicopters, including VH-HFH, did not<br />
have the upgraded bladder-type fuel<br />
tanks. These tanks reduce the risk of<br />
post-impact fuel leak and subsequent<br />
fires.<br />
R44 Service Bulletin 78, issued by<br />
Robinson Helicopter Company on<br />
20 December 2010, advised that R44<br />
helicopters with all-aluminium fuel tanks<br />
be retrofitted with bladder-type tanks as<br />
soon as practical, but no later than<br />
31 December 2014. In February this year<br />
the manufacturer revised the date of<br />
compliance to 31 December 2013.<br />
Tragically, the post-impact fire from<br />
another R44 crash claimed two more<br />
lives at Jaspers Brush, NSW in February<br />
2012 (ATSB investigation AO-2012-021).<br />
Aircraft wreckage<br />
What we’ve learnt from<br />
this accident<br />
This accident reinforces the importance<br />
of thorough inspections by maintenance<br />
personnel and pilots. The investigation<br />
identified that self-locking nuts used in<br />
many aircraft, including R22, R44 and<br />
R66 helicopter models, can become<br />
hydrogen-embrittled and fail. The<br />
Robinson Helicopter Company and the<br />
Civil Aviation Safety Authority (CASA)<br />
have published information advising pilots<br />
and maintenance personnel that any<br />
cracked or corroded nuts be replaced.<br />
The ATSB also urges all operators and<br />
owners whose R44 helicopters are fitted<br />
with all-aluminium fuel tanks to replace<br />
those tanks with bladder-type fuel tanks<br />
as soon as possible. Compared to the allaluminium<br />
tanks, the bladder-type tanks<br />
provide improved cut and tear resistance<br />
and can sustain large deformations<br />
without rupture. The safety benefits<br />
of incorporating the requirements of<br />
manufacturer’s service bulletins in their<br />
aircraft as soon as possible cannot be<br />
underestimated. •
The success of the system<br />
ATSB investigation AO-2010-035<br />
Often things go wrong in safety because<br />
we’re all human and prone to error.<br />
Inevitably, in any type of operation, some<br />
human, somewhere, is eventually going<br />
to make a human error. That includes<br />
the field of aviation. But it’s for that<br />
very reason that our systems have so<br />
many defences built into them. The<br />
success of these defence systems was<br />
demonstrated in a 27 May 2010 incident<br />
at Singapore’s Changi International<br />
Airport. Several events on the flight<br />
deck of an Airbus A321-231 distracted<br />
the crew during the approach. Their<br />
situational awareness was lost, decision<br />
making was affected and inter-crew<br />
communication degraded.<br />
At 6.45 pm, the aircraft, operating as<br />
Jetstar flight JQ57 from Darwin Airport,<br />
was undertaking a landing. The first<br />
officer (FO) was the pilot flying (PF) and<br />
the captain was the pilot not flying for the<br />
sector. The FO had, on the instructions of<br />
Air Traffic Control, descended to 2,500 ft<br />
and turned onto the designated heading.<br />
The FO disconnected the autopilot.<br />
Immediately, the master warning<br />
continuous chime was activated for<br />
six seconds. An AUTO FLT A/P OFF<br />
message was activated and remained<br />
displayed on the monitor. The FO called<br />
for action, requesting that the captain set<br />
the ‘Go Around Altitude’. However, the<br />
captain was preoccupied with his mobile<br />
phone. The FO set the altitude himself,<br />
but the landing gear was left up, and the<br />
landing checklist was not initiated.<br />
About two minutes later, as they<br />
descended through 750 feet, the<br />
undercarriage was still up. The master<br />
warning chimed and the ‘EGPWS – Too<br />
Low Gear’ alarm sounded, alerting<br />
the crew to the situation. Neither the<br />
captain nor the FO communicated their<br />
intentions to each other—a problem<br />
since the FO perceived that the captain<br />
wanted to land, while the captain had<br />
always intended to go around.<br />
The go-around was completed<br />
successfully, and the aircraft landed<br />
safely, but it could not be considered a<br />
textbook approach.<br />
‘It is not, by any means, an ideal series of<br />
events,’ said ATSB Chief Commissioner,<br />
Martin Dolan. ‘However, the defences<br />
that exist helped to retrieve the situation,<br />
and our investigation did not identify any<br />
organisational or systemic issues that<br />
might adversely impact the future safety<br />
of aviation operations. In addition, the<br />
aircraft operator proactively reviewed<br />
its procedures and made a number of<br />
amendments to its training regime and<br />
other enhancements to its operation.<br />
Everyone has learned valuable lessons<br />
from this.’ •<br />
Proposed changes to reporting<br />
requirements<br />
The ATSB is developing new<br />
regulations for the mandatory<br />
reporting of accidents and incidents,<br />
and confidential reporting of safety<br />
concerns in Australia.<br />
‘This is an important step in the<br />
ongoing development of aviation<br />
safety in Australia,’ said Martin<br />
Dolan, Chief Commissioner of the<br />
ATSB. ‘We have been working with<br />
industry for the last couple of years<br />
to develop these reforms in the<br />
interests of ensuring that reporting<br />
makes the greatest possible<br />
contribution to future safety.’<br />
There are two changes proposed<br />
to the mandatory reporting of<br />
accidents and incidents.<br />
‘The first is that we are proposing to<br />
share with CASA all the mandatory<br />
notifications that we receive,’ said<br />
Mr Dolan. ‘It is a standard practice<br />
around the world for the regulator to<br />
be copied into a notification. In many<br />
countries it is the regulator who<br />
receives the notification in the first<br />
instance. With this change CASA<br />
will be better placed to perform its<br />
safety regulation functions.’<br />
This change will not place any<br />
new burdens or responsibilities on<br />
aviation stakeholders.<br />
The second change will involve<br />
the revision of the existing list of<br />
accidents and incidents that need<br />
to be reported as immediately<br />
reportable and routine reportable<br />
matters.<br />
Mr Dolan says that, ‘The new<br />
system we are working on will be<br />
less prescriptive than it is now. The<br />
requirement to report will be based<br />
around the severity of the risk that<br />
surrounds an occurrence.’<br />
There will also be some changes<br />
made to the Voluntary and<br />
Confidential Reporting (REPCON)<br />
system as a result of the ATSB’s<br />
increased role in rail from 1 January<br />
2013.<br />
‘REPCON will be a multi-modal<br />
scheme covering the aviation,<br />
maritime and rail transport<br />
industries,’ explained Mr Dolan.<br />
‘However, rest assured that the<br />
scheme will continue to give a<br />
high level of protection for people<br />
who submit reports. The priority of<br />
REPCON will always be to provide<br />
a secure avenue for people to share<br />
their concerns while protecting their<br />
identity.’<br />
‘The expansion of REPCON will<br />
enable all three industries to learn<br />
from each other’s experiences.’<br />
The next step for the ATSB will be<br />
reviewing the comments received<br />
from industry, and assessing any<br />
suggestions for integration into the<br />
amendments.<br />
More information will be published<br />
in future editions of Flight Safety<br />
Australia. •
Night flying–make sure you’re qualified<br />
ATSB investigations AO-2011-043 and<br />
AO-2011-087<br />
Two ATSB investigations into fatal<br />
accidents highlight the dangers facing<br />
pilots who fly at night without the<br />
appropriate qualifications.<br />
One accident resulted in the death of a<br />
pilot of a Robinson R22 helicopter. The<br />
other accident involved a Piper Saratoga<br />
PA-32R-301T aircraft, and claimed the<br />
lives of the pilot and three passengers<br />
and left two other passengers seriously<br />
injured.<br />
‘Flying at night presents unique, and<br />
dangerous challenges,’ said Julian Walsh,<br />
General Manager of Strategic Capability<br />
at the ATSB. ‘It is troubling that some<br />
pilots are ignoring their own lack of<br />
qualifications, and putting themselves in<br />
these situations.’<br />
The helicopter accident took place on<br />
27 July 2011, 14 kilometres north-west of<br />
Fitzroy Crossing in Western Australia. The<br />
owner-pilot had departed from the Big<br />
Rock Dam stockyards about half an hour<br />
after sunset on a moonless evening. As<br />
the flight progressed, conditions became<br />
very dark and the pilot was probably<br />
forced to operate using the helicopter’s<br />
landing light. The pilot was attempting to<br />
return to Brookings Spring homestead<br />
at low level in an area without any local<br />
ground lighting.<br />
About halfway into the flight, the pilot<br />
inadvertently allowed the helicopter to<br />
develop a high rate of descent, resulting in<br />
a collision with terrain.<br />
The subsequent investigation found<br />
that the pilot’s licence had not been<br />
endorsed for flight under the night Visual<br />
Flight Rules (VFR). Also, there was no<br />
evidence that the pilot had received any<br />
night flying training, although anecdotal<br />
reports suggested that this was not the<br />
first time the pilot had flown at night. An<br />
examination of the helicopter found no<br />
evidence of any pre-existing defects or<br />
anomalies.<br />
The second aircraft accident happened<br />
in March 2011, at Moree in New South<br />
Wales. The Piper Saratoga was returning<br />
to Moree Airport from Brewarrina Airport<br />
with a pilot and five passengers on board.<br />
R22 helicopter wreckage of VH-YOL<br />
The flight had been conducted under the<br />
night VFR.<br />
The aircraft flew over the airport at about<br />
8.00pm before the pilot conducted a left<br />
circuit for landing. Witnesses observed<br />
the aircraft on a low approach path as it<br />
flew toward the runway during the final<br />
approach leg of the circuit. The aircraft<br />
hit trees and collided with level terrain<br />
about 550 metres short of the runway<br />
threshold.<br />
Although the pilot had a total aeronautical<br />
experience of about 1,010 flying hours, he<br />
did not satisfy the recency requirements<br />
of his night VFR rating. In addition, the<br />
aircraft’s take-off weight was found to be<br />
in excess of the maximum allowable for<br />
the aircraft, reinforcing the importance of<br />
pilots operating their aircraft within the<br />
published flight manual limitations.<br />
‘Flying at night adds a level of complexity<br />
to every development,’ commented Mr<br />
Walsh. ‘If a safety situation arises, the<br />
element of darkness makes it that much<br />
more difficult to react effectively.’<br />
Flying safely at night requires pilots to rely<br />
on well-developed skills that address the<br />
risks that night flight poses. Night recency<br />
requirements, as determined by the Civil<br />
Aviation Safety Authority, are a minimum<br />
standard that assists pilots to identify<br />
and address those risks. Though multiple<br />
factors contributed to both accidents, the<br />
fact that both pilots were flying in night<br />
conditions when they were not properly<br />
qualified to do so demonstrates the<br />
dangers of such practices.<br />
‘If you are going to be flying at night,’<br />
said Mr Walsh, ‘it is vital that you have<br />
received the proper training, and that<br />
your qualifications are up to date.’ The<br />
ATSB takes this issue seriously enough<br />
that the topic of flying at night will be a<br />
future subject for the Avoidable Accidents<br />
series.<br />
The reports are available from the ATSB<br />
website www.atsb.gov.au •
Wirestrikes go unreported<br />
A new research investigation has found<br />
that more than 40 per cent of aviation<br />
wirestrikes that occur in Australia<br />
were not reported to the ATSB. This<br />
investigation commenced following<br />
anecdotal information from stakeholders<br />
who were aware of more wirestrikes<br />
than had been reported.<br />
by electricity distribution companies.<br />
And then there’s the fact that disused<br />
overhead wires are not tracked, so<br />
when they are damaged by an aircraft,<br />
electricity companies aren’t notified.<br />
Finally, there are many private power<br />
lines out there, and we don’t have any<br />
figures for them.’’<br />
‘We’re urging pilots, and all aviation<br />
stakeholders, to report any wirestrike to<br />
the ATSB even if there’s no damage to<br />
the aircraft and/or no injuries. There may<br />
not even be any damage to the wires.<br />
But the more we know, the better we<br />
can do our job, which is to make flying in<br />
Australia safer.’<br />
The report Underreporting of Aviation<br />
Wirestrikes is available on the ATSB<br />
website at www.atsb.gov.au<br />
Notifications of safety related events can<br />
be made via the toll free number<br />
1800 011 034 (available 24/7) or via the<br />
ATSB website. •<br />
Wirestrike<br />
Wirestrikes pose an on-going danger<br />
to Australian aviators. They can happen<br />
to any low-flying aircraft involved in any<br />
operation, such as aerial agricultural,<br />
other aerial work, recreational or scenic<br />
flights. Intrigued by the possibility that<br />
this lack of reporting was common,<br />
the ATSB reached out to electricity<br />
distribution companies, asking for<br />
information. And the electricity<br />
companies delivered.<br />
Before this investigation, 166 wirestrikes<br />
were reported to the ATSB between<br />
July 2003 and June 2011. The new data<br />
from the electricity companies, however,<br />
revealed another 101 occurrences that<br />
had not been reported to the ATSB. At<br />
least 40 percent of the wirestrikes in<br />
Australia had never been formally tallied.<br />
‘And it’s possible that the incidence<br />
of wirestrikes may actually be even<br />
higher,’ said Dr Godley, the ATSB’s<br />
Manager of Research Investigations<br />
and Data Analysis. ‘There are several<br />
reasons for us to believe that. Firstly,<br />
a major telecommunications company<br />
did not have a single repository of this<br />
information to be able to provide the<br />
ATSB with information of wirestrikes on<br />
its network. In addition, not all wirestrikes<br />
result in a broken wire or interrupted<br />
power supply, and so are not recorded<br />
When wildlife strike<br />
Bats and galahs are among the most<br />
common wildlife to be struck by<br />
Australian aircraft according to a new<br />
ATSB research report.<br />
The report provides the most recent<br />
information on wildlife strikes in<br />
Australian aviation. In 2011, there<br />
were 1,751 birdstrikes reported to<br />
the ATSB. Most birdstrikes involved<br />
high capacity air transport aircraft.<br />
For high capacity aircraft operations,<br />
reported birdstrikes have increased<br />
from 400 to 980 over the last<br />
10 years of study, and the rate per<br />
aircraft movement also increased.<br />
For aeroplanes, takeoff and landing<br />
was the most common part of a<br />
flight for birdstrikes. Helicopters<br />
sustained strikes mostly while<br />
parked on the ground, or during<br />
cruise and approach to land.<br />
Birdstrikes were most common<br />
between 7.30 am and 10.30 am with<br />
a smaller peak in birdstrikes between<br />
6pm and 8pm, especially for bats.<br />
All major airports, except Hobart and<br />
Darwin, had high birdstrike rates per<br />
aircraft movement in the past two<br />
years compared with the average<br />
for the decade. Avalon Airport had a<br />
relatively small number of birdstrikes.<br />
But, along with Alice Springs, Avalon<br />
had the largest strike rates per<br />
aircraft movement for all towered<br />
aerodromes in the past two years.<br />
In 2010 and 2011, the most common<br />
types of wildlife struck by aircraft<br />
were bats/flying foxes, galahs, kites<br />
and lapwings/plovers. Galahs were<br />
more commonly involved in strikes<br />
of multiple birds.<br />
Animal strikes were relatively rare.<br />
The most common animals involved<br />
were hares and rabbits, kangaroos<br />
and wallabies, and dogs and foxes.<br />
Damaging strikes mostly involved<br />
kangaroos, wallabies and livestock.<br />
The report is a reminder to everyone<br />
involved in the operation of aircraft<br />
and aerodromes to be aware of the<br />
hazards posed to aircraft by wildlife.<br />
While it is uncommon for a birdstrike<br />
to cause any harm to aircraft crew<br />
and passengers, many strikes<br />
result in damage to aircraft. Some<br />
birdstrikes have resulted in forced<br />
landings and high speed rejected<br />
takeoffs.<br />
Timely and thorough reporting of<br />
birdstrikes is vital. The growth of<br />
reporting to the ATSB seen over<br />
the last 10 years has helped us to<br />
understand better the nature of<br />
birdstrikes, and where the major<br />
safety risks lie. This helps everyone<br />
in aviation to manage their safety<br />
risks more effectively.<br />
The report Australian aviation wildlife<br />
strike statistics: Bird and animal<br />
strikes 2002 to 2011 is available for<br />
free on www.atsb.gov.au •
REPCON BRIEFS<br />
Australia’s voluntary confidential aviation reporting scheme<br />
REPCON allows any person who has an aviation safety concern to report it to the ATSB<br />
confidentially. All personal information regarding any individual (either the reporter or any<br />
person referred to in the report) remains strictly confidential, unless permission is given by<br />
the subject of the information.<br />
The goals of the scheme are to increase awareness of safety issues and to encourage<br />
safety action by those best placed to respond to safety concerns.<br />
Ambiguous procedures<br />
for missed approach<br />
Report narrative:<br />
The reporter raised a safety concern about<br />
the ambiguity that lies within the rules<br />
surrounding the turn onto any missed<br />
approach with the wording ‘Track XXX ‘<br />
and the missed approach point defined<br />
by a radio aid. The concern is, should a<br />
pilot turn the aircraft so as to make good a<br />
track of XXX, or should the pilot intercept<br />
the radial XXX outbound from the missed<br />
approach point. The rules do not specify<br />
one way or the other.<br />
Responses/received:<br />
The following is a version of Airservices<br />
Australia’s response:<br />
Departure and Approach Procedures<br />
(DAP)<br />
Airservices Australia’s DAP, page 1-1,<br />
paragraph 1-7 states:<br />
‘All procedures depict tracks, and pilots<br />
should attempt to maintain the track by<br />
applying corrections to heading for known<br />
or estimated winds.’<br />
Aeronautical Information Publication<br />
In addition, the Australian Aeronautical<br />
Information Publication (AlP), paragraph 1.1<br />
0.2 refers to a missed approach conducted<br />
from overhead a navigation facility:<br />
In executing a missed approach, pilots<br />
must follow the missed approach<br />
procedure specified for the instrument<br />
approach flown. In the event that a missed<br />
approach is initiated prior to arriving at the<br />
MAPT [Missed Approach Point], pilots<br />
must fly the aircraft to the MAPT and then<br />
follow the missed approach procedure.<br />
The MAPT in a procedure may be:<br />
a. the point of intersection of an electronic<br />
glide path with the applicable DA; or<br />
b. a navigation facility; or<br />
c. a fix; or<br />
d. a specified distance from the Final<br />
Approach Fix (FAF).<br />
Application<br />
Airservices Australia considers there are<br />
generally two different scenarios when<br />
conducting a missed approach and these<br />
are described, in general terms, as text on<br />
the DAP plate as follows:<br />
1. Turn Left (or Right), Track xxx°, Climb to<br />
xxxxft<br />
Tracking is made without reference to<br />
the Navaid and the expectation is that<br />
the pilot will use Dead Reckoning (DR) to<br />
achieve the nominated track. Allowance<br />
for wind must be included to make good<br />
this nominated track. A Navaid may<br />
be used to supplement track keeping<br />
during the missed approach when it is<br />
a straight continuation of the final track,<br />
however guidance is not mandatory. Most<br />
procedures in Australia that have been<br />
designed with a navigation facility utilise<br />
DR navigation in the missed approach<br />
segment. The area of consideration when<br />
designing an instrument approach and<br />
landing procedure is larger for DR tracks<br />
than those assessed when a navigation<br />
aid is used.<br />
2. Turn Left (or Right), Intercept xxx° xx NDB<br />
(or VOR), Climb to xxxxft<br />
Tracking is made with reference to the<br />
Navaid and the expectation is that the pilot<br />
will make an interception of the nominated<br />
track. Where an intercept is required it will<br />
be both stated and shown in diagram on<br />
the procedure plate. As an example, refer<br />
to the approach chart for Cairns ND8-8 or<br />
VOR-8.<br />
The missed approach instruction states,<br />
‘At the NDB or VOR, Turn Left to intercept<br />
040° CS VOR or NDB. Climb to 4000ft<br />
or as directed by ATC.’ This is displayed<br />
diagrammatically on the procedure plate.<br />
The primary reason is to avoid critical<br />
terrain located near or within the splay<br />
tolerance area. The use of the navigation<br />
facility can significantly reduce this area<br />
compared to a DR track and also provides<br />
situational awareness to pilots and ATC<br />
as to where the aircraft will be during that<br />
phase of flight. If a pilot does not intercept<br />
the radial/bearing, the aircraft may not<br />
be contained within the splay protection<br />
area and result in the aircraft not clearing<br />
an obstacle by the required minimum<br />
obstacle clearance.<br />
ATSB comment:<br />
Enquiries conducted by the REPCON<br />
Office have revealed a different<br />
perspective between ATC and flight crews<br />
in respect of how missed approaches<br />
should be conducted from overhead an aid<br />
(NDB/VOR).<br />
The ATSB provided a number of<br />
suggestions to CASA that may assist in<br />
removing the ambiguities relating to the<br />
missed approach procedure, particularly<br />
where the MAPT is overhead an aid.<br />
The following is a version of the response<br />
that CASA provided:<br />
CASA has reviewed this matter internally<br />
with subject matter experts and considers<br />
that Airservices Australia’s comment<br />
is accurate in that it reflects the way<br />
procedure designers design these types of<br />
missed approach procedures. That there<br />
seems to be misunderstanding within<br />
industry suggests a need to explain this<br />
reasoning in the Aeronautical Information<br />
Publication. CASA will be generating a<br />
Request for Change (RFC) to the AlP. This<br />
should ensure that pilots are provided with<br />
a greater level of information regarding a<br />
missed approach. The AlP change will be<br />
coordinated with Airservices.<br />
How can I report to REPCON?<br />
Online:<br />
www.atsb.gov.au/voluntary.aspx
58<br />
FEATURE<br />
Air Blue Flight 202<br />
Pride before a<br />
Macarthur Job looks at how<br />
an A321, minutes away from<br />
touchdown, crashed into the<br />
Margalla Hills<br />
Captain Pervez Iqbal Chaudhary’s last day on earth did not begin<br />
well. The investigation report published after his death noted that<br />
while programming the flight management system for Air Blue Flight<br />
202, he appeared to be confusing the destination, Islamabad, with<br />
the origin, Karachi.<br />
Flight 202 took off at 7.41am on July 28 2010. The aircraft was an<br />
Airbus Industrie A321, built in 2000, with just over 16,000 hours<br />
of service. It had been serviced that day, with no defects recorded.<br />
The cockpit voice<br />
recorder, recovered<br />
scorched but<br />
intact a few days<br />
later, revealed<br />
an aggressive<br />
interrogation<br />
that continued at<br />
intervals for about<br />
an hour<br />
During climb, and contrary to company procedures, the highly<br />
experienced Captain Chaudhary chose to examine the knowledge<br />
of the comparatively junior first officer in a harsh and overbearing<br />
manner. The cockpit voice recorder, recovered scorched but intact<br />
a few days later, revealed an aggressive interrogation that continued<br />
at intervals for about an hour. First officer Muntajib Ahmed had<br />
been an F-16 pilot in the Pakistan Air Force, but under Chaudhary’s<br />
verbal assault he ‘remained subdued, appearing under-confident<br />
and submissive,’ the Pakistan Civil Aviation Authority report said.<br />
About 155nm from Islamabad, the crew selected the automatic<br />
terminal information service frequency, and learned that the duty<br />
runway was runway 12. The captain also checked the weather<br />
conditions at Peshawar and Lahore. Finding them anything but<br />
encouraging, he appeared to become apprehensive.
Flight Safety Australia<br />
Issue 87 July–August 2012<br />
59<br />
The single runway at Islamabad Airport is oriented 12-30.<br />
Approach procedures are for ILS, DME, VOR and straight-in<br />
approaches to runway 30, and a circling approach to land on<br />
runway 12. There are two prohibited areas in the vicinity, one to<br />
the south-west and another to the north-east, and a hilly area to<br />
the north-east of the airport.<br />
As the aircraft neared Islamabad, the crew realised that, after<br />
making an instrument descent on the ILS for runway 30, they<br />
would be required to execute a visual circling approach to<br />
runway 12. Becoming increasingly worried about poor weather<br />
and low cloud, the captain called Islamabad Approach to<br />
request a right-hand, downwind visual approach to the runway.<br />
The radar controller refused this, because of ‘procedural<br />
limitations’.<br />
The captain then decided to fly the circling approach in<br />
navigation mode, and the aircraft began descending at 8.58am.<br />
Shortly afterwards, the radar controller informed the aircraft to<br />
‘expect arrival to ILS, runway 30, circle to land runway 12’.<br />
The first officer then asked Approach if they could now<br />
be cleared to a ‘right downwind runway 12 for the approach’.<br />
This time the controller responded:<br />
‘Right downwind runway 12 is not available at<br />
the moment because of low clouds’.<br />
Acknowledging, the captain responded: ‘we understand right<br />
downwind is not available—it will be ILS down to minima and<br />
then left downwind—OK?’ The crew then discussed a waypoint<br />
five nm to the north-east of the runway, on a radial 026 from<br />
the runway 12 threshold. Discussion followed on another<br />
intended waypoint.<br />
At 9.34am, with the A321 now down to an altitude of 4300ft, the<br />
radar controller cleared it to descend to 3900ft in preparation for<br />
intercepting the ILS for runway 30, to be followed by a circling<br />
approach to land on runway 12. Two minutes later, at an altitude<br />
of 3700ft, the aircraft became established on the ILS with both<br />
autopilots engaged, and the crew extended the undercarriage.<br />
Now in contact with the control tower, the crew again asked:<br />
‘How’s the weather for a right downwind?’ The tower controller<br />
responded that a right downwind was not available—only a left<br />
downwind for runway 12.<br />
It was the captain’s intention to descend to 2000ft on the ILS,<br />
(little more than 300 feet above the runway altitude of 1688ft)<br />
but the first officer reminded him that 2500ft was minimum<br />
descent altitude.<br />
The crew levelled out at 2500ft, disengaged no. 2 autopilot, and<br />
with only no. 1 autopilot engaged, continued to fly the aircraft<br />
on the runway heading to the VOR.<br />
The crew’s intended break-off to the right from the ILS approach<br />
to fly the right downwind circuit was delayed because they had<br />
not become visual in the poor visibility. Meanwhile, the tower’s<br />
confirmation that an aircraft of a competing airline had just landed<br />
safely (albeit on the third attempt) put the captain under more<br />
pressure to complete his approach and landing.<br />
Almost immediately the aircraft broke out of cloud, and the tower<br />
instructed the crew to report when established on a left downwind<br />
for runway 12. Seconds later, passing over the VOR, 0.8km short<br />
of the runway 30 threshold, the crew turned the aircraft to the right<br />
on the autopilot, and very shortly afterwards lowered the selected<br />
altitude to 2300ft, presumably in an effort to remain visual in the<br />
poor conditions. The aircraft began descending again, violating the<br />
minimum descent altitude.<br />
The tower controller now suggested to the captain that he fly a<br />
bad weather circuit, but the captain ignored this transmission,<br />
commenting to the first officer: ‘Let him say whatever he wants<br />
to say’. It was evident that the captain had already decided to fly a<br />
‘managed approach’, using waypoints unknown to Islamabad Air<br />
Traffic Control.<br />
Although the captain had said he would fly the circling approach in<br />
the navigation mode, the aircraft was still in the heading mode. The<br />
first officer pointed this out, saying: ‘OK sir, but are you visual?’<br />
The captain replied, ‘Visual! OK’.<br />
While planning for his intended approach pattern, the captain told<br />
the first officer where in the circuit he was to extend the flaps.<br />
At 9.39am, when the aircraft was more than 3.5nm from the
60<br />
FEATURE<br />
Air Blue Flight 202<br />
runway centreline, and abeam the threshold of runway 12<br />
on a heading of 352 degrees, the crew turned the aircraft left<br />
onto 300 degrees through the autopilot, and the autopilot was<br />
reselected to navigation mode.<br />
A minute later, when the aircraft was one nm to the south of a<br />
prohibited area, the tower controller instructed the crew to turn<br />
left in order to avoid entering the no-fly zone. Shortly afterwards,<br />
with the aircraft now five nm to the north of the airport, the<br />
aircraft’s ground proximity warning system enunciated:<br />
‘TERRAIN AHEAD’! The first officer urged: ‘Sir! Higher ground<br />
has been reached! Sir, there is terrain ahead! Sir, turn left’!<br />
By this time the captain was displaying frustration, confusion<br />
and some anxiety, his speech indicating that he was<br />
becoming rattled.<br />
At 9.40am, the tower controller asked the crew if they were<br />
visual with the airfield. The crew did not respond to the<br />
transmission, the first officer asking the captain: ‘What should<br />
I tell him, sir?’<br />
At the insistence of the radar controller, the tower controller<br />
then asked the crew again if they were visual with the ground.<br />
Both the captain and the first officer said they were. Then<br />
again the first officer exclaimed: ‘Sir! Terrain ahead is coming!’<br />
The captain replied: ‘Yes, we are turning left.’<br />
But the aircraft was not turning. At the same time, two more<br />
‘TERRAIN AHEAD’ enunciations sounded. In his increasingly<br />
flustered state, and trying to turn the aircraft to the left on the<br />
autopilot, the captain was moving the heading bug onto reduced<br />
headings, but failing to pull out the heading knob to activate<br />
change, as required with the autopilot in navigation mode.<br />
Forty seconds before impact, the autopilot mode was changed<br />
from ‘navigation’ to ‘heading’. At this stage, the aircraft’s<br />
heading was 307 degrees, but the captain had reduced the<br />
selected heading to 086 degrees. As a result, the aircraft<br />
immediately started to turn the shortest way towards this<br />
heading, in this case to the right, towards the Margalla Hills.<br />
From that time on, more ground proximity warning system callouts,<br />
‘TERRAIN AHEAD, ‘TERRAIN AHEAD, PULL UP!’ began<br />
sounding, continuing until impact.<br />
Meanwhile, the first officer called out twice in an alarmed voice,<br />
‘Sir turn left! Pull up! Sir, sir, pull up!’ In response, the thrust<br />
levers were advanced, the autothrust disengaged, the selected<br />
altitude was changed to 3700ft and the aircraft began climbing,<br />
still turning right. Seconds later the thrust levers were retarded<br />
to the climb detent, the autothrust re-engaged in the climb<br />
mode, and the selected altitude reduced to 3100ft.<br />
The first officer called out yet again, ‘Sir—pull up, sir!’ and the<br />
no. 1 autopilot was disconnected, with the aircraft still rolling 25<br />
degrees to the right. The captain then applied full left stick with<br />
some left rudder. The aircraft began turning left at an altitude of<br />
2770ft and increasing.<br />
In the last few seconds of the flight, the captain applied more<br />
than 50 degrees of bank to increase the turn, also making<br />
some nose-down inputs. The aircraft pitched down nearly five<br />
degrees. As its speed increased, the auto thrust spooled down<br />
the engines, and the aircraft began descending at a high rate.<br />
Although the first officer again shouted, ‘Terrain sir’ and the<br />
captain started to make pitch-up inputs, the high rate of descent<br />
could not be arrested in time. For the last time, the first officer<br />
called out: ‘Sir we are going down ... Sir we are going d...’<br />
Seconds after 9.41am, in a slightly nose-down attitude and<br />
a steep left bank, the aircraft flew into the Margalla Hills at an<br />
elevation of 2858ft. Its rate of descent was more than 3000ft<br />
per minute. The aircraft was completely destroyed and all 152<br />
people on board were killed instantly.<br />
The weather at Islamabad Airport at the time of the crash<br />
was three octas of cumulus cloud at 1000ft, four octas<br />
of stratocumulus at 3000ft and seven octas of altostratus<br />
at 10,000ft, with a visibility of 3.5km. The wind from 050<br />
degrees was 16kt. The temperature was 24 degrees C and rain<br />
was likely.<br />
There was also a weather warning, valid to 12 noon, for<br />
thunderstorms and rain for 50 miles around, and for south-east<br />
to north-east winds at 20 to 40kt, gusting up to 65kt or more.<br />
Visibility could reduce to one kilometre or less in precipitation.<br />
Moderate to severe turbulence could occur in 1-2 octas of<br />
cumulonimbus at 3000ft.<br />
Findings<br />
The captain’s behaviour towards the first officer was harsh,<br />
snobbish and contrary to established norms. This curbed<br />
the first officer’s initiative, created a tense environment, and<br />
a conspicuous communication barrier.<br />
The captain seemed determined to make a right-hand<br />
downwind approach to runway 12, despite his knowledge<br />
that Islamabad procedures did not permit this, and there<br />
was low cloud in the area.<br />
Contrary to established procedures for circling to land<br />
on runway 12, the captain elected to fly the approach in<br />
the navigation mode and asked the first officer to feed<br />
unauthorised waypoints into the flight management system.<br />
The first officer did not challenge his instructions.
Flight Safety Australia<br />
Issue 87 July–August 2012<br />
61<br />
The intention of the captain to fly this type of<br />
approach was not known to air traffic control.<br />
His violation of established procedure took the<br />
aircraft beyond the protected area.<br />
The captain exhibited anxiety, confusion and<br />
geographical disorientation, particularly after<br />
commencing descent.<br />
After a delayed break-off from the ILS because of<br />
poor visibility, the captain turned right, but did not turn<br />
left to parallel the runway.<br />
While flying the northerly heading, the captain descended<br />
below the MDA to 2300ft. This time the first officer<br />
did not challenge him. The captain also failed to<br />
maintain visual contact with the airfield.<br />
The tower controller could not see the aircraft on<br />
downwind or final legs, and sought radar help. The<br />
aircraft was identified close to the no-fly zone and was<br />
instructed to turn left.<br />
When the tower asked the crew if they had contact with<br />
the airfield, the first officer’s question to the captain, ‘What<br />
should I tell him, sir?’ indicated a possible loss of visual<br />
contact, as well as geographical disorientation.<br />
the aircraft’s ground proximity<br />
warning system enunciated:<br />
‘TERRAIN AHEAD’!<br />
The first officer urged: ‘Sir! Higher<br />
ground has been reached!<br />
Sir, there is terrain<br />
ahead! Sir, turn left’!<br />
The crew took the aircraft out of the protected area, 7.3nm<br />
from the runway 12 threshold.<br />
During the last 70 seconds of the flight, despite calls from<br />
the tower, the GPWS sounding ‘Terrain ahead’ 21 times,<br />
‘Pull up’ 15 times, and seven warnings from the first officer,<br />
the captain did not pull up.<br />
The first officer did not assert himself as he watched the<br />
captain’s steep banks, continued flight into hilly terrain at<br />
low altitude in poor visibility, and failure to pull up.<br />
Conclusion<br />
The accident was primarily caused by the crew’s violation of<br />
all established procedures for a visual approach to runway 12,<br />
their disregard of several calls by air traffic controllers, and of<br />
21 GPWS warnings of rising terrain.<br />
The official investigation termed the crash ‘a classic CRM<br />
failure’. Why this failure occurred is unclear; Captain<br />
Chaudhary’s motivation and state of mind remain unknown.<br />
The investigation declared: ‘Both the crew members were …<br />
medically fit to undertake the flight on 28 July 2010.’ However,<br />
unconfirmed reports appearing in Pakistani newspapers in<br />
2011 said that Chaudhary had been treated in hospital for<br />
diabetes, hypertension and cardiac problems.
62<br />
FEATURE<br />
Fly neighbourly<br />
WATCH OUT WHALES ABOUT!<br />
The majestic<br />
spectacle of<br />
seeing some of<br />
the world’s largest<br />
mammals from the<br />
air is one of the<br />
moments when all<br />
the hassles and<br />
expense of owning<br />
an aircraft seem<br />
a small price to<br />
pay for a moment<br />
of magic. But<br />
there are simple<br />
commonsense<br />
rules for aerial<br />
whale watchers<br />
to obey.<br />
From May to November whales migrate along the<br />
Australian coastline, often with new calves, and<br />
your aircraft’s speed, noise, shadow or downdraft can<br />
cause them considerable distress.<br />
For the safety of the mammals and the public, laws<br />
for approaching whales (and dolphins) from above are<br />
enforceable over both state and commonwealth waters.<br />
During the 2012 whale migration season, Operation<br />
Cetus will again be active across Australia and New<br />
Zealand. It will conduct joint federal, state and national<br />
ocean patrols to protect whales, monitor flights over<br />
them and educate the public about whale approach<br />
laws. In 2011, Operation Cetus patrols detected<br />
over 45 alleged offences involving over-enthusiastic<br />
whale watchers or operators, with 33 requiring<br />
further investigation.<br />
As a pilot, it is your job to spot and navigate around a<br />
whale’s position and movements, and to ensure that<br />
your aircraft maintains the minimum whale approach<br />
distances throughout the flight.<br />
Whale approach laws vary between coastal areas and<br />
you are responsible for checking the regulations and<br />
guidelines specific to the waters you are flying over.<br />
Some of these include:<br />
aircraft (including gliders, airships and balloons,<br />
but not helicopters) must not fly lower than 1000ft<br />
within a 300m radius of a whale<br />
helicopters (including gyrocopters) must not fly<br />
lower than 1650ft within a 500m radius of a whale<br />
helicopters must not hover over the no-fly zone<br />
no aircraft of any type is permitted to approach<br />
a whale head-on<br />
no aircraft of any type is permitted to land on<br />
water to watch whales<br />
if a whale shows any sign of disturbance you<br />
must cease your approach and alter your flight<br />
path immediately.<br />
These regulations also apply to dolphins.<br />
Signs of disturbance<br />
The following reactions may indicate that a whale or<br />
dolphin is disturbed:<br />
attempts to leave the area, or avoid the vessel<br />
(quickly or slowly)<br />
regular changes in direction or speed of swimming<br />
hasty dives<br />
changes in breathing patterns<br />
increased time spent diving, compared to time<br />
spent at the surface<br />
changes in acoustic behaviour<br />
aggressive behaviours, such as tail slapping and<br />
trumpet blows.<br />
It is very important to be able to recognise some general<br />
behaviours of cetaceans that may be related to distress,<br />
fear, or disturbance. In such cases cetaceans should<br />
be left alone, and it is vital to immediately move out of<br />
the area:<br />
Blowing air underwater should be taken as a<br />
warning sign<br />
Lobtailing (tail slapping) and tail sweeping<br />
Anomalous dive sequences and unusually prolonged<br />
dives with substantial horizontal movements.<br />
Remember that you should never chase cetaceans.<br />
It is always better to have an expert on board because<br />
distress signs are not always easy to recognise.<br />
For a complete list of whale approach laws visit<br />
environment.gov.au/whales To report an incident<br />
email compliance@environment.gov.au or call<br />
1800 110 395
Flight Safety Australia<br />
Issue 87 July–August 2012<br />
63<br />
500m/1650ft<br />
300m/1000ft<br />
photo: Shutterstock
64<br />
FEATURE<br />
Hazard ID<br />
continued from page 28<br />
The following scenario illustrates a day in the life of City Air,<br />
a fictitious airline.<br />
City Air has recently rolled out the latest version of its SMS<br />
course to operational staff. The course included a module<br />
on hazard identification: what hazards are, how to identify<br />
them, and how and when to report them. It also talked about<br />
the risk assessment process the airline followed and its<br />
feedback process to those who submitted the hazard incident<br />
report. All these are crucial for supporting the safety culture<br />
of the organisation and improving staff engagement with, and<br />
commitment to, the safety reporting system.<br />
As you read through the scenario note down your thoughts,<br />
identify the hazards and help staff improve safety at City Air.<br />
In the next issue of Flight Safety Australia we will follow up on<br />
any reader feedback. The following questions could assist you:<br />
What are the hazards in the scenario?<br />
Should they be reported and why?<br />
Will they assist in improving safety at City Air?<br />
Scenario<br />
Note: The characters and airline in the story are fictional.<br />
The stories have been compiled from data and experiences<br />
from different situations, airlines and countries, and are not<br />
a reflection of any particular airline.<br />
At check-in<br />
Tuesday morning appears to be a regular working day for<br />
ground staff at the City Airport. Check-in opens on time and<br />
passengers are ready to check in or drop their bags off.<br />
At counter one, passenger Sarah presents her cabin bag to the<br />
agent. It appears to be larger than the size accepted as cabin<br />
baggage. The check-in agent asks Sarah to put the bag in the<br />
cabin baggage test unit next to the counter, but then realises<br />
there is no test unit nearby. Sarah refuses to check the bag in<br />
and leaves for the boarding gate.<br />
At counter four, the check-in agent hears that passenger Gary<br />
is going camping and has a small gas burner in his cabin<br />
baggage. The check-in agent tells Gary he is unable to take the<br />
burner on board, or pack it in his checked-in luggage, because<br />
it is a dangerous goods item.<br />
While Dianne checks in at counter four she is talking to her<br />
travel companion and mentions the quality of the bathroom<br />
cleaner she has packed, which will easily remove the stains<br />
on the tiles of her beach house. The agent overhears the<br />
conversation and explains to the passengers that cleaning<br />
agents are considered dangerous goods and Dianne will not<br />
be able to check in her bag until she has removed the cleaner<br />
from it.<br />
At counter two, 11-year-old Patrick and his little sister Jane<br />
(five years old) have just turned up on their own. They explain<br />
that their grandmother is parking the car and will be in the<br />
terminal shortly, but they are flying back home without her.<br />
When the check-in agent looks up the children’s details<br />
on the computer, he notices that they are not identified as<br />
‘unaccompanied minors’ in the reservations system.<br />
At the gate<br />
At gate one, Anna approaches the gate agent and asks if<br />
she can change her seat allocation. The seat she has been<br />
allocated is in the emergency exit row and she thinks it will<br />
not recline. The agent makes the change, expecting the seat<br />
to be filled by another passenger because check-in is open<br />
for another 15 minutes.<br />
Boarding has commenced at gate three. The agent at the<br />
gate notices passenger Robert carrying what appears to be<br />
a small suitcase with a cover. When the agent sees Robert’s<br />
boarding pass she notices that he has used web check-in<br />
and decided to ask him if he is carrying anything particular<br />
in the suitcase. Robert explains that it is an oxygen cylinder<br />
he carries because of a respiratory condition. The agent asks<br />
Robert to show her the oxygen cylinder, and also if she can<br />
see a medical certificate permitting him to travel on an aircraft.<br />
She notices that the oxygen bottle is a brand listed in the<br />
dangerous goods manual, but after seeing Robert’s medical<br />
certificate allows him to board the aircraft. However, the gate<br />
agent then realises she has never actually seen an oxygen<br />
bottle that could be transported as cabin baggage.<br />
On the tarmac<br />
While a City Air staff member is marshalling passengers onto<br />
an aircraft via the tarmac she notices a teenage passenger<br />
using her mobile phone. When the staff member approaches<br />
her, passenger Victoria explains she was texting her mother to<br />
tell her that the flight was about to depart. Victoria also says<br />
that because she was using earphones, she had not heard the<br />
boarding announcement at the gate telling passengers to turn<br />
off mobile phones before walking on to the tarmac. Victoria<br />
turns her mobile phone off and boards the aircraft.<br />
At bay 6, ramp staff are handling an aircraft that is due to<br />
depart in 35 minutes. One of the tug drivers drops off two<br />
barrows at bay 6, on his way to the baggage room. As he<br />
approaches the taxiway crossing, he receives a radio call.<br />
He answers it and talks for what seems to be about 30<br />
seconds, taking his eyes off the road. After the conversation<br />
he lifts his head and sees an aircraft taxiing in front of his tug.
Flight Safety Australia<br />
Issue 87 July–August 2012<br />
65<br />
CANBERRA ² BRISBANE<br />
CBR ² BNE<br />
FLIGHT<br />
FSA87<br />
BOARDING TIME<br />
2030<br />
GATE<br />
8<br />
SEAT NO.<br />
12B<br />
PASSENGER<br />
CITIZEN / JOHN MR<br />
FLIGHT<br />
FSA87<br />
On board<br />
Almost all the passengers have boarded the aircraft departing<br />
from gate one. Sarah is trying to make her sports bag fit in the<br />
overhead locker. There is no room for the bag, so she presses<br />
the call button. One of the cabin crew comes over to help her<br />
and says that the sports bag is too big and heavy and should<br />
have been checked in. Sarah agrees and the bag is taken by<br />
one of the ground staff.<br />
John and his wife Claire realise they have left vital medications<br />
at home and will have to disembark. They tell ground staff they<br />
have checked in four bags, so these have to be offloaded. It<br />
takes more than half an hour for ramp staff to find the bags. An<br />
executive sitting in the emergency row with his wife decides<br />
that they also have to disembark because he will not make<br />
it to his meeting. The emergency exit row is now empty and<br />
according to the airline’s policy at least two passengers need<br />
to sit in that row, so they can help to open the over-wing exits<br />
in an emergency. The cabin crew now have to find suitable<br />
passengers to sit in the exit row. All this causes another<br />
15-minute delay.<br />
Preparation for take-off<br />
The last door on the delayed flight at gate one is closed and<br />
the cabin crew are securing the cabin for take-off. The safety<br />
demonstration has finished and the crew are walking to their<br />
seats. A passenger is talking on his mobile phone. The cabin<br />
crew ask him to turn it off. In the meantime, another passenger<br />
stands up and starts to walk to the toilet. Cabin crew remind<br />
the passenger that the seatbelt sign is on, so she has to<br />
stay seated.<br />
The young passenger returns to her seat and apologises,<br />
saying that she had been listening to music during the safety<br />
demonstration and that this was the first time she had ever<br />
been on an aircraft.<br />
In the next edition of Flight Safety we will discuss some of the<br />
hazards that can be identified in the above scenario. We will<br />
talk about why they needed to be reported and what possible<br />
consequences they could have for the safety of City Air.<br />
Remember that all reported hazards are important data for<br />
your SMS. They should all be reported, even if the problem<br />
can be fixed on the spot.<br />
The eleven basic risk factors (BRFs)<br />
1. Hardware<br />
2. Design<br />
3. Maintenance management<br />
4. Procedures<br />
5. Error-enforcing conditions<br />
6. Housekeeping<br />
7. Incompatible goals<br />
8. Communication<br />
9. Organisation<br />
10. Training<br />
11. Defences<br />
For more information<br />
ICAO Doc 9859. AN/474 Safety Management Manual<br />
(SMM) Second edition, ICAO (2009), Montreal, Canada<br />
ICAO Doc 9859. AN/474 Safety Management Manual<br />
(SMM) Third edition, ICAO (2012) is due for release shortly<br />
SMS for aviation: a practical guide. CASA resource kit,<br />
due mid-July 2012.
66<br />
AV QUIZ<br />
Flying ops | Maintenance | IFR operations<br />
FLYING OPS<br />
1. Fog formation of significance to aviation becomes<br />
more likely:<br />
a) as the ambient temperature approaches the dew<br />
point, particularly if there is a light surface wind to<br />
promote mixing.<br />
b) as the ambient temperature approaches the dew point,<br />
particularly if there is no wind.<br />
c) as the dew point depression decreases, particularly if<br />
there is no wind.<br />
d) as the dew point depression increases, particularly if<br />
there is a light wind to promote mixing.<br />
2. At the leading edge of a cold front, the atmosphere is:<br />
a) unstable, because the temperature decreases rapidly<br />
with increasing height.<br />
b) unstable, because the temperature increases rapidly<br />
with increasing height.<br />
c) stable, because the temperature increases rapidly<br />
with increasing height.<br />
d) stable, because the temperature decreases rapidly<br />
with increasing height.<br />
3. In a continuous-flow fuel-injected piston engine, one<br />
function of the fuel manifold valve assembly is to:<br />
a) time the delivery of fuel to the appropriate cylinder<br />
during engine operation.<br />
b) provide a positive fuel shut-off to the fuel nozzles<br />
during engine shutdown.<br />
c) compensate for air density.<br />
d) compensate for ambient air pressure and temperature.<br />
4. With reference to helicopter operation, a vortex ring<br />
state is:<br />
a) a lenticular rotating air mass at the top of an obstacle in<br />
the presence of a strong wind.<br />
b) a rotating air mass in the lee of an obstacle in the<br />
presence of a strong wind.<br />
c) a stable state that occurs when a helicopter is<br />
moving rapidly forward and the main rotor downwash<br />
recirculates through the rotor.<br />
d) a hazardous condition in helicopter flight usually<br />
associated with a high rate of descent, a comparatively<br />
low airspeed, a relatively high power setting and the<br />
main rotor downwash recirculating through the rotor.<br />
5. Autokinesis is:<br />
a) an illusion where a point source of light in a dark<br />
environment appears to move.<br />
b) a sensation of pitching nose-down during acceleration.<br />
c) a false sensation that an aircraft is banked.<br />
d) a false turning sensation.<br />
6. An anti-servo tailplane is one where:<br />
a) a small trim tab is moved in order to move the<br />
main tailplane.<br />
b) there is one fixed surface and two moving aerofoil<br />
surfaces.<br />
c) a small trim tab moves to oppose the movement of<br />
the main stabilator.<br />
d) a small trim tab moves to assist the movement of<br />
the main stabilator.
Flight Safety Australia<br />
Issue 87 July–August 2012<br />
67<br />
7. If a pilot permits the elevator to move after tailwheel<br />
contact when a tailwheel aircraft bounces during<br />
landing, any resultant movement of the elevator:<br />
a) will always be upwards, thus reducing the<br />
subsequent bounce.<br />
b) will always be upwards, thus increasing the<br />
subsequent bounce.<br />
c) will always be downwards, reducing the<br />
subsequent bounce.<br />
d) will always be downwards, contributing to the<br />
subsequent bounce.<br />
8. During flight, pilots must maintain a time reference<br />
that is accurate to within:<br />
a) ± 2 minutes and is powered independently of the<br />
aircraft electrical system.<br />
b) ± 2 minutes.<br />
c) ± 30 seconds.<br />
d) ± 15 seconds<br />
9. In aircraft design, longitudinal stability can be<br />
achieved by:<br />
a) designing a greater incidence on the tail plane than<br />
on the main plane.<br />
b) designing a lesser incidence on the tail plane than<br />
on the main plane.<br />
c) washout on the main plane.<br />
d) dihedral on the main plane.<br />
10. A GNSS satellite transmits on two frequencies:<br />
a) in order to correct for ionospheric propagation<br />
delay of the signal.<br />
b) in order to provide redundancy.<br />
c) to split the data from the identification component.<br />
d) to achieve selective availability.<br />
MAINTENANCE<br />
1. The FAR 23 requirement for fuel pump delivery<br />
capability is a minimum of:<br />
a) 125 per cent of the maximum fuel flow required by the<br />
engine at take-off power.<br />
b) 150 per cent of the maximum fuel flow required by the<br />
engine at take-off power.<br />
c) 175 per cent of the maximum fuel flow required by the<br />
engine at take-off power.<br />
d) 200 per cent of the maximum fuel flow required by the<br />
engine at take-off power.<br />
2. During starting of an engine with a Hall-effect ignition<br />
system, a common method of retarding the spark is to:<br />
a) initiate the spark from the leading edge of the<br />
timing pulse.<br />
b) initiate the spark from the trailing edge of the<br />
timing pulse.<br />
c) provide a second distributor cam for starting.<br />
d) close the point gap.<br />
3. On a turbocharged piston engine, the upper deck<br />
pressure is the pressure of the air:<br />
a) at the turbine inlet.<br />
b) leaving the intercooler.<br />
c) leaving the turbo compressor outlet.<br />
d) in the cooling air plenum chamber above the cylinders.<br />
4. A recent Airworthiness Bulletin (AWB 27-001 issue 3)<br />
concerning corrosion of stainless steel control cable<br />
fittings recommends a:<br />
a) 15-year retirement life of fittings made from a certain<br />
grade of stainless steel.<br />
b) 15-year retirement life of all stainless steel or carbon<br />
steel control cable fittings.<br />
c) 20-year retirement life of fittings made from a certain<br />
grade of stainless steel.<br />
d) 20-year retirement life of all stainless steel control<br />
cable fittings.<br />
5. Visual inspection of control cable fittings made from<br />
SAE-AISI 303Sc stainless steel for the defects as<br />
outlined in AWB 27-001:<br />
a) is a satisfactory way of inspecting provided high<br />
magnification is used.<br />
b) will not necessarily reveal evidence of internal inter<br />
granular corrosion.<br />
c) is not satisfactory, but dye penetrant inspection<br />
is satisfactory.<br />
d) is satisfactory in conjunction with magnetic<br />
particle inspection.
68<br />
AV QUIZ<br />
Flying ops | Maintenance | IFR operations<br />
6. A helicopter operated under night VMC must have a<br />
separate and independent power source for:<br />
a) turn coordinator and directional gyro.<br />
b) attitude indicator and transponder.<br />
c) standby attitude indicator and directional gyro.<br />
d) attitude indicator, standby attitude indicator or<br />
turn indicator.<br />
7. Where a helicopter is operating under night VMC,<br />
in order to comply with CAO 20.18, an acceptable<br />
alternative source of power required for some specific<br />
instruments is:<br />
a) a separate fuse for each gyro instrument.<br />
b) a separate circuit breaker for each gyro instrument.<br />
c) a separate circuit breaker and sub-bus for the<br />
specified instruments.<br />
d) a separate emergency bus running directly from the<br />
battery for the specified instruments.<br />
8. Referring to an inflated tyre and wheel assembly,<br />
particularly if hot, the safest direction from which<br />
to approach is:<br />
a) the side at which it is installed on the axle.<br />
b) the side away from which it is installed on the axle.<br />
c) the front or rear of the tyre i.e. in the plane of rotation.<br />
d) above.<br />
9. A piston engine with a continuous-flow type of fuel<br />
injection system requires a:<br />
a) positive displacement fuel pump i.e. one in which<br />
the fuel flow is proportional to the engine RPM.<br />
b) positive displacement fuel pump i.e. one in which the<br />
fuel flow is inversely proportional to the engine RPM.<br />
c) constant pressure fuel pump in which the output<br />
pressure is constant regardless of flow.<br />
d) constant pressure diaphragm type pump.<br />
10. Part number MS21251 refers to a:<br />
a) turnbuckle barrel or body.<br />
b) cable eye end.<br />
c) cable stud end.<br />
d) turnbuckle lock-nut.<br />
IFR OPERATIONS<br />
Building an Approach<br />
For something different with this quiz, I thought I would give<br />
you some extracts from a novel called The Temple Tree by<br />
David Beaty, in which he very ably describes the flight testing<br />
of an ILS at a fictitious airport called Tallaputiya in Ceylon<br />
(Sri Lanka), flying a Boeing 707. Then we can consider how<br />
you might visualise the approach being constructed and flown.<br />
… In the cockpit of a 707 flying over Colombo at three<br />
thousand feet. ‘Coming up to Tallaputiya now’ … The pilot<br />
punched the stop clock as the radio compass turned abruptly<br />
180 degrees.<br />
‘We go out on a course of 100 degrees for two minutes.’ He<br />
pointed to the round dial of the ILS cut exactly in two halves<br />
– one yellow and one blue – by the localiser needle. ‘Dead<br />
on the beam outbound’ … ‘Two minutes’, the first officer<br />
said. ‘Procedure turn.’ The pilot tilted up the port wing to alter<br />
course forty-five degrees to the right and started to descend.<br />
… Gracefully the aircraft executed a pear-shaped manoeuvre<br />
back toward the beam.<br />
… Hannacker kept his eyes on the ILS needles – the localiser<br />
at full travel over in the yellow sector, the glide path tucked up<br />
at the top of the instrument, both showing the aircraft had not<br />
yet started to cut the beams. Then very gradually, the localiser<br />
needle started to move, and at exactly the same time, the pilot<br />
slightly increased the left bank. Imperceptibly the 707 slid<br />
into the beam on to a heading of 280 degrees. The needle on<br />
the radio compass now indicated Tallaputiya beacon dead<br />
ahead and nine miles away, exactly in line with their course.<br />
From the top of the ILS … the glide path needle began<br />
slowly to descend, till it cut the round face of the instrument<br />
horizontally across.<br />
‘On glide path.’ ‘Descending at five hundred feet per minute’.<br />
… Airspeed 140 knots, altimeter unwinding methodically.<br />
‘The glide path is three degrees.’ …
Flight Safety Australia<br />
Issue 87 July–August 2012<br />
69<br />
1. If a holding pattern was constructed over the Talliputiya<br />
beacon (NDB), with the inbound track being the initial<br />
approach track, and it was a ‘standard’ pattern, which of<br />
the following would apply?<br />
a) Left hand, 2 minutes<br />
b) Left hand, 1 minute<br />
c) Right hand, 2 minutes<br />
d) Right hand, 1 minute<br />
2. From what direction would the Boeing be arriving in<br />
order to go ‘straight in’ to the initial approach and not<br />
require a sector entry?<br />
a) East South East<br />
b) West North West<br />
c) North North West<br />
d) South South East<br />
3. If the 707 was experiencing a 20-knot northerly wind<br />
along the initial approach, what approximate heading<br />
would be flown to maintain the track?<br />
a) 100<br />
b) 090<br />
c) 290<br />
d) 280<br />
4. Still tracking outbound on the initial approach, the<br />
localiser needle begins to move right. Which of the<br />
following is correct?<br />
a) Command sense, fly left to correct<br />
b) Command sense, fly right to correct<br />
c) Non command sense, fly left to correct<br />
d) Non command sense, fly right to correct<br />
5. Still tracking outbound…<br />
If the localiser needle was to move to the position in the<br />
diagram, how many degrees off track is the aircraft?<br />
a) 1 degree off track to the right<br />
b) 4 degrees off track to the right<br />
c) 1 degree off track to the left<br />
d) 4 degrees off track to the left<br />
6. After two minutes outbound the Boeing executes a turn<br />
back inbound to the ‘front’ beam of the localiser. Which<br />
of the following is correct concerning the turn?<br />
a) It is a left-hand procedure turn to 145 degrees initially,<br />
then after the specified time, reversal turn onto 325<br />
degrees for intercept<br />
b) It is a right-hand procedure turn to 145 degrees<br />
initially, then after the specified time, a reversal turn<br />
onto 325 degrees for intercept<br />
c) It is a left-hand procedure turn to 055 degrees initially,<br />
then a reversal turn onto 235 degrees for intercept<br />
d) It is a right-hand base turn to 145 degrees initially, then<br />
a reversal turn onto 325 degrees for intercept<br />
7. If the aircraft were descending at 600fpm on the<br />
glideslope, what approximate groundspeed would<br />
it be doing?<br />
a) 140kt<br />
b) 100kt<br />
c) 120kt<br />
d) 160kt<br />
8. Now established inbound heading 285 and descending,<br />
the localiser needle moves to the position in the<br />
diagram. How many degrees off track is the aircraft?<br />
a) 2 degrees off track to the left<br />
b) ½ a degree off track to the right<br />
c) 2 degrees off track to the right<br />
d) ½ a degree off track to the left<br />
9. The heading is altered to re-intercept the localiser.<br />
Once this is achieved, which of the following headings is<br />
correct to remain on the localiser?<br />
a) 280 since the wind is lighter<br />
b) 275 since the wind is stronger<br />
c) 285 since the wind is steady<br />
d) 290 since the wind is stronger<br />
10. If the heading is now 290, what would the fixed card<br />
radio compass (the ADF) be indicating, if tuned to the<br />
Tallaputiya beacon (the NDB)?<br />
a) 350 R<br />
b) 170 R<br />
c) 010 R<br />
d) 360 R
70<br />
CALENDAR<br />
Dates for your diary<br />
Upcoming events<br />
July 28<br />
Access all information areas<br />
seminars – Brisbane<br />
Register online now!<br />
go to www.casa.gov.au/avsafety<br />
ACT/NEW SOUTH WALES<br />
July 4<br />
AvSafety Seminar – Camden<br />
www.casa.gov.au/avsafety<br />
July 17<br />
AvSafety Seminar – Forbes<br />
www.casa.gov.au/avsafety<br />
July 18<br />
AvSafety Seminar – Temora<br />
www.casa.gov.au/avsafety<br />
July 22<br />
AvSafety Seminar – Sydney<br />
www.casa.gov.au/avsafety<br />
August 22<br />
Aviation Safety Education Forum – Sydney<br />
www.casa.gov.au/avsafety<br />
SOUTH AUSTRALIA<br />
July 19<br />
AvSafety Seminar – Murray Bridge<br />
www.casa.gov.au/avsafety<br />
WESTERN AUSTRALIA<br />
July 24<br />
AvSafety Seminar – Exmouth<br />
www.casa.gov.au/avsafety<br />
Nov 7–8<br />
ATO Professional Development Program<br />
www.casa.gov.au<br />
QUEENSLAND<br />
July 24–26<br />
Aircraft Airworthiness & Sustainment<br />
Conference – Brisbane<br />
www.ageingaircraft.com.au/aasc.html<br />
July 26<br />
AvSafety Seminar – Horn Island<br />
www.casa.gov.au/avsafety<br />
July 28<br />
Aviation Safety Education Forum – Brisbane<br />
www.casa.gov.au/avsafety<br />
August 1<br />
AvSafety Seminar – Cairns<br />
www.casa.gov.au/avsafety<br />
August 2<br />
AvSafety Seminar – Atherton<br />
www.casa.gov.au/avsafety<br />
August 8<br />
AvSafety Seminar – Gympie<br />
www.casa.gov.au/avsafety<br />
August 9<br />
AvSafety Seminar – Maroochydore<br />
www.casa.gov.au/avsafety<br />
August 25<br />
Aviation Careers Expo – Brisbane<br />
www.aviationaustralia.aero/expo/<br />
August 29<br />
AvSafety Seminar – Redcliffe<br />
www.casa.gov.au/avsafety<br />
October 10–12<br />
Regional Aviation Association of Australia<br />
(RAAA) Convention – Coolum, Queensland<br />
www.raaa.com.au/<br />
NORTHERN TERRITORY<br />
July 25<br />
AvSafety Seminar – Alice Springs<br />
www.casa.gov.au/avsafety<br />
July 26<br />
AvSafety Seminar – Uluru<br />
www.casa.gov.au/avsafety<br />
August 22<br />
AvSafety Seminar – Gove<br />
www.casa.gov.au/avsafety<br />
August 27<br />
AvSafety Seminar – Darwin<br />
www.casa.gov.au/avsafety<br />
August 29<br />
AvSafety Seminar – Victoria River Downs<br />
www.casa.gov.au/avsafety<br />
VICTORIA<br />
July 5<br />
AvSafety Seminar – Lilydale<br />
www.casa.gov.au/avsafety<br />
July 17<br />
AvSafety Seminar – Tyabb<br />
www.casa.gov.au/avsafety<br />
August 1<br />
AvSafety Seminar – Lethbridge<br />
www.casa.gov.au/avsafety<br />
INTERNATIONAL<br />
July 9–15<br />
Farnborough International Airshow –<br />
Farnborough, UK<br />
www.farnborough.com/<br />
August 27–30<br />
ISASI 2012 43rd Annual Seminar –<br />
Baltimore, Maryland USA<br />
www.isasi.org/isasi2012.html<br />
August 28–29<br />
Asia Pacific Airline Training Symposium<br />
(APATS) – Singapore<br />
www.halldale.com/apats-2012<br />
September 17–18<br />
Flight Safety Conference – London, UK<br />
www.flightglobalevents.com/flightsafety2011<br />
October 23–25<br />
International Air Safety Seminar –<br />
Santiago, Chile<br />
www.flightsafety.org/aviation-safety-seminars/<br />
international-air-safety-seminar<br />
October 23–25<br />
International Cabin Safety Conference –<br />
Amsterdam, The Netherlands<br />
www.ldmaxaviation.com/Cabin_Safety/<br />
International_Cabin_Safety_Conference<br />
To have your event listed here,<br />
email the details to fsa@casa.gov.au<br />
Copy is subject to editing.<br />
Please note: some CASA seminar dates may<br />
change. Please go to www.casa.gov.au/<br />
avsafety for the most current information.<br />
CASA events<br />
Other organisations’ events
AUSTRALIAN<br />
Flight Safety Australia<br />
Issue 87 July–August 2012<br />
71<br />
pa.com.au<br />
PO Box 26 Georges Hall NSW 2198 • T: 02 9791 9099 • F: 02 9791 9355 • www.aopa.com.au<br />
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QUIZ ANSWERS<br />
AUSTRALIAN<br />
pa.com.au<br />
Flying ops<br />
1. (a)<br />
2. (a)<br />
3. (b)<br />
4. (d)<br />
5. (a)<br />
6. (c)<br />
7. (d) when bouncing from tailwheel to<br />
mainwheels, down elevator increases<br />
the downward velocity of the mains.<br />
8. <br />
(c) ENR 1.1.19.4<br />
9. (b)<br />
10. (a)<br />
Maintenance<br />
1. (a) FAR §23.955(c).<br />
2. (b)<br />
3. (c)<br />
4. (a) CASA AWB 27-001.<br />
5. (b) CASA AWB 27-001 figure 4.<br />
6. (d) AWB 24-005 and CAO 20.18<br />
7. (d) AWB 24-005 issue 2.<br />
8. (c)<br />
9. (a)<br />
10. (a)<br />
IFR operations<br />
1. (d) AIP ENR 1.5-22 PARA 3.1.3 and 3.2.1 (c)<br />
2. (b) AIP ENR 1.5-23 FIG 3.2a<br />
AIP ENR 1.5-17 PARA 2.4.1b (3)<br />
3. (b) Initial approach TR is 100 outbound with a northerly wind, thus drift correction<br />
to the left 090.<br />
4. (c) Outbound on an ILS with this ‘raw data’ equipment, the localiser is non<br />
command, hence a turn opposite to the needle i.e. to the left (it could indicate<br />
that the northerly wind is strengthening).<br />
5. (a) With ILS, each ‘dot’ is only ½ a degree, remembering that on this instrument<br />
presentation the outside of the circle is considered to be one ‘dot’.<br />
6. (b) AIP ENR 1.5-19 PARA 2.7.2a<br />
It is the ‘international version’ of a procedure turn as shown where applicable<br />
in Jeppesen plates, as distinct from the ‘80/260’ version in Airservices plates.<br />
Procedure turns are defined by the initial turn direction.<br />
7. (c) The rule of thumb to maintain the 3 degree glideslope is groundspeed x 5 = R.O.D.<br />
Thus 600 ÷ 5 = 120kt. Note, not the I.A.S. of 140kt.<br />
8. (d) Each ‘dot’ is ½ a degree, and needle is now command sense.<br />
9. (d) The original HDG of 285 was not keeping the 707 on the LOC and with the<br />
north wind it must be stronger, thus more drift allowance needed.<br />
10. (a) HDG 290, LOC TR 280, thus with the NDB ahead 360 – 10 = 350 R
72<br />
NEXT ISSUE / PRODUCT REVIEW<br />
Essential aviation reading<br />
COMING NEXT ISSUE<br />
Sept – Oct 2012 online<br />
www.casa.gov.au/fsa<br />
Aviation communication – why<br />
‘plane’ speaking matters<br />
A fresh look at fatigue – new rules<br />
Hazard ID and SMS ... part 2<br />
... and more close calls<br />
Product reviewDS-B BOOK<br />
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Maintenance Guide for Pilots – userfriendly<br />
summaries of everything you<br />
need to know. Available from the online<br />
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2012<br />
Have trouble finding<br />
aviation information?<br />
CASA, Airservices, ATSB, the Bureau of Meteorology and<br />
the RAAF, present a new series of aviation safety education<br />
forums. The full-day forums (to run from 0900-1630) will<br />
feature presentations from each of these industry members,<br />
covering vital aviation safety information. There will be a<br />
special focus on human factors issues.<br />
Come armed with your tablet or smartphone—presenters<br />
will show how you can ‘access all areas of aviation safety<br />
information’ online.<br />
Book now!<br />
Access all information areas forums<br />
Brisbane Griffith University 28 July 2012<br />
Sydney University of NSW 22 August 2012<br />
Melbourne Swinburne University 17 September 2012<br />
Adelaide University of SA 28 September 2012<br />
Perth<br />
Mt Pleasant Baptist<br />
Community College<br />
03 October 2012<br />
Register now! Attendance is free but bookings<br />
are essential.<br />
Go to www.casa.gov.au/avsafety and register online.<br />
For more information, contact your local Aviation Safety<br />
Adviser, on 131 757.
There has never been a better time<br />
to be with good people.<br />
Good people to be with.<br />
QBE Insurance (Australia) Limited ABN: 78 003 191 035, AFS Licence No 239545<br />
Contact details for you and your broker:<br />
Melbourne Ph: (03) 8602 9900 Sydney Ph: (02) 9375 4445<br />
Brisbane Ph: (07) 3031 8588 Adelaide Ph: (08) 8202 2200