Flight Safety Magazine March-april 2009

Transcript

TThe war on error Mar–Apr 2009 Issue 67 To boldly go where no man can ... UAVs Should I have flown? Av. med And ... more ‘close calls’ EError management for pilots & LAMEs FFocus on flight planning ERROR MANAGEMENT ROADSHOW coming to a city near you ‘Practical error management for pilots and LAMEs’ – a nationwide road show in June – brought to you by CASA’s human factors’ team, and featuring: Keynote speaker - Dr. Tony Kern multiple award-winning aviation safety expert and the author of fi ve books on aviation professionalism, including Redefining Airmanship and Flight Discipline. The full-day seminars are practically-focused for pilots & LAMEs, and cover: background to human error: physiology and psychology violation and error-producing conditions & countermeasures for LAMEs & pilots developing a personal safety management system (PSMS) to integrate seamlessly with organisational safety management systems flight discipline & compliance: the cornerstone of professionalism practical error management – tips & strategies for individuals. Each seminar participant will also receive: Blue Threat Fieldbook – tailored to Australian conditions, so that you can track your own errors & develop personal countermeasures A year’s free subscription to online assessment tools ERROR MANAGEMENT ROADSHOW JUNE 2009 Date City Venue Wednesday 10 June 2009 Brisbane Comfort Inn & Suites, Kessels Road Robertson Gardens Friday 12 June 2009 Cairns Holiday Inn 123 Esplanade, Cairns Monday 15 June 2009 Darwin Darwin Airport Inn cnr. Henry Wrigley & Sir Norman Brearley Drives, Marrara Wednesday 17 June 2009 Adelaide Flight Training Adelaide Kittyhawk Lane, Parafield Friday 19 June 2009 Monday 22 June 2009 Perth Runway Bar & Café Eagle Drive, Jandakot Dingley International Hotel Boundary Road, Dingley Wednesday 24 June 2009 Hobart Mercure Hotel Bathurst Street, Hobart Friday 26 June 2009 Sydney Bankstown Sports Club Greenfield Parade, Bankstown Melbourne Places are limited, and on a ‘first-in, best-dressed’ basis. So to secure your place, please register: E: [email protected] or P: CASA human factors via 131 757 CONTENTS Features ISSUE NO. 67, MAR-APR 2009 8 MANAGER, AVIATION SAFETY PROMOTION David Pattie EDITOR, FLIGHT SAFETY AUSTRALIA Margo Marchbank ADVERTISING SALES P: 131 757 or E: [email protected] CORRESPONDENCE Flight Safety Australia GPO Box 2005 Canberra ACT 2601 P: 131 757 F: 02 6217 1950 E: [email protected] W: www.casa.gov.au/fsa/index.asp CHANGED YOUR ADDRESS? To change your address online, go to http://casa.gov.au/change For address-change enquiries, call CASA on 1300 737 032 DISTRIBUTION Bi-monthly to 85,000 aviation licence holders and cabin crew in Australia and internationally. CONTRIBUTIONS Stories and photos are welcome. Please discuss your ideas with editorial staff before submission. Note that CASA cannot accept responsibility for unsolicited material. All efforts are made to ensure that the correct copyright notice accompanies each published photograph. If you believe any to be in error, please notify us at [email protected] DESIGN & PRODUCTION Spectrum Graphics – www.sg.com.au ‘The war on error’ Flight Safety gives an update on error management as a prelude to CASA’s error management roadshow in June. CHIEF EXECUTIVE OFFICER, CASA John McCormick 20 ‘Focus on flight planning’ The importance of having a well thought-out plan before you get airborne. 26 ‘To boldly go where no man can’ Part 1 of a new series on developments in unmanned aerial systems. 31 ‘Life cycle of an Australian airworthiness directive’ Roger Alder & Richard Allen track a unique Australian AD – on ‘rudder gust locks’. 39 Win a Snap-on tool kit! Submit your corrosion defect SDR via the CASA website for a chance to win. 43 AIP update Amendments to the AIP as of 12 March 2009 58 AvSafety Advisors 2008 Update on the Aviation Safety Advisors’ activities last year. 61 Alcohol & other drugs - random testing New video online demonstrates procedures for AOD testing 62 ‘Should I have flown?’ Dr David Fitzgerald examines the risk of fl ying with an undisclosed medical condition. 64 ‘What ELT?’ The changeover to 406 MHz emergency locator transmitters. Regulars PRINTING IPMG (Independent Print Media Group) NOTICE ON ADVERTISING Advertising appearing in Flight Safety Australia does not imply endorsement by the Civil Aviation Safety Authority. Warning: This educational publication does not replace ERSA, AIP, airworthiness regulatory documents, manufacturers’ advice, or NOTAMs. Operational information in Flight Safety Australia should only be used in conjunction with current operational documents. Information contained herein is subject to change. The views expressed in this publication are those of the authors, and do not necessarily represent the views of the Civil Aviation Safety Authority. © Copyright 2009, Civil Aviation Safety Authority Australia. Copyright for the ATSB and ATC supplements rests with the ATSB and Airservices Australia respectively– these supplements are written, edited and designed independently of CASA. All requests for permission to reproduce any articles should be directed to FSA editorial (see correspondence details above). Registered–Print Post: 381667-00644. ISSN 1325-5002. COVER: Matt Hall Red Bull. Photos: © 2 AirMail 5 Flight Bytes –aviation safety news 16 ATC Notes – news from Airservices Australia 18 Accident reports – International 19 Accident reports – Australian 31 Airworthiness pull-out section 33 40 SDRs Directives 44 Close call 44 46 48 ‘Heli-skiing’ ‘Grey gloom – by George’ ‘In-flight fright’ 52 ATSB supplement 66 Av Quiz 70 Calendar 71 Quiz Answers A IR M A IL PAR AVION A CONTRIBUTION FROM A READER WHO IS OBVIOUSLY A MAN OF FEW WORDS! 2 ‘KEVIN’ OF CANBERRA EMAILED FSA MAR–APR09 After recently spending four hours flying from Adelaide to Bankstown, I found myself unable to enter the Sydney basin due to non-VMC. With just under one hour of fuel left (plus fi xed reserves), I had to make some quick decisions. I decided to turn towards Goulburn with Canberra (my home) as a backup. I found Goulburn buried in cloud, so I proceeded to Canberra. Starting to feel a bit nervous, I dialled up CB approach and found the most helpful and most professional ATC service I could have hoped for. I explained my situation (including endurance) and received first class service in response. The YSCB ATIS was read out to me when I was ready, and the controller helped me feel comfortable. I’d like to thank ATC for providing the service they do - especially in times of need. And to other pilots who get nervous (sometimes too nervous to ask for help) - remember that ATC will give you whatever support they can whenever you need it. JUSTIN YOUNG EMAILED ABOUT AN ERROR IN THE JAN-FEB EDITION OF AVQUIZ Thank you for the recent FSA publication (Jan-Feb 2009. I enjoy receiving them as they are always insightful and interesting to digest. I want to draw your attention, though, to an error in the ‘AvQuiz’ section under Maintenance, question 8. If the correct choice is (c) ‘QFE and at full throttle on takeoff …etc’, then what is indicated on the answer page (p71) is wrong. It says: (c) QNH is the atmospheric pressure at the aerodrome level. It should say QFE, which is station level Ed: As always, thanks to the readers who find the quiz so worthwhile, and email their appreciation (and corrections!) – your comments are forwarded to the quizmaster, who values your feedback. We’ll print the response next issue. AS DID DON GORRIE The Flight Safety Australia Jan - Feb 2009 FLYING OPS quiz question 6, did not have a correct answer. The question was ‘An ELT transmitting only on 121.5 MHz will:’ The answer given was (b). ‘Not be detectable by satellite after 01 February, 2009 unless it also transmits on 406 MHz.’ The question stated that the ELT is only transmitting on 121.5 MHz, so including ‘unless it also transmits on 406 MHz’ is incorrect. The ELT in question can’t transmit on 406MHz. The correct answer should have been ‘Not be detectable by satellite after 01 February, 2009.’ DAVID KEMP WAS MOVED TO EMAIL REGARDING ONE OF THE JAN-FEB ISSUE ‘CLOSE CALLS’ LOSING IT SAVING FACE I have been employed in aviation engineering for 30 years, as a LAME on heavy transports for over 20 years, and more lately as an aviation engineering instructor. I always enjoy reading Flight Safety Australia and knowing that it is always sent to my home when published is a real plus of being a licensed aviation professional. I look forward to its arrival and always put away some quiet time to read it. As a LAME, I find the magazine generally entertaining and informative. Unfortunately it is the opinion of other engineers that the magazine is overly focused on pilots in its content and [why] I believe some of my peers in aviation engineering don’t read it or merely flick through it. I do enjoy FSA and I normally read the whole publication cover-tocover, even … the stories where lots publicly or anonymously confess to their flying ‘sins’; hopefully to share their experiences for the benefit of others. On page 48 there was such a pilot confession of unprofessional behaviour … He explained … that he had learned a valuable lesson and he would take those learned behaviours forward to improve his airmanship. 3 He did acknowledge his failings during the takeoff incident but at no time did he acknowledge his unprofessional behaviour of his actions after the flight. I quote, AIRMAIL (c). QNH is the atmospheric pressure for a particular area, representing an average area pressure not specific coverage representing QFE. A IR M A IL PAR AVION ‘I WAS RELIEVED TO TUCK THE AIRCRAFT AWAY THAT AFTERNOON AND RETURN HOME TO MY UNSUSPECTING WIFE.’ At no time did he mention that he considered the potential engine damage that may have happened to the Grumman Tiger he was flying. As he states he ‘tucked away’ the aircraft, suggesting to the readers that the incident was not noted in the technical log of the aircraft, or even reported to the aircraft’s owner or operator. 4 FSA MAR–APR09 Using takeoff power with a lean mixture and on one magneto as he described in his story is a recipe for serious engine detonation, which as most engineers and pilots know is a highly undesirable and a common reason for engine destruction. It was probably due to detonation that the engine apparently failed to deliver sufficient power. The fact that he didn’t hole a piston or do any other damage at that takeoff (with catastrophic consequences for him and his passenger) is a minor miracle, but to park the aircraft and apparently not report the event was the biggest single act of poor airmanship of the day, as the consequences to other unsuspecting aviation personnel using this aircraft may yet prove catastrophic. GORDON MARSHALL EMAILED REGARDING A PREVIOUS AIRMAIL CONTRIBUTION his angle of climb (reference the ground). Let’s say Hilton was to climb in nil wind conditions he would have a climb angle of approximately 12 degrees. If, however, he was climbing on a day that was blowing 15kts, his climb angle would be 15 degrees in a headwind, and 10 degrees in a tailwind. The wind has no significance in our rate of climb, but sure does make a difference in the amount of ground covered whilst we get to that height. Safe flying - Gordon Marshall Just a quick note regarding a letter in your airmail section (issue 66) from Hilton Selvey regarding ‘Rate of Climb vs Angle of Climb’. Ed: keep those emails coming in – we’re only too happy to have the ‘bouquets’, and want to know the ‘brickbats’ so that we can continue to improve the magazine. If we were to use Hilton’s figures of VX of 80kts and assuming an RV6 has a climb rate of approximately 1700fpm, we can approximate State of the Art, Two Place, Touring and Training Aircraft – Certified IFR (FAR Part 23) • Safety – robust modular design with incredible visibility • Performance – advanced aerodynamics with high manoeuverability • Comfort – 48” wide cockpit with huge baggage space • Utility – Useful load after full fuel 192 kg • Simplicity – FADEC Engine with digital engine monitoring display • Economy – 132 knots cruise at 23 litres per hour, up to 500 nm range plus reserves • Affordability – low purchase price and low operating costs Book a demonstration flight now! Call 0419 355 303 Contact Nigel Hutchinson–Brooks Liberty Aircraft Company Pty Ltd A.C.N. 118 727 889 Tel 03 5662 5658 Fax 03 5662 5179 Email [email protected] Details at www.libertyaircraft.com That was granddaughter, Anna Holman’s wish for Nancy Bird Walton, speaking at ‘Nancy-Bird’s’ memorial service in January. One of the final links to the early days of aviation in Australia was broken with the death of Nancy Bird Walton. Mrs Walton, who preferred to be known as Nancy-Bird, was taught to fly by another aviation legend, Charles Kingsford Smith, and was the first woman in Australia to obtain a commercial pilot’s licence. She pioneered an air ambulance service in outback NSW, became the commandant of the Women’s Air Training Corps during World War II and was founder and long-time president of the Australian Women Pilots’ Association. She was named a national living treasure in 1997 and her place in Australian aviation history was recognised last year when Qantas named its first Airbus A380 superjumbo after her. She had been in and out of hospital in recent months and died on 13 January of natural causes, in the Sydney suburb of Mosman, aged 93. The Australian 14 January Her flying career, along with those of seven other women pilots is depicted in a feature-length documentary: Flying Sheilas, which gives an insight into the stories of eight Australian female military and commercial pilots. Flying Sheilas depicts their extraordinary flying careers, and is a rich visual spectacle showing where they were fortunate enough to live and work, both in Australia and beyond. Their stories are intertwined through the career of Melbourne born pilot, Susan Michaelis, who introduces each of them and shows how they played a part in her career. For more information go to www.flyingsheilas.com ALL SAFE AS US PLANE CRASHES INTO HUDSON RIVER A plane carrying 148 passengers and up to six crew crashed into New York’s Hudson River and was sinking into the waters after everyone was safely rescued. Dozens of frantic passengers clustered on the wings of the US Airways plane seeking to stay above the rising freezing waters as they were evacuated from the plane onto waiting boats. The Federal Aviation Authority (FAA) said all the people on board had survived and been rescued after flight 1549 crashed shortly after take-off from LaGuardia Airport in New York on its way to Charlotte, North Carolina on Thursday. 5 Australian Associated Press 16 January In February, birdstrike was confirmed as the cause of the crash, after experts at the Smithsonian Institute confirmed that the bird remains Simply The BEST! 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Insurance Solutions from A–Z Insurance is issued by Allianz Australia Insurance Limited AFS Licence No. 234708 ABN 15 000 122 BFD219 BFD21 BFD2 BFD FFD21 FD 19 1 99 Insurance is issued by Allianz Australia Insurance Limited ABN 15 000 122 850. JN 67567 Av Aviat Aviation_D1.indd ation_D1.ind 1.indd d 1 13/1/09 13/1/0 /09 1:39:53 9:53 PM level of information into the future and also provide a platform for new ways to communicate with the industry. If you have any feedback, please email [email protected] Canberra Times, 14 February AUSTRALIAN AEROBATIC PILOT DIES IN CRASH One of Australia’s best aerobatic pilots died in a fiery plane crash in the NSW Riverina. Tom Moon was killed when the single-engine Extra 300 aircraft crashed halfway along the runway at Temora, about 80km from Wagga Wagga, just after 10.30am (AEDT) on Tuesday 20 January. Australian Aerobatic Club president Paul Bennet said Mr Moon, a former president of the club, was well-liked and wellrespected. He said the tight-knit aerobatic community was in shock at the loss of a man considered one of the most qualified aerobatic pilots in the country. He was very experienced, very skilled. ‘There’s not really very many like him in the country.’ He started competing in 1988 and won the Australian National Aerobatic Championships in 1999, 2000, 2002 and 2003. Australian Associated Press 20 January NEW-LOOK WEBSITE FOR CASA As part of our continuing improvement, late February will see the launch of a new-style CASA website. All current content will be available through an improved navigation and layout. CASA’s website will provide the same high AVIATION DEATHS FELL IN 2008 The number of deaths in aviation accidents fell to 502 in 2008 from 692 in 2007, even though more accidents occurred during the year, the International Air Transport Association says. Some 109 accidents were recorded in 2008, compared to 100 in 2007, with fatal ones increasing to 23 from 20, the airline industry association said. North Asia posted the best record in 2008, with zero hull losses or severe accidents (in which the aircraft is destroyed or substantially damaged). Europe recorded 0.42 hull losses, while North America and Asia Pacific posted 0.58 each. Africa reported hull losses of 2.12 in 2008, marking a substantial improvement from 4.09 in 2007. A quarter of the accidents arose from ‘runway excursions’: when airplanes exit the runway during take-off or landing. Thirty per cent of all accidents were due to ‘deficient safety management’ from the airline, according to IATA. AND A QUIRKY ‘CLOSER’ … JUMBO RECYCLING EFFORT January saw the opening of the world’s first hostel built onboard a 747-200, and located at the entrance to Stockholm Arlanda Airport. The 72-bed Jumbo Hostel offers 25 rooms in all, most containing three beds (called Jumbo Combo rooms), with all rooms having a flat screen TV and access to wireless broadband. Shared showers and toilets are located in the corridor, except for the Cockpit Suite, which has its own shower and WC. The Cockpit Suite, in which parts of the original cockpit have been retained, provides a panoramic view of the airport. The hostel is the brainchild of Swedish hostel owner Oscar Diös. The aircraft, a decommissioned 747-200 built in 1976, was last operated by Transjet, a Swedish airline; was originally built for Singapore Airlines, and later served with Pan Am. 12 January 2009 Australian Associated Press 20 February Sell your Aircraft for only $17.00 per month PlaneSales.com.au Your online Aircraft Marketplace PM 7 FLIGHT BYTES jet were Canada geese. The pilot, Captain Chesley ‘Sully’ Sullenberger, was hailed a hero for saving all the passengers and crew on board with his quick thinking. As a prelude to CASA’s nationwide June road show: ‘Practical error management for pilots and LAMEs’, Flight Safety editor, Margo Marchbank, looks at this important human factor in aviation safety. 8 FSA MAR–APR09 E RRO R ‘Eventually you are going to make a mistake, that’s a given. The trick is not to make it a fatal mistake.’ From the beginning, humans have made mistakes. Icarus, that original aviator of Greek mythology, perished in a classical CFIT, after flying too close to the sun. He made the mistake of ignoring the standard operating procedures set by the design engineer, his father Daedalus. And Roman writer, Cicero, also recognised this fundamental of the human condition, when he declared around the year 60 BCE, ‘Any man is liable to err, but only a fool persists in error’. It’s to mitigate this persistence of error that the CASA human factors (HF) section have invited error management expert, Tony Kern, to speak at June’s error management road show, which will appear at a number of cities around Australia. (See the inside front cover of this issue for details of dates and venues.) ‘Eventually you are going to make a mistake, that’s a given. The trick is not to make it a fatal mistake.’ Stephen Coonts The Minotaur Most will be aware of that oft-quoted figure from the Federal Aviation Administration (FAA) in the US, which attributes over 75 per cent of aviation accidents to human error. John Hiles, an FAA aviation safety inspector specialising in maintenance human factors, points out in presentations on the topic that since aviation’s beginnings in 1903, ‘machine or mechanical causes of accidents have declined markedly, while human causes have escalated dramatically’. Generally, errors made by pilots are characterised differently to those occurring in the maintenance area. Using the threat & error management (TEM) model, CASA’s advisory publication on the new single-pilot human factors and TEM syllabus (CAAP 5.59-1(0), classifies errors into three types: aircraft handling errors procedural errors, and communications errors. 9 EXAMPLES OF ERROR Aircraft handling errors Manual handling/flight controls: vertical/lateral and/ or speed deviations, incorrect flaps/speedbrakes, thrust reverser or power settings. Automation: incorrect altitude, speed, heading, autothrottle settings, incorrect mode executed, or incorrect entries. Systems/radio/instruments: incorrect packs, incorrect antiicing, incorrect altimeter, incorrect fuel switches settings, incorrect radio frequency dialled. Ground navigation: attempting to turn down wrong taxiway/ runway, taxi too fast, failure to hold short, missed taxiway/ runway. Procedural errors SOPs: failure to cross-verify automation inputs. Checklists: wrong challenge and response, items missed, performed late or at the wrong time. Callouts: omitted, incorrect callouts. Briefings: omitted briefings, items missed. Documentation: wrong weight & balance, fuel information, ATIS, or clearance information recorded, misinterpreted items on paperwork, incorrect log book entries, incorrect application of MEL procedures. Communication errors Pilot to external: missed calls, misinterpretation of instructions, incorrect read-back, wrong clearance taxiway, gate or runway communicated. Pilot to pilot: within crew miscommunication or misinterpretation. Source: Threat & Error Management, Captain Dan Maurino, 2005 ERROR MANAGEMENT R The road show very deliberately caters for both pilots and LAMEs, targeting low-capacity regular public transport, charter, private and flying training organisations. As one HF trainer (Gordon Dupont, a former aircraft maintenance engineer, and investigator for the Canadian Aviation Safety Board) explains, ‘Human factors training is nothing more than training a person how to avoid the error they never intend to make’. It’s all about understanding what can predispose us to errors, and what steps we can take to prevent an ‘error from occurring, or prevent that error from causing an accident’. 10 While much of the work on developing TEM has focused on airline operations, using the data from line operations safety audits (LOSA) where experienced pilot observers undertake and document line flights, TEM principles are being applied more broadly to other aviation sectors. The LOSA archive, as at December 2006, included more than 5500 TEM-based observations from 28 commercial airlines in over 14 countries around the world. An earlier analysis of the 4532 flights then observed, revealed that three quarters involved one or more errors; of these, one-fifth were mismanaged so badly that an ‘undesired aircraft state’ resulted, with significant and detrimental consequences. And, given the rigorous procedures usually followed by the airlines studied, a relatively y high g percentage of procedural errors occurred on 20 per cent of flights, followeed closely by checklist errors: 18 per cent of fligh hts studied. FSA MAR–APR09 Perhaps the most tellingg statistic to come out of that study was the fact that ‘flight crews failed to detect 45 perr cent of all errors’, reinforcing an importan nt principle of error management: ‘An error which is not detected cannot be managed’. STRATEGIES FO OR MANAGING ERR ROR It’s not rocket scien nce: effective error management requires deetection and response, requiring a focus on such h areas as: maintaining good situational awareness task management avoidance of error-producing conditions, for example shift/roster design standard operating procedures (SOPs) attitudes conservatism diligence planning & preparation review & evaluation. Not surprisingly, the strategies focus on ‘planning and preparation’ before the flight, with a critical follow-up after landing: ‘review and evaluation’ – the debrief. R FIRST AUSTALIAN RECRUIT The latest recruit joinin ng the fast-paced world of the Red Bull Air Racee Championship circuit is no stranger to thesse error management strategies. Matthew (M Matt) Hall became the first Australian pilot to o join the Red Bull Air Race team late last yeear, after a successful qualifying run in Spaiin. He is one of four rookies to join the 200 09 competition, where 15 pilots will competee in a series of races held around the world d, beginning with Abu Dhabi on 17 April. This year, there are new race rules: after two qualifying rounds, the 10 fastest will secure a plaace in the race; on race day, the five slowest willl race a wild card race for two extra places. Th hese ‘top 12’ will then compete in the first of the finals on race day: then the ‘super eight’ in the ‘semi’, aand the ‘final four’, with the winner earning himself 12 points. Matt has employed these strategies and others at the highest level in the stressful environment of the aerobatic pilot. He happily confesses to being ‘anal’ in his approach to planning and preparation, a ccombination of his innate character, (‘I revolve around routine and setting higgh goals’) and the legacy of 18 years as a fighter pilot and fighter combat insttructor. This military experience he feels stands him in good stead in his tran nsition to the Red Bull Championship, giving a solid grounding in discipline: ‘knowing what’s right and what’s wrong, and doing what’s right; airmanship, procedures, knowledge and fitness.’ While he says he’s not a ‘yes sir, no sir type of guy,’ the military emphasis on procedures has helped in setting parameters. His preparation for a race is highly structured, blow by blow, second by second. ‘It’s all thought out on paper, and written down. For an aerobatic competition, and it will be the same for the Red Bull air race, I will sit down and pull the flight apart. For a seven or eight minute flight, I’ll have maybe 10 pages of notes, second-by-second of exactly what I’m doing: what energy state I’m looking for, what G I’m going to use, when I’m going to transfer from out in front onto the wing tip, how aggressively I am going to jolt the stop, what’s going to happen with the control forces as I’m de-accelerating up the hill. I write it all down … almost like a script; then I learn the script. Then I’ll start flying it “slow time” on the ground, and then I’ll start flying it real time. That’s the big thing I learned in the air force: preparation techniques, mental techniques and visualisation.’ Matt joins two other ex-military pilots in the series: Mike Mangold, two-time world champion, from the United States, an ex-fighter pilot like Matt; and Nigel Lamb, ex-Rhodesian Air Force, flying helicopters, who represents the United Kingdom. ‘When I talk to those two guys there’s a distinct difference in the way we talk – everybody’s really good pilots, but Hannes (Hannes Arch, 2008 series winner) is a bit more freespirited. He’s very focused, but his focus is, “I’m going to try and do this and see how it goes”, whereas Mike Mangold’s will be “I am going to do this, and I know how it’ll go”. And the ‘know’ comes from preparation.’ Being very clear on exactly what you’re going to do, an exact and detailed flight plan, Matt says, means that extraneous factors encountered in various race venues, such as confined spaces, buildings etc do not become an issue. ‘I will fly that flight plan having confidence that I’m not going to hit any of those buildings, or trees. I’m looking at the gate. I’ll have in the back of my mind if something goes wrong, what I have to do so I don’t screw up. Kind of like a crop duster pilot: he acknowledges where the wires are, and then he’s confident that he’s not going to hit them. Then he’s just got to remember, if something goes wrong, and he gets distracted, that he’s got to bring that knowledge forward.’ And how does his very structured flight plan cope with a scenario such as an unauthorised helicopter entering the competition space? ‘In every flight I do, I’ll just think of a couple of ‘what-ifs’, and I won’t go into them in depth, but I’ll always be thinking “engine failure”. Typically they will almost always have the same response: roll away, get away from the crowd, pull the power back and slow down, and stay within the confines of where you have been operating, until you figure ‘And after that, there’s the results – they’re definitely my last priority, because if they overtake safety or professionalism, there’s no future in it.’ 11 ERROR MANAGEMENT ‘The main aim of Red Bull is to entertain people safely,’ he explains. ‘Safety is my first goal – I don’t want to injure myself, or other people, or damage the aircraft. The second is professionalism – showing that people can rely on me and my team, both for flying and administration. And after that, there’s the results – they’re definitely my last priority, because if they overtake safety or professionalism, there’s no future in it.’ out what the real problem is. Stay straight above the track, even if you’re on fire, and do what you’ve got to do.’ He was in America, flying his aerobatics plane, when this ‘what-if’ became a reality. The engine caught fire. ‘In fact the fuel lines broke, with a lot of fuel going out onto the exhaust; the whole plane was on fire, and the engine stopped – but I just thought I had an engine failure. It was low-level aerobatics, so it was all over really quick – I was on the ground probably in fifteen to twenty seconds. I was at an inverted 45 down line, about 500 to a thousand feet, when the engine stopped. So the reaction was a roll upright, pull back, quick switches, nothing, then a wingover and flare. And as I was rolling down the runway, I realised I was on fire.’ RACE PREPARATION 12 ‘I’ll be given the track, so the first thing I’ll do is to work out the entry and exit criteria for each gate for the most efficient race lines. Then I start writing down how those angles are going to be achieved. “Say I want a 30 degree angle for gate 2, so I’ll exit gate 1 at this, and then an estimated two-second delay, and then an 8G turn to roll out just prior to gate 2”. I’ll start plotting it out on a piece of paper. Then I’ll note estimated speeds; where my eyes are going to be; “I’ll get to here, transfer gaze to gate 2 or maybe gate three for a quick look – then back to pull to the AMP building, and when I hit the building, stop roll to it” – writing everything down – what I expect to see. FSA MAR–APR09 Once I’ve done that, I’ll sit down for maybe 15-20 minutes; calm myself right down, close my eyes and visualise it. I’ll see the background, see the terrain, see the AMP building. I’ll start “G-straining” as well, because it’s that graphic. “Here comes the gates, pull and then stop, unload, roll”. Now with less than an hour to go, I’ll look at the actual weather conditions – I will correct my lines for the weather, for some gates you may need to extend slightly to allow for the effects of wind, and then go into my mental preparation routine, which is really the same as elite sportsmen. I think positive thoughts; how to calm down or arouse myself depending on where I’m at – whether I need to fire myself up or calm down. Within 20 minutes of take-off, I’m ready for flight - get my flying suit on, parachute, do a pre-flight of the plane, which has already been set up, 12 mins to take off, close canopy, eight minutes, start, do run ups. And then I’m in the plane. I often have nerves in the plane for the last few minutes, but I ‘remove’ myself from where I am and play silly kids games in the cockpit, and the nerves go away. There’s no more preparation you can do.’ Engine failure is a ‘what-if’ which should be on all pilots’ radar, but managing G forces is in the combat or aerobatic pilot’s domain. Understanding your own tolerance to G forces, which can vary enormously according to physiology, fitness and training, is critical to the aerobatic pilot’s safety. According to Matt, the main risk from ongoing exposure to high Gs is spinal damage. While you can mitigate this to some extent by being physically fit, especially focusing on core strength exercises, Matt admits his regular scans show that his ‘L3 and L4 vertebrae are a worry’. ‘Depending on your tolerance – you grey out, and then you black out - you lose consciousness because you lose oxygen to the brain,’ he explains. ‘Up to about four seconds you can pull an amazing amount of G, but if you go more than four seconds, the brain and the eyeballs lose their residual oxygen. I can pull 12G for about seven or eight seconds using a straining technique to stay conscious, but it’s extremely fatiguing: your heart rate is up to about 230/240. These planes can’t pull more than 12G for more than 5-6 seconds, so they’re self-limiting. The 180 degree or 270 degree turns, or the half-Cuban – they’re the threat areas for consciousness, so if I’m starting to lose vision, the warning sign – if I can’t clear it in half a second by using the straining technique, I’ll come out of the track. That’s my personal risk management.’ complex aircraft; commercial pressures; the Matt’s new race plane is an MXS(R), one of five now flying in the series, and one which was originally modelled from the Giles. His will be a second generation version, and he is grateful that he has the backing of a good engineer. ‘I’ve got a really good team behind me – my mechanic has had about three years on the circuit, and is really experienced, which reduces a lot of the stress, so I can focus on a fast plane, a fast track and being safe.’ associated risk of boredom, and resulting number of personnel working on one aircraft; communication in such a noisy, dispersed situation; fatigue; and the difficulty of ensuring smooth and effective shift handovers. Add to this the fact that scheduled maintenance is largely preventative maintenance, with the mistakes of omission; and unscheduled maintenance is often performed at night and subject to intense commercial pressure, and you have the perfect stage for errors. The United Administration considerable States (FAA) work on Federal has Aviation undertaken the subject of maintenance error management. The agency quotes a Boeing study on the causes of 276 WORK THE WROK OF AN EVIL GENIUS That’s how one writer, somewhat dramatically, but perhaps accurately, has described the maintenance environment: as the ‘work of an evil genius’ perfectly designed to encourage human beings to make errors. Alan Hobbs, writing in a recent Australian Transport Safety Bureau (ATSB) report, argues that, ‘As automated systems become increasingly common, humans are performing less direct manual control of equipment and systems … maintenance is becoming a major remaining point of direct interaction between people and technology.’ According to Hobbs, the maintenance environment poses some significant hazards, which include working at heights; extremes of cold or heat; and noise. Other factors with the potential to induce errors include working in confined spaces; working on large, increasingly in-flight shutdowns – incorrect installation 13 topped the list, representing 33 per cent of shutdowns. This was reinforced by the Civil Aviation Authority’s ‘top 5’ errors list: 1. Incorrect installation 2. Electrical wiring 3. Cross-connections 4. Forgotten tools and parts 5. Failure to lubricate. ‘the maintenance environment poses some significant hazards’ The odds are stacked There’s only one way to disassemble but... 40,000+ ways to reassemble incorrectly FAA: Maintenance Human Factors DVD presentation ERROR MANAGEMENT Error management, and human factors training generally, are now recognised as being of equal, if not greater importance, in the maintenance sector. Maintenance is one of the largest costs facing airlines: it has been estimated that every hour of flight requires 12 man-hours of maintenance, so maintenance errors can have a direct and significant effect on flight safety. THE DIRTY DOZEN 1. Lack of communication – in good communication, the ‘mental pictures must match’ 2. Lack of teamwork – the larger the organisation, the more this can be a problem 3. Norms – short for ‘normal’, or the way things are done around an organisation 4. Pressure – aviation is time-sensitive, but many of the errors result from ‘self-pressure’ 5. Complacency – overconfidence 6. Lack of knowledge – even if we use it often, we only retain about 20 per cent of what we learn 7. Lack of awareness 8. Lack of resources 9. Distraction – about 15 per cent of aviation accidents 10. Assertiveness – failing to speak to up when things don’t seem ‘right’ 11. Fatigue – we often fail to realise how much our judgement is impaired by fatigue until it’s too late 14 12. Stress – our subconscious response to the demands placed on us. Adapted from: Avoid the dirty dozen with safety nets – Gordon Dupont FSA MAR–APR09 The CHC Helicopters Australian business unit, is the largest such organisation in Australia, operating in every sphere of air work, providing, for example, aero medical and emergency services, transport to the off-shore resource industry, aircraft to the Victorian Police and SAR support for the RAAF. They have 16 operational bases throughout Australia and East Timor. There’s the heavy maintenance hub and main store in Adelaide, as well as a large store in Darwin; each base also has on-site engineering support. According to chief engineer, Greg Booth, and safety auditor, Max Marton, as with many similar operations, there are posters of the ‘dirty dozen’ on display at every one of their bases. For CHC, the top three of the dozen, Greg says, are ‘“pressure” – at least perceived pressure, which varies greatly from individual to individual; “distraction”; and compliance with procedures, or “lack of knowledge” about changes in document information’. A recentlycompleted audit identified this as an issue, which Max Marton says means redoubling their efforts on training to ‘bring everybody up-to-speed’. It’s also one of the challenges in operating widely- dispersed bases: ensuring communication is as effective as possible. CHC has a ‘robust and sophisticated safety management system’, with a database integrating safety and quality reporting. All the bases are online, and the engineers are trained to report any deficiencies, or defective product. ‘It gives everybody a voice,’ Max says, ‘a free and open reporting culture exists within CHC.’ Maintenance manuals have been identified as being a source of error, with difficulties arising from translations of manuals into English; unclear or ambiguous procedures; and insufficient detail. CHC operates several types of helicopter, the American (Bell) and Sikorsky versus the types such as the Agusta Westland and Eurocopter originating from Europe. They maintain very close links with the manufacturers, although Greg admits, that even with this liaison, ‘translation at some times can be a challenge’. All their approved data comes through the CHC head office in Adelaide through an integrated electronic library system ‘Alert’. This also provides detailed tracking and distribution of all data to all of CHC’s bases. Safety reporting is also completed electronically, ‘bypassing the busy desk at a remote base’. Max argues this avoids the danger with paper-based reports that they can be inadvertently ignored, or disappear under an ever-increasing pile. There is a hierarchy of actions, with select people designated to open up the report, evaluate it, and initiate a chain of events, according to the type of issue. large database of reported occurrences. We also have a weekly cross to the parent headquarters in Vancouver, so we can compare notes. We’re lucky too, in that we can learn from their occurrences (other international CHC sister companies). We get the benefit of combining experiences through the database and problems have the potential of being identified earlier, which is good for safety,’ he concluded. ‘Say we had replaced a particular seal for the third time,’ Max explains. ‘This would then initiate a discussion within the database, and the chief engineer (amongst others) would be invited into the discussion, and determine what sort of remedial action is required.’ ‘Three times a year we review the reporting database, with a major review conducted annually,’ Max continued. ‘The system has been in place for a long time, e, so we have h a CESSNA AIRCRAFT MILESTONE April 2008 – 1400 employees in Cessna’s nine Citation service centres in the US completed the first round of a company-developed, human factors (HF) training program. This program represents the first stage of one of the first inhouse HF training programs approved for Part 145 certified repair stations by the FAA. Aviation Maintenance magazine 1 January 2009 For more information Redefining Airmanship Human Error Tony Kern, 1997. McGraw-Hill. James Reason, 1990. Cambridge University Press. Threat & Error Management Captain Dan Maurino. Coordinator flight safety and human factors program, ICAO. Canadian Aviation Safety Seminar (CASS) Vancouver, April 2005. Teaching & Assessing Single Pilot Human Factors and Threat & Error Management Civil Aviation Safety Authority CAAP 5.591(0). Error Management Training – Defining Best Practice Matthew JW Thomas, University of South Australia. ATSB Aviation Safety Research Grant project 2004/0050 On Error Management – Lessons from Aviation Robert L Helmreich – British Medical Journal, March 2000 (Deportment of Psychology, University of Texas, Austin) Patrick R Veillette (Ph.D) in Aviation Week Feb 2005 Ashleigh Merritt & James Klinect. University of Texas LOSA Collaborative, 12 December 2006. Threat & Error Management Defensive Flying for Pilots: An Introduction to Threat & Error Management Cessna’s Human Factors Training in a Class by David Jensen. Aviation Maintenance magazine, Itself 1 January 2009. Introducing an Error Management Program into FAA, June 2001. Downloadable from an Organization An Overview of Human Factors in Aviation Maintenance Alan Hobbs. ATSB Safety Report, AR-2008-055. December 2008. Operator’s Manual – Human Factors in Aviation FAA, June 2005. Downloadable from Maintenance www.hf.faa.gov/opsmanual Maintenance Human Factors Toolkit Presentation tool kit on DVD, produced by the FAA (available from CASA Safety Promotion) Human Factors: Avoid the ‘Dirty Dozen’ with Safety Nets Gordon Dupont. Airbeatt magazine, Jan/Feb 2009 Human being pilot - human factors for aviation professionals David Robson, 2008 Aviation Theory Centre ERROR MANAGEMENT 15 ATC.MRCQ Pilot Information Nights increase awareness of ATS system Airways clearance versus departure instructions W hen ATC issues ‘airways clearance’, this authorises a flight to ‘operate in controlled airspace along a designated track or route at a specified level to a specified point or flight planned destination’ (AIP ENR 1.1-2 para 3.6). If there is no amendment to the airways clearance in the departure instructions (e.g. “ABC, cleared for take-off, make right turn…”), the aircraft must comply with the set course requirements, even if the flight is cleared ‘direct’ to a tracking point or destination as part of the airways clearance. 16 FSA MAR–APR09 Which Runway? P ilot Information Nights, aimed to improve pilot awareness of Air Traff fic Services (ATS), are proving popular with the GA community and are promoting safety responsible behaviour with pilots. Consisting of small group visits to Airservices’ Air Traffic Control centres, Pilot Information Nights are part of our Regional Aviation Awareness Program. The safety messages provided to pilots are based on current and emerging issues appearing in safety critical data analysis, incident reports, investigations and from other sources. Pilot Information Nights give GA pilots, including student pilots and smaller operators, the chance to experience the workings of the ATS operational environment first hand including Air Traffic Control and AusFIC; receive safety information on topics like Violations of Controlled Airspace (VCA), Runway Incursions, Flight Planning and SARTIME management; and participate in discussions to enhance their awareness of issues affecting safety. For more information about Pilot Information Nights, or to arrange for one to be held in your area, contact: Vicki Huggins Public Affairs —Melbourne p: 03 9235 7423 e: [email protected] Bryan Nicolson Public Affairs —Brisbane p: 07 3866 3745 e: [email protected] New phraseology improves runway safety R ecent safety investigation findings support the requirement for a pilot to notify ATC of the taxiway they are on when requesting a runway crossing. These phraseology changes will help to mitigate against the risk of runway incursion and to improve ATC, pilot and vehicle driver situational awareness. Changes to the Manual of Air Traffic Services (MATS), introduced last November, require a controller to “include the point of crossing when authorising surface traffic to cross an active runway.” The same phraseology provisions will be included in AIP, and are planned to be introduced in March. They will however, be optional for pilots. To cross a runway the following exchange will take place between a pilot and ATC: PILOT: “Tower, C172 request clearance to cross runway 17.” ATC: “C172 on Taxiway N cross Runway 17.” PILOT: “Taxiway N cross Runway 17, C172.” ATC will always include the location in their phraseology, regardless of whether the pilot includes it in their request. Departing from the rules T here have been a number of recent occurrences in the non-radar environment where Air Traffic Control (ATC) have had to correct the tracking of a departing aircraft because it has failed to set course within 5NM of the departure aerodrome. As per AIP ENR 1.1-15 para 7.3 Establishment on Track, ‘unless tracking via a Standard Instrument Departure (SID) or otherwise instructed by ATC, a pilot in command must remain within 5NM of the departure aerodrome to establish flight on the departure track as soon as practicable after take-off.’ ATC rely on aircraft establishing on the correct track for the purposes of separation. It is imperative that if there are operational requirements or other reasons why a pilot requires to be established on track outside 5 NM from the departure aerodrome, approval must be given by ATC. 17 T o meet the obligations of our safety policy and the regulatory requirements of CASA and ICAO, Airservices Australia aims to achieve a number of objectives in relation to safety. There are 15 objectives within our Safety Management System (SMS). These objectives are divided into three groups, those that help us achieve good safety outcomes, those that assist in assuring good safety outcomes, and one element requires that we promote safety. A requirement of the safety promotion objective is that Airservices must provide safety related information which will assist our stakeholders, customers, contractors and other Air Navigation Service Providers (ANSPs) improve their safety performance. Airservices actively encourages consultation between us, our customers and other stakeholders with an emphasis on the communication of safety lessons. This is achieved through the exchange of: t Safety Incident Reports; t Advice on Air Traffic Services and Company operational procedures and practices; t Summaries of investigations undertaken with a particular emphasis on lessons learnt and recommendations made to prevent recurrence; and t
Information that will assist Airservices and Companies in the conduct of investigations. To formalise this exchange of safety related information, the Airservices Safety Management group has established Letters of Agreement (LoA) with a number of domestic and international airlines, General Aviation companies and organisations and also neighbouring ANSPs. These LoAs outline the manner in which information will be exchanged, include necessary information protection requirements and detail the communications protocols between safety experts from both organisations that enter into the agreement. ATC NOTES Airservices Exchange of Safety Information Letters of Agreement Additionally, establishment of the LoA provides an opportunity for companies to be involved in a range of Airservices Safety Management activities including participation as subject matter experts in risk management activities and attendance at regular industry safety forums. If you would like further information about the Airservices exchange of safety information LoA processes or believe your company may wish to enter into an agreement please contact Glen Lang on the details below. Glen Lang Northern Safety Programs Manager p: 07 3866 3773 m: 0400 743 928 e: [email protected] International Accidents/Incidents 07 December 2008 - 15 January 2009 18 FSA MAR–APR09 Date 07 Dec Aircraft Location Fatalities Damage Description Learjet 23 Tlaxcala, Mexico 2 Destroyed The Learjet was reported as making a 2nd landing attempt, it began rapid ascent, then nose-dived into the lake. 15 Dec BN-2A Trislander Mk.III-2 Caribbean Sea, Atlantic Ocean Written off The Trislander gave a distress call and possibly crashed shortly after that. It was found the pilot’s licence had been suspended since October 2006. 19 Dec BN-2A Islander Olpoi, Vanuatu 1 Written off The BN-2A Islander flew into the side of a forested mountain. The pilot died in the accident; one passenger is still missing. 20 Dec Boeing 737-524 Denver Airport, Colorado 0 Written off The Boeing 737 suffered a runway incursion at taxiway WC, went down a ravine and caught fire. The engine separated from the wing and the undercarriage collapsed. Thirty-eight occupants were taken to hospital. 03 Jan Learjet 45 Telluride Regional Airport, Colorado 0 Substantial Two crew on board the Learjet 45 suffered minor injuries in a landing accident in snowy conditions. 04 Jan Cessna 650 Citation Vll Vancouver Airport, Canada 0 Substantial The Cessna 650 exited the runway at a high speed and came to rest in the grass approximately 400ft north of runway 08R. 04 Jan Cessna 550 Citation ll Wilmington-New Hanover County, North Carolina 0 Substantial The Cessna was on approach and gear failed to respond. It made a successful gear-up landing, and slid off the runway into the grass. 04 Jan Basler BT 67 Turbo 67 Tony Camp, Antarctica 0 Substantial The Basler was on a trial approach run at 200ft AGL with low visibility. The pilot inadvertently descended, and flew into the ground. 11 Jan Xian MA60 CaticlanMalay Airport, Phillippines 0 Substantial The Xian undershot the runway on landing. It swerved sharply to the left when it touched the runway after the initial impact and hit a concrete barrier, seriously damaging its nose. 15 Jan Airbus A320-214 Hudson River, New York 0 Written off The Airbus had a birdstrike with a flock of geese and lost power in both engines. The captain decided to ditch in the river. 15 Jan Ilyushin 76 MD Makhachkala Airport, Russia 3 Written off The Ilyushin taxied to the runway; at the same time another Ilyushin came in to land. The wing of the landing aircraft struck the flight deck of the stationary aeroplane, ripping away a large part of the forward fuselage and causing a fire. 15 Jan Ilyushin 76 MD Makhachkala Airport, Russia 0 Substantial The Ilyushin came in to land when another aircraft was on the runway. The wing struck the stationary aircraft. None of the 31 occupants was hurt. Notes: compiled from information supplied by the Aviation Safety Network (see www. aviation-safety.net/database/) and reproduced with permission. While every effort is made to ensure accuracy, neither the Aviation Safety Network nor Flight Safety Australia make any representations about its accuracy, as information is based on preliminary reports only. For further information refer to final reports of the relevant official aircraft accident investigation organisation. Information on injuries is unavailable. Australian Accidents/Incidents 01 December 2008 - 29 January 2009 Aircraft DH-82A Tiger Moth Aerospatiale Ind. SV 4 C Piper Warrior PA-28-161 Amateur-built Hornet AG Location Shute Harbour (ALA), QLD Burra (VFR), 030° M 31Km, SA Kalgoorlie/Boulder Aerodrome, WA Gloucester (ALA), W M 37Km, NSW Injuries Nil Damage Serious Nil Serious Nil Serious Nil Serious During the take-off run, the pilot lost directional control of the aircraft and ran off the runway. The aircraft collided with a ditch. 07-Dec Great Lakes Aircraft Co. 2T-1A-2 Torquay (ALA), VIC Nil Serious During short final approach to runway 27, the pilot could not control the descent and the aircraft sustained a hard landing. The left main landing gear strut buckled and collapsed during the landing roll. The aircraft veered off the runway to the left. After brakes were applied, the aircraft nosed over and came to rest on the left wing and the left main landing gear strut. 08-Dec Liberty Aerospace XL-2 Bankstown Aerodrome, NSW Serious 16-Dec Enstrom 280FX Albury Aerodrome, Nil SE M 20Km, VIC While the solo student pilot was conducting a touch-and-go landing on runway 11R, the aircraft landed heavily, then bounced and veered to the left. The aircraft became airborne and the pilot reported severe vibration. During the subsequent landing on runway 11R, the aircraft bounced, veered left and touched down on the grass before becoming airborne once more. The left wing dropped and the wing tip touched the ground causing the aircraft to cartwheel into the ground. The aircraft came to rest on runway 11C. During the initial climb, the helicopter struck a powerline and sustained serious damage. 01-Dec 02-Dec 04-Dec 05-Dec Minor Serious Description Insufficient power was applied to effect a backtracking turn along the runway and the aircraft taxied into a ditch, striking a concrete culvert. During the landing roll, the brakes locked up. The aircraft subsequently nosed over and came to rest inverted. During the taxi, the nose landing gear sheared off at the oleo. Australian Accidents/Incidents 01 December 2008 - 29 January 2009 Aircraft Bell 212 17-Dec Injuries Minor Damage Serious Cessna 182P Peak Hill (ALA), Skylane WA Nil Serious 18-Dec Liberty near Two RN (VFR), NSW Aerospace XL-2/Cessna 152 Fatal Serious It was reported that a Liberty XL-2 and a Cessna 152 collided near Bankstown. The Liberty XL-2 returned to Bankstown. The Cessna 152 collided with terrain. The investigation is continuing. 18-Dec Air Tractor AT-301 Robinson R44 Boggabilla (ALA), Nil NSW Oakey Aerodrome, Minor W M 8Km, QLD Serious Immediately after becoming airborne, the left wing stalled, striking the ground. The aircraft struck a channel bank and came to rest in a paddock. Immediately after departure, the helicopter yawed to the right and impacted terrain. The pilot and passenger sustained minor injuries. 22-Dec Piper PA32R-300 Lance Fitzroy Crossing Aerodrome, 238° M 9Km, WA Serious During the cruise the aircraft experienced a total power loss, resulting in a forced landing. 24-Dec Cessna 172L Skyhawk Scone Aerodrome, Fatal 276° M 63Km, NSW Serious While en route in reported marginal weather conditions, the aircraft collided with terrain. The passenger was fatally injured with the pilot receiving serious injuries. The investigation is continuing. 25-Dec Cessna 172M Skyhawk Amateurbuilt A600 Talon Beech 76 Duchess Lake A/C LA-4-200 Buccaneer Leongatha Aerodrome, VIC Proserpine / Whitsunday Coast Aerodrome, QLD Bankstown Aerodrome, NSW near Boonah (ALA), QLD Fatal Serious Nil Serious Nil Serious Minor Serious Shortly after departure, the aircraft struck a power line and collided with terrain. The pilot, who was the sole occupant was fatally injured. During takeoff, the helicopter’s rotor RPM reduced and the pilot lost control. The helicopter landed heavily and rolled onto its right side, sustaining serious damage. During circuit training, the non-flying pilot inadvertently selected the gear up while the aircraft was on the take-off run. The nose wheel collapsed. Shortly after the landing gear was retracted, the pilot noticed that the aircraft was not climbing normally. The pilot stopped the climb, checked the engine controls but the engine power did not increase. The pilot carried out a forced landing into a paddock, but on late final approach the left wing tip contacted an obstacle and the aircraft impacted the ground. During aerial agricultural operations, the aircraft collided with terrain. The pilot was fatally injured. The investigation is continuing. 20-Dec 26-Dec 28-Dec 29-Dec-08 Location Dili International Airport, 091° M 15km Nil Serious Description During cruise, the transmission low oil pressure warning light illuminated and the pressure gauge indicated low oil pressure. Approximately 10 seconds later the transmission chip light illuminated. The pilot completed an emergency landing. After shutdown, the crewman reported smoke from the rear of the helicopter. During the approach, the pilot observed fire from the engine & smoke entering the cockpit. 29-Dec-08 PZL Nyngan WarszawaAerodrome, 245° Okecie M-18A M 36Km, NSW Fatal Serious 29-Dec-08 Piper PA-28-151 Cherokee Nil Serious 31-Dec-08 Beech F17D Jamestown Staggerwing (ALA), SA Nil Serious 11-Jan-09 Bell TH-1F near Bald Hills Mast (VFR), QLD Nil Serious During the approach at 150 ft AGL, the helicopter’s engine sustained a total power loss and the helicopter landed heavily.The main rotors impacted with the tail section and the helicopter sustained serious damage. 11-Jan-09 Amateurbuilt Mustang Moorabbin Aerodrome, 179° M 25Km, VIC Fatal Serious The aircraft collided with terrain. The pilot sustained fatal injuries. 20-Jan-09 ExtraFlugzeugbau GMBH EA 300S Temora Aerodrome, NSW Fatal Serious During aerobatic manoeuvres, the aircraft collided with the runway. The aircraft caught fire and the pilot sustained fatal injuries. 20-Jan-09 Robinson R22 Beta Ban Ban Springs (ALA), NT Nil Serious During mustering operations, the pilot landed the helicopter to shut a gate. All the required cyclic friction and collective friction locks were secured and the pilot left the helicopter. On returning to the helicopter, the pilot observed the station manager coming towards the helicopter and got out of the helicopter without resecuring the helicopter. The helicopter’s RPM surged and it became airborne, hovered backwards, the tail rotor struck the ground and it rolled on its side. 29-Jan-09 Eurocopter EC120B Colibri Cessnock (ALA), NSW Nil Serious During the cruise at low level due to low broken cloud, the helicopter struck a powerline that impacted the windscreen and its side supports. The pilot conducted a forced landing in a nearby quarry. Jandakot Aerodrome, WA While passing over the threshold for landing, the aircraft descended rapidly and bounced several times, before running off the edge of the runway. The aircraft came to rest back on the runway, where the pilot and passengers evacuated without injury. On short final the aircraft encountered sudden cross-wind turbulence, resulting in the aircraft contacting a fence. Text courtesy of the Australian Transport Safety Bureau (ATSB). Disclaimer – information on accidents is the result of a co-operative effort between the ATSB and the Australian aviation industry. Data quality and consistency depend on the efforts of industry where no follow-up action is undertaken by the ATSB. The ATSB accepts no liability for any loss or damage suffered by any person or corporation resulting from the use of these data. Please note that descriptions are based on preliminary reports, and should not be interpreted as findings by the ATSB. The data do not include sports aviation accidents. 19 ACCIDENT REPORT Date 17-Dec An important aspect of any flight away from home base is thorough flight planning. Having a well thought-out plan before you get airborne will help you enjoy the flight, arrive refreshed and return alive. 20 FSA MAR–APR09 Even if you are going somewhere familiar, having some key details worked out beforehand, and then getting the most up-to-date weather and NOTAMs, is a must. BEFORE THE FLIGHT Begin pre-flight planning several days in advance. Study the applicable charts and plan the route. Then plan for alternatives. Refamiliarise yourself with the AIP and your legal requirements. Check the weather forecasts. If you are taking the aircraft away from m home base, check if there are enough hours left on it to complete your flights. Know your aircraft and its systems. Are you familiar with the systems fitted to the aircraft? VHF radio/s GPS Seek out some local knowledge on the routes and destination. Navigation aids (know how to use them for tracking) Ask yourself whether the proposed flight is within your capabilities? Update your personal minimums to reflect your currency levels. Autopilot (if fitted) Brief your passengers about the realities of flying in light aircraft. Transponder (if fitted) TCAS or TCAD (if fitted) While the shortest distance between two points is a straight line, this may not be the safest, or the wisest, route when flying. By all means draw the straight line on the chart, but then think about: what terrain you are flying over; airspace you are flying through; aerodromes you are in the vicinity of; the weather that will affect your flight – especially cloud; and likely traffic. Then consider a practical route which takes into account these factors. Think about the best way to depart the airfield and arrive at your destination. It may be that you can’t go straight there – you may need to go via reporting points (VRP), for example. Plugging the VRPs straight into your GPS has advantages, but consider how many other people are doing exactly the same thing. Be particularly careful when arriving exactly overhead VRPs for this very reason. ALTERNATIVE ROUTE While in this preliminary flight-planning phase, you should make provision for at least one other safe alternative route – a plan ‘B’. In planning this alternative route, take the same level of care as you do with your primary route. Having a well-researched plan ‘B’ takes a lot of pressure off if the weather deteriorates and you have to use it. CONSIDER THE AIRSPACE EN ROUTE Ensure that you apply the correct tracking tolerances to avoid controlled or restricted airspace. (AIP ENR 1-1. PARA 19.11) Controlled airspace – vertical and horizontal clearance Restricted airspace – is it active? Check ERSA & NOTAMs CTAF/Rs – are you overflying or passing in the vicinity of one? (CAR 166A) FUEL Will you need a refuelling stop on the way? If you do, allow plenty of time for this, as invariably it will take far longer than you think to refuel, let the passengers out for a toilet break, and then get them back into the aircraft. Check that fuel (suitable for your aircraft) is available at your planned fuel stops Is there a call-out fee? Can you use a credit card? Do you need a CARNO? FUEL RESERVES Allow for taxi fuel Consider applying the recommended fi xed & variable fuel reserves (CAAP 234) Plan for alternate and any required holding fuel (INTER or TEMPO) In flight, lean the fuel mixture in accordance with the flight manual. FLIGHT LOG STUDY Prepare a flight log with as much relevant information as you can: legs, distances, tracks, airspeed, i cruising altitudes, radio frequencies, frequenc fuel, and so on. You can fill in a lot of information beforehand, and then finish the calculations, once you have ve the up-to-date we weather on the day. Now turn your attention to studying the AIP. It is important that you check the AIP P and the applicable pp sections of the AIP supplements to determine if there is any information that might affect your flight. Don’t just rely on getting the area NOTAMs on the day, as they are not the sole source of all temporary aerodrome and airspace inform information. On your flight log, make a note of each h enroute ATC VHF frequency and a change over position or time. Make a note of all CTAF AF & CTAF/R frequencies en route Make a note of the frequencies of all ontrack (and off track) navigation aids. 21 LEGAL REQUIREMENTS AIP ENR 1-10 paragraph 1.1 essentially says that, before a flight, the pilot-in-command must obtain and become familiar with, all FLIGHT PLANNING PLANNING THE ROUTE information concerning that flight, including: current meteorological information; fuel requirements; alternatives available; NOTAMS and supplements; aerodrome conditions; ON THE DAY Allow plenty of time on the day to be sure that final pre-flight preparation is not rushed, and be realistic about the time you need to plan, get your passengers ready, and any intermediate stops en route. engine inoperative procedures; and Obtain the most recent weather and NOTAMs and check them carefully. If in doubt, discuss the conditions with a more experienced pilot. one engine inoperative performance data. File a flight plan. Brief yourself on your other requirements, for example: fuel reserves, cruising altitudes and VFR met minima. Make sure the aircraft has all the equipment you will need for the whole time you are away: aircraft performance data; and in the case of twin-engine aircraft – Tie-downs; CHECK THE WEATHER Take a look at the long-range forecast to get an idea of whether the flight is feasible. 22 Fuel card; Control locks; Spare oil; Lifejackets and survival equipment; TALK TO A LOCAL FSA MAR–APR09 It can be worth getting some local knowledge on the area or your route (including aerodrome information) well before the trip. Most local operators are very happy to provide information and will probably offer you plenty of other advice and tips. PERSONAL MINIMUMS Think about visibility restrictions, terrain, possible turbulence, and the effects of these on your workload, and handling of the aircraft – and you will realise why it is important to set personal minimums. Personal minimums take into account a wide range ange of criteria, particularly pilot, aircraft, environment nvironment and external pressures. They are an invaluable tool in assisting you to decide if a particular particula situation (route, weather, aircraft type, etc), is within your personal limits. When you aree worki working out how long it will take you to get ready and airborne on n this flight, ig allow some time to go through the ‘I’M SAFE’ checklist. BRIEF YOUR PASSENGERS Discuss the vagaries of light aircraft trips with your passengers passengers, in particular: Departure and arrival times ca cannot be guaranteed – the weather may have other plans. pla The weight of baggage they can bring is limited – anything over their limit will be left behind. Turning back, taking an alternative route, or diverting, is always a possibility. What your contingency plans will be if you are delayed, diverted, or have to cancel. Something to clean the screen with. There is a real danger in focusing on the gain of reaching your destination compared with the lossess associated with not going, or turning back. For example, extra costs, missed appointments, disappointed passengers, etc. Don’t fall into this trap – look for the gainss from the alternative action – being alive and safe with an intact aircraft (with probably very relieved passengers), having avoided the potential major losss (and cost) of bent metal, al, injuries, or worse. wor WEATHER You must obtain the most up-to-date weather ther before your flight. Weather issued on the morning of an afternoon n flight is good for f assessing sing the trends, but should be up updated. It is equally important to devote a generous amount of time me to weather we interpretation – especially specially when conditions are borderline – so that you can consider how the conditions might affect your flight. Using a highlighter pen to mark the key points as you read the forecast is useful. There are two distinct steps you need to follow when looking at the weather and deciding if it is good enough for your flight. Firstly de-code the weather briefings, making sure you look up any codes you don’t recognise (the GEN section of the AIP, the Bureau of Meteorology and Airservices Australia websites, and the weather interpretation card, all have information to help de-code aviation weather forecasts). Secondly, build a mental picture of what the weather forecasts and reports are saying, and how this will affect your flight. Be honest with yourself when trying to form a picture of what is happening. If you’re not sure, ask someone who has more experience to help you. If you decide to proceed with the flight – with the intention of seeing what the conditions are like – do it only on the basis that you will divert or turn back when they surpass a specified value (e.g., ‘I will divert or turn back if the visibility and cloud base deteriorates below X’). If you do not feel comfortable with the conditions, it’s time to tell your passengers the flight is off. Making such a decision requires a fair amount of personal discipline, but this can be made considerably easier by having a robust set of personal minimums to guide you. NOTAMS Having the latest NOTAMs is very important. TALK TO A LOCAL If the weather conditions on the day aree approaching yo your personal al minimums, call the local operator(s) again, to gauge their assessme sment of the conditions en route and at the destination. destinatio FILE A FLIGHT PLAN We highly recommend you file a flight plan, an, or at a minimum organise your own flight following service. Tell someone where you are going and when you are planning to get there. Provide written instructions on what, specifically, to do if you don’t check in with them by a certain time. If you are asking a family mem member to complete this task, be aware that the stress of you not checking-in could make this very difficult for them. Filing a flight plan will ensure that someone will miss you if you don’t arrive, so that search and rescue operations can start immediately. Equally, when you have filed a flight plan, remember to amend the SARTIME, or terminate the flight plan when you do arrive safely. DON’T FORGET TO CANCEL SARTIME Contact CENSAR on 1800 814 931 SARTIME E is the time nominated by a pilot for the initiation of a search and rescue action if a report has not been received from the pilot by the nominated Airservices Australia unit. Although you don’t have to submit a SARTIME, it makes sense to let someone know where you’re going, and when you’re planning on getting there. Your SARTIME is logged with the centralised Airservices database – CENSAR. If a fl flight ight is over the designated SARTIME, the first first step is for 23 FLIGHT PLANNING Read the NOTAMs carefully – highlighting the ones tha hat will affect your flight. ATC to put out calls to aircraft in the area, to keep a lookout for the missing plane. Fifteen minutes after the SARTIME has elapsed, the information goes to AUSSAR, and a formal search is initiated. Why should I cancel it? The majority of searches happen because of failure to cancel SARTIME, leading to a massive waste of time and resources. It’s easy to lodge SARTIME, and then at the end of a flight, become distracted with all the necessary checks and procedures, and forget to cancel SARTIME. So, to cancel your SAR, contact CENSAR on 1800 814 931. IN THE AIRCRAFT 24 FSA MAR–APR09 Gather your kneeboard with the completed flight log, your pre-folded charts, any aerodrome pages you could need, and any other useful information. Arrange them so that you have them nearby, and in the order you will need them. An important part of in-flight management is to review the situation continually, and update alternatives during the flight. For example, reviewing the cloud base in relation to enroute terrain, or reviewing surface wind conditions at the destination, are important points to consider. Even if the weather ahead seems fine, you must always maintain an awareness of what the weather is doing behind you, and be able to recognise when the conditions are about to fall below the limits you’ve set. GOOD TIPS Draw 10 nm rings around airfields you will pass nearby, so you will know whether your track takes you into their area, and you need to speak to them on the radio. Use a highlighter pen to mark relevant weather and NOTAMs. Put 10 nm distance markers along the track line to help you keep track of time and distance travelled, distance from/to features, and drift. Draw wind vectors on your chart to remind yourself of the general flow. Prepare groundspeed checks along your track. By choosing easily identifiable features there is more chance you will remember to do them, and they will be more accurate. Mentally note a reciprocal compass heading just in case you need to turn back. Always have an alternate aerodrome in mind – and sufficient fuel to get there. Avoid flying close to aerodromes unless you need to, as they tend to be the busier airspace. FOR MORE INFORMATION NOTAMs & meteorological information NAIPS (Airservices Australia) www.airservicesaustralia.com/brief AvFax (ERSA: En Route Supplement Australia) Met only Bureau of Meteorology website (www.bom.gov.au) and go to ‘Aviation Services’ DECTALK (ERSA) Adapted from Vector, November-December 2008, with kind permission of the Civil Aviation Authority of New Zealand. BOB TAIT’S AVIATION THEORY SCHOOL Has New Premises at Redcliffe Aerodrome - Queensland Full-time BAK and PPL courses now available! Check out our web page at www.bobtait.com.au BAK & PPL All CPL subjects plus IREX Courses available full-time or by home study PO Box 2018 Redcliffe North QLD 4020 P:07 3204 0965 F:07 3204 1902 W:www.bobtait.com.au E:[email protected] CONCEPT AVIATION THEORY COLLEGE PPL course commencing 16/03/2009 IREX course commencing 17/03/2009 Courrse s s held in our classroom at Bankstown Airrpo port In line with Concept’s phiilo loso s phy, we have gone to a great deal of effort to make e th hes e e co ourrse ses tth he best you will find anywhere. T The h re are sparkling new visual presentations and grraphi hics c tha at ma make ke the ke PPL course a lot of fun an nd ea asy tto understand. Our IREX cou ours ou rse wiill be rs e pr p esen ente te ed by one of th the most experienced aviation teachers in the e bu b siine ness s . Studying for the IRE R X iss som som o et ethi h ng hi ge eve very ve ryyone dr d ea eads ds, bu ds butt we wil wililll ge g t yo y u ovver er the line. We aiim to t g get ett you through first titime me. me All course notes will be pro rovided we week e by we week ekk and d wililll go int nto an nto n ind ndexed d binde derr whic wh w hic ich h we willl supply. ssu u Call now for full details or to reserve yo your ur pos positittio ion on n tthe he c cou ou urs rse of you o r ch hoi o ce CONCEPT AVIATION SUPPLIES PO Box Box CP43 P437 Condell Park NSW 2200 Cond Building 621 Airport Avenue nuee Bankstown Airport NS SW 220 2 00 Auustralia liaa Phone 02 9791 1 022 0222 Fax 02 9791 791 0409 0409 www.concepttavia aviatio tion tio i .com io m.a .a .au ADVERTISING 25 They’re almost the stuff of science fiction, but, specialists argue, the next ten years will see enormous growth in their civil use. In the first of a series of articles, Flight Safety editor, Margo Marchbank, explores developments in unmanned aerial systems (UAS), described as ‘the fastest growing area of aerospace research and development globally’, and the 26 implications such systems have for aviation safety. FSA MAR–APR09 ‘To broeldnlyo he can’ go wm an Unmanned aerial systems (UAS), often known as UAVs, (unmanned aerial vehicles), can range from something the size of a dragonfly on steroids to large aircraft of B747 proportions. They are more correctly referred to as UAS, since the components make up a ‘system, consisting of the UAV or ‘flight vehicle’; the ground station; and the communication or data links. UAS IN AUSTRALIA Last year was a significant one for UAS in Australia on several fronts. The first was the successful trial of the Israeli-manufactured Heron (pictured above, and opposite) conducted over six weeks in May-June by Australian Customs’ Border Protection Command. During the trial, the 8.5 metre long Heron, which has a wingspan of 16.6 metres, and a range of more than 1800km, flew from Weipa in far north Queensland, over the Gulf of Carpentaria, Torres Strait and the Grreat Barrier Reef, testing its potential for maritiime surveillance and border protection. CASA staff in Canberra and Cairns were ved, along with Airservices, Customs involv he Israeli manufacturers, in what CASA’s and th Gary Carr describes as a ‘huge effort and a huge success’ success’. Unlike manned aircraft, according to Customs, the Heron can fly ‘low and slow, down to 65 knots, allowing its cameras to pick up small detail such as the name of the ship on the hull, and the crew (so as to determine their ethnic heritage), or whether there is livestock on the ship’. Currently border patrol is carried out using the Dash 8, whose carbon footprint, in the current environmental climate, could be a factor in the Heron’s favour, with the Heron’s Rotax 912 engine burning far less fuel than the Dash 8’s twin turbo-props. Following the trial, the Government is assessing the longterm viability of UAS for coastal surveillance. Diagrams Juanita Franzi - Aero Illustrations p26, 28, 29 CASA has been a leader in the area of UAS from the start, beginning in the late nineties with work to write regulations encompassing areas such as UAS, operations, maintenance and ground control requirements. CASR Part 101, a first in the world, which came into effect in 2002, gave a framework under which all classes of UAS could be regulated. Mal Walker, then a Canberrabased flying operations inspector, was the driving force behind the development of Part 101, something which was recognised last year. He and another UAS ‘pioneer’, Filippo De Florio, became the first recipients of the ‘De Florio & Walker Pioneer Award’ created in their honour by Unmanned Vehicle Systems International, a worldwide UAS organisation representing 35 member countries. In 1997, Mal led a team reviewing legislation concerning operation of various unmanned aircraft, and saw a need for consistent legislation to allow the progressive integration of such aircraft into civil airspace. Together, Mal and his team successfully implemented Photo: Australian Customs UAS RESEARCH Australia is well placed to contribute to the growth of UAS, and capitalise on forecast growth of a $53 billion spend worldwide on UAS (both military and civil) over the next five years. Unlike many countries around the world, European nations in particular, Australian airspace is not congested. Australia has several UAS-designated areas: West Sale in Victoria; Marulan in NSW – the University of Sydney’s ‘test site’; and a proposed area in Queensland around Kingaroy. The Queensland State Government is giving considerable support to UAS development, and is funding the joint venture Australian Research Centre for Aerospace Automation (ARCAA) with research partners, the Queensland University of Technology (QUT) and the Commonwealth Scientific & Research Organisation (CSIRO). A new custom-built laboratory facility at Brisbane Airport’s Da Vinci precinct, housing the ARCAA, is due for completion later this year. 27 UAVs/UAS UAS REGULATIONS the new regulations, and he oversaw UAS activities until he retired from CASA in 2007. Other agencies are more conservative in their approach. Nicholas Sabatini, former associate administrator with the U.S Federal Aviation Administration, prefaces remarks about the ‘integration of UAS’ by quoting medicine’s Hippocratic Oath, ‘First, do no harm’ as exemplifying the FAA’s approach. ‘Working with our international counterparts, the FAA is committed to do no harm as it addresses the safe integration of unmanned aircraft in civil airspace,’ he states. UNMANNED AIRCRAFT – THE BEGINNING 28 Unmanned aircraft are not new. Balloons fitted with explosive devices had been used in conflict between Austria and the Venetians in 1849, with limited success – when the wind blew the Austrians’ balloons fitted with timers, off course. During the American Civil War, both Union and Confederate armies were similarly unsuccessful in their balloon bombing attempts. Around the time of the First World War, Englishman, Archibald Low, acknowledged as the ‘father of radio guidance systems’ was working on a radio-controlled aircraft. From that time, UAS have continued to evolve, and until relatively recently in their history, have been used mainly for military purposes, such as weaponry platforms, reconnaissance or surveillance. Recent conflicts, in Iraq and Afghanistan for example, have seen the widespread use of UAS such as the Predator, loaded with Hellfire missiles, which can stay in the air for around 40 hours; and the jet-powered Global Hawk, which operates at 60,000 feet, with an endurance of about 24 hours. The Jane’s Defence News quotes an Israeli Air Force (IAF) officer as saying that, ‘Out of 28,000 operational flight hours [for the IAF] in 2005, 18,000 were conducted by UAVs [which is] about 65 per cent’. Another former IAF spokesman said, ’By the end of the next decade [2020], I believe that more than half of IAF platforms will be unmanned.’ FSA MAR–APR09 CIVIL-USE UAS However, UAS are coming into their own in the civil sphere, and as a consequence, according to CASA’s Gary Carr, ‘aviation authorities around the world see the integration of UAS into civil airspace as one of the most significant current safety challenges’. Whereas UAS in the military context, Gary says are ‘mission-centric’, with safety and retrieval not being the main focus, in the commercial sphere, it’s completely different. They are particularly suited to the many operations which can be classified as ‘dull, dirty or dangerous’: for the routine, boring tasks, and data-gathering in environments too risky for humans, such as volcanoes, hurricanes and bushfires. © Kendal McGuffie – Aerosonde trial at Hamilton THE ‘DULL, DIRTY AND DANGEROUS’ DOZEN: Weather research/monitoring – flying into hurricanes, tornados, bushfires Environmental research – volcano investigations, Arctic/Antarctic cryospheric research; tracking wildlife populations Mineral exploration – aerial survey across desolate terrain, not ‘friendly’ to humans; pipeline leaks Locating of unexploded ordnance/artillery, especially land mines Agriculture – crop spraying, monitoring, e.g. detecting fungus on wine grapes; spraying rice crops at night, with the possible wire obstructions identified and pre-programmed. Coast and border surveillance – as in the Customs’ trial Telecommunications – UAS operating as mobile relay platforms, almost like a disposable satellite, or in disaster zones for emergency telecommunication News/media – news-gathering, video footage Maritime research – eg tracking whale populations, locating schools of fish to catch, oil spill tracking 29 Powerline inspections – often conducted using micro- or very small UAS Traffic control – both ground and ATC, monitoring traffic and accidents over major highways, and traffic over busy airports An Australian UAS success story is the Aerosonde, pictured ((left opposite), which was used in a joint project with the US National Oceanic & Atmospheric Administration over the northern hemisphere summer last year (South Florida Sun–Sentinel). The propeller-driven Aerosonde, with a three-metre wingspan, is manufactured in Melbourne, and is well-suited to its meteorological research role. It has a 1.6hp engine, a flight management computer, and cruising at around 100kph covering almost 3700km, uses a meagre 5.68 litres of fuel. With its tough polymer construction, it is designed to withstand the eye of the hurricane, and has been clocked enduring the buffeting of a hurricane for more than 20 hours, providing valuable and potentially life-saving data for meteorologists. Its capacity to fly as low as 300ft above the ocean, not possible for manned aircraft, means that the Aerosonde can capture surface temperatures, wind, barometric pressure and humidity readings from that vital ‘slice’ of the atmosphere. However, the FAA, concerned about manned aircraft safety, and the potential for collision with small aircraft which might have been evacuating from the path of the hurricane, would not allow the Aerosonde to fly near the US mainland during the 2008 summer hurricane season. Gary Carr argues that ultimately ‘economics will drive the uptake of UAS’, as they have the potential to offer cheaper alternatives to manned aircraft for a variety of tasks, given the rising cost of fuel for manned aircraft, and environmental considerations such as emissions and carbon trading. However, he says, there are still a number of hurdles to be overcome before civil UAS can be safely integrated in shared airspace. UAVs/UAS Aerial photography – real estate marketing, sports events, stadium monitoring. There are several issues facing regulators and industry alike. Unmanned Systems, a Dutch initiative, set up to establish standards for UAS under 150kg. 1. Lance argues that by 2020, there will be limited commercial UAS operations, mainly because of the pace of regulation internationally. The necessity to get individual countries to line up and agree creates some significant legal hurdles, but the commercial push from industry is likely to pick up pace, in the face of major cost savings offered by future UAS operations. 2. 30 3. FSA MAR–APR09 4. The radio frequency spectrum - available bandwidth. The radio spectrum is swamped already, with only a very limited bandwidth allocated for UAS, which require massive bandwidth to transmit information. The Australian Communications & Media Authority (ACMA) controls bandwidth in Australia. The FAA’s Nicholas Sabatini says that the issue of bandwidth for UAS should also be an agenda item for the 2011 World Radiocommunication Conference. The ‘holy grail’ for UAS is how Gary Carr describes the requirement for them to be capable of ‘sense and avoid’. It’s one thing for the UAS to ‘sense’ that another aircraft is in the vicinity, but not so easy for manned aircraft to detect a UAS, given the variation in size and operating requirements of UAS. The concept of ‘equivalent safety’ has been mooted, that is, UAS should be ‘as safe’ as manned aircraft, but that creates another set of issues, in defining and understanding manned aircraft safety. What criteria do you use to assess ‘aviation safety’? Fatality rates? Mid-air collisions? Public and industry acceptance of UAVs, reassuring the public in particular, that Australia’s high aviation safety standards would not be compromised by the introduction of UAS to civil airspace. Any new technology is regarded with suspicion in some quarters, and UAS are no different. These considerations and others are why CASA is continuing involvement on an international level with the development of standards and protocols for UAS. Lance Thorogood is the CASA representative on the various working groups set up by the International Civil Aviation Organization (ICAO) to look at international UAS operations. There are four working groups examining: airworthiness; operational issues; dangerous goods & airspace; and a recentlyestablished group which Lance heads, given the task of bringing together all the acronyms, abbreviations and definitions in the area, in an effort to create standardisation in the industry. There is also the JARUS working group, the Joint Authorities for Rulemaking on AUSTRALIA’S UAS CLASSIFICATION CASR Part 101’s operating rules identify three classes of UAS Micro UAS – under 100g Small UAS – 100g to 150kg Large UAS – 150kg and above The regulatory interest is chiefly in the large UAS, which require personnel approval and a UAS operating certificate; a certificate of registration; a maintenance program; and a special certificate of airworthiness, either in the experimental or restricted category. For further information Australian Research Centre for Aerospace Automation www.arcaa.aero/ ‘Small unmanned aircraft to fly into hurricanes to assist with forecasting’ South Florida Sun-Sentinel 4 April 2008 Brief history of UAVs List Lab, University of Florida http://aln.list.ufl.edu/uav ‘Attack of the drones’ Flight Safety Australia, NovemberDecember 2002 p56-58 ‘Unmanned aerial system review’ World Airnews, January 2009 p15-22 ‘Determination & Evaluation of UAV Safety Objectives’ Reece Clothier & Rodney Walker, QUT, 2006. Accessed from http://eprints.qut.edu.au ‘UAV 2003 – a roadmap for deploying unmanned aerial vehicles in transportation’ US Department of Transport/ Research & Special Programs Administration – Volpe Center ‘Unmanned aircraft in Australia – a regulatory perspective’ Gary Carr, Certification Programs Coordinator Heli Pacific presentation, May 2008 Unmanned Vehicle Systems - International www.uvs-international.org/ International not-for-profit association of manufacturers and researchers in the unmanned vehicle field UAS - the global perspective 2007/2008 UVS International & Blyenburgh & Co. 2007 www.uvs-info.com PULL-OUT SECTION Life cycle of an Australian airworthiness directive AIRWORTHINESS 31 PcC Pic Cou Co our u rrtteesy urt essy sy o off Da Dave avvee Gib Gibley Gi bley ey y Our story begins when the maintenance controller of a fleet of Fairchild (Swearingen) SA226 and SA227 series aeroplanes (Metroliners) made an urgent phone call to CASA’s Airworthiness Engineering Group. The caller described how, on final approach to landing, the rudder on a Metroliner became completely locked in the neutral position. The operator’s engineering staff made an immediate investigation into the rudder control system and discovered that the rudder gust lock assembly had failed in such a way that it became fully engaged. The Metroliner gust lock assembly is essentially a spring-loaded plunger. When the cockpit control is moved to the ‘lock’ position by the pilot, the housing moves forward and the spring presses the plunger against the locking quadrant of the flight control, ready for the hole in the quadrant to line up with the plunger. When the hole lines up, (when the control surface is in the neutral position) the pin drops in, and the flight control is locked. The Airworthiness Engineering Group’s Roger Alder and Richard Allen tell the story of how a service difficulty report (SDR) became a unique Australian airworthiness directive (AD) and how that AD, having served its purpose, came to be cancelled. PULL-OUT SECTION The spring-loaded plunger is retained in the housing by a roll pin. The roll pin moves in a slot in the housing. In this case, the housing had failed, allowing unrestricted movement of the p plunger. g This then fired out of the housing and engagged with the control surface quadrant, even th hough the cockpit control was still in the ‘un nlock’ position. 32 The caller also reported that they had inspected the rest of the aircraft in their fleet and had found mo ore cases of rudder gust lock housing cracking,, the pre-condition to the failure that they haad just experienced. FSA MAR–APR09 The Metroliner is widely used, not only in Australia but throu ughout the world. This unsafe condition which haad come to light through the maintenance con ntroller’s proactive service difficulty reporting had not been addressed by any existing F Fairchild (now M7) service bulletin or FAA A airworthiness directive, so CASA decided d to issue an emergency Australian airworthiness directive, which became AD/SWSSA226/96 - Rudder Gust Lock. This uniquee Australian emergency AD was drafted on th he basis that this gust lock failure had not occu urred because of inadequate maintenance, poor design or a manufacturing defect, but was an n ageing aircraft issue. Many aircraft op perating in the commuter category in Australia, including Metroliners, are considered ‘fl fleet leaders’ because they have accumulated d very high flight times times which are well w in excess of any other aeroplane of the same type in any other aer cou untry in the world. These aircraft are of speecial interest to t manufacturers because deffects related to time t in service - such as the gust lock - are mo ore likely to be found in the ‘fleet e leaders’ first. CA ASA calculated a retirement life for the gust locck, and required any gust locks that had excceeded the retirrement life as published in thee AD to be removved from service within 100 flig ght hours after the effective date of the AD. Wh Where gust locks had been removed to meet the requirements of the AD, the AD also gave approval to conttinue operation, provided there was a suitab ble alternative to secure the rudder against dam mage from wind gusts while Continued on page 38 SELECTED SERVICE DIFFICULTY REPORTS Airbus A319115 Escape slide unserviceable. Ref 510007547 LH over-wing escape slide unserviceable. The slide failed tests with all tubes having excessive porosity on almost all seams and surfaces. P/No: D3186511. TSN: 9,512 hours/7,253 cycles. TSO: 2,484 hours/505 cycles. Airbus A330201 Landing gear steering system faulty. Ref 510007722 Nose wheel steering system faulty. Brake and steering control unit (BSCU) and nose wheel steering servo valve replaced. Airbus A330202 Air data computer ADIRU faulty. Ref 510007664 No2 Air data inertial reference unit (ADIRU) faulty. P/No: 46502003030316. (1 similar occurrence) Airbus A330203 APU wiring FOD. Ref 510007556 APU wiring loom located in cargo compartment unserviceable. Investigation found that a dog had escaped from its crate and had bitten through wires in the loom. Dog had also made a mess in the cargo compartment which required cleaning before departure. Investigation continuing. Airbus A330303 Captain’s seat belt strap and buckle separated. Ref 510007693 Captain’s LH side seat-belt strap and buckle separated from seat. Airbus A330303 Hydraulic pressure line swage fi tting failed. Ref 510007513 Loss of ‘green’ system hydraulic fluid. Investigation found No.5 spoiler hydraulic pressure line failed at swaged fitting. Airbus A330303 Passenger compartment lighting - smoke/fumes. Ref 510007570 Smoke and fumes emanating from lights in forward galley overhead panels. Investigation could find no faults, but found evidence of insects and moths behind the lighting panel. BAC 146200 Landing gear selector suspect faulty. Ref 510007612 Landing gear failed to extend with normal selection. Emergency selection of landing gear carried out. Suspect either selector switch/handle or rotary actuator on hydraulic valve. Investigation continuing. (1 similar occurrence) BAC 146300 Flight compartment windshield cracked. Ref 510007735 RH co-pilot’s ‘B’ windshield outer ply cracked. Investigation continuing. P/No: NP1701022. TSN: 787 cycles. (7 similar occurrences) Boeing 717200 Engine and APU fire bottle squibs open circuit. Ref 510007483 Engine and APU fire bottle squibs (5off6) failed functional test. All six squib circuits open circuited. Further investigation found an additional nylon gasket had been installed between the squib discharge housing and squib discharge housing retainer, preventing a continuous ground path to the extinguisher bottle. P/No: 891501. (1 similar occurrence) Boeing 727277 Ground proximity system transceiver unserviceable. Ref 510007575 Radio altimeter transmitter/receiver failed operational check following fitment. P/No: 20676315151. Boeing 737229 Leading edge slat mount holes worn elongated. Ref 510007656 No. 5 slat inboard mount attachment holes worn. Mount loose. P/No: 6546422268. (1 similar occurrence) Boeing 737376 Escape slide malfunctioned. Ref 510007641 No1R door slide raft malfunctioned during test. The slide inflated but rotated 90 degrees blocking doorway. Actuator inlet struck the fuselage scratching protective finish aft and below door cut out. P/No: 737M25651015. TSN: 38,361 hours. TSO: 688 hours. (8 similar occurrences) Boeing 737376 Hydraulic system, main hose burst. Ref 510007700 Hydraulic hose located between ‘B’ system pressure module and acoustic filter burst. Loss of system ‘B’ hydraulic fluid. Investigation continuing. P/No: AS116080264. Boeing 737476 Landing gear selector contaminated. Ref 510007574 Landing-gear red indicator lights failed to extinguish following landing-gear ‘Down’ selection. Landing gear extended normally. Investigation found debris in the landing-gear selector handle preventing it from fully contacting switches in the ‘Down’ detent. Boeing 737476 Pitot/static system faulty. Ref 510007526 Pitot/static system faulty. Pitot heat switches cycled with no effect. Problem corrected itself on descent. Investigation continuing. Boeing 737476 Trailing edge flap control system torque tube worn. Ref 510007679 Trailing edge flap torque tube worn due to contact with slat return hydraulic line. P/No: 657327117. (3 similar occurrences) BAC Jetstm3206 Gust lock damper pivot pin/ bush corroded. Ref 510007653 Rudder gust lock pivot pin PNo 137502F7 and bush PNo FCT39X1-2 heavily corroded and pivot bracket PNo 137502F8 cracked. P/No: 137515F407. Boeing 73776N Air conditioning compartment door separated. Ref 510007473 LH air conditioning pack fan check valve access door separated from aircraft. Investigation continuing. P/No: 22156391. Boeing 717200 APU FOD. Ref 510007658 APU oil filler cap loose and nil oil evident in sight glass. During compressor inspection, FOD damage noted on compressor wheel. Suspect high frequency vibration on camloc on borescope access panel with one receptacle missing. P/No: 4502440. TSN: 14,402 hours/14,962 cycles. (1 similar occurrence) Boeing 73776N APU failed to start. Ref 10007616 APU failed inflight start. Investigation continuing. P/No: 38007021. TSN: 12,850 hours/12,326 cycles. (5 similar occurrences) Boeing 7377Q8 Battery faulty. Ref 510007674 Main battery removed due to fault indications. Workshop investigation found very low electrolyte levels in all cells, with three cells internally shorted and welded to surrounding cells due to extremely high temperatures. Investigation continuing. P/No: CVH531KA. (1 similar occurrence) Boeing 737838 Battery discharged – suspect faulty charger. Ref 510007561 Battery discharged. Suspect faulty battery charger. Investigation continuing. P/No: 893003. TSN: 19,572 hours. TSO: 19,572 hours. (2 similar occurrences) Boeing 737838 Fuel storage fuel system suspect faulty. Ref 510007571 Fuel system imbalance. Suspect fuel pump lost priming. Investigation continuing. Boeing 737838 Fuselage skin damaged. Ref 510007727 Fuselage skin damaged/torn in area of upper LH static port located aft of L1 door. Skin holed for approximately 25.4mm (1in). Damage is located in a critical area at Stn 389 to Stn 392 - WL208 to WL212. Investigation continuing. (11 similar occurrences) Boeing 73786N Landing gear selector unserviceable. Ref 510007589 During climb, crew were unable to retract the landing gear. Investigation continuing. (1 similar occurrence) PULL-OUT SECTION AIRCRAFT ABOVE 5700KG Boeing 717200 Cabin cooling system sleeve ruptured. Ref 510007687 RH air conditioning pack flexible sleeve on ducting from temperature control valve ruptured P/No: 70056930016. Boeing 7378BK Landing gear brake hydraulic line ruptured. Ref 510007553 RH main landing gear No. 3 brake hydraulic supply line ruptured. P/No: BACH8A04EN0294K. 33 Boeing 7378FE Fuel storage nut cracked and corroded. Ref 510007527 RH wing fuel tank access panel 632CB leaking. Investigation found cracked dome nut. (2 similar occurrences) AIRWORTHINESS 1 December 2008 – 31 January 2009 Boeing 7378FE Landing gear brake system hose leaking. Ref 510007634 LH main landing-gear upper brake hose leaking. Loss of system ‘A’ hydraulic fluid. P/No: BACH8A04EN0294K. Boeing 747438 Emergency power supply bottle incorrectly fi tted. Ref 510007627 Door 3 RH emergency power supply (EPS) bottle incorrectly installed. Investigation found the mounting bracket fitted inside out, and safety bolts left in the trigger-firing mechanism. Further investigation found door 3 LH mounting bracket also fitted inside out. Investigation continuing. Boeing 747438 Engine pylon strut fuse pin panel missing. Ref 510007665 No. 4 engine pylon outboard strut fuse pin panel missing. Investigation continuing. P/No: 65B8968642. (12 similar occurrences) Boeing 747438 Potable water system hose ruptured. Ref 510007472 Potable water hose ruptured at drain valve. Loss of potable water. P/No: 60B50403739. Boeing 747438 Potable water system indicator suspect faulty. Ref 510007601 Potable water indicating zero. Nil leaks in system. Potable water indicator suspect faulty. Boeing 747438 Rear toilet waste bin smoke/ fumes. Ref 510007493 Smoke from R5 rear toilet waste bin. Fire extinguisher discharged. Investigation found a discarded cigarette butt in the bin. Boeing 74748E Air conditioning compartment air inlet door missing. Ref 510007698 No. 2 air conditioning pack ram air inlet door forward section missing. The aft section of the door remained in place. Inlet door actuator attachment bolt to door operating arm also sheared off. The forward hinge for the door was also damaged. PULL-OUT SECTION Boeing 767336 Wing fuel feed tube bonding out of tolerance. Ref 510007555 LH wing front spar fitting fuel feed tube bonding out of tolerance. Found during incorporation of EI 767-028-0053R02. (2 similar occurrences) 34 Boeing 767338ER Auto throttle system failed. Ref 510007660 Auto throttle system failed. Investigation found nil interface with thrust management computer (TMC). System tested normal following TMC re-rack. (1 similar occurrence) Boeing 767338ER Seat electrical headrest wiring burnt. Ref 510007666 Wiring located in seat 5E electrical headrest, chafed and burnt. Investigation continuing. (1 similar occurrence) Boeing 767338ER Strut inboard access panel missing. Ref 510007626 RH strut inboard access panel missing. Panel found on runway with all fasteners in secured position. Investigation continuing. P/No: 311T106576. (8 similar occurrences) FSA MAR–APR09 Bombardier DHC8202 Cabin cooling system aircycle machine seized. Ref 510007645 Aircycle Machine (ACM) seized. P/No: 78279018. TSO: 3,091 hours/638cycles/23 months. (11 similar occurrences) Bombardier DHC8315 Aircraft structure lightning strike. Ref 510007621 Aircraft suffered a suspected lightning strike. Inspection could find nil damage. (1 similar occurrence) Bombardier DHC8402 Baggage door handle incorrect stowed. Ref 510007595 Forward baggage door handle incorrectly stowed, causing door light to illuminate. Investigation found the door to be fully locked and the handle had not moved towards the unlocked position. Suspect handle incorrectly stowed when door closed. (7 similar occurrences) Bombardier DHC8402 Elevator tab control system actuator failed. Ref 510007675 RH elevator pitch trim actuator failed. TSN: 624 hours/694 cycles. (1 similar occurrence) Bombardier DHC8402 Flight compartment windshield inner pane shattered. Ref 510007489 (photo below) First officer’s windscreen inner pane shattered. Investigation continuing. (2 similar occurrence) Bombardier DHC8402 Landing gear door incorrect operation. Ref 510007566 Main landing gear hydraulic bypass door in ‘Open’ position preventing retraction of landing gear. RH main landing gear safety switch internal short circuit between terminal 1 and terminal 5. Switch was a new item fitted before this flight. P/No: 444EN496. Dornier DO328100 Fuselage skin corroded. Ref 510007719 Upper aft fuselage skin corroded in area between skin and copper bonding plate across composite section. TSN: 16,987 hours/14,776cycles/156 months. Beech 200 Rear pressure bulkhead stringer clip cracked. Ref 510007740 Rear-pressure bulkhead stringer clip cracked. Found during inspection iaw AVCON SB08-01. Crack length approximately 6.35mm (0.25in). TSN: 1,936 hours/3,212 landings. (4 similar occurrences) Dornier DO328100 Wing skin cracked. Ref 510007524 RH wing lower skin cracked in forward section outboard of engine. NDT inspection confirmed the crack. Investigation continuing. TSN: 24,567 hours/22,071 cycles. TSO: 24,567 hours/22,071 cycles. Embraer EMB120 Landing gear door unlatched and open. Ref 510007533 LH main landing gear door unlatched and open after takeoff. Embraer EMB120 Landing gear selector handle unserviceable. Ref 510007619 Landing gear selector handle seized preventing landing gear from being selected ‘Up’. Investigation continuing. P/No: 12025226501. Embraer EMB120 Passenger compartment lighting holder smoking/arcing. Ref 510007730 Fluorescent lighting holder located between rows 1BC and 2BC smoking and arcing. P/No: BC10047005. (1 similar occurrence) Fokker F28MK1000 Power lever throttle stuck. Ref 510007716 Throttle controls blocked during attempt to increase thrust. Throttles eventually unblocked. Extensive investigation could find no defects. Fokker F28MK1000 Rudder control system suspect faulty. Ref 510007648 Rudder fault messages appeared. Rudder limitermonitor unit P/No EARLM8504-413 removed as a precaution for investigation. Investigation continuing. Israel 1124 Fuselage bulkhead web cracked. Ref 510007603 Bulkhead web located in rear cabin cracked. TSN: 34,804 hours/24,515 cycles. Saab SF340B Nose landing gear downlock actuator faulty. Ref 510007608 Nose landing gear downlock actuator preload tension high. P/No: AIR864122. Saab SF340B Pneumatic system duct cracked. Ref 510007609 RH bleed air supply to air conditioning pack rubber duct cracked at clamp attachment area. P/No: 9303688100. AIRCRAFT BELOW 5700KG Beech 200 Fuselage door hinge lugs cracked. Ref 510007544 Cargo door hinge aft lugs located on airframe side of door hinge cracked. Cracks confirmed by NDI. P/No: 1014301973. TSN: 9,348 hours/14,939 landings. Beech 200 Landing gear position and warning system switch short circuit. Ref 510007738 Beech 200 Wing attachment bolt cracked. Ref 510007655 LH lower forward wing attachment bolt cracked in bolt head radius. Found during NDT inspection iaw AD/B200/38. P/No: 10140241S. TSN: 10,303 hours/8,527 cycles/8,527 landings/178 months. (2 similar occurrences) Beech 58 Landing gear actuator brush damaged. Ref 510007536 Landing gear electric motor brushes chipped and broken. Brushes had been replaced approximately two hours previously. P/No: 35175A. TSN: 2 hours. Beech B200C Trailing edge flap actuator drive shaft broken. Ref 510007669 LH inboard trailing edge flap actuator driveshaft failed. P/No: 1013800002. Britten Norman BN2A26 Aircraft fuselage cracked and corroded. Ref 510007701 Aircraft corroded/cracked in the following areas:- 1. RH flap nose cap ribs 2. rudder trim tab hinge 3. elevator leading edge 4. RH leading edge of horizontal stabilizer 5. crack in LH horizontal stabilizer spar 6. centre belly skin 7. centre floor 8. rear fuselage frame 9. left centre floor. Found during inspection iaw AD/BN2/53 (SB190). Cessna 172 Brake disc faulty manufacture. Ref 510007680 Newly supplied brake discs oversized. Discs will not fit into wheel half bores. Removed “old” (2off) disc hub diameters measured at 139.1285mm and 139.1031mm (5.4775in and 5.4765in). Supplied “new” disc hub diameters (4off) measured at 139.331mm, 139.382mm, 139.293mm and 139.293mm (5.4855in, 5.4875in, 5.484in, and 5.484in). Existing wheel half bore diameter 139.217mm (5.481in). Cessna 210N Hydraulic pressure switch failed. Ref 510007585 Hydraulic pressure switch failed. P/No: 98807101. Cessna 401B Wing spar cap corroded. Ref 510007744 LH wing front spar upper spar cap corroded. Found when upper wing skins removed to investigate bulging at butt joint P/No: 082250049. TSN: 2,987 hours. Cessna 402C Electrical power wiring corroded. Ref 510007686 Main wiring loom located under floor short circuited and corroded between wires L54B20, L32D20, H363A20 and H311B20 causing numerous electrical defects. TSN: 16,998 hours. Cessna U206F Horizontal stabiliser spar bracket cracked. Ref 510007510 Horizontal stabiliser rear spar reinforcement bracket cracked from lower bolt hold to the edge of the bracket. Found during inspection iaw CAP 55-10-01. P/No: 12326231. Cessna U206F Main landing gear legs cracked. Ref 510007509 LH and RH main landing gear legs P/No 1241117-1 and P/No 1241117-2 cracked in numerous places. Investigation found the cracking was only in the plating and not in the leg itself. Plating of the leg is an unapproved process. P/No: 12411171. Cessna U206G Starter lead damaged. Ref 510007579 Starter lead chafed through by mixture cable. Starter lead and mixture cable badly damaged. Battery showed signs of excessive heat. Gulfstream 500S Wing spar cap cracked. Ref 510007549 LH wing lower spar cap cracked. Crack located at WS 24.00. Found during inspection iaw AD/AC/42 Amdt7 and SB 90C. P/No: 1800037. TSN: 17,915 hours/468 months. (1 similar occurrence) PAC 750XL Electrical panel locknuts damaged. Ref 510007535 Electrical distribution panel locknuts damaged and loosened due to heavy current flow melting the nylon locking feature in the nuts. P/No: MS21044. PAC 750XL Vertical stabiliser attach pickup and upper lugs corroded. Ref 510007632 (photo below) Vertical stabiliser attachment pickup assembly and LH and RH upper lugs contained severe exfoliation corrosion. P/No: 11104391. TSN: 2,711 hours. Pilatus PC12 Engine oil temperature wire damaged. Ref 510007558 Engine oil temperature wire 2E21B24 damaged in cannon plug at the oil temperature bulb. The wire was split under the insulation of the shielded wire. P/No: WIRE2E21B24. TSN: 8,164 hours/6,759 cycles. Piper PA28161 Nose landing gear fork failed. Ref 510007537 Nose landing gear fork failed allowing nose wheel to separate. Nose landing gear collapsed causing damage to aircraft and propeller. P/No: 3512302. TSN: 15,613 hours. TSO: 15,613 hours. (1 similar occurrence) Diamond DA40 Firewall to fuselage corroded. Ref 510007546 Disassembly of firewall from fuselage found the fireproof ceramic matting saturated with water. The engine mount bolts were heavily corroded on the bolt shanks. Suspect caused by inadequate attachment and sealing of the firewall. Gippsland GA8 Horizontal stabiliser ribs cracked at pivot mounts. Ref 510007663 No1 tailplane rib cracked at the forward channel mount bolt hole. Found during inspection iaw SBGA8-2002-02. (2 similar occurrences) Swearingen SA227AC Hydraulic transducer failed. Ref 510007683 LH hydraulic pressure transducer failed. Loss of hydraulic fluid. Hydraulic pumps changed and filter inspected due to nil fluid. P/No: 2719154003. Swearingen SA227AT Elevator tab control system actuator intermittent. Ref 510007718 Elevator pitch trim actuator intermittent in operation. Investigation continuing. P/No: DL504M6. TSO: 2,488 hours. (1 similar occurrence) Swearingen SA227DC Cabin door seal out of adjustment Ref 510007732 Main cabin door seal out of adjustment. Loss of cabin pressure. P/No: 2724089009. ROTORCRAFT Bell 206B Main rotor transmission mount bearing loose. Ref 510007676 Main transmission mount drag assembly bearing loose due to failure of staking. P/No: 206031509103. Bell 212 Main transmission failed. Ref 510007584 Main transmission low oil pressure. Approximately 10 seconds later, the chip detector illuminated. After landing, the crewman reported smoke from the rear of the helicopter. On attempting to tie down the main rotor it was discovered that the rotor was seized and would not turn in either direction. Investigation continuing. TSN: 4,024 hours/324 months. TSO: 775 hours/41 months. Cirrus SR20 Nose landing gear cracked. Ref 510007667 Nose landing gear cracked. Found during inspection iaw SB2X-32-18. P/No: 11907005. TSN: 501 hours/62 months. (9 similar occurrences) Diamond DA20C1 Aileron control bellcrank incorrectly fi tted. Ref 510007481 (photo below) RH wing aileron control bellcrank incorrectly installed into bracket P/No 20-2710-00-01. Bellcrank was held in position in bracket by the tension of the AN4-16 bolt instead of the bolt being inserted through the hole in the bellcrank. P/No: 2027100002. TSN: 2,000 hours. Swearingen SA227AC Flight compartment power supply failed. Ref 510007695 Cockpit lighting power supply failed. P/No: LT52A. Piper PA31 Emergency exit separated. Ref 510007497 Emergency exit separated from aircraft during flight. Nil damage to surrounding structure. Investigation found the operating system handle bent slightly forward. P/No: 5525921. TSN: 9,838 hours. Piper PA31 Landing gear downlock hook stiff. Ref 510007565 RH main landing gear downlock hook stiff in operation. Bolt P/No 400-188 through hook found to be tight. P/No: 4198300. (1 similar occurrence) Bell 412 Collective control cylinder servo valve seized. Ref 510007697 Collective control cylinder servo valve seized in the ‘down’ position. P/No: 212076005105. TSN: 2,522 hours/152 months. TSO: 160 hours/18 months. Eurocopter AS332L Main transmission chip detector illumination – suspect contaminated water. Ref 510007607 Main transmission chip detector light illuminated. Investigation found no evidence of metal contamination and it is suspected that the detector was contaminated by rain due to poor protection of detector from weather. P/No: ME4638. Eurocopter AS350B2 Rescue hoist cable cutter activated. Ref 510007613 Rescue hoist cable cutter fired during hoist pre-flight testing. P/No: Y1265111. TSN: 10 hours/14 cycles. Eurocopter EC135 Main landing gear skid shoe cracked. Ref 510007739 LH rear skid shoe assembly cracked and split apart. One of the attachment clamps was also split. P/No: L321M1025101. TSN: 3,891 hours/5,934 cycles/5,933 landings/96 months. PULL-OUT SECTION Cessna A152 Wing attachment fi tting worn. Ref 510007539 Main wing attachment fittings P/No 0422405-5, P/ No 0722707-1 and P/No 0523309-5 worn in the bolt holes. P/No: 04224055. TSN: 8,520 hours. Grob G115C2 Alternator drive belts too small faulty manufacture. Ref 510007661 Newly supplied alternator drive belts P/No 37A19773-376 found to be too small in diameter and when fitted does not allow adequate clearance between alternator and engine case. The belts have identical part numbers to the old belts manufactured in Korea. The new belts are manufactured in the EU. P/No: 37A19773376. 35 AIRWORTHINESS Cessna 441 Cabin cooling system duct separated. Ref 510007528 Air cycle machine (ACM) outlet duct separated. Aircraft had just completed a major inspection. Robinson R44 Engine exhaust pipe holed. Ref 510007712 Engine exhaust pipe bulged in area of exhaust pipe to muffler junction. P/No: C16932. TSN: 435 hours. PULL-OUT SECTION Robinson R44 Tail boom skin cracked and corroded. Ref 510007736 Tail boom skin cracked and corroded in area under VHF COMM antenna. Severe corrosion and several cracks were found with one crack over 50.2mm (2in) in length. Found during removal of the antenna when sealant deterioration was found. TSN: 1,700 hours. 36 Robinson R44 Tail rotor pedals jammed – pitch control slider severely corroded. Ref 510007673 Tail rotor pedals jammed. Investigation found the tail rotor pitch control slider severely corroded (rusted). Aircraft operates in a corrosive environment. P/No: C0311. TSN: 136 hours/12 months. PISTON ENGINES Continental GTSIO520M Engine cylinder induction tube cracked. Ref 510007529 (photo below) No. 4 and No. 5 cylinder induction tubes cracked. One tube also deformed around clamping face. Engine had recently been overhauled. Suspect damage caused to engine during transit. TSO: 40 hours. end nipple is welded to the line at the manifold end. Suspect caused by fatigue due to insufficient support. P/No: 630657. TSO: 1,150 hours. Continental IO520D Engine crankcase nut cracked. Ref 510007662 Crankcase through bolt/cylinder hold-down bolt nut cracked and bolt loose. P/No: 6152541. TSN: 228 hours. (1 similar occurrence) Continental IO520F Engine camshaft worn. Ref 510007580 Camshaft lobe worn. Metal contamination of oil filter. TSO: 268 hours. Continental IO520L Engine cylinder piston broken. Ref 510007521 No. 6 cylinder piston skirt broken away. Metal contamination of engine. P/No: SA631475. TSN: 718 hours. (4 similar occurrences) Continental IO550N Engine cylinder piston pin broken. Ref 510007714 (photo below) No. 2 cylinder piston pin broken. Polish marks on cylinder walls. Metal contamination of oil system. P/No: 630046. TSN: 712 hours. FSA MAR–APR09 Continental LTSIO360E Engine oil pump drive shaft broken. Ref 510007593 RH engine oil pump drive gear shaft broken. During start-up the engine failed and the propeller feathered. TSN: 4,937 hours. TSO: 882 hours. Continental GTSIO520M FCU pressure service port blanking cap separated. Ref 510007743 RH engine fuel control unit fuel pressure service port blanking cap separated from fitting. Cap had been incorrectly fitted during engine installation. Minor oil leak was also noted from VAPC controller to engine oil return line due to defective packing PNo MS28778-6. P/No: AN9294J. Continental IO360E Engine fuel pump incorrect data. Ref 510007583 Incorrect release certificates received with new fuel pump. P/No: 64936851A4. Continental IO360E Engine fuel pump out of adjust. Ref 510007582 Newly fitted engine fuel pump could not be adjusted. P/No: 64936851A4. TSN: 5 hours. Continental IO360E Engine fuel pump out of adjust. Ref 510007582 Newly fitted engine fuel pump could not be adjusted. P/No: 64936851A4. TSN: 5 hours. Continental IO360K Engine fuel distribution injector line broken. Ref 510007542 No. 6 cylinder fuel injector line broken at area where Continental O300C Engine cylinder worn. Ref 510007507 Engine cylinders worn resulting in excessive oil consumption, fouled spark plugs and excessive blow by. Found during inspection iaw AD/Eng/4 Amdt 10. P/No: A50222. Lycoming IO360A1A Engine cylinder cracked. Ref 510007710 Engine No1 cylinder cracked at top spark plug hole. Found during compression tests, iaw AD/Eng/4 Amdt 10. TSO: 594 hours. Lycoming IO360L2A Engine FCU contaminated. Ref 510007690 Engine fuel control unit blocked with contaminant. Found during inspection iaw CASA AWB Engines 73. See also SDR 510007691 and SDR 510007692. P/No: 25765362. TSN: 2,106 hours. TSO: 510 hours. (3 similar occurrences) Lycoming IO540AE1A5 Engine exhaust pipe holed. Ref 510007712 Engine exhaust pipe bulged in area of exhaust pipe to muffler junction. P/No: C16932. TSN: 435 hours. Lycoming IO540AE1A5 Engine fuel pump faulty. Ref 510007577 Engine-driven fuel-pump diaphragm faulty. Leaking oil from drain. P/No: LW15473. TSN: 594 hours. (9 similar occurrences) Lycoming IO540AE1A5 Engine muffler collapsed. Ref 510007576 Muffler collapsed and deformed at junction with tailpipe. P/No: C16932. (1 similar occurrence) Lycoming LTIO540J2BD Engine cylinder exhaust valve broken. Ref 510007672 RH engine No3 cylinder exhaust valve broken. P/No: LW16740. TSN: 780 hours/12 months. (3 similar occurrences) Lycoming O235H2C Engine fuel pump failed. Ref 510007470 Engine driven fuel pump valve swage failed. Plate, spring and seal loose inside pump. Metal contamination of carburettor inlet filter. P/No: LW15472. TSN: 1,728 hours. Lycoming O235H2C Engine fuel pump failed. Ref 510007470 (photo below) Engine-driven fuel-pump valve swage failed. Plate, spring and seal loose inside pump. Metal contamination of carburettor inlet filter. P/No: LW15472. TSN: 1,728 hours. Lycoming O540E4C5 Engine cylinder base stud fractured. Ref 510007592 No. 4 cylinder upper forward base stud fractured. Remaining nuts on the cylinder held normal torque. P/No: 5015. TSO: 1,615 hours. (1 similar occurrence) Lycoming TIO540AJ1A Engine starter casing cracked and corroded. Ref 510007639 Starter motor mount casing cracked. Cracking was as described in Cessna SB08-80-02 and Lycoming mandatory Service Bulletin 577A. TSN: 43 hours. Lycoming TIO540J2BD Engine crankshaft counterweight attachment broken. Ref 510007685 (photo below) GE CF348E5 Engine compressor section fan module vibrates. Ref 510007726 No.1 engine fan module excessive vibration at 4.1 units. Vibration then dropped to 3.5 units after approximately five seconds. All other engine data normal. Investigation continuing. GE CF680C2 Engine fuel distribution tube leaking. Ref 510007694 No. 4 engine fuel tube leaking at mid-tube connection. Tube located between fuel flow transmitter and hydro mechanical unit (HMU). Leaking fuel damaged fire retardant material on thrust reverser cowl. GE CF680C2 Engine MEC suspect faulty. Ref 510007479 RH engine failed to shut down when selected. Suspect faulty main engine control (MEC). Investigation continuing. (4 similar occurrences) GE CF680E1 Engine starter drive shaft sheared. Ref 510007508 No. 1 engine low oil quantity. Suspect caused by overboard dump via the starter drain pad. Investigation found that the starter drive shaft had sheared and migrated aft, allowing an oil leakage path across the starter adapter pad. Rolls Royce RB211524G Engine air inlet section damaged. Ref 510007650 No. 4 engine acoustic panel damaged and delaminated at approximately 9 o’clock position. Panel contained two holes of approximately 76.2mm (3in) diameter. A rubber spinner tip was also found embedded in the panel. Spinner had been changed on 27 December, 2008 due to missing tip. Investigation found four outlet guide vanes (OGV) cracked beyond limits in an area directly aft of the damaged panel. Cracks ranged between 152.4mm and 177.8mm (6in and 7in). Cracked OGV’s necessitated an engine change. P/No: RB211524GT. Rolls Royce RB211524G Thrust reverser faulty. Ref 510007491 No. 4 engine thrust reverser faulty. Investigation continuing. (5 similar occurrences) Rolls Royce TAY65015 Engine low power. Ref 510007646 LH engine failed to achieve take-off power. Investigation and ground runs carried out with no faults found. Outside air temperature was 43 degrees C and is suspected that the extreme ambient temperature was the cause of the problem. PROPELLERS GE CF680E1 Engine suspect faulty. Ref 510007625 No. 2 engine spooled down to approximately 60 per cent. Investigation continuing. (2 similar occurrences) Hamilton Standard 14RF19 Propeller hub section nuts loose. Ref 510007707 LH propeller retaining bolt nuts (6off12) under required torque. Propeller hub P/No 814721-1 requires NDT inspection. Found during inspection iaw AD/ PHS/18 Amdt 3. GE CFM567B Engine fuel distribution filter contaminated. Ref 510007496 No. 2 engine fuel filter contaminated. Filter bypass light illuminated. Investigation continuing. P/No: ACC462F2038M. (6 similar occurrences) Hartzell HCB3TN3 Propeller controlling cable clip separated. Ref 510007688 (photo below) RH propeller control cable-securing clip separated. Loss of propeller control. P/No: RA1039C. GE CFM567B Engine fuel pump leaking. Ref 510007633 No. 2 engine-driven fuel pump leaking beyond limits. Investigation continuing. P/No: 8283005. (9 similar occurrences) over-pressurised due to a suspected constant speed unit (CSU). TSN: 91 hours. McCauley 3FF32C501 Propeller assembly damaged. Ref 510007611 RH propeller feathered following shut down. Propeller was removed and sent to overhaul facility. Following examination the following faults were found: 1. latch screw sheared 2. other latch screw bent towards propeller centre 3. sheared portion of latch screw embedded into latch plate by the piston 4. repairable damage to piston skirt 6. minor internal scoring on cylinder. Propeller had been fitted for four hours following repair for similar problems on another aircraft. P/No: 3FF32C501. TSO: 1,499 hours. McCauley 4HFR34C652 Propeller governor suspect faulty. Ref 510007532 LH engine nil oil pressure. Engine shut down and emergency single engine landing carried out. Suspect faulty propeller governor. Investigation continuing. P/No: 89741016. (4 similar occurrences) COMPONENTS Eastern Aero Marine T9 Life Raft EAM T9 EPIRB incorrect part. Ref 510007541 Incorrect EPIRB fitted to life raft. Model MRB4 EPIRB fitted is not authorised per CMM(25-60-19). The approved model is MRB3. EPIRB has worn a hole between the left and right chamber assembly. A list of other problems was also found Goodrich rescue hoist faulty. Ref 510007729 Rescue hoist was being used for training. The cable was routed over the cable cut switch and activated the cable cutter. The cable was incompletely cut. Investigation found cable cutter P/No 300414-1 was incorrectly fitted. P/No: 42325120. TSO: 1,377 cycles. Kelly Aerospace 4091709001 Turbocharger turbine wheel separated. Ref 510007706 (photo below) Exhaust turbocharger turbine wheel separated from shaft at ring groove area. Turbocharger was on first flight since fitment. P/No: 4067870010. IAE V2527A5 Engine anti-icing system duct split. Ref 510007478 No. 1 engine anti-ice duct split. Hot air caused overheating of electronic engine control (EEC). Investigation continuing. P/No: D36110013500200. TSN: 2,268 hours/1,542 cycles. TSO: 2,268 hours/1,542 cycles. PWA PT6A114 Engine AD requirement. Ref 510007581 Engine inspected iaw AD/Eng/5 Amdt9. Nil defects evident. (5 similar occurrences) PWA PW123E Engine over-torqued. Ref 510007657 No. 1 engine over-torqued to approximately 130–135 per cent, with propeller RPM approximately Hartzell HCC3YR1 Propeller CSU unserviceable. Ref 510007594 Propeller cylinder unit P/No E7157-1RB2281 separated from hub unit causing oil leak and problematic pitch control/operation. Piston was also cracked. Investigation found that the P/No A2420-6) fine pitch stop had been crushed mechanically in the propeller indicating that the propeller cylinder was Note: occurrence figures based on data received over the past five years. PULL-OUT SECTION TURBINE ENGINES 450–500rpm followed by an uncommanded auto-feather. Investigation could find no definitive cause for the over-torque, but numerous items were changed. (5 similar occurrences.) 37 AIRWORTHINESS LH engine crankshaft counterweight attachment broken, allowing the counterweight to move and contact camshaft. The bent camshaft then broke the cam followers and holed the crankcase. Loss of engine oil. P/No: LW10346. Continued from page 32 PULL-OUT SECTION 38 parked. The AD was deliberately written in such a way to give operators flexibility to use a range of measures to achieve the desired result. life for the same item listed in the FAA approved limitations section of the Metroliner maintenance manual. (The FAA did not raise an AD in this case.) At the same time, CASA also engaged in urgent communication with the manufacturer and the FAA, advising them of the problem and of the action that CASA had taken. The manufacturer agreed the action was justified, and within two weeks, Fairchild had issued a service bulletin placing a life on the gust lock and fully supporting the actions taken by CASA. When CASA became aware that the manufacturer had published a mandatory retirement life on the gust lock, the AD, its safety role performed, was cancelled. FSA MAR–APR09 ‘The AD was deliberately Later, the manufacturer amended the Section Chapter 05 of the written in Limitations maintenance manual for the Metroliner so such a way to that it now included a retirement life for the give operators gust lock assembly. flexibility to POSTCRIPT use a range This was a good result: the unsafe condition of measures that had been covered by CASA’s emergency airworthiness directive was now adequately to achieve the addressed, so there was no need for a desired result.’ continuing AD to mandate a retirement After an aircraft is pushed out of a hangar, and into service, having been given its type certificate; inevitably, problems are going to arise which the designer and/or manufacturer did not, or could not, anticipate, and which consequently are not covered in the original manuals. When these problems are discovered, and reported by means of SDRs and other industry feedback, airworthiness directives such as the unique emergency ‘rudder gust lock’ case above, work to mitigate the risk of such unforeseen ‘unsafe conditions. Compliance to the AD mitigates the risk created by this unanticipated ‘unsafe condition’, effectively returning the aircraft to the original design standard of its type certificate. Fill out the form with the details of the corrosion defect. In the description field of the SDR enter the word ‘SNAPON’ to be in the running to win a Snap-On Expandable ¼ drive General Service tool set with two socket sets (Imperial and Metric) valued at over $800. Remember to fill in the submitter’s details so that we can contact you if verification of any detail is required. A valid entry MUST: Identify an account of corrosion that ‘would not’ have been found whilst performing a current published inspection procedure and has the potential to affect the structural integrity of the aircraft if left untreated. If you have submitted an SDR in the past, and you feel that the occurrence was a good example of a corrosion defect that currently has no inspection to catch it and was found during an unrelated maintenance task then you can notify us of the SDR number (or aircraft rego and approximate date) via email to [email protected] with a brief description of the defect (don’t forget to mention ‘SNAP-ON’ in the subject title). Include some pictures of your example to point out the corrosion finding. (pictures and movies can be attached after submitting the SDR, limited to 2MB for each attachment) There is no limit to the amount of times a participant can enter, but each entry must relate to a separate corrosion finding. CASA reserves to the right to verify and investigate information submitted via the SDR system. The winner will be judged by a panel of CASA Airworthiness experts and their decision will be final. The best entries will be published in the May-June 2009 issue of Flight Safety with any pictures and description of aircraft, owner’s or operator’s details removed for privacy reasons. Submit your corrosion SDR and be in the running to win this expandable tool set with two socket sets (RRP over $800) courtesy of SNAP-ON TOOLS I[hl_Y[:_\ÓYkbjoH[fehji TO REPORT URGENT DEFECTS 97BB0 ')'-+- <7N0 &(,('-'/(& or contact your local CASA Airworthiness Inspector [freepost] Service Difficulty Reports, Reply Paid 2005, CASA, Canberra, ACT 2601 Online: www. casa.gov.au/airworth/sdr PULL-OUT SECTION To enter the competition, simply submit your SDR via the CASA website. website Visit http://casa http://casa.gov.au/airworth/sdr/ gov au/airworth/sdr/ index.htm and click on the ‘SDR and SUP online form’. Be received o on n or before the closing date of 09 April 2009. Be the first reported case of the defect if multiple reports are received. r NOT be fro om employees, associated agencies or ffamilies ili off CASA C or Snap-On. Additionally: 39 AIRWORTHINESS As a safety initiative, CASA, Flight Safety magazine and Snap-On Tools are running a ‘corrosion competition’ to encourage the reporting and identifying of airworthiness concerns such as structural corrosion. APPROVED AIRWORTHINESS DIRECTIVES 12 March 2009 Part 39-105 - Lighter Than Air There are no amendments to Part 39-105 - Lighter than Air this issue PULL-OUT SECTION Part 39-105 - Rotorcraft 40 FSA MAR–APR09 Bell Helicopter Textron 205 Series Helicopters AD/BELL 205/3 - Main Rotor Blade - Modification CANCELLED AD/BELL 205/9 - Servo Cylinder Upper Control Tube Fittings - CANCELLED AD/BELL 205/16 - Fire Detection System - Audible Warning - CANCELLED AD/BELL 205/21 - Swashplate Scissors Lever Bolts Inspection - CANCELLED AD/BELL 205/29 - Main Rotor Blade Bolt Washer Inspection - CANCELLED AD/BELL 205/33 - Synchronised Elevator - Inspection, Modification and Retirement - CANCELLED AD/BELL 205/36 - Fuel Boost Pumps - Inspection CANCELLED AD/BELL 205/41 Amdt 1 - External Cargo Suspension Kit - Load Restriction and Modification - CANCELLED AD/BELL 205/42 - Main Rotor Hub Inboard Fitting Life Reduction - CANCELLED AD/BELL 205/47 - Hydraulic Servo Cylinder Assembly - Spanner Link Assembly Inspection and Rework CANCELLED AD/BELL 205/49 - Elevator to Horn Assembly Attachment - Modification - CANCELLED AD/BELL 205/50 - Main Rotor Grip/Blade Bolt Inspection and Rework - CANCELLED AD/BELL 205/51 Amdt 1 - Vertical Fin Spar Cap CANCELLED AD/BELL 205/59 - Swashplate Outer Ring CANCELLED AD/BELL 205/75 - Swashplate Support Assembly Bell Helicopter Textron Canada (BHTC) 206 & Agusta Bell 206 Series Helicopters AD/BELL 206/130 Amdt 3 - Main Landing Gear Cross Tubes Bell Helicopter Textron 212 Series Helicopters AD/BELL 212/14 - Fuel Boost Pumps - Inspection CANCELLED Eurocopter AS 332 (Super Puma) Series Helicopters AD/S-PUMA/83 - Hinged Door Upper and Lower Catches Eurocopter AS 350 (Ecureuil) Series Helicopters AD/ECUREUIL/71 Amdt 3 - Tail Rotor Blade Trailing Edge AD/ECUREUIL/134 - Starter-generator Damping Assembly Eurocopter AS 355 (Twin Ecureuil) Series Helicopters AD/AS 355/60 Amdt 3 - Tail Rotor Blade Trailing Edge Kawasaki BK 117 Series Helicopters AD/JBK 117/31 - Tail Rotor Balance Weights Part 39-105 - Below 5700 kg AD/PC-12/54 - Fuselage Overboard Vent Installation Aerospatiale (Socata) TBM 700 Series Aeroplanes AD/TBM 700/51 - Wiring Harness Inspection Piper PA-36 (Pawnee Brave) Series Aeroplanes AD/PA-36/4 - Flap Control - Modification CANCELLED AD/PA-36/5 Amdt 1 - Pre-Certification Requirements Modifications - CANCELLED AD/PA-36/7 - Wing Main Spar Centre Section Modification - CANCELLED AD/PA-36/8 Amdt 1 - Forward and Aft Wing Attachment Fittings - Inspection and Modification AD/PA-36/10 - Spray Pump Windmill - Modification CANCELLED AD/PA-36/11 - Muffler Clamp - Installation CANCELLED AD/PA-36/13 - Fuel Tank Vent - Inspection CANCELLED AD/PA-36/16 - Control Rod End Bearings Replacement - CANCELLED AD/PA-36/18 Amdt 1 - Wing Main Spar Carry Through Assembly - Inspection AD/PA-36/20 Amdt 2 - Engine Mount Attach Brackets - Inspection and Modification Airtractor AT-300, 400 and 500 Series Aeroplanes AD/AT/24 Amdt 2 - Overturn Skid Plate Beechcraft 200 (Super King Air) Series Aeroplanes AD/BEECH 200/67 Amdt 5 - Fuselage Rear Pressure Bulkhead Cessna 170, 172, F172, FR172 and 175 Series Aeroplanes AD/CESSNA 170/85 - Alternate Static Air Source Selector Valve Placard Cessna 177 Series Aeroplanes AD/CESSNA 177/34 - Alternate Static Air Source Selector Valve Placard Cessna 180, 182 and Wren 460 Series Aeroplanes AD/CESSNA 180/94 - Alternate Static Air Source Selector Valve Placard Cessna 185 Series Aeroplanes AD/CESSNA 185/50 - Alternate Static Air Source Selector Valve Placard Cessna 188 (Agwagon) Series Aeroplanes AD/CESSNA 188/20 Amdt 2 - Aileron Control Cables Cessna 206 Series Aeroplanes AD/CESSNA 206/66 - Alternate Static Air Source Selector Valve Placard Cessna 207 Series Aeroplanes AD/CESSNA 207/40 - Alternate Static Air Source Selector Valve Placard Cessna 208 Series Aeroplanes AD/CESSNA 208/24 - Alternate Static Air Source Selector Valve Placard Cessna 210 Series Aeroplanes AD/CESSNA 210/75 - Alternate Static Air Source Selector Valve Placard Cessna T303 Series Aeroplanes AD/CESSNA 303/14 - Alternate Static Air Source Selector Valve Placard Cessna 336 Series Aeroplanes AD/CESSNA 336/15 - Alternate Static Air Source Selector Valve Placard Cessna 337 Series Aeroplanes AD/CESSNA 337/31 - Alternate Static Air Source Selector Valve Placard Dornier 228 Series Aeroplanes AD/DO 228/12 Amdt 1 - De-bonding of Surface Protection on Rudders and Elevators Gippsland Aeronautics GA8 Series Aeroplanes AD/GA8/5 Amdt 2 - Horizontal Stabiliser Inspection Pilatus PC-12 Series Aeroplanes Piper PA-46 (Malibu) Series Aeroplanes AD/PA-46/1 - Aft Rudder Cable - Inspection CANCELLED AD/PA-46/2 - Interface of Elevator to Horizontal Stabiliser - Inspection and Modification - CANCELLED AD/PA-46/4 Amdt 2 - Wing and Wing to Fuselage Fairing Rivets - CANCELLED AD/PA-46/34 - Stall Warning Heat Control Part 39-105 - Above 5700 kg Airbus Industrie A330 Series Aeroplanes AD/A330/95 Amdt 2 - Air Data Inertial Reference Unit Operational Procedure AD/A330/99 - Centre Wing - Frame 40 Rear Fitting Web Avions de Transport Regional ATR 42 Series Aeroplanes AD/ATR 42/25 - Wire Bundles in the Rear Baggage Zone Bombardier (Canadair) CL-600 (Challenger) Series Aeroplanes AD/CL-600/54 Amdt 1 - Overwing Emergency Exit Placards AD/CL-600/104 Amdt 1 - Inboard Flap Actuator AD/CL-600/107 - Angle of Attack Transducer Bombardier (Boeing Canada/De Havilland) DHC-8 Series Aeroplanes AD/DHC-8/144 - De-Ice Busbar Sealant Cessna 560 (Citation V) Series Aeroplanes AD/CESSNA 560/10 - Angle of Attack System Embraer EMB-135 and EMB-145 Series Aeroplanes AD/EMB-145/22 - Landing Gear Electronic Unit Fokker F100 (F28 Mk 100) Series Aeroplanes AD/F100/93 - On-Ground Wing Leading Edge Heating System APPROVED AIRWORTHINESS DIRECTIVES CONTINUED....... Part 39-106 - Turbine Engines CFM International Turbine Engines - CFM56 Series AD/CFM56/28 - Low Pressure Turbine Rear Frame Rolls Royce (Allison) Turbine Engines AE 3007 Series AD/AE 3007/6 Amdt 1 - High Pressure Turbine Stage 2 Wheels Turbomeca Turbine Engines - Arriel Series AD/ARRIEL/30 - Digital Engine Control Unit Software AD/ARRIEL/31 - Reduction Gear Box Intermediate Pinion Part 39-107 - Equipment Emergency Equipment AD/EMY/8 - Life Jackets - Inspection and Modification - CANCELLED AD/EMY/9 - Life Jackets - Modification - CANCELLED AD/EMY/17 - Life Jackets - Retirement - CANCELLED AD/EMY/19 - Life Jackets - Inspection - CANCELLED AD/EMY/21 - Life Jackets (RFD) - Inspection CANCELLED Fuel Supply and Metering Equipment AD/FSM/31 Amdt 2 - Fuel Injection Servo Plugs Instruments and Automatic Pilots AD/INST/1 - Gyro Horizon Indicators Power Failure Warning Flag - Modification - CANCELLED AD/INST/7 - H14 Automatic Pilot Servo Housing Inspection - CANCELLED AD/INST/12 - SEP 6 Automatic Pilot Roll Computer Clutch Circuit - Modification - CANCELLED AD/INST/13 - Venting of SEP 2 Servomotor Clutches Modification - CANCELLED AD/INST/14 - SEP 6 Automatic Pilot Pitch Computer Clutch Circuit - Modification - CANCELLED AD/INST/16 - King KG 102 Directional Gyro Modification - CANCELLED AD/INST/17 - King K1 525 Indicator - Modification CANCELLED AD/INST/18 - Collins PN-101 Pictorial Navigation System Slaving Accessory 328A-3G - Modification CANCELLED AD/INST/20 - Sep 2 Automatic Pilot Trim Servomotor Venting - Modification - CANCELLED AD/INST/21 - King KFC200 - IAFCS - Bridle Cable Clamps - Inspection - CANCELLED AD/INST/25 - Aerosonic Encoding Altimeters Replacement - CANCELLED AD/INST/26 - Navomatic 200A Automatic Pilot Computer - Amplifier Nav Input - Modification CANCELLED AD/INST/28 - A.R.C. PA1050A Actuator and DA1050A Decoupler Adapter - Cessna 1050A I.F.C.S. - Inspection and Modification - CANCELLED AD/INST/33 Amdt 1 - King KAP/KFC 200 Autopilot CANCELLED AD/INST/35 - Collins APP-80/80A Autopilot Panel CANCELLED AD/INST/36 - Collins ALI-80( ) Barometric Altimeter - CANCELLED Propellers - Variable Pitch - Dowty Rotol AD/PR/33 Amdt 3 - Hub Assembly D;MC7?DJ;D7D9;>KC7D <79JEHIJEEB8EN :h$8_bb@e^died_iY^_[\iY_[dj_ÓYWdZj[Y^d_YWbWZl_ieh\eh CW_dj[dWdY[>kcWdc[dgbVi^dcVcYlZWa^c`hidZchjgZXdci^cj^c\ ZYjXVi^dcdeedgijc^i^Zh I]Z;66bV^ciZcVcXZ]jbVc[VXidghegZhZciVi^dchnhiZb ^hYZhXg^WZYVhVÈ\^VciAZ\d"a^`ZXdaaZXi^dcd[]jbVc [VXidgh^c[dgbVi^dc#ÉJhZi]ZWadX`hidWj^aYVegZhZciVi^dc PULL-OUT SECTION There are no amendments to Part 39-106 - Piston Engines this issue i]Vildg`h[dgndj#I]Z9K9XdkZghVhZid[\ZcZg^Xide^Xh WaZcY^c\i]ZWVh^Xhl^i]XdcXZeihl]^X]i]ZegZhZciZgXVc Veeanidi]ZheZX^ÒXldg`eaVXZ#>i^cXajYZhi]Z[daadl^c\ bV^c ide^Xh/ ™ >cigdYjXi^dcid]jbVc[VXidgh ™ =^hidgnd[]jbVc[VXidgh ™ =jbVc[VXidghheZXiVXaZh ™ I]ZE:6GbdYZal^i][Vi^\jZ ™ =jbVcZggdgVcYZkZcigZedgi^c\ ™ BV^ciZcVcXZVXX^YZcih ™ L]ZgZid\ZibdgZ^c[dgbVi^dc >i^hCDIXdbejiZg"WVhZYigV^c^c\Ä^i^hYZh^\cZY[dgndjid iV^adgbV^ciZcVcXZ]jbVc[VXidghegZhZciVi^dchWnVYY^c\! YZaZi^c\!VcYbdY^[n^c\ha^YZhVhi]ZngZaViZidndjgdg\Vc^hVi^dc# 86H6^hY^hig^Wji^c\Xde^Zhd[i]Z9K9dcWZ]Va[d[i]Z;66Äid dWiV^cndjgXden!ZbV^a hV[Zinegdbdi^dc5XVhV#\dk#Vj ;dgbdgZ^c[dgbVi^dc!\did ]iie/$$lll#Vbidca^cZ#Xdb$ ejWa^XVi^dc$Vgi^XaZ#_he4ejW>Y2&^Y2**,& 41 AIRWORTHINESS Part 39-106 - Piston Engines 42 FSA MAR–APR09 AIP CHANGES AIRSERVICES UPDATE - AL58 EFFECTIVE 12 MARCH 2009 The International Civil Aviation Organization’s (ICAO) regional supplementary procedures (Doc 7030) require that pilots are advised of SIGMET up to two hours’ flying time ahead. The AIP and Air Traffic Services (ATS) manual have been amended accordingly. ‘Aviation special weather’ - SPECI, which can be obtained from an automatic broadcast service (ABS), no longer needs to be ‘directed’ or ‘broadcast’ to aircraft by ATS. The availability of SPECI from an ABS meets the requirement for in-flight information service. If an ABS is not available, pilots may request weather information from ATS as part of the on-request flight information service. Owing to difficulties in identifying aircraft using area forecasts (ARFOR) for operational control, and to capture all possible users, amended ARFOR will be communicated by broadcast only. The broadcast will be repeated at H+15 and H+45 to ensure adequate dissemination. There is new, clearer wording for the ‘Hazard Alert’ paragraphs. ‘MAINTAIN’ and ‘AMENDED’ - GEN 3.4 paras 4.7, 5.5 and 5.14.6 Previously, the word ‘MAINTAIN’ instructed aircraft to climb to their initial level on departure. However, when issuing level change instructions, ICAO specifically precludes using ‘MAINTAIN’. When allocating levels in departure instructions, controllers will use the phrase ‘CLIMB TO …’ However, ‘MAINTAIN’ will still be used by clearance delivery in airways clearance and on pre-departure clearance. Clearing an aircraft at an ‘amended level’ in an airways clearance to provide a ‘paper stop’ for air traffic control (ATC) separation will also cease. Aircraft will be cleared at an initial level, or at their planned level, unless there is an operational reason to do otherwise. Therefore, the prefi x ‘AMENDED’ will not be used: A. when an initial level for ATC traffic management purposes has been issued as part of an airways clearance – in which case ‘MAINTAIN’ shall be used; or B. during normal progressive climb/descent instructions. Including location with runway crossing request - GEN 3.4 para 5.14.5 To further mitigate runway incursions, and to improve the situational awareness of ATC, other pilots and vehicle drivers, pilots can include their location on the manoeuvring area in their runway crossing request. This change complements similar ATC phraseology changes. SIGMET and AIRMET dissemination - GEN 3.5 para 5.1.3 and 5.3.3 The issuing of a SIGMET or AIRMET report by the Bureau of Meteorology does not meet the conditions for ATC to issue a ‘Hazard Alert’. Although this change was made in 2007, these AIP paragraphs were accidentally left out from that change. Air traffic control will continue to disseminate SIGMET and AIRMET reports as part of ATC-initiated flight information service. 43 Content of a clearance - ENR 1.1 para 3.19.2 The updated paragraphs describing the contents of a clearance now mirror ICAO’s and align AIP with the ATS manual. There is no change in operational practice. Approach expectation - ENR 1.1 para 11.5.2 Air traffic control informs pilots of the type of approach to expect via the ATIS. However, pilots wishing to conduct a specific approach should request it prior to standard instrument arrival (STAR) clearance issue, or prior to top of descent for arriving aircraft not on a STAR eligible route. SARTIME cancellation - ENR 1.1 para 67.2.3 Cancel SARTIME by calling CENSAR on 1800 814 931, to reduce multiple message-handling and reduce frequency congestion. PJE broadcasts - ENR 5.5 para 2.1.3 Pilots must complete all necessary parachute jumping exercise (PJE) broadcasts (CASA Instrument 278/97 and current AIP). Air traffic control cannot do this, and often will not have access to all the frequencies required, so the last part of para 2.1.3 has been deleted. AIP CHANGES Hazard Alerting, SIGMET, SPECI and amended ARFOR - GEN 3.3 para 2 44 FSA MAR–APR09 by Kris McLean I started flying in sailplanes thirty years ago, wondrous flying machines which can go great distances nc without an engine. From there I move moved ve into powered fi xed wing: C172s, Warriors and the like. Warrio Eve Eventually entually ally I got into helicopters. I soon learned they y are re flying m machines of a different pedigree altogether; al ltog o ther; there are ar a lot more moving parts and an nd they hey are harder to m manage. n They are also easier eas as er to overload: d dual ual u a in n a ttwo-seater with full fue in fuel i summer mmer can not o only on nly make you illegal, itt ca can make k it impossible bl to get airborne. Turning is different too; left pedal turns in T American-built machines are accomplished with iincreased tail rotor pitch and consume more power m mo p than right pedal turns. Despite this, th hi left turns are generally preferred as they are less inclined to accelerate than right pedal. Furthermore, rotary wing aircraft can be easier to tip over than planks, so much so that the training syllabus has a section on not doing it. ‘Avoiding dynamic rollovers’ it’s called. The big day was fine but b blowy, y, so I was w careful to land into wind because bec two up in a 22 at ssix and half thousand d feet don’t leave much in the way of that great saviour of average pilots - surplus power margin! We had a ball, checked out all the Victorian ski fields, then filled up at Hotham and did Kosciusko too. We ew were on the way home when I got the idea for just us one more picture. What is it about human n nature that makes us greedy? We’d had a great, safe day’s flying, but I had to push my luck for one more photo opportunity. As we approached up-slope to a hilltop, the snow was heaped up into a long drift that looked steeper the closer we got to it. The wind had dropped during the day to just five to eight knots, so I decided to turn down wind and try for some more level ground. Instinctively, I turned left. Big mistake, the low-rotor RPM horn came on mid-turn, and by the time I’d got us pointing down slope, the machine settled with power at 35 knots and started to slide. I tried to wind on some more throttle, but the governor had already maxxed it out. Slipping downhill, I racked my brain for some ideas on what to do next. It occurred to me that there hadn’t been a lesson in my training on what to do when careening down a steep, snow-covered slope in a helicopter. Clearly I needed to do something before I ended up with a bent whirly-bird. I attempted to raise the collective. The lowrotor RPM horn came on again, so I tried lowering it. The skids started to dig in and it felt like we might nose over. Finally, in desperation, I kicked in a boot full of left pedal. The bird slewed, slowed immediately, but started a dynamic rollover to the right. I actually breathed a sigh of relief. For the first time in the last five, terrifying seconds, I knew exactly what to do. I floored the lever and pushed in as much up-slope stick as I could. We plopped back onto two skids &and I looked anxiously over to my passenger. ‘New slant on heli-skiing, hey?’ he said and flashed me a wan smile. t is a h I felt like a W ut o b wrung-out dish a t cloth, but I knew i man that we couldn’t stay u h there; we had a ture us down-slope na nasty es ? list and it would be k a m y dark in a few more d e e hours. I booted junior gr ’d had a out and handed him the mobile phone in We af e s , t case I came to grief a re flying, extracting myself from the g y ’s d predicament I’d put us in. a d I took a few deep breaths, I ha my calmed myself, then raised bu t sh ne the lever and wiggled the u p o pedals to free up the skids. t or o to f k The bird unstuck clumsily and I c lu e pho had cyclic everywhere till I got a r hover. Next I tried for some out- m o it y. n u t r of-ground-effect manoeuvring to po check there was nothing wrong op with the engine. Lastly, I put down facing into wind on the edge of a precipice so I could nose over after I picked up my passenger. The rest of the day was uneventful. So what’s to learn? Well I needn’t have taken on full fuel at Hotham, and I definitely shouldn’t have used left pedal, or turned down wind at altitude. I should maybe have shut down, got out and given the helicopter a thorough inspection before taking off again. I’m very grateful to have escaped the episode unscathed. All I can say is, if you take a chopper to the snow be careful, do a reserve power check and always land into wind, because it’s no fun scaring the daylights out of yourself and your passengers. 45 HELI-SKIING After nine hundred hours in my little R22, most of it at 500ft, I finally decided I knew enough about the vagaries of the helicopter to try my hand in Australia’s bit of high ground, the Snowy Mountains. With a max altitude below 7000ft, the destination seemed low enough to be safe if I was cautious,, so w when the opportunity to do some high country flying y with my sibling presented itself, I grabbed grabb it. Grey glooemor–ge by G by Patrick Fogarty og gart y 46 FSA MAR–APR09 I knew that special VFR suggested that the weather was not that flash, but I knew the area well and still had good clearance over my track I was over the moon. My recently-acquired PPL represented the culmination of a lifetime’s passion for flying. Desp pite only being able to afford a lesson or two a month, I went solo after six hours and earned my PPL with a minimum of fuss in just on minimu mum hours. I may not have been flying often, but I was practising radio ccalls and checklists in the car every day. The day started fairly innocuously. I was to fly down to Nowra to see some guys, a good chance to get a couple of hours up and nd visit a new airport. I knew the scenery on the coast was well worth seein eeing and was looking forward to the trip. As I got to the airport I was looking king to the sky with an optimist’s eye. The forecast was for scattered cloud at 1000ft with a few at 3500ft, and I imagined lots of blue between the grey (even if it wasn’t there). Once I had checked out the plane and got clearance, I took off and climbed on my initial track to Lake George South. At 800ft above Canberra airport (2600 QNH), I was just pushing the bottom of the few at 1000, so I radioed the tower to stay at 2600. The tower gave me clearance ‘special VFR, track as required under 3000’. At this point I felt the first twinge. I knew that special VFR suggested that the weather was not that flash, but I knew the area well and still had good clearance over my track. Besides, once I reached Lake George, the country flattened out to Goulburn, and I would make a call then whether to cross the ranges to Nowra or return. As I picked a route between the ridges to Lake George I was forced to lose 100ft, then another 100ft, in order to stay out of cloud. The cloud base was pushing me down. It was certainly no longer a few clouds. After being pushed to 2500 ft, I made the decision that I would get clearance and return as soon as I got to Lake George. will fly themselves perfectly well if pilots As I crossed the southern edge of Lake George I breathed a sigh of relief. Then suddenly my whole world went wrong - my world went grey, all grey! which was workload I didn’t need. I first I had been navigating with reference to the ground and in truth, for some time, hadn’t looked at the horizon. When I crossed the boundary of the lake the ground became the same grey as the sky, exactly. The feeling was incredible; my stomach was gripped with intense nausea and my eyeballs pushed through the windshield looking for a feature I could use, any feature. I was seeing things. In the absence of a good reference, my brain was happy to cling to anything, with potentially disastrous consequences. and suggested I might consider following the I would like to think that it took two to three seco econds to get a grip, but in reality I think it took fi five ve to 10 seconds. I knew the statistics. I had read that at VFR pilots last an average of 45 seconds when faced with unexpected IFR, and at 300ft above the water I knew I didn’t have that long. I also knew the other rule: trust the instruments, no matter what. I had the advantage that it was a fairly still day and the aircraft was in perfect trim before I crossed the lake edge (a leftover from my glider experience). I knew I had the coordination skills to fly IFR easily, but the mental aspect was incredible. I fell back to my glider days. My instructor used to say ‘planes would just leave them alone’. I got a T-pattern going and nudged the plane up a hundred or so feet. In truth, I had no idea if I was in cloud or not. The grey water was a perfect match for the sky. I knew that about half way across the lake there was a visible fence at a true right angle to my flight path, and that if I stuck to the instruments till then I would get a muchneeded visual reference for reinforcement. the grey murk and concentrate on the dials. I had to call for clearance back to Canberra, called approach on 124.5 and was redirected back to Canberra tower as I could not get to 3000ft. Tower cleared me by whatever route, main road back. A great idea and not one I was in any condition to think of myself. As the fence loomed up I noted it with relief, but stuck to the dials and did a gentle left turn to follow the road. From there I followed the road along the lake edge and through the cuttings to the northern suburbs of Canberra. I then cut across to join a right circuit for runway 30. As I joined the circuit, the tower had me look out for a green bird dog in front of me in the circuit. I had no chance. The emotion I felt at seeing the tarmac with its little white dashes meant I would have struggled to see a 747 7 on finals, nals let alone a small camouflaged war bird. I lande ded on R30 and got back to the office before 9.30a 0am. That night I wrote the couple co of words on the line that have often reminde nded me that I was lucky; sometimes you only get one ne cha chance. I took the incident as an incentive to do an IFR rating, and although I now live in the UK and haven’t flown enough to finish it, I believe all pilots should keep their IFR skills in good nick if they intend to fly in anything other than blue-sky days. Then suddenly my whole world went wrong - my world went grey, all grey 47 GREY GLOOM This thought helped me stop ‘seeing things’ in 48 FSA MAR–APR09 In-flight by Geoffrey Gibbons It was a good day for a VFR flight from Bankstown to Maroochydore and I was healthy and well-trained. The twin-engine Piper Seminole I was about to fly was brand new. The baggage was loaded, and a close friend and two beautiful blondes were ready to climb aboard. I turned to board and froze when my gut feeling said ‘drop everything and go home now’. However, it was a momentary thing, and the laughter of the girls snapped me out of it. Although quite new to multi-engine flying, I was starting to settle down after an uneventful departure. As we transited the light aircraft lane, Sydney was clothed in a twinkling haze out the starboard window. The passenger in the back carefully opened a thermos and poured me a coffee. Yes! She’d remembered to be mindful of the change in air pressure. The passenger beside me lit a cigarette and stuck it in my mouth. Setting the autopilot, I almost missed her provocative grin. Man! This is what being a pilot is all about! A good friend, beautiful girls and a zip up the coast in an aircraft expensive enough to let me pretend that I was smarter, stronger, richer and better looking than I am. Then, like most, a life-threatening problem began in a small way. Overhead Port Macquarie my friend asked, ‘Aren’t these trips measured in engine hours, Geoff? What are the chances of putting on a bit more power?’ The engines were already set at cruise. Mixture, manifold pressure and props were at a setting where the Lycomings were purring comfortably and I had no intention of changing anything. I gave him a ‘She’ll be right mate,’ and he settled down. But, things were getting worse in our tightly-confined space: the chatter in the cockpit was decreasing, and the level of discomfort increased exponentially. However, I was oblivious to it all, as we were approaching Coolangatta and I was thinking about our passage past the western side of the Brisbane primary control zone. This man had been my friend for two years, but when I turned to speak to him he was almost unrecognisable. In my earlier working life I’d done a little nursing in a psychiatric ward, and at 1500ft AMSL it was all there. With his lips pressed flat together, eyes granite hard and shoulders set for the swinging of a punch, I could see that the friend I had loved like a brother was no longer aboard the aircraft. Before I could speak, his growing rage surfaced, and he growled. ‘It wouldn’t kill you to put some power on and save us some dough!’ The dominoes were falling rapidly around me. I decided to give him what he wanted: the first order of business was to fly the IN-FLIGHT FRIGHT My eyes were ‘hard out’ the port side of the aircraft, when the sound of the engines jumped, increasing suddenly. With a start I turned, just in time to see my friend’s arm slip back into the rear cabin. I reset the power immediately, but I was utterly stunned; I’d never had a passenger do that to me. In fact, I had never even heard of such a thing! For a passenger to touch the controls of an aircraft in flight without the consent of the pilot is a breach of protocol the size of the Great Australian Bight. I wanted to say something, but what? I felt heaviness in the pit of my stomach and a burning behind my eyes because I finally realised just how much the mood in the aircraft had changed. The two girls had stopped talking completely. Quite a lot of time had passed since my earlier refusal and my friend had been ‘stewing’ ever since. The right thing was to keep cool, turn around and say something firm but polite. It was important to resolve this situation because Brisbane CTR was coming up fast. 49 W ith a star t I turne just in d, time to see my friend ’s arm sl ip bac k into th e rear cabin plane safely. Hunched up and afraid, the girls sat curled in their seats and their white faces finally convinced me. Time to pour on the power. I reached for the throttles and then had a shattering realisation. The scene outside the windows had changed radically. The ocean wasn’t where it was supposed to be. Pushing my forehead against the window, I saw, directly below, a huge Boeing RPT aircraft parked on the ground adjacent terminal buildings. I felt my heart jump as I began to hear the words of the anxious flight service officer for the first time in some minutes. A few minutes doesn’t sound like much, but horizontal movement across the ground at around 4500 metres per minute will put you over a control zone boundary in a flash. Brisbane airport was below, and the flight service officer had my undivided attention. He vectored me to Redcliffe airport. I increased the prop rpm, then pushed the power almost to the gate. The shout of approval from my mate in the back irritated the hell out of me! 50 FSA MAR–APR09 We cleared the control zone quickly, and it wasn’t long before the Hornibrook Viaduct hove into view. However, I wasn’t even close to breathing a sigh of relief, because I desperately wanted to get this bloke on the ground. He was laughing; but it wasn’t healthy laughter, or the gentle mirth of good company. It wouldn’t kill you to put some power on and save us some dough! I blew into the circuit at Redcliffe airport like a rocket. Punching holes in the air crosswind at 160 knots, I stood the Seminole on its wing and turned for a left downwind for runway 07. My turn for base wasn’t a base at all, but a single teardrop onto final. Loading the wings to wash off speed, I dropped gear and full flaps as I lined up with the runway. Oh that beautiful runway! It looked like it had just been laid by God Himself for a hapless pilot who’d just been dropped into a meat grinder. The threshold swept by, and for the first time that day I did something truly great; the landing. It was so gentle and centred that I didn’t even feel the wheels touch the ground. In all the flying I have done (including sailplanes), it really was my best landing ever. We were down and safe. But I couldn’t help thinking about how much safer those paying passengers were in Brisbane primary control zone. As we got out of the Seminole in front of the terminal building, my friend had settled into a cheerful mood - almost as if nothing had happened. The girls were strained and quiet, and although I was shell-shocked myself I straightened up, spoke in a level voice and calmly walked the three of them into the terminal. Not long before a kindly old ex-Qantas pilot had told me that the ‘op’ isn’t over until your passengers are cleared from the surface movement area. When the passengers were settled with a coffee, I rang the number I’d been told to ring while still in the middle of the CTR. The angry air traffic controller said, ‘Next time, put the crazy bastard in the baggage compartment!’ It was over. However, there is a postscript. Three weeks after this incident that ‘friend’ of mine took a switchblade to a man who was a gentle soul, and carved the nose right off his face. The same knife he had with him on the day of my CTR incursion. My licence was temporarily suspended, because crossing a control zone boundary without first obtaining an airways clearance is one of the big ones. I filled out the Form 225 in a simplified manner because I was afraid of what this bloke might do to me if there was any further investigation. However, I did stand in front of the flight standards examiner, look him in the face and tell him every appalling detail. Fellow pilots: it is not for me to tell you how to conduct your operations. But I humbly urge you. Know something about the mental state of your passengers. Know something before it’s too late for you, them and the Boeing 747 you collide with. Never forget: you are ‘pilot in command’ and the buck stops with you. ;l[h^WZW Mh_j[ je ki WXekj Wd Wl_Wj_ed _dY_Z[djehWYY_Z[djj^WjoekÊl[ X[[d_dlebl[Z_d$?\m[fkXb_i^ oekhijeho"oekÊbbh[Y[_l[ 9BEI; 97BB5  +&& Write about a real-life incident that you’ve been involved in, and send it to us via email: fsa@casa. gov.au. Clearly mark your submission in the subject field as ‘CLOSE CALL’ 51 ADVERTISING Articles should be between 450 and 1,400 words. If preferred, your identity will be kept confidential. Please do not submit articles regarding events that are the subject of a current official investigation. Submissions may be edited for clarity, length and reader focus. The Australian Executive Director's Message FSA MAR–APR09 On 2 December 2008, the Minister for Infrastructure, Transport, Regional Development and Local Government released the National Aviation Policy Green Paper. One of the Paper’s stated objectives was to strengthen the governance arrangements for the Australian Transport Safety Bureau (ATSB). 52 The Government has decided to establish the ATSB as a statutory agency ncy and to introduce a Commission structure to enhance its independence. This will ensure that it continues to conduct the most thorough investigations possible and to foster appropriate safety action. It will also enhance the quality of the Bureau’s relationship with the industry and the aviation community. Legislative amendments to the Transport Safety Investigation Act 2003, to give effect to the governance changes, are expected to be introduced into Parliament in early 2009, with the new Commission to be in place by 1 July 2009. The Government is currently developing an Aviation White Paper to guide the aviation industry’s growth over the next decade and beyond. The Government aims to give industry the certainty and incentive to plan and invest for the long term, to maintain and improve our excellent aviation safety record, and to give clear commitments to travellers, airport users, and the communities affected by aviation activity. The Government is now inviting comments on the Aviation Green Paper to be considered in the development of the White paper which is expected to be released in the second half of 2009. The Green paper is available on the internet, at Meanwhile, on the legislation front, the Aviation Legislation Amendment (2008 Measures No.2) Bill 2008 is currently before the Parliament. This Bill contains important measures to address matters concerning the maintenance of Cockpit Voice Recorders and the reporting of safety incidents that arose out of the ATSB’s investigation of the fatal accident at Lockhart River on 7 May 2005. Both sets of amendments seek to ensure Australia is in the best possible position to learn from accidents and incidents. Kym Bills, Executive Director Aircraft depressurisation – what cabin crew need to know epressurisation, also called decompression, is the reduction of atmospheric pressure inside the cabin of a pressurised aircraft. ft Aircraft ft depressurisation events are rare, but they can occur with little or no warning. D An ATSB safety bulletin for cabin crew, published in January 2009, provides an overview of aircraft ft depressurisation events, highlighting key information that cabin crew should know in the event of an aircraft ft depressurisation or failure to pressurise. The Th aim of this bulletin is to increase cabin crew’s knowledge about depressurisations and to supplement their airline’s emergency procedures. A review of the ATSB’s aviation safety database identified fi 310 accidents and incidents between September 1998 and August 2008 where a pressurisation problem occurred. High capacity passenger aircraft ft were involved in 124 of those occurrences. The public’s perception of depressurisations is of rapid depressurisation, in which there is a sudden change in cabin pressure causing objects to be ‘sucked’ out of the aircraft. ft Thankfully, rapid or explosive depressurisations and the significant fi aircraft ft damage associated with them are very rare. Only two Australian accidents since 1998 involved a rapid or explosive decompression. However, a real danger lies in gradual or subtle depressurisations. These Th are caused by a slow air leak from the pressurised cabin, such as through an improperly sealed door. As gradual depressurisations occur over a longer time, they can be diffi fficult to detect before oxygen masks fall from the cabin ceiling. Sensors fitted fi to commercial aircraft ft will provide the flight crew with a cockpit warning if the air pressure in the cabin drops fl to the equivalent of 10,000 feet. Passenger oxygen masks are designed to automatically deploy before cabin pressure reaches 15,000 ft. ft Once a pressurisation problem is identifi fied by the flight crew, all cabin crew and passengers should immediately don their nearest oxygen mask. Cabin crew should always put their own mask on before instructing or helping others with their masks, as there is not always time to assist others before becoming unconscious. Staying calm and breathing normally are important, as hyperventilating uses up more oxygen. Once breathing through an oxygen mask, cabin crew should secure themselves as best as possible. Cabin crew must put their safety first by remaining secured. If a crew member puts their safety at risk and is injured, there will be one less trained safety professional who can assist if the situation escalates. The ATSB safety bulletin also provides supplementary information to cabin crew on common physical effects ff of depressurisation and how to use an oxygen mask. Q ATSB Research and Analysis Report AR-2008-075(2) FSA Mar-Apr 2009.indd 48-49 Aviation Safety Investigator Cirrus changes parachute system design blanking cap had probably been inadvertently fitted fi to the test port on the engine during maintenance and that the plastic cap had detached from the test port just prior to the accident. O Soon after, ft the aircraft ft impacted terrain close to the M7 motorway. Witnesses reported that the aircraft ft appeared to be attempting to land on the motorway but, just prior to impact, it veered away from the road to the right and struck the ground in a nose-down, right winglow attitude. Th The aircraft ft was seriously damaged and both occupants sustained serious injuries. Some of the emergency services personnel who attended the aircraft ft accident had no prior knowledge of the CAPS and the potential dangers it posed, if it had not been deployed. The Th ATSB warned the attending police site controller of the existence and potential danger of the CAPS. Following consultation with the ATSB and an aircraft ft manufacturer’s representative, emergency service personnel subsequently cut through the roof of HYY to remove the injured occupants. An examination of the wreckage indicated that the aircraft ft struck several trees before heavily impacting rising terrain. The Th impact completely detached the right main landing gear assembly and fractured the fibreglass laminate structure of the left ft main landing gear. Both wings were extensively damaged and both internal wing fuel tanks were breached. The rear fuselage and empennage assembly broke away from the main fuselage at a point behind the rear baggage compartment and came to rest alongside the main wreckage. Th The flight control cables between the rear fuselage and the main wreckage remained intact. Th investigation determined that The the engine stopped due to the loss of a blanking cap from the un-metered fuel pressure test port in the engine fuel system. Testing showed that the engine would not operate with the cap missing. The investigation revealed that, instead of the normal steel cap, a plastic The pilot had activated the CAPS at an estimated height of 90 to 120 ft above ground level, well below the aircraft ft manufacturer’s recommended decision altitude for successful parachute deployment. The Th rocket fi fired, however the parachute did not deploy and the rocket became entangled in the aircraft ft’s empennage. It is possible that the entanglement of the rocket and deployment harness around the tailplane and fl flight controls may have affected ff the controllability of the aircraft ft, resulting in the aircraft ft diverting from the intended flight path. 53 ATSB n 5 February 2007, a Cirrus SR22 aircraft ft, registered VH-HYY, with a pilot and one passenger on board, was being operated on a private fl flight from Canberra, ACT to Bankstown, NSW. As the aircraft ft approached the Cecil Park area, at a height of 800 ft above ground level, the pilot reported to air traffic control (ATC) that the fi engine had lost power and he was attempting a forced landing. The aircraft ft was fitted with a Cirrus Airframe Parachute System (CAPS) designed to recover the aircraft ft and its occupants to the ground in the event of an in-fl flight emergency. The pilot informed ATC of his intention to deploy the CAPS, after ft which no further calls were received from the pilot. Following examination of the CAPS components from this aircraft ft and further functional testing of production CAPS components in the US, the aircraft ft manufacturer issued an Alert Service Bulletin incorporating design changes to the CAPS in the worldwide fl fleet of Cirrus aircraft. ft The aircraft ft and engine manufacturers are also making a number of changes to their processes and procedures based on lessons learnt from this accident. The Australian Transport Safety Bureau will forward copies of this report to the relevant state emergency authorities to alert them to the dangers posed by ballistic parachute systems in light aircraft. ft Q ATSB Investigation Report 200700361 28/1/09 2:27:16 PM Investigation briefs 54 Collision with terrain Collision with terrain Collision with water Occurrence 200607478 On 9 December 2006, the pilot of an Air Tractor Inc. AT802A aircraft, ft registered VH-CJZ, was conducting night agricultural spraying operations under the night visual flight rules, at a property 19 km NE of Collarenebri, NSW. In conjunction with a pilot in another agricultural spraying aircraft, ft the Air Tractor pilot was utilising an airstrip located on the property as a base for the operation. At about 2140 Eastern Daylight-saving Time, the aircraft ft was returning to the airstrip when it impacted the ground 1.4 km from the landing strip. The pilot was fatally injured. The aircraft Th ft was destroyed by impact forces and a post-impact fi fire. Occurrence 200707066 At about 0730 Western Daylightsaving Time on 17 November 2007, the wreckage of a Cessna Aircraft ft Company C172M aircraft, ft registered VH-TCS, was discovered on the side of a hill, at Uaroo Station, in the Pilbara region of WA, about 500 m from the property air strip. The aircraft Th ft had been destroyed by impact forces and a post-impact fire. fi The pilot, the sole occupant, was fatally injured. Occurrence 200707039 On 17 November 2007, the owner-pilot of a Cessna Aircraft Company C337G, registered VH-CHU, was conducting a private flight in accordance with the visual flight rules (VFR) from Moorabbin Airport, Vic. to Merimbula, NSW. The pilot, who had three passengers onboard, had indicated that he would be tracking along the coast. The aircraft did not arrive at Merimbula and on 19 November 2007 aircraft wreckage and three of the deceased occupants were found on a beach between Venus Bay and Cape Liptrap, Vic. There were no survivors. FSA MAR–APR09 Earlier, the pilot had made a 20-minute positioning flight fl from the operator’s base at Wee Waa, NSW, to the airstrip. The pilot then conducted two 30-minute spraying flights, fl with a short period on the ground. Th The aircraft ft remained running while that replenishment was conducted. The accident occurred when the pilot was returning at the conclusion of the second flight. Examination of the aircraft ft wreckage revealed no evidence of an in-fl flight fire or any mechanical fault with the aircraft ft, engine, or systems which may have contributed to the occurrence. The intensity of the post-impact fire, deformation to the integral wing fuel tank structure and ground marks, indicated that there was suffi fficient fuel on board the aircraft ft for the operation. There was no evidence that the aircraft ft struck trees or powerlines. It could not be conclusively determined why the aircraft ft impacted the ground. It was possible that the pilot may have experienced a medical event that was not evident during the post-mortem medical examination. However, based on the evidence available, it is probable that the pilot experienced spatial disorientation and a subsequent loss of control of the aircraft ft resulting in it impacting the ground. Q FSA Mar-Apr 2009.indd 50-51 Information obtained from persons who knew the pilot indicated that he had most likely departed from the airstrip during the morning of 16 November 2007, however, the actual time of the takeoff could not be determined. There were no reported witnesses to the takeoff, ff any subsequent flight, or the accident. Tyre marks made by the aircraft ft indicated that the aircraft ft had departed from runway 27 to the west. Th was no evidence of an engine or There aircraft ft system problem which could have contributed to the accident. There Th was no evidence that the pilot had a pre-existing physiological condition that could have contributed to the accident. The Th aircraft ft manufacturer’s tabulated take-off ff data showed that the aircraft ft should have had suffi fficient performance to take off ff from runway 27 and climb clear of terrain. There was evidence to indicate the possibility of adverse meteorological phenomena such as strong wind gusts and ‘willy-willies’ in the area on the days before, during and subsequent to the accident. The willy-willies were reported to be diffi fficult to see, forming and dissipating rapidly, and travelling in the same direction as the prevailing wind. The Th air within willy-willies is very unstable, with rapid rising thermals and downdrafts ft created. While the reason that the aircraft ft impacted terrain could not be conclusively determined, it is probable that the aircraft ft encountered adverse meteorological phenomena such as strong wind gusts and willy-willies, just after ft takeoff ff. Q The investigation found that while manoeuvring over water at low level in conditions of reduced visibility, the pilot probably became spatially disorientated and inadvertently descended into the water. A contributing factor was the pilot’s lack of instrument flying qualification and minimal instrument flying training and experience. The operation of visual flight rules flights into instrument meteorological conditions (IMC) continues to be a significant risk factor in general aviation, but there are a number of countermeasures which can be used to reduce the risk. The Civil Aviation Safety Authority (CASA) advised, in relation to VFR into IMC safety promotion activities, that in 2005 and 2006 they conducted a number of special workshops for private and commercial pilots, which included how to avoid weather emergencies, what to do if caught out in worsening weather, and how to maximise chances of survival if a crash occurred. Media discs (CDs and DVDs) produced by CASA related to weather and decision making, Weatherwise, Weather to fly, Inflight decision makingg and Setting your own standards are available. Also available is a VFR into IMC ‘briefingin-a-box’ for flight schools and a video titled 178 seconds to live. Furthermore, a number of products with a focus on human factors such as airmanship and decision making were being developed. Q Occurrence 200607687 On 20 December 2006, a Kawasaki KH4 helicopter lost collective pitch control and impacted terrain while performing agricultural aerial spray operations approximately 21 km NE of Mount Gambier, SA. The helicopter was substantially damaged but the pilot was uninjured. When the accident site was surveyed, the main rotor mast and main rotor blade assembly were found to have separated from the helicopter. They were located a short distance away. Examination of the wreckage revealed that the helicopter’s main rotor mast thrust bearing had failed catastrophically in flight. That bearing was a critical item for safe operation and continued airworthiness. It supported the full weight of the helicopter and transferred thrust loads generated by the main rotor blades. The bearing had performed satisfactorily for a considerable time in service and it was not considered a premature failure. The investigation was unable to establish conclusively the factors that led to failure of the mast bearing. No evidence was found of manufacturing or material defects. Nor was there any evidence of improper installation procedures or maintenance practices. In view of the apparent absence of similar failures in Australian and North American databases, and the absence of any contrary evidence, the failure appears to be an isolated event and unlikely to be an indicator of an airworthiness issue with the helicopter type. Despite the low probability associated with a mast bearing failure of this type, the consequences of such an event could have been fatal for the pilot onboard. This report has been provided to Australian operators and maintainers of Kawasaki KH4 and Bell 47G3 series helicopters as a future alert for this type of occurrence. Q Uncontained engine starter failure Occurrence 200706589 On 24 October 2007 at Darwin aerodrome, an Airbus A330-300, registered VH-QPE, made two unsuccessful attempts to start the right engine. A review of the Quick Access Recorder data indicated that the fi first automatic start attempt lasted 1 minute 10 seconds and resulted in an engine start fault and no N2 rotation. Th second attempt was a manual start The lasting 6 minutes, at which time smoke and sparks were observed from under the engine cowls. Subsequent inspection of the engine revealed an uncontained failure of the starter turbine and secondary damage to the integrated drive generator. Rotor strike Occurrence 200704706 On 24 July 2007, at 1500 Central Standard Time, a Robinson R22 Beta helicopter, registered VH-VHQ, with the pilot as the sole occupant, departed from a helipad at Maryfield fi Station, NT, in order to recommence cattle mustering activities. Visitors to the station, who had recently participated in a number of short local flights, were still in the general area of the helipad during the departure. Th pilot reported that, during the initial The climb aft fter takeoff ff, and at a height not above the tops of the surrounding trees, the helicopter was struck by a gust of wind that resulted in height loss and activation of the helicopter’s ‘low RPM’ warning horn. Th aircraft The ft was fitted with two General Electric CF6-80E1-A3 turbofan engines. The starter, part number 3505468-4, was Th reported to have been in service for 14,988 fl flight hours and 2,428 cycles. Th starter was returned to the The manufacturer to conduct a failure investigation Th starter manufacturer’s internal The investigation report of the uncontained starter failure found that the damage sustained by the starter components was consistent with a crash engagement. Crash engagements result in signifi ficant damage to the clutch, and can also damage the overrunning bearing and lead to further starter damage. Th failure scenario provided by the The starter manufacturer noted that the crash engagement resulted in the overrunning bearings being damaged, with continued normal operation cycles contributing to further bearing deterioration. Although operation of the starter in this condition with no load for an extended period of time ultimately resulted in the starter failure, the starter was designed to separate the blades from the turbine disk and contain them in such an event. Damage to the surrounding components therefore occurred because the starter design failed to contain the separated turbine blades. Th manufacturer has proposed corrective The actions involving design changes to the starter, to reduce the likelihood of uncontained starter events. Q 55 In response to the warning horn, the pilot reported that he opened the throttle, with the effect ff of over-riding the engine RPM governor, lowered the collective lever, and pushed forward on the cyclic stick. Th pilot stated that the low RPM resulted The in a loss of altitude and airspeed before he was able to recover control of the aircraft. ft ATSB Loss of control During the recovery manoeuvre by the pilot, one of the visitors was struck in the head by the helicopter’s main rotor and was fatally injured. On-site examination of the helicopter, its engine and flight control systems found nothing that would have contributed to the development of the accident. Results obtained during the ground test of the engine and its associated systems following the accident, suggested that the non-completion of three overdue routine maintenance items had similarly not contributed to the accident. This accident highlighted the hazards associated with conducting helicopter operations in close proximity to people and the need for positive coordination and control of those people at all times. Q 28/1/09 2:27:21 PM REPCON briefs Australia’s voluntary confidential aviation reporting scheme REPCON is established under the Air Navigation (Confidential fi Reporting) Regulations 2007 and allows any person who has an aviation safety concern to report it to the ATSB confi fidentially. Unless permission is provided by the person that personal information is about, the personal information will not be disclosed. Only de-identified fi information will be used for safety action. To avoid doubt, the following matters are not reportable safety concerns and are not guaranteed confidentiality: fi 56 (a) matters showing a serious and imminent threat to a person’s health or life; (b) acts of unlawful interference with an aircraft ft; FSA MAR–APR09 (c) industrial relations matters; (d) conduct that may constitute a serious crime. Note 1: REPCON is not an alternative to complying with reporting obligations under the Transport Safety Investigation Regulations 2003 (see www.atsb.gov.au). Note 2: Submission of a report known by the reporter to be false or misleading is an offence ff under section 137.1 of the Criminal Code. If you wish to obtain advice or further information, please call REPCON on 1800 020 505. Operator maintenance human factors training-update R200800035 Report narrative: The reporter expressed concerns about Th the operator’s engineering human factors training. The Th refresher training is conducted on-line using a training package with an assessment test. Individuals are required to conduct the training in their own time and it is expected to take approximately 2 hours to complete. The Th reporter was informed that the training is required to comply with European standards, European Aviation FSA Mar-Apr 2009 indd 52-53 Safety Agency (EASA) 145 and the soon to be introduced Australian legislation, Civil Aviation Safety Regulations (CASR) 145. The reporter claims to have observed a range of shortcuts being taken during the assessment test including: the test being conducted by a different ff person; sharing of answers; and the test being completed without reading the training material. In addition, the reporter claims that some managers indicated they did not care how the training was completed as long as it was recorded as being completed. The Th reporter expressed concerns that computer-based training for human factors is inappropriate, and the lack of adequate time allocated to complete the training means that shortcuts might/will be taken. Reporter comment: The Th human factors training needs to be carried out again in a class room situation otherwise the whole training package has been a ‘box ticking’ process. REPCON comment: This report was published in the Th November December 2008 Flight Safety Australia magazine including the operators response. Subsequent to that response, the ATSB has received a response from CASA which is included below. REPCON contacted CASA and supplied them with the de-identified fi report and a version of the operator’s response. CASA advised that human factors training is included in the Civil Aviation Order (CAO) 100.66 (Module 9), and was introduced in February 2007 as the precursor of the proposed Civil Aviation Safety Regulations (CASR) Part 66 (Personnel Licensing) and 147 (Maintenance Training Organisations). The CAO is voluntary for those individuals and industry organisations that may benefi fit from early access to the licensing and training based on the EASA Category A, B1 and B2 licence outcomes. The Th CAO is not mandatory as it operates in parallel with the existing Civil Aviation Regulation 31 licensing regime. However, if a decision is made to use the CAO, all the requirements for the licence must be met including human factors training. CASA also added that in terms of the proposed future human factors training, there is a requirement that all future licence holders (CASR Part 66 licences) receive human factors training as part of gaining a licence and that maintenance organisations (CASR Past 145) provide their staff ff with initial and ongoing (refresher) human factors training. Training for CASR Part 66 licence issue is delivered by CASR Part 147 (Maintenance Training Organisations) using national competency-based standards. An underpinning knowledge of human factors is required for an individual to be assessed as competent before they can be issued and initial licence. These standards are available on the National Training Information Service website www.ntis.gov.au. The foundation of CASR Part 145 is to replicate EASA Part 145 as far as practicable for use in Australia. Therefore, it is not expected that the area of human factors will change from the requirements that EASA currently require to comply with at 145.A.30(e) in their legislation. The Th Acceptable Means of Compliance and Guidance that EASA has published on 145.A.30(e), would allow for the development of a program to suit any prospective Australian 145 organisation. Until CASA Part 145 is effective ff in legislation, CASA do not have the regulatory powers to approve organisations inclusive of human factors training elements. CASA also advised that the operator is one of the leaders in the country in this field fi and has established a very thorough system to deal with human factor issues and manage human factors training in maintenance-related areas. Engine failure during takeoff update R200800041 Report narrative: The reporter expressed concerns about Th a Cessna 404 (C404) aircraft ft that experienced a series of engine failures during attempts to take off ff at an airport. The reporter claims that during the Th aircraft ft’s first attempt to take off ff, an engine failed shortly after ft lift ft-off ff and the aircraft ft settled back onto the runway. Aft fter the engine was restarted, the aircraft ft was taxied back to the threshold. A further four attempts to take off ff were made with similar results. The reporter indicated that no checks were conducted to determine why the engine had failed. REPCON comment: This report was published in the November December 2008 Flight Safety Australia magazine including the operators response. Subsequent to that response the ATSB has received a response from CASA which is included below. REPCON supplied CASA with the de-identifi fied report and a version of the operator’s response. CASA advised that they undertook an operational surveillance of the operator and intend to take no further action. CASA believes that there was a fuel vapour lock problem and have confi firmed that there was only one engine failure during the initial takeoff. ff The pilot was aware of the problem and correctly diagnosed what had occurred and took acceptable action before completing a second takeoff ff. The operator had checked and adjusted the aircraft ft fuel system. CASA also reported that two to three times a year, the operator’s C404 engines experience ‘bog down’ which is caused by the ambient temperature and humidity conditions that occur in summer affecting ff the fuel system. This is a known issue and the operator Th maintenance organisation have a practice of checking the fuel pressures in the engine fuel injection system if a bog down is reported. The operator’s C404 aircraft ft are checked if it happens and fuel pressures adjusted in accordance with the Aircraft ft Maintenance Manual and a Manufacturer’s Service Bulletin which addresses this problem. After ft the summer, the engine fuel pressures are checked again and adjusted as necessary. Catering loading procedures R200800051 Report narrative: The reporter expressed safety concerns Th about a cabin crew notice applicable to some of the operator’s aircraft, ft which allows catering staff ff to start loading produce during refuelling operations as long as any obstruction can be pushed out of the way. The example given is towards door R2.The Th reporter believes that this is in direct contravention of CASA Civil Aviation Order (CAO) 20.9 that requires aisles and exits to be unobstructed during loading. Reporter comment: CAO 20.9 requires that all exits be unobstructed while refuelling with passengers on board and pushing an item from door L2 toward door R2 would clear door L2 but obstruct door R2 if an evaluation was required. REPCON comment: REPCON contacted the operator and supplied them with a copy of the deidentified fi report. The operator responded that they were trialling new procedures for the disembarkation of passengers from the left ft rear of the aircraft ft and the cabin crew notice quoted in the REPCON report detailed the procedures utilised in that trial. Th operator also indicated that their The investigation found the reporter had only selectively stated some of the procedures in that notice and so the report was not a true representation of the intended trial procedures. The reporter did not state that the notice stipulated the time when the caterers could board, that is, only aft fter a signifi ficant number of passengers had disembarked. The procedures also defined fi what catering could be loaded while the remaining passengers were disembarking so that an ‘obstruction’ situation as detailed in Civil Aviation Order (CAO) 20.9, would not occur. Th The reporter also did not mention that the notice included specifi fied procedures on other refuelling-related issues including, but not limited to, the requirements with the galley carts, stairs at the aircraft, ft precautionary disembarkation, refuelling zone requirements and related cabin crew responsibilities plus the duration and place for the trial. Th operator believes that the cabin crew The notice was within and above the intent of CAO 20.9. Th The notice and procedures were retired when the trial finished over 5 months ago and the operator reported that they have reverted to the formal documented procedures in its manual. 57 REPCON reports received Total 2007 117 Total 2008 121 What happens to my report? ATSB It is also believed that the system has been independently reviewed by Boeing. The comment related to computer based training versus face-to-face is valid. There is a UK Civil Aviation Advisory Publication that identifies fi face-to-face facilitated training as preferable to online computer based training (CBT). Face-toface facilitated training maximises the achievement of learning outcomes. Some CBT modules do not provide sufficient ffi access to participant experiences and discussion. As the training in question in this instance is refresher training, CBT may be appropriate. Concerns about this approach might arise if the operator were not to follow its own published guidelines or standard operating procedures. From the response provided by the operator, it does not appear that this is the case. For Your Information issued Total 2007 58 Total 2008 99 Alert Bulletins issued Total 2007 1 Total 2008 12 Who is reporting to REPCON? Aircraft maintenance personnel 31.0% Air Traffic controller 4.0% Cabin crew 2.0% Facilities maintenance personnel /ground crew 0% Flight crew 30.0% Passengers 6.0% Others* 28.0% # 29 Jan 2007 to 31 December 2008 * examples include residents, property owners, general public How can I report to REPCON? On line: ATSB website at Telephone: 1800 020 505 by email: [email protected] by facsimile: 02 6274 6461 by mail: Freepost 600, PO Box 600, Civic Square ACT 2608 For further information on REPCON, please visit our website or call REPCON on: 1800 020 505. 28/1/0 /09 2:27:21 PM AvSafety advisors: 2008 round up In late 2006, CASA appointed six aviation safety advisors (ASA): Albert Fleming, Charles Galea, Lloyd Mais, Tim Penney, Andrew Warland-Browne and Michael White, whose brief was to ‘move about the industry to provide practical safety education, advice and support’. In 2008, following the success of the program in 2007, they were joined by Peter Ball, Teraya Miller, Stephen Nota, Mark Richardson and Malcolm Wardrop, allowing nationwide coverage. 58 www.casa.gov.au/advisors 1: AvSafety seminars by topic - Australia-wide )$-. +$.. ,$)& ))$,' ,$)& -$/. DeZgVi^dchVi Cdc"IdlZgZY6ZgdYgdbZh H^ijVi^dcVa6lVgZcZhh K;G^cid>B8 ;jZaGZaViZY6XX^YZcih K86h E^adiBV^ciZcVcXZ GZhedch^W^a^i^Zhd[E>8 6^gHV[Zin=jbVcEZg[dgbVcXZ Dg\Vc^hVi^dcVa8jaijgZ /$(* /$,, '-$() So what have the aviation safety advisors been up to in 2008? FSA MAR–APR09 The annual review of the aviation safety advisor program includes looking at what the team has been doing out with the industry: activities such as the AvSafety seminar program, as well as visits to operators and fielding industry enquiries. 2: AvSafety seminars by location )$*+ -$+/ )$*+ .$/(+$+( '*$*. The following series of graphs highlights the efforts in 2008. A total of 145 seminars was conducted in 2008, up from 81 in 2007, and dealt with topics ranging from operations at non-towered aerodromes, to fuel-related accidents and pilot maintenance. The first two graphs show the number of seminars – a total of 145; firstly by topic and then by state. The ‘overseas’ section of graph 2 represents the ‘fuel-related accidents/ incidents’ series of seminars Andrew WarlandBrowne co-presented with the Civil Aviation Authority of New Zealand in April, 2008. The following two graphs then show how many people in each state attended the AvSafety seminar program – a total of 5209 – and how many attended each seminar. But this data about the AvSafety seminars does not tell the whole story. Equally important to the program is the amount of time the ASA team spends in contact with the industry – a CHL K>8 FA9 L6 H6 DkZghZVhCO CI I6H (&$&& ',$++ L^i]^ci]ZhZhiVi^hi^Xhi]ZgZlZgZhdbZkVg^Vi^dc^cZVX]hiViZ"[dg^chiVcXZ^cCHLD>86 lVhi]ZbdhiegZkVaZcil]ZgZVh^cL6h^ijVi^dcVaVlVgZcZhhlVhi]ZbdhiedejaVghZb^cVg 3: Participants by state '/& '*& )+) '(). +(* +/( '')& '&*( K>8 FA9 CHL L6 H6 DkZghZVh I6H CI total of 1575 visits and 2600 contact hours in 2008. This graph shows on average how much time the team spends with operators in each of the regions. PROFESSIONAL TRAINING COURSES www.caaa.com.au From both the visits and general enquiries the team receive, we track the topics of interest to the industry. This feedback is vital in understanding the needs and concerns of industry, which in turn assists CASA to develop targeted and improved education and communications products now and in the future. DANGEROUS GOODS TRAINING (CASA APPROVED) • Dangerous Goods Awareness Courses via Correspondence and Company tutorial • Dangerous Goods Acceptance and Shippers Training 26th and 27th March 25th and 26th May Melbourne 14th and 15th May 6th and 7th August Sydney 12th and 13th May 17th and 18th Sept Perth '+. *') ).* *,, )&+/ .-( ./) DeZgVi^dchVi Cdc"IdlZgZY 6ZgdYgdbZh H^ijVi^dcVa6lVgZcZhh K;G^cid>B8 K86h ;jZaGZaViZY6XX^YZcih GZhedch^W^a^i^Zhd[E>8 E^adiBV^ciZcVcXZ 6^gHV[Zin=jbVc EZg[dgbVcXZ Dg\Vc^hVi^dcVa8jaijgZ .// CREW RESOURCE MANAGEMENT TRAINING • Company specific tutorial courses • Correspondence courses also available SAFETY MANAGEMENT SYSTEMS • Safety Management Training (1 week) Perth 8th to 12th June Melbourne 13th to 17th July • Safety Management Workshop (2 day) Perth 4th and 5th May • Risk Management (2 day) '-,' Perth 27th and 28th July • Accident & Incident Investigation (2 day) Perth 29th and 30th July PRINCIPLES AND METHODS OF INSTRUCTION 5: ASA Visits per state and average hours per visit Australia-wide • 2 Day Training Course Perth 28th and 29th May Check website for new course dates and locations! *%% '#* PROFESSIONAL MANUAL DEVELOPMENT )*% )%% (*% (%% &#* '*% • Operations Manuals • Dangerous Goods Manuals • Safety Management Systems '%% &#% &*% &%% %#* *% %#% K^h^ih 6kZgV\Zi^bZ]gh '#% Hdji]Zgc Cdgi]Zgc :VhiZgc HnYcZn LZhiZgc % 1800 754 774 FREECALL 08 9274 8277 (P) enq [email protected] www.caaa.com.au AVSAFETY ADVISORS 4: Participants by topic - Australia-wide 59 5: Talking points at ASA visits - Australia-wide HZXjg^in$6H>8 cYjhign AdXVaDeZgVi^dcVaBViiZgh % &%% '%% (%% )%% +%% *%% 6: Enquiry topics for ASA - Australia-wide 60 FSA MAR–APR09 Dg\Vc^hVi^dc8VeVW^a^in8EÉh!FBVcV\Zgh HZgk^XZ9Za^kZgn$HZgk^XZ8ZcigZ =jbVc[VXidghI:B!8GB GZaVi^dch]^eh86H6$>cYjhign HZXjg^in$6H>8 HBH ;an^c\IgV^c^c\ 6aXd]daDi]Zg9gj\h6D9 8Zgi^[^XVi^dc6D8!8D6!6ZgdYgdbZh A^XZch^c\ZiX 6^gheVXZ GZ\#^ciZgegZiVi^dc :c\^cZZg^c\$IZX]c^XVa$6^gldgi]^cZhh AdXVaDeZgVi^dcVaBViiZgh EgdYjXihHV[ZinEgdbdi^dc > Chipmunk Test >> More on ASIC’s >> Simulators – are they any use? >> Travel stories Ph: 02 9791 9099 Email: [email protected] m.au Web: www.aopa.com.au QUIZ ANSWERS FLYING OPS ANSWERS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. (d) there is no minimum hour requirement for high performance (80 KTAS + cruise) aircraft. RA-Aus ops manual 2.07 .2 (b) RA-Aus ops manual 2.07.5 (a) GEN 3.5 12.4.1; (b) was the previous format. (d) (c) on some types, fuel loss will occur only when the fuel is switched off. (a) GEN 1.5 1.5. (c) ENR 1.1. 34 and following table; the request to cross has been deleted. (b) CAO 20.3. (d) (d) IFR OPS ANSWERS 1 2 3 4 5 6 7 8 9 10 (e) AIP GEN 3.5- 25, Para 12.4.1 and AIP ENR 1.10- 2, Para 1.2.5 (c) AIP ENR 1.1- 93, Para 73.2.7 (d) AIP ENR 1.5- 31, Para 6.2 (b) AIP ENR 1.5- 23,24, Para 3.3.1, 3.3.3 (c) AIP ENR 1.5- 23, 24, Para 3.4.1 (d) HDG 245/ ADF MBY 342R, Thus TR is 227 to MBY, LOC is 222 so ILS scale means full scale right. (a) AIP ENR 1.6- 3, Para 3.12 Note (b) Approach Plate- Distance Scale (c) AIP ENR 1.5- 32, Para 7.2 C (e) AIP ENR 1.5- 12, Para 1.18.2 and AIP ENR 1.5- 33, Para 8.1 a. MAINTENANCE ANSWERS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. (c) AWB 34-013 warns of the problem. (a) AWB 34-013. (a) 35 x 0.75 ÷ 4.5. (b) the convention for measuring the length varies with the type. (d) (c) (a) (d) thirst is not the fi rst symptom of dehydration. (b) (b) Where is your aircraft right now? Track your aircraft in real-time with spidertracks, the world’s leading portable aircraft tracking system. + No installation required, simply plug it in and start tracking + No software to install, view all of your tracks at www.spidertracks.com + Rentals available from as little as $80 per month plus ongoing costs + Track your aircraft, manage your fleet, protect your people, invest in your business + Book your FREE no obligation demonstration today. Call 1800 461 776 or email [email protected] P 1800 461 776 E [email protected] www.spidertracks.com QUIZ ANSWERS 71 Support AOPA - working for YOU On sale first week of March LEADING EDGE SAFETY SYSTEMS The LEADER In Aviation Safety Management Services We are a group of aviation safety specialists with previous airline, CASA and general aviation backgrounds. We offer practical and tailored services to th he aviation in ndustrry and can assist you with meeting the followin ng CASA req quirremen nts:: UÊ “«i“i˜Ì>̈œ˜ œv ->viÌÞ >˜>}i“i˜Ì -ÞÃÌi“à ­
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