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Safety is no accident

Accident investigation and aviation safety


Wake in fright
Wake turbulence 101
Jul-Aug 2010
Issue 75
A matter of degree
Aviation & universities
After all these years
Ageing aircraft
Close calls
And ... more
Be heard, Be hear Be
be seen, b en, e
be safe be sa e b sssaa
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www.casa.gov.au/elearning
visit now
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Be heard, be seen, be safe
Online tutorials at your own pace, at any time.
For general enquiries regarding the online tutorials
please email elearning@casa.gov.au
Complete each topic in 5-10 minutes.
Class D & non-towered
aerodromes eLearning
Regulars
CONTENTS
Features
8 Safety is no accident
The painstaking work of air crash investigators.
20 Wake in Fright
Wake turbulence is your invisible enemy.
24 A matter of degree
The academic approach to ight training.
29 After all these years
The implications of our ageing general aviation eet.
40 When it all comes unstuck
What can go wrong with aircraft bonding.
44 AOC survey report
Information from the AOC Holders Safety Questionnaire.
58 Repercussions of the Concorde disaster
A tragedy that marked the beginning of the end for supersonic transport.
64 A new road for diabetics
Protocols for pilots with Type 1 diabetes.
2 Flight Bytesaviation safety news
16 ATC Notesnews from Airservices
Australia
18 Accident reportsInternational
18 Accident reportsAustralian
31 Airworthiness pull-out section
33. SDRs
38. Directives
46 Close Calls
46 Thunderstorms in area
48 Red means danger
51 Fail safe
52 ATSB supplement
66 Av Quiz
71 Quiz answers
70 Calendar
ISSUE NO. 75, JUL-AUG 2010
DIRECTOR OF AVIATION SAFETY, CASA
John McCormick
MANAGER, SAFETY PROMOTION
Gail Sambidge-Mitchell
EDITOR, FLIGHT SAFETY AUSTRALIA
Margo Marchbank
WRITER, FLIGHT SAFETY AUSTRALIA
Robert Wilson
DESIGNER, FLIGHT SAFETY AUSTRALIA
Fiona Scheidel
ADVERTISING SALES
P: 131 757 or E: fsa@casa.gov.au
CORRESPONDENCE
Flight Safety Australia
GPO Box 2005 Canberra ACT 2601
P: 131 757 F: 02 6217 1950
E: fsa@casa.gov.au
W: www.casa.gov.au
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For address-change enquiries,
call CASA on 1300 737 032
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holders, cabin crew and industry personnel
in Australia and internationally.
CONTRIBUTIONS
Stories and photos are welcome. Please
discuss your ideas with editorial staff before
submission. Note that CASA cannot accept
responsibility for unsolicited material.
All efforts are made to ensure that the correct
copyright notice accompanies each published
photograph. If you believe any to be in error,
please notify us at fsa@casa.gov.au
PRINTING
IPMG (Independent Print Media Group)
NOTICE ON ADVERTISING
Advertising appearing in Flight Safety
Australia does not imply endorsement by
the Civil Aviation Safety Authority.
Warning: This educational publication
does not replace ERSA, AIP, airworthiness
regulatory documents, manufacturers
advice, or NOTAMs. Operational
information in Flight Safety Australia should
only be used in conjunction with current
operational documents.
Information contained herein is subject
to change. The views expressed in this
publication are those of the authors, and do
not necessarily represent the views of the
Civil Aviation Safety Authority.
Copyright 2010, Civil Aviation Safety
Authority Australia.
Copyright for the ATSB and ATC
supplements rests with the ATSB and
Airservices Australia respectively
these supplements are written, edited and
designed independently of CASA.
All requests for permission to reproduce
any articles should be directed to
FSA editorial (see correspondence
details above).
RegisteredPrint Post: 381667-00644.
ISSN 1325-5002.
COVER: Fiona Scheidel
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FLIGHT TRAINING
AUSTRALIA
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WELCOME, MAAT
To assist industry to meet the requirements for safety
management systems (SMS), and make a successful
transition to the new Civil Aviation Safety Regulations,
CASA has developed a web-based manual authoring &
assessment tool, or MAAT.
Writing manuals, and the associated document control,
require high-level technical knowledge, skill in technical
writing and a commitment to good administrative
practices. For large organisations with a dedicated
staffand a budget to matchthats an achievable goal.
However, for medium and small operators, particularly
those in regional and rural areas without access to a
dedicated technical librarian and skilled technical writers,
delivering manuals to CASAs required standard is not
as easy.
CASA recognises this, and so to support such operators,
CASA trialled an SMS builder tool, in a CD format.
This gave step-by-step guidance in preparing an AOC
application, and a structure and content for writing the
required manuals.
However, there were disadvantages with this format.
To use the CD, a separate program had to be loaded on to
each computer using it. It also required regular updates
in the form of patches with the latest legislation update
details. The 2008 ICAO Australian audit showed the
timing was right to build on the step-by-step guidance in
the CD, and to deliver this material online. Enter MAAT.
The manual authoring & assessment tool supports
industry in developing their manuals so that they are
ready for the new regulations: to have manuals which
then require CASA assessment. This applies especially to
developing the documents required by CASRs for ight
operations, existing charter operators, low- and high-
capacity regular public transport operations; as well as
the new maintenance regulations under CASR Parts to
come into effect over the next couple of years.
The good news for operators who have prepared manuals
using the previously developed CD is that they can load
these manuals into MAAT for future use.
Operators can still write manuals and submit them to
CASA using existing processes.
However, there are distinct advantages with using MAAT.
POST HASTE
First some housekeeping - all mail for CASA should
be addressed to our central address: GPO Box 2005
Canberra ACT 2601.
Using the correct address will ensure your letter reaches
the right person in CASA, which is a large organisation
with constantly mobile staff. Some regional ofces
are reporting considerable problems with incorrectly
addressed mail.
CHANGES FOR AIRSERVICES
READERS
This is the last edition of Flight Safety Australia that
Airservices Australia employees will receive without
directly subscribing to the magazine.
To continue receiving FSA from the SeptemberOctober
edition, Airservices employees will need to email their
address and contact details to fsa@casa.gov.au before
31 July.
The change will not affect Airservices employees who
already subscribe through CASA using their aviation
reference number (ARN), or personal details.
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FLIGHT TRAINING
AUSTRALIA
i..o.ators |. >ro(ess|o.a| >||ot ra|.|.q
2010 COURSE DATES
Course Dates Price
CPL Theory 28 June, 16 August,
11 October
$2950
*
IREX Theory 5 July, 2 August $1250
*All 7 subjects individual subjects may be purchased,
see www.yfta.com for full details
PLACES ARE LIMITED BOOK NOW
ph: (07) 3715 4000 email: marketing@ftaus.com
FLIGHT TRAINING AUSTRALIA
Queenslands largest ight
training organisation
Proudly owned and managed
by airline pilots
CRICOS Provider code: 01208J RTO 32009
www.yfta.com
The standardised format and content streamlines
approval of the large number of manuals CASA receives
from industry. Using the supplied guidance material
and sample texts pre-approved by CASA allows for
a speedy approval process by CASA inspectors, because
they can concentrate on technical assessment, rather
than formatting errors, as these are minimised. If the
sample texts are used without addition or subtraction,
there is no requirement for extra approval by CASA,
resulting in a reduction of up to 75 per cent in approval
time and associated costs. The manual also aligns with
the most up-to-date legislative requirements, as MAAT
automatically updates when new legislation becomes
available.
An additional benet of manuals created online is that the
system is fully auditable; and it is easy to report on the
status of any manual in the system regardless of its level
of completion.
CASA has also developed a tutorial so you can become
familiar with how MAAT works. If you would like to view
this tutorial, please contact the MAAT team at MAAT@
casa.gov.au who will set up a user name and password so
that you can access it.
SULLENBERGER RIGHT TO DITCH
The US National Transportation Safety Board (NTSB) has
backed pilot Chesley Sully Sullenbergers decision to
ditch US Airways ight 1549 on the Hudson River, in New
York, in January 2009, after it hit a ock of Canada geese
while at 2700ft. Sullenberger, (and rst ofcer Jeffrey
Skiles), became an international hero after everyone on
the ight survived the potentially fatal accident.
Simulations of the Airbus A320s ight at Airbus
headquarters in Toulouse by experienced pilots, including
an Airbus test pilot, bore out Sullenbergers decision.
In eight of fteen attempts, the fully-briefed simulator
pilots managed to return to New York La Guardia airport
but only if they reacted immediately to the emergency.
The one attempt made to simulate returning to La Guardia
after a 35-second delay was not successful.
Sullenberger told the NTSB that, based on the aircrafts
position, altitude, airspeed, and heading away from the
airport, and the time it took to stabilise the aircraft and
analyse the situation, he had determined that returning
to La Guardia was not possible. The inquiry endorsed
this decision: Therefore, the NTSB concludes that the
captains decision to ditch on the Hudson River, rather
than attempting to land at an airport, provided the highest
probability that the accident would be survivable, it said.
Another nding was that Sullenberger had the Airbuss
sidestick pulled back to the rear stop for the last 50
vertical feet of the ight.
The inquiry found four factors contributed to the
outcome: They were: (1) the decision-making of the ight
crewmembers and their crew resource management;
(2) the fortuitous use of an aircraft equipped for an
extended overwater ight, including the availability of
the forward slide/rafts, even though it was not required
to be so equipped; (3) the performance of the cabin crew
in the evacuation of the airplane; and (4) the proximity
of seven ferries, a re department boat and two coast
guard vessels to the accident site and their immediate and
appropriate response.
SPORT AIRCRAFT &
TRANSITION TRAINING
Some sport aircraft pilots have asked questions
concerning the application of the civil aviation regulations
to transition training and familiarisation ights for pilots
taking delivery of an unfamiliar experimental aircraft
from its current owner. CASA is examining these issues
and will provide some guidance in the next edition of
Flight Safety Australia (the September-October issue).
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ROBOT ROCKS
Helicopter pilot training is a serious and sometimes risky
business, particularly in its rst hours. A German helicopter
operator hopes to make it a little safer with concept study
for a full-motion simulator to teach low-hour students the
fundamentals of rotary wing ight.
Heli Aviation GmbH presented its Heli Trainer at the ILA
air show in Berlin in June. The project, co-developed
with the Max Planck Institute for Biological Cybernetics
aims to develop a realistic ight trainer for safe, effective
and cost-efcient pilot training. Heli says the advantage
of its trainer is that: critical ight
manoeuvres can be repeated as
often as required and simulated
right up to a safe forced landing,
whereas in practical ight training,
the ight instructor has to intervene
immediately when incorrect ight
control actions are made.
The trainer cabin is attached to a
six-axis, heavy-duty robot with a
carrying capacity of up to 500kg. It is
the only industrial robot in the entire
world certied to carry passengers. A
linear traversing axis can be added
as an option to simulate run-on
landings and take-offs.
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BUSINESS GOING BUST
Business aviations safety weaknesses are landings and
level busts, safety experts told the 10th annual European
Business Aviation Convention and Exhibition in Geneva.
Overrunning runways - even long ones - and ying
through cleared ight levels were both mistakes made
disproportionately by business aircraft pilots, the UK Civil
Aviation Authoritys Simon Williams said.
Williams revealed that although business aviation
represents only eight per cent of trafc in European
Union skies, it was responsible for 20 per cent of ight
level busts, and 20 per cent of altimeter setting errors.
Safety analyst, Bob Breiling, of Breiling Associates, said
landing mishaps accounted for more than 50 per cent of
all business aircraft accidents, a higher proportion than in
other aviation sectors.
BEACON FOR THE FEW
Were diverging from our safety ight plan on this one,
but we hope youll forgive us on the basis that any excuse
to mention a Spitre is a good one. The British Royal Air
Force Museum in Hendon, north London has announced
plans for the Battle of Britain beacon, to be completed by
the 75th anniversary of the battle in 2015.
The beacon will be a sculpted aluminium tower that will
house an exhibition devoted to the battle in which about
3000 Allied pilots (including 32 Australians) between July
and October 1940, halted the advance of the German
Luftwaffe and postponed Nazi Germanys plans to invade
Britain.
According to the Museums website, The new building will
allow wider public access and ensure that the Museums
unique collection of Battle of Britain aircraft, memorabilia
and archives is preserved for the education of future
generations.
The aim of the building is to act: as a gateway to London
and an iconic landmark; a lasting tribute to the sacrice
and bravery of an international force of men and women;
an education resource in the lessons of the Second
World War, for generations to come; an inspirational
new interpretation for 21st Century of the worlds nest
collection of aircraft and artefacts of the period; and a
salute to the city of London and the enduring legacy of
freedom and democracy.
The shimmering 116m aluminium structure will dominate
the local skyline and be visible from central London. (Does
that mean we justify mentioning it as a NOTAM?)
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HELP US to
HELP YOU
,. .. zz ,11
CASAs Safety Promotion seeks interested industry
members willing to take part in research to assist
in developing our aviation safety promotion products
and campaigns.
Please email safetyproducts@casa.gov.au to register
your interest, providing your contact details and area of
expertise (e.g. airworthiness, human factors, fying training,
safety management). This will enable us to enlist your help in
developing safety promotion products that will contribute to
safe skies for all.
*CASAs Safety Promotion branch develops a variety of campaign materials
and products, communicating regulatory reform & safety initiatives to industry.
Recent products include the Look out! DVD on situational awareness; the SMS
toolkit; and the campaign surrounding the transition from GAAP to Class D.
A call to the
aviation industry
AIR NORTH REPORT
The preliminary report into the crash of an Embraer
120ER Brasilia at Darwin airport has conrmed the two
pilots were performing a simulated engine failure when
the accident occurred. Greg Seymon, 40 and Shane
Whitbread, 49 were killed when the aircraft crashed into
bushland on the nearby RAAF base during a training
exercise.
Witnesses reported that the take-off appeared normal
until a few moments after becoming airborne, when the
aircraft rolled and diverged left from its take-off path, the
Australian Transport Safety Bureau report said.
The report said the simulated left engine failure, known
as a V1-cut manoeuvre, was made about one second after
the aircraft became airborne. Asymmetric ight, whether
from a simulated or actual engine failure, involves an
element of risk, the report said. Examination of the
aircrafts engines, propeller hubs, aircraft rudder power
control unit and hydraulic actuators, as well as the cockpit
voice recorder (CVR) and ight data recorder (FDR),
is continuing. The ATSB said it found no safety issues
relating to Air Norths eet.
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PROMISING START
An Australian aviation company is about to mark a minor
but signicant milestone. Sometime during the currency
of this issue the rst commercially-operated Whitney
Boomerang will mark its rst 1000 hours of operation
not bad going for just over two years of service. Dean
Wilson Aviation managing director, Gary Dean, says the
aircraft has performed impeccably for the rst 1000
hours of its 22,000 hour design life. All weve had to do is
recalibrate a fuel sender reader: there have been no issues
with airframe, avionics or engine, he said.
During the aircrafts rst two years in service with a West
Australian ying school maximum take-off weight for the
type was able to be increased from 825 to 850kg.
The Boomerang is designed as a primary ight trainer,
similar in many respects to the respected, but ageing Piper
Tomahawk, but with innovations including a steel tube
safety cage for the side-by-side cockpit. This was tested
for a 12g impact at the NSW Roads and Trafc Authoritys
Rosebery crash laboratory in Sydney.
The aircraft uses tried and true aviation technology.
Airframe construction is conventional stressed skin
aluminium, primary instruments are mechanical, and
power comes from the venerable Lycoming IO-235 engine
that has been around in one form or another since 1949.
Dean Wilson Aviation plans to build a more powerful IO-
320- engined model with a constant speed propeller for
use as an IFR and navigation trainer.
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The story that begins when an aircraft crashes, (or has a major in-
ight incident) often ends in a small room in central Canberra. The
Australian Transport Safety Bureaus (ATSB) audio analysis room
is a slightly sombre place, ttingly, because the sounds and words
analysed there can be from the last moments of pilots lives. Its a
small black room, padded and silent, despite the racks of high-end
stereo ampliers and loudspeakers that give it a strangely domestic
feel. They contrast with its other contents: test equipment and brightly
coloured metal boxes, some scorched and some crushed. They are
ight data recorders and cockpit voice recorders.
Investigators listen to cockpit voice recordings many times, alert for
nuances in sometimes desperate conversations, and other audible
clues: engine and propeller speeds can be deduced from the pitch of
background noise; the click of a switch being moved can be isolated to
a certain control or system; and warning tones can be compared with
the repertoire of ight deck horns, voices and alerts every certied
aircraft type must leave on le with the Civil Aviation Safety Authority
(CASA).
Following the signing of a memorandum of
understanding between CASA and the ATSB,
Flight Safety writer, Robert Wilson, looks at the
role of accident investigation in aviation safety.
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Flight data recorders are opened and their
secrets, whether on tape or computer chip,
are revealed, by download in the case of a
modern solid-state recorder, and by playing
back the tape on a similar undamaged unit in
the case of older tape recorders.
In a nearby engineering room pieces of
metal, rubber and plastic, some of them
recognisable as aircraft parts only after close
examination, speak silently but eloquently
about re, failure and scarcely conceivable
impact forces. A closer look at the scorched
relics conrms relatively few of them are
from crashes involving private pilots.
Assembling truth
from wreckage is
one of the ways
the ATSB tries
to make aviation safer. The other half of the
puzzle is talking to people, for even in a crash
with no survivors there will be people to talk
to; witnesses, maintenance staff, the aircrafts
previous crew, and family and colleagues of
the crew, who are often vital in painting a
picture of the 72 hours before the crash. To
get answers rather than evasions requires
an innovation every bit as important as the
digital ight recorder: the no-blame approach.
ATSB director of aviation safety investigation,
Ian Sangston, says taking a no-blame, no-
liability approach to safety investigation is
more useful than afxing blame, because
it reveals the truth and allows safety
improvements to be built on that foundation.
If you want to get people to talk to you and
work with you, you pretty much have to adopt
that approach, he says.
Our role is to nd out what happened, not to
blame or punish. If we took that role nobody
would talk to us and transport would be less
safe because the opportunity to learn from
accidents and incidents would be lost.
The no-blame approach to safety investigation,
while well established in Australian aviation,
is under threat in other skies. The aviation
industry worldwide is expressing concern at
the trend for litigation to bring punishment
and blame to bear in the aftermath of
accidents.
Delegates to this years Royal Aeronautical
Society conference in London on the
criminalisation of air accidents heard it
was becoming more common for criminal
prosecutions to follow accidents.
The conference heard recent and current
proceedings had arisen following the Helios
and Concorde crashes, and the mid-air
collisions over Uberlingen in Switzerland and
over the Amazon in Brazil in 2006.
Aviation barrister, Charles Haddon-Cave, told
Flight International that as a consequence the
industry was tending to engage in defensive
engineering, not just technical, but personal
and administrative. Procedures were now
being designed as a bulwark against criticism,
rather than an improved way of doing things,
he said.
Our role is to nd out what
happened, not to blame or punish.
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The International Society of Air Safety Investigators in a strongly-
worded resolution this year said among other things: Criminal
investigations and prosecutions in the wake of aviation accidents can
interfere with the efcient and effective investigation of accidents and
prevent the timely and accurate determination of probable cause and
issuance of recommendations to prevent recurrence.
Increasing safety in the aviation industry is a greater benet to society
than seeking criminal punishment for those guilty of human error
or tragic mistakes.
In Australia, pilots can be, and have been, sued for their alleged role
in crashes, but the ATSB does not cooperate in adversarial legal cases.
ATSB investigations and data are never used in litigation proceedings
or any other attempt to establish liability, Sangston says.
Were not into that. It specically says in the act that the aim of
investigations is not to apportion blame or liability, or to be seen to
be doing that.
This approach is one factor that contributes to the ATSB receiving
about 15,000 notications of accidents and incidents a year. ATSB
director safety data research and technical, Julian Walsh, says, We
enjoy a very healthy reporting culture in Australia.
Of those 15,000 notications, about 8000 equate to accidents or
incidents, and the remainder are duplicates or other matters, he says.
We still store and log them in our system, Walsh says. Our message
to the industry is we dont mind, we prefer to make the assessment.
If in doubt, its better to report.
About 80 incidents and accidents are
investigated every year one in a hundred of
all actual occurrences reported to the bureau.
The decision to investigate is based on the
signicance of the accident in terms of
deaths and injuries, and the probability of its
revealing signicant lessons.
This focus on nding signicant lessons
reects a subtle change in focus the ATSB
is taking in choosing its investigations, the
Bureaus commissioner, Martin Dolan, says.
As an illustration, he points out that while
(VH-registered) private aviation accounts
for about one-seventh of aviation activity in
Australia; private ying represents over half
of the fatalities in Australian aviation.
Theres about a 40-times more likelihood
per hour that you will die as a private pilot,
compared to the equivalent exposure on the
roads. This is about the same exposure that
motorcyclists have, Dolan says.
The comparison is valid, Dolan says, not
only because of the broadly-similar mortality
rates, but because of philosophical similarities
between private pilots and motorcycling. I
think both are about an ethos of freedom and
mobility, and both embrace a certain level of
risk, Dolan says.
He says there comes a point when continuing
with detailed investigation of private aircraft
crashes makes little or no further contribution
to safety, given the repetitive and predictable
nature of many of these crashes:
Over the last 10 years, the majority of
contributing factors relate to things pilots did
or did not do, and accidents and fatalities are
driven in the same proportion and the same
set of factors as they were ten years ago,
Dolan says.
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Safety is better served by the ATSB using engaging means to educate
and inform pilots. Theres a need to go beyond reports, to produce
clear, simple and compelling safety messages, he says.
We see cooperation with CASA as an important part of this, Dolan
adds. Our two organisations have a common interest in effective
safety education.
In a further shift in its investigation focus, the ATSB has recently added
a new level of investigation, Level 5. These investigations are less
involved than level 1-4 investigations, but by conducting additional
investigations, even brief ones, the aim is to add to the safety database
of Australian aviation.
The aim of these is just to gather some facts and circumstances around
an occurrence, perhaps by interviewing the pilots or getting a copy of
the operators internal report, Walsh says.
Its a very short report, without any analysis, but we make comments
to point people in the direction of research. The idea is that those
will be put into a quarterly bulletin and will add to the database of
investigations.
The recently-commenced Level 5 program aims to conduct 120
investigations, which would bring the ATSB to about 200 investigations
a year. Sangston says the Level 5 program is already adding to the air
safety picture.
As has already happened, when we make a few enquiries, gather
evidence, all of a sudden there can be alarm bells ringing, and a short
report can turn into a more signicant investigation, he says.
Likewise, it also happens in reverse when investigations are
downgraded from Level 4 to Level 5.
The result, eventually, will be to ll in the gaps in the air safety
picture. When you have enough snippets in the database, you may
be able to begin a safety issues investigation. Thats where theres no
major incident, but the data appears to be pointing towards an issue,
Sangston says. One we have at the moment is a number of incidents
of pilots taking off and knocking over runway lights.
The ATSB routinely shares data with CASA, but does so strictly for
the purpose of improving safety. Every business day, CASA receives
factual information from the ATSB on air safety occurrences. CASA
reviews the information to decide if further investigation is needed.
The data can also be analysed to uncover air safety trends.
CASA also conducts its own air safety investigations, but has a slightly
different focus to the ATSB. The manager of CASAs accident liaison
and investigation unit, Richard White, says its investigations can be
more difcult than ATSB investigations, as there is no compulsion for
industry to talk to CASA. The investigation focus is specically on what
happened; whether regulatory contraventions may have occurred;
and whether intervention of some kind, in the interests of safety, may
be necessary or appropriate.
TELLING THE STORY
(images above) Flight data
recorders have evolved from using
metal foil as a recording medium
(bottom), to magnetic tape
(middle), and most recently solid-
state computer memory (top).
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The ATSB investigations are extremely
thorough and may take some time to
complete. Often CASA needs to know in
advance of the formal report what the issues
are so it can take corrective action, White
says. Liaison with the ATSB is an important
part of the process.
CASA has a number of methods it applies for
enhancing aviation safety, White says. Most
of its safety investigation actions are carried
out through safety promotion and educational
activities, and through the advice it gives on
operational and technical matters to pilots,
engineers and operators.
CASA also encourages pilots, engineers and
operators to comply with legislation and
to conduct their activities at a high level of
safety through a counselling process and by
recommending remedial training.
Administrative enforcement actions, such
as retesting, suspension or cancellation of
licences can follow a CASA investigation. A
CASA investigation may involve ensuring a
person who is demonstrably unable and/
or unwilling to comply with legislative
requirements, is prevented from continuing
with the aviation-related activities they would
otherwise be authorised to do, White says.
clues usually rests with local police. A crash scene is not a
crime scene, but when we ask police to treat it like a crime
scene they know exactly what we mean, Sangston says.
White, who investigated crashes for the New Zealand Civil
Aviation Authority before joining CASA, emphasises the
importance of preserving the crash scene. An old adage
for accident investigators is keep your hands in your
pockets during the rst walk through the wreckage, he
says.
He says the need to keep the accident scene untouched
until investigators arrive is very important, second only
to safety considerations. The clues can be very subtle:
marks on the ground; or in one case I attended, scrapes
in the road where a propeller made contact, revealing
information on speed and direction.
The third investigator of civilian air crashes in Australia,
Detective Inspector John Hurley of the NSW Police Forces
Air Wing, is often the rst among agencies to arrive at a
crash scene. The Air Wings eet of ve helicopters and a
Cessna 206 means he can usually be at a crash site within
two hours of the impact. It is not unusual for him to call
the ATSB to notify them of a crash before they hear of
it through other channels. Thats part of the close and
courteous relationship between all crash investigation
agencies, he says.
He says being the rst on the scene of a fatal crash is
always a little unsettling, even to an ofcer hardened by
almost three decades of police work.
Myself and a crewman walking through the silence of the
forest approaching a crash site; its an eerie sensation.
But you have to move on and put your investigators hat
on, so to speak.
Hurley is a 29-year veteran of the NSW police force with
26 years spent as a detective. I was a country detective
on the far South Coast, then I was chief of detectives at
Kogarah [in Sydney]. He went on to stints in special crime
investigation on drug and organised crime cases. For
relaxation he learned to y, then to y aerobatics.
His combination of aviation and investigation experience
led to him being selected as the Air Wings rst aviation
fatality investigator in 2006. To his long experience,
he has added training and qualications from the
ATSB, the International Aviation Safety Network, the
Directorate of Defence Aviation and Air Force Safety and
Craneld University.
Whites role in accident investigation is delicate.
He lacks the freedom to offer indemnity in the
same way as the ATSB. I tell people before an
interview that a formal conversation with me
can never be a no-jeopardy situation, he says.
Usually people cooperate and are willing to
provide information about the occurrence,
and it is rare for people to deliberately breach
the legislation when involved in accidents
and incidents.
The rst stage in a major investigation is to
examine the scene. Until ATSB investigators
arrive, the responsibility for preserving the
We dont suspend somebodys licence to
punish them; if we suspend, its because
of a safety issue.
13
He is also the Safety Manager for the Police Air Wing.
He manages investigations conducted by the NSW Police
Force into fatal accidents involving anything that ies
in the state of NSW, including general aviation, airlines,
charter, helicopters, base jumpers, parachutists, hang
gliders, gliders and recreational aircraft.
Typically, there will be about 20 investigations open and
at varying stages of enquiry. The record, since he began in
2006, was 38 investigations on the go.
The ATSB will run an investigation and well run a parallel
investigation, Hurley says. Legislation prevents them
from sharing information with us until its released in a
nal report. Then it becomes a public document and that
report is usually included in our nal brief of evidence that
goes before the coroner.
Where we differ from an ATSB investigation is that we
have to satisfy coronial requirements in regard to identity,
date, place, manner and cause of death and as such the
apportionment of blame or responsibility sometimes
occurs in that process.
Should a matter have elements of criminality involved
then another course of action needs to be adopted. Should
this occur then the matter would usually be referred by the
Coroner to the ofce of the Director of Public Prosecutions
for legal direction.
His police career has taught him to avoid jumping to
conclusions about the cause of the crash.
Its a discipline, to keep an open mind. As a criminal
investigator I approach every accident as an evidence-
based, fact-gathering process. I need to satisfy myself;
Has this accident occurred as a result of a criminal
act? Yes or no? Is this a suicide? Yes or no? What caused
the accident?
Hurley has found re-creating the crashed aircrafts
ight prole, using recording equipment on the
Police Air Wings helicopters, to be a key investigative
tool. What you see on the ground and what
you see from the air are usually very different,
he says.
M
yself and
a crew
man
walking
through the
silence of
the forest
approaching
a crash site;
its an
eerie
sensation.
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Investigating sport aircraft accidents
Recreation Aviation Australia has been
investigating crashes involving sport aircraft for
26 years.
We investigate accidents involving everything
from powered parachute onwards, including
weight-shift trikes, three axis and high-
performance sport aircraft, says RA-Aus
operations manager, Lee Ungermann.
RA-Aus, and its predecessor the Australian
Ultralight Federation, investigate sport aircraft
crashes which rarely meet the ATSBs criteria for
an investigation, and work closely with the ATSB
on the relatively few Bureau investigations which
do involve sport aircraft.
The catchcry is that we do investigation to
prevent similar accidents from happening again,
Ungermann says. We go on site with the police,
and act as subject matter experts to produce
reports for the coroner.
Ungermann says GPS units make very good de-
facto ight data recorders. We can obtain data
on altitude, heading, ground speed, latitude and
longitude from an intact GPS, and can overlay
ight routes on Google Earth.
If the GPS is damaged, we can
take it to the ATSB who will
have a look for us.
Ungermann says RA-Aus and its
trained voluntary investigators
were able to share information
and procedures for dealing with
issues such as safe disarming
of ballistic parachutes. That
was an area our organisation
had experience in, because a
lot of aircraft in our category
use them, he says.
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Yet he often drives back to a crash scene
for another look, sometimes within hours of
returning to Bankstown. He agrees it makes
for some very long days, but he stresses
professionalism, experience and dedication
as qualities an investigator must have.
While here are no new accidents in aviation,
every investigation we do is unique, he says.
However, Sangston emphasises that air safety
investigation is, in the main, a desk job.
Theres a bit of a misnomer that air safety
investigation is about being out there kicking
tin in the eld. Youre probably in the eld for
15 per cent of the time, maximum. The rest of
the time youre in the ofce, he says.
Investigators come from varied backgrounds.
The ATSBs staff includes LAMEs, pilots, air
trafc controllers, human factors experts,
technical and recording analysts, and
materials, avionics and electrical engineering
experts.
The bureau has several investigators devoted
to instrument analysis, ranging from needle
impact to data recovery, to analysis and
interrogation of EFIS systems and electronic
recording media. Information can also be
recovered from GPS systems and FADEC
engine management computers. The bureau
is developing equipment and standards to
maximise access to this information. This
involves liaison with equipment and chip
makers about what information is available
and the best way to read it.
Sangston says the complexity of modern aircraft, particularly air
transport aircraft, is requiring more computing and electronics
specialists for investigations.
We found the QF72 investigations very technically intense, he says.
The ATSB draws on expertise from manufacturers and overseas
safety agencies. We recognise we have limitations, but we have plans
in place to call for assistance.
Technological advance is also affecting investigations into sport
and general aviation aircraft. They are not required to carry ight
recorders, although low-cost versions are now available for them. But
Walsh says the work of crash investigators is being made easier by the
amount of solid-state electronics in modern small aircraft, particularly
in sports aircraft. Were surprised and happy at the amount of
data that modern aircraft electronic systems record and can make
available, Walsh says.
According to Ian Sangston, Weve already had a case where we brought
an electronic system, not a dedicated recorder to the distributor, who
said you wont get anything off that, but our guys kept on playing
with it and they did.
However, technology can create new hazards. In some aircraft theres
now an explosive capsule that comes out to deploy a parachute. We
have to be aware of it, so that our people on the site can work safely,
Sangston says.
Other hazards are quieter, but debilitating in their own way. We have
had incidences of investigators suffering critical incident stress. Youd
think that would be from the broken bodies and broken aeroplanes,
but its not necessarily so. It can come from dealing with next-of-kin
and going through that process.
One of the rst things ATSB investigators do is establish contact with
next-of-kin, Sangston says.
Theyre involved in the draft report, involved
in nalising the report. Generally the guys will
sit in with them at the inquest and that can be
quite traumatic.
Some investigators take on too much
emotional burden Sangston says. That can
lead to stress and strain. It can be insidious, or
they can see something once that just knocks
them over. It could happen if they see a child,
and it reminds them of their own children.
Some of it is cumulative, and some of it is
ashback, but we have systems in place,
and were always looking to improve them.
We have a [counselling] service provider.
We cant force people to use it, but its
always there.
Hurley is aware that his closeness to the
industry comes at a cost. Some investigations
I go to are those where I know the pilots, he
says. One was the crash that killed [champion
aerobatic pilot] Tom Moon. Tom waved to me
as he taxied past our hangar at Bankstown
Airport a couple of days before it happened.
I subsequently found myself at the scene of
his accident, managing the investigation.
Despite its costs, Sangston says involvement with relatives is a vital
part of the ATSBs work. Stakeholder management is well worth
investing in. We see advantages in it all the time.
Next-of-kin are a vital source of information in building the crash
picture, Sangston says. One of the main things we need to obtain
early from the next-of-kin is the persons 72-hour history. We need to
understand had they been sick, had they been prescribed medicine,
was there an emotional or relationship problem, or were they having
trouble sleeping? Was it good sleep?
What next-of-kin want after accidents is for no-one else to go through
what theyve had to go through. Thats our agenda too.
A common theme among all the investigators is dedication to their
work. All three speak of the satisfaction of being able to make aviation
incrementally safer.
I love it. Its a privilege to be able to contribute, in a small way to
improving safety, Sangston says.
Hurley says, Ill be doing this until they ask me to go elsewhere. Asked
what he most likes, he responds: Getting to the truth of the matter
for the benet of the relatives of those who have tragically lost their
lives. This is unfortunately never quick or easy, but getting the correct
answers to the hard questions is what makes it all worthwhile.
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FOR MORE INFORMATION
INTERNET
Australian Transport Safety Bureau: www.atsb.gov.au
International Society of Air Safety Investigators: www.isasi.org
The Evolution of Flight Data Analysis: http://asasi.org/papers/2007/
The_Evolution_of_Flight_Data_Analysis_Neil_Campbell.pdf
Aviation Safety Network: www.aviation-safety.net
BOOKS
Air Crash, Macarthur Job, Aerospace Publications, Volume 1,
1991 & Volume 2, 1992.
Air Disaster: Volume 1 (1995), Volume 2 (1996), Volume 3 (1999),
Volume 4 (2001) Macarthur Job, Aerospace Publications.
Beyond the Black Box: The Forensics of Airplane Crashes,
George Bibel, Johns Hopkins University Press, 2007.
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Y
ou are nearing the 20 DME Class C step heading north out
of Anywhere. Its a great VFR fying day and you are cruising
at three thousand fve hundred, right on the Control Area
(CTA) step lower limit.
You check your GPS: the distance from Anywhere is 20.0nm.
Great, you think, Im at the step and Im good to go! Without
further visually confrming your position, you commence climb to
the next step limit of four thousand fvehundred.
Shortly aferwards, you hear ATC calling an aircraf in your area.
You answer and ATC tells you that you have infringed the C LL 3500
step on your climb-out. What went wrong?
Tere are two main problems in this relatively common scenario.
First is an inappropriate reliance on GPS when visual reference
(pilotage) is the required primary means of navigation for VFR
aircraf. Second is a failure to apply the required navigation
tolerances to make sure controlled airspace is not infringed.
Notes

Twenty point oh: good to go?


Be cautious using a single visual abeam fx as it does not always
guarantee clearance from CTA steps.
Use an on-track fx or a line of position between two visual fxes to
establish defnite clearance of a CTA step. Make sure you have correctly
identifed the fxes you use.

Fixing position clear of CTA using visual fxes


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Airservices incident investigations have revealed a worrying
trend at some towered airports.
It appears a culture is developing in which some pilots are
landing without a clearance from air trafc control. Tis
clearly has the potential to present a serious risk to other
airport users.
One of the primary functions of the control tower is to
provide runway separation. Runways are potentially
dangerous places and movements need to be strictly
controlled to ensure everybodys safety. Because clearances
for runway movements, for example runway crossings, do
not always occur on the tower frequency, pilots on fnal may
not have full situational awareness of what is happening
on the runway. Lack of a landing clearance may be due
to an aircraf or obstacle entering or on the runway, and
frequency congestion or workload may prevent ATC issuing
instructions to go around.
Unless CLEARED TO LAND, CLEARED TOUCH AND
GO, or CLEARED FOR THE OPTION (touch and go, full
stop, stop and go, or go around), pilots must go around if
they do not receive a landing clearance. Te only exception
to this is in the event of an emergency.
It is therefore critically important that you have a decision
point in mind for a time, or place, at which you will go
around if you cannot obtain a clearance to land.
Remember: no clearance, no land!
To land or not to land:
that is the question
Avalon airspace changes
Remember: Avalon airspace changed to a Class D Control
Zone with Class E airspace surrounding on 3 June 2010. A
broadcast area is in place for VFR fights entering the Class E
airspace. Pilots must contact Avalon Tower on frequency 120.1
before entry. Check NOTAMs and the Airservices Australia
website for further details.
While GPS is a great tool for the VFR pilot, it must be used
within the navigation requirements ofAIP.
For a VFR fight you must be able to navigate by visual
reference to the ground or water, or by using any of the
methods specifed for IFR fights that you are qualifed
for - except below 2000f, when you must be able to
navigatevisually.
One IFR navigation method is the use of a self-contained
navigation system. Tis can only be used as the primary
means of navigation if the system installed has been
approved by CASA and the pilot operates the system
in compliance with this approval. If you dont meet
these requirements, your GPS can only be a secondary
navigationreference.
AIP also requires that, when operating in Class E or
G airspace, appropriate tolerances must be applied to
your fight path, depending on the navigation method
you are using. For visual navigation by day this is +1nm
for operations between 0- 2000f AGL and +2nm for
operations between 2,001-5,000f AGL.
In our example above, the pilot should have allowed at
least 1 or 2nm (depending on terrain height) beyond the
step before commencing climb. Te pilot should also have
cross-checked their GPS with a positive visual fx clear of
the step. Tis is particularly important if using a GPS with
a map display, as the map indication of the CTA steps may
not be completely accurate.
So, when VFR, use GPS for what it is - a great secondary
reference for visual navigation. When operating around
controlled airspace dont rely on GPS alone: apply a
suitable bufer from CTA and take a good look out
thewindow.
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International Accidents/Incidents 30 March - 22 May 2010
Australian Accidents/Incidents 27 March - 30 May 2010
Date Aircraft Location Fatalities Damage Description
30 Mar Antonov 74 Ivanovo, Russia 0 Substantial Aircraft overran runway after take-off was aborted due to engine failure.
10 Apr Tupolev 154M Smolensk, Russia 96 Destroyed Polish Air Force VIP transport struck trees and crashed on approach to former
military airfeld in fog. President of Poland and other senior Polish leaders
among dead.
12 Apr Rockwell T-39N
Sabreliner
near Blue Ridge,
Georgia, USA
4 Destroyed US Navy training aircraft crashed in dense woods on cross-country exercise,
igniting a 6ha forest fre.Three bodies recovered.
13 Apr Boeing 737-322 Manokwari-
Rendani Airport,
Indonesia
0 Written off Merpati Nusantara Airlines fight was landing when it overshot runway 35 by
200m before coming to a stop in a river bed. It struck a bridge, breaking the
fuselage. Ministry of Transport said runway was wet from drizzle.
13 Apr Airbus A300B4-
203F
near Monterrey
International
Airport, Mexico
7 Destroyed On fnal approach, aircraft crashed on to a motorway, about 2km short of
runway threshold. It hit a car, killing the driver. Another person was found dead
later. Aircraft broke up and caught fre.
19 Apr de Havilland
Canada DHC-6
Twin Otter 300
Kangel Danda
Airfeld, Nepal
0 Substantial Aircraft diverted by weather to remote mountainous airstrip where it was
damaged in forced landing.
21 Apr Antonov 12BP Barangay Laput,
Philippines
3 Destroyed Cargo aircraft crashed in rice paddy near the town of Mexico, Philippines.
Media reports mentioned in-fight fre.Three of six crew killed.
25 Apr Bell UH-1H Near Wellington
New Zealand
3 Written off Three crew were killed and a fourth seriously injured when helicopter crashed in
heavy fog, about 40km north of Wellington.
1 May Blriot XI replica Plasy airfeld,
near Plzen, Czech
Republic
0 Substantial Replica of frst aircraft in Bohemia made hard landing during an airshow
celebrating 100 hundred years of fying in Czech republic
4 May Antonov 2 Near Marianivka,
Ukraine
0 Written off Engine stopped at 500ft after take-off, prompting immediate forced landing.
Aircraft damaged in post-landing fre
12 May Airbus A330 Near Tripoli, Libya 103 Destroyed Airliner operated by Afriqiyah Airways destroyed when it crashed while on
approach to Tripoli International Airport, Libya. An 11-year-old boy survived.
15 May Antonov 28 near Poeketi,
Suriname
8 Destroyed Aircraft departed from cruise fight and crashed in a wooded area of eastern
Suriname.
16 May De Havilland
Canada DHC-3
Turbine Otter
Biscarrosse, France 0 Substantial Seaplane nosed over during a water landing, and came to rest upside down.
17 May Antonov 24B Salang Pass,
Afghanistan
44 Destroyed Aircliner crashed in a mountain pass at 13,000ft. People in area reported heavy
fog.
19 May Embraer EMB-
110 Bandeirante
near Cascavel
Airport, Brazil
0 Substantial Cargo aircraft attempted to land in foggy, overcast weather and touched down
in soy bean feld 500m from runway threshold.
22 May Boeing 737-800 Mangalore-Bajpe
Airport, India
166 Written off Aircraft overran runway and slid down a wooded valley, bursting into fames.
AIP India says 'Aerodrome located on hilltop.Valleys 200ft to 250ft immediately
beyond paved surface of runway.'
Date Aircraft Location Injuries A/C Damage Description
27 Mar North American
Aviation AT-6D
Harvard
Jamestown
(ALA), SA
Minor Serious On touchdown, the aircraft encountered a wind gust. The pilot could not maintain
directional control. The aircraft ran off the runway, struck a fence and came to rest
in a drain.
28 Mar Piper PA-30 Twin
Comanche
Perth Aerodrome,
E M 43Km, WA
Fatal Serious It was reported that the aircraft collided with terrain. Both occupants were fatally
injured. The investigation is continuing.
31 Mar Robinson R44 near Roper Bar
(ALA), NT
Nil Serious During takeoff when the helicopter was about 15 ft AGL, it encountered a wind
gust causing a loss of lift. The pilot ran the helicopter onto the ground, but lost
control when the skid caught under the fence and the helicopter hit the ground on
its side.
1 Apr Piper PA-28-161
Warrior
Moorabbin
Aerodrome, VIC
Nil Serious The pilot misjudged the approach and the aircraft was too low to avoid colliding
with dense vegetation.
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 fnal
reports of the relevant offcial aircraft accident investigation organisation. Information on injuries is unavailable.
19

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Australian Accidents/Incidents 27 March - 30 May 2010 cont.
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 fndings by the ATSB. The data do not include sports aviation accidents.
2 Apr Jabiru J400 Busselton
Aerodrome, WA
Nil Serious During the initial climb, the engine lost power. The pilot turned the aircraft and
conducted a glide approach and landed on runway 03. During the landing roll, the
brakes failed and the left brake was reported to be on fre. The aircraft ran off the
runway and subsequently hit a small ditch before rolling into a fence.
4 Apr Victa Airtourer
115/A1
Hobart
Aerodrome, 255
M 17Km, TAS
Nil Serious During the fight, the engine failed. The pilot conducted a forced landing on a
nearby road. On landing, the aircraft's left wing collided with a tree and the aircraft
spun into an embankment. The investigation is continuing.
5 Apr Beech C24R
Sierra
Tyabb (ALA), VIC Nil Serious On landing, the aircraft bounced before landing nose down. The nose landing gear
detached from the aircraft, the propeller struck the ground, and the aircraft left the
runway, coming to a stop in the grass.
7 Apr Cessna 172N
Skyhawk
near Epic Energy
Five (ALA), SA
Nil Serious While landing crosswind, the pilot encountered strong wind gusts that pushed the
aircraft off the side of the landing strip. The pilot decided to go around, but was
unable to gain altitude due to a tailwind and the aircraft confguration. The pilot
attempted to land in low scrub next to the runway, but the aircraft bounced and
nosed over. Both occupants were uninjured.
10 Apr Cessna A188B/
A1 AgTruck
Ayr (ALA), W M
9Km, QLD
Fatal Unknown The aircraft was reported to have impacted terrain. The investigation is continuing.
11 Apr Cessna 152 Bankstown
Aerodrome, NSW
Nil Serious The aircraft landed heavily damaging the nose landing gear.
13 Apr Cessna 180K Coonamble
Aerodrome, NW
M 22Km, NSW
Nil Serious During the landing fare, the aircraft encountered a wind gust, which caused the
aircraft to land hard, bounce, and swing to the right. The left landing gear collapsed.
The aircraft sustained serious damage.
18 Apr Cessna 337H
Super Skymaster
Goolwa (ALA),
118 M 12Km, SA
Nil Serious During takeoff the aircraft did not accelerate normally. The pilot rejected the
takeoff, but the aircraft overran the strip and came to rest after striking a fence,
trees and a dry creek bed. An engineering inspection revealed that the right main
landing-gear wheel bearings were not moving freely.
19 Apr Schweizer
269C-1
Mareeba
Aerodrome, S M
185Km, QLD
Nil Serious During initial climb, the engine failed. The pilot conducted an autorotation on
to rocky terrain, where the helicopter overturned, resulting in serious damage.
Inspection revealed water in the fuel lines.
22 Apr Cessna 180A Rolleston (ALA), S
M 25Km, QLD
Nil Serious At 500ft on fnal approach, the engine failed and the pilot conducted a forced
landing in a heavily grassed, rough paddock. The subsequent engineering
inspection revealed a broken fuel cable.
22 Apr Robinson R22
Beta
Alexandria
Station (ALA),
148 M 62Km, NT
Nil Serious During cruise, the engine sustained a partial engine failure, and the pilot conducted
a forced landing. The helicopter landed heavily and rolled onto its side. During the
subsequent engineering inspection, no fault could be found with the engine.
28 Apr Amateur-built
Rebel
Williamtown
Aerodrome, ENE
M 19Km, NSW
Nil Serious During cruise, the windscreen caved in, and the pilot conducted a forced landing.
10 May Piper PA-44-180
Seminole
Ballarat
Aerodrome, VIC
Nil Serious The aircraft landed with the landing gear retracted.
11 May Amateur-built
Super Pulsar 100
near Goolwa
(ALA), SA
Minor Serious During cruise, the engine lost power and subsequently failed. During the forced
landing approach onto a nearby paddock, the left wing and nose dropped and
the aircraft impacted the ground. The aircraft was seriously damaged. It was
suspected that the engine failed due to carburettor icing.
11 May Air Tractor
AT-502
Hillston (ALA),
057 M 16Km,
NSW
Nil Serious While conducting agricultural spraying, the aircraft struck a powerline that
impacted the right wing and a section of the leading edge detached from the wing.
The pilot conducted a forced landing but the right wing impacted the ground and
the aircraft was seriously damaged.
12 May Eagle Aircraft
Australia Eagle
X-TS 150
Jandakot
Aerodrome, WA
Serious Serious During approach, the aircraft collided with terrain. The aircraft sustained serious
damage and the two occupants were seriously injured. The investigation is
continuing.
14 May Bell 206B
Jetranger
Mackay
Aerodrome, 260
M 30Km, QLD
Nil Serious During agricultural spraying operations, the helicopter struck a powerline and hit
the ground.
20 May Bell 206L-3
Longranger
Latrobe Valley
Aerodrome, 206
M 37Km, VIC
Fatal Serious During forestry spraying operations, the helicopter struck a powerline and
subsequently collided with terrain. The pilot, the sole occupant, sustained fatal
injuries and the helicopter was destroyed. The investigation is continuing.
21 May Piper PA-31-350
Chieftain
Marree (ALA), SA Nil Serious On fnal approach, the pilot did not use a checklist, and the aircraft was landed with
the landing gear retracted.
27 May Bell 206B (III)
Jetranger
Port Pirie
Aerodrome, 016
M 19Km, SA
Nil Serious During the power line inspection, the pilot heard a loud bang. When the forward
speed of the helicopter decreased, it entered a spin. The pilot reduced power to
correct the spin, but the helicopter hit the ground resulting in substantial damage.
Inspection revealed that the tail rotor blade had separated in fight.
30 May Robinson R22
Beta
Kowanyama
Aerodrome, S M
22Km, QLD
Serious Serious While conducting mustering operations, the helicopter tail rotor struck a tree and
the helicopter then collided with terrain. The helicopter was seriously damaged and
the pilot suffered serious injuries.
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Small aircraft should land well past the
touchdown point of large aircraft
Wake turbulence vortices fall
below the path of the aircraft
Vortices stop at touchdown
Plane spotters know wake turbulence. From their
viewpoint near the airport fence it manifests itself
on still days as a sudden wind, rushing with a
strange, Pentecostal intensity about 90 seconds
after a heavy aircraft has passed overhead.
Pilots who have encountered wake turbulence take
a less poetic view. For them, it makes itself known
by sudden uncommanded roll - sometimes to
inverted, with alarming yaw, also uncommanded,
and often accompanied by merciless loss of
altitude typically from low level. Any wing that
produces lift produces wake turbulence. This
means all winged aircraft (including rotary-winged
ones) produce wake turbulence.
Under the new class D procedures,
the responsibility for wake turbulence
avoidance now rests on VFR pilots
shoulders. So, Flight Safety does a
refresher coursewake turbulence 101.
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Illustration: Juanita Franzi, Aero Illustrations
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Small aircraft should rotate well before
the large aircraft and stay away from
the large aircraft's course
Vortices start at rotation and drop
below the path of the aircraft
Remember your basic aeronautical knowledge
(BAK) course about how a wing produces lift
through generation of low pressure suction
over its upper surface? Wake turbulence,
more correctly called wingtip or wake
vortices, happens when the higher pressure
air underneath the wing follows the laws of
physics and attempts to ow into the low-
pressure zone above it. The path it follows
is to move outwards under the wing towards
the wingtip and curl up and over the wings
upper surface.
Minor contributors to the vortex are the
pressure differential, also causing air to move
inwards over the wing. There are also small
trailing-edge vortices, formed by outward and
inward-moving streams of air meeting at the
trailing edge. These move outwards to the
wingtip and join the main wingtip vortex. It
grows larger as it departs the wingtip. Jet blast
and propeller wash add to a dangerous recipe
for following aircraft.
Viewed from behind, the left vortex rotates
clockwise, and the right vortex rotates
anticlockwise. Like a cyclone, the vortices
have a core and an outer circle. The core can
vary in size from only a few centimetres in
diameter, to a metre or more, depending
on the type of aircraft. A heavy aircraft can
generate a circular wind near the core moving
at up to 100 metres per second (194 knots).
The core is surrounded by an outer swirl
which can be up to 30m in diameter. Its
rotation speed decreases as the distance from
the core increases.
The strongest vortices are produced by heavy
aircraft, ying slowly, with aps retracted,
or clean. Flying clean and slow requires
increased angle of attack, which increases
vortex production.
Wake turbulence is generally thought of as a problem that large
aircraft leave behind them for smaller ones to encounter. This is true,
but aircraft of any size can produce, and fall victim to, dangerous
wake turbulence. There are documented cases of wake turbulence
accidents between single-engine general aviation aircraft and wake
turbulence-induced pitch excursions (a horrid euphemism) between
wide-bodied airliners. And there is at least one accident report on the
public record of an agricultural aircraft crashing after ying into its
own vortices.
Wake vortices generally persist for about three minutes, or longer
in still air. Wake vortices near the ground are most persistent in
light winds of three to 10kt. A point to note is that light crosswinds
in an otherwise stable atmosphere can make vortices drift. A three
to ve knot crosswind will tend to keep the upwind vortex near the
runway, and may cause the downwind vortex to drift toward another
runway. Turbulent or variable winds usually cause vortices to break up
more rapidly.
The greatest hazard from wake turbulence is induced roll and yaw.
This is especially dangerous during takeoff and landing, when there
is little altitude for recovery. Aircraft with short wingspans are most
affected by wake turbulence because they tend to roll faster than
aircraft with longer wingspans.
The effect of wake turbulence on an aircraft depends on many factors,
including the weight and the wingspan of the following aircraft, and
relative positions of the following aircraft and wake vortices. In the
mildest form there may be only rocking of the wings, similar to that of
ying through ordinary mechanical turbulence.
In the most severe form, a complete loss of control of the aircraft may
occur. The potential to recover from severe forms of wake turbulence
will depend on altitude, manoeuvrability and power of your aircraft.
Small aircraft following larger aircraft can be subjected to rolls of more
than 30 degrees. Most commonly, the trailing aircraft encounters both
vortices and is rolled in both directions.
The most dangerous situation is for a small aircraft to y directly into
the wake of a larger aircraft. This usually happens when the smaller
aircraft ies beneath the ight path of the larger aircraft. Flight tests
in this situation have encountered sudden and severe roll, usually with
loss of control. If the aircraft is own between the vortices, sink rates
of more than 1000 feet per minute can be added to the situation.
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Flight tests conducted by pilots attempting to y
into the vortex at a slightly skewed angle produced a
combination of pitching and rolling, which typically
deected the aircraft away from the wake. Research
shows the greatest potential for a wake turbulence
incident occurs when a light aircraft is turning from
base to nal behind a heavy aircraft ying a straight-in
approach.
The light aircraft crosses the wake vortices at right
angles, resulting in sudden pitching that can cause
structural damage to the aircraft.
Avoiding wake turbulence
Your best defence against wake turbulence is to stay
away from it. To do this, you need to recognise where
it occurs.

Do not get too close to the aircraft in front.

Do not get below the aircraft in fronts ight path.

Be particularly wary in still air or light winds.
The onus to avoid wake turbulence has recently shifted
towards pilots. Under the class D airspace procedures
introduced on 3 June, if youre ying VFR, you are
entirely responsible for avoiding the wake turbulence
from heavier aircraft ahead, including when you are
landing. The same applies if youre ying IFR and
you accept responsibility to follow or maintain own
separation with a heavier aircraft ahead. In these
circumstances, air trafc control (ATC) assistance will
be limited to issuing a wake turbulence caution.
Climb angles and tail winds are a couple of wild cards
in this game of survival. Remember that large aircraft
will often make their climb-out at an angle few general
aviation aircraft can match. The result: even if you
rotate before a jet, to avoid its wake, you could still y
through it, perhaps at an uncomfortably low altitude.
And with low airspeed and high angle-of-attack in the
heavy aircraft, this wake turbulence is likely to be as
bad as it gets.
Tail winds are another sneaky game-changer: they blow
vortices along the runway so that even if you touch
down after a heavy aircrafts landing point, you might
still encounter them.
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PO Box 2018 Redcliffe North QLD 4020 P:07 3204 0965

F:07 3204 1902

W:www.bobtait.com.au E:bobtait@bobtait.com.au
AVIATION THEORY SCHOOL
Hangar N Wirraway Drive, Redcliffe Airport. QLD 4021
Check out our web page at www.bobtait.com.au
Courses available full-time or by home study
All CPL subjects plus IREX BAK & PPL
Helicopters and wake turbulence
Then theres helicopter wake turbulence.
Because of the high-power nature of helicopter
ight its usually signicantly stronger than for
that of a xed-wing aircraft of similar weight.
A helicopters rotating wings produce spiral
wake turbulence similar to an aeroplanes
stationary ones, and add its own unique
effects, such as downwash.
Just as aeroplanes produce their greatest
wake turbulence in low airspeed and high
angle-of-attack situations, the strongest wake
turbulence from a helicopter also occurs at
lower airspeeds (2050 knots), as this is usually when the most power
is going through the rotors, putting their blades at high angle of attack.
The action to take when piloting a small aircraft near helicopters is to
avoid taxiing within three wingspans of a helicopter that is hovering,
or hover taxiing. Avoid ying beneath the ight paths of helicopters.
Wake turbulence is an invisible but avoidable hazard. Its particularly
dangerous when it occurs near the ground, and is also often stronger
there because aircraft in take-off or landing congurations produce
more turbulence. But the cure is simple. All you have to do is avoid
where it is likely to be. If in doubt, increase your separation from other
aircraft. In other words, wait and the problem will go away.
Illustrations: Juanita Franzi, Aero Illustrations
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Aviation as a university
subject is taking off in
Australia. Flight Safety
Australias Robert Wilson
examines the issues
driving the academic
trend in aviation.
a MATTER
of DEGREE
Would you go to a dentist who had learned the
art of pulling teeth by working in the outback,
or perhaps in Papua New Guinea? Professor
Patrick Murray doesnt think so, and he
wonders why we treat pilots differently.
A hundred years ago if you wanted to be a
dentist, you would just become one, the
associate professor in Grifth Universitys
aviation department says. All you had to
do was put up a sign. The trade progressed
through a master and apprentice phase, but
as knowledge and technology advanced, the
technical skills needed to be supplemented
with broader non-technical skills, and
eventually it became the norm for dentists to
learn their profession at university. Now, you
wouldnt consider going to a dentist who was
effectively self-taught.
Head of Grifths Aviation department, Paul
Bates, takes it further. If you look at a dentist,
100 years ago their role was mainly drilling
and pulling teeth. But my daughter is unlikely
to have a lling in her entire life.
The role of the dentist
has changed, with
preventative medicine
becoming key, and we
would say the role of the
airline, pilot has also evolved
similarly.
Grifth University, in suburban Brisbane,
is one of 10 Australian universities teaching
degrees in aviation. As a practical vocation with a
strong requirement for theoretical understanding,
it is a tting subject for university teaching,
Bates says.
While aeronautical engineering has been taught
at universities for decades, ying aircraft as an
academic subject is relatively new in Australia.
Grifth has been teaching Aviation for about 20
years and has well established undergraduate,
postgraduate and PhD research programs.
However, it has been on the curriculum in
other countries for many more years. The US
University Aviation Association was founded in
1947 to promote college-level aviation education.
Embry-Riddle Aeronautical University in the US
can trace its antecedents back to 1925, and as
a ying school, was training pilots before World
War II. It became a university in 1970. About 25
per cent of airline pilots in the US are Embry-
Riddle graduates.
But university aviators are quick to say that they
have not retreated to the supposed ivory tower
of academia. The perception of a university
as an ivory tower is out of date, Bates says.
Universities are very much these days driven
by public policy and industry relationships, and
respond very rapidly to those needs. If you dont
respond youre left behind. The reality is that
universities are changing rapidly like the rest
of society.
Aviation department staff at Grifth are drawn
from the industry, and maintain close links
with it, Murray, a former Cathay Pacic check
captain and Civil Aviation Safety Authority
executive says. The majority of lecturing staff
are professional pilots. We try and keep a blend
of full-time staff and a signicant number of
part-time adjunct staff, all of whom are aviation
industry professionals, he says.
The University of NSW Aviation Department argues strongly for
academic ight training on its website, and says it gives the graduate
an advantage that will extend beyond their career in the cockpit or
on the ight deck. For most of us, the choice to do a degree is about
doing something that separates us from the competition. Around the
world, more pilots are getting a degree as well as their ying licences,
and airlines look favourably upon such well-rounded individuals. It
makes a lot of sense to have a wider understanding of the industry
you intend to be part of, and in later life it will help particularly when
going for command or management positions.
Caps and gowns are new to aviation, but ight training has long had
an academic component. It began with the work of Royal Flying
Corps Major Robert Smith-Barry, who, in response to a training
crash rate that rivalled the RFCs combat losses, pioneered the
combination of classroom theory instruction and dual ight training
at Gosport, England in 1917. His technical innovation, in those days
before intercom, was a rubber speaking tube the Gosport tube
that connected instructors and students cockpits on the Avro 504J
training aircraft.
And university yers also concede that the skills and knowledge
required to y a large aircraft to a commercial standard of competence
have long been, at least the equivalent in intellectual intensity and
effort to earning an undergraduate degree, a comparison borne
out by the choice of long-standing and
reputable ying schools as the partners
of many university aviation departments.
The basic ying skills havent changed all
that much.
Theyre mostly laid out in Smith-Barrys
syllabus from Gosport, Murray says. But
he argues that its what happens next that
makes university education superior.
The traditional system is one of
experiential learning, he says. People
undergoing a conventional training course
are taught pretty much the minimum
they need to know to hold a commercial
pilots licence.
They are then effectively told: Whatever
it is you need to learn we cant really
teach you, but go off for a couple of years
and if you come back youll have it.
The problem with experiential learning
is that it can be a brutal teacher, Bates
and Murray argue. Cast your mind back
to riding a bicycle: its the way we learn
things, but unfortunately in aviation we
dont have the option of falling off and
For most of
us, the
choice to do
a degree is
about doing
something
that separates
us from the
competition.
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Phillips also sees a safety benet from
academic pilot training because the university
format allows for more time to be spent in
areas that do not get a strong focus elsewhere.
UniSA includes human factors, human
performance & limitations, threat & error
management, risk & safety management and
crew resource management in its degree, he
says. In the average ying school there would
in all likelihood be only two of these, or at
best perhaps three.
Murray says university pilot education is here
to stay. Regardless of who you talk to were
moving into a pilot shortage. It had arrived
in 2007, but in the last couple of years, the
global nancial crisis (GFC) created a pause.
Thats now ending. And the projections are for
a massive pilot shortage, he says.
Even if the existing way was considered quite
good, there isnt going to be the luxury of
doing it in future. There are a couple of drivers.
The quality driver, and also the imperative
that in times of expansion there have to be
new ways of improving training effectiveness.
He stresses the advantages of university
education in producing a rounded individual,
who can not only y, but communicate
effectively with engineers and management,
and have a thorough understanding of non-
technical as well as technical ying skills.
He believes that sound stick-and-rudder skills
will always be essential, but with 70 per cent
of accidents being caused by human factors,
it is vital that future pilots have solid skills in
this area.
A school leaver who wants to be a pilot is
around 18 years-of-age, and while there are
some mature 18-year-olds, maturity tends to
come with time.
One way of doing that at the moment is to give
someone a commercial pilots licence and get
them to go out and mature in an environment
such as PNG or the bush. Alternatively, you
can mature them in a more controlled
environment. One of those has traditionally
been the military, who do it extremely well -
university is becoming another pathway.
... the advantages
of university education
... a rounded individual,
who can not only y, but
communicate effectively
with engineers and
management, and have a
thorough understanding
of non-technical as well
as technical ying skills.
getting back on, Murray says. And
he argues there are many better
ways of progressing towards the
ight deck of an airliner than
piloting old-technology, single-
pilot aircraft from remote outback
airstrips.
The bulk of ying in GA (general
aviation) is geared towards single-
pilot operations, whereas the airlines
are looking for other skill sets, Bates
says. A university course is a change
in the way you do things, so that
you can concentrate specically on
producing an airline pilot. A newly-
qualied doctor can practise under
supervision in a major hospital,
as can an accountant in a big city
practice. Theres no going bush
for these professions, Bates says,
and Grifths aim is to produce
junior airline pilots who are equally
employable straight out of the box,
so to speak.
The Rudd Government has recently
said that universities should be turning out people with qualications
for industry. That happens to align with our own view that we should
be turning out graduates, not with qualications where they can go
out and learn by themselves for a couple of years, but people who are
t-for-purpose with their degree, Bates says.
The head of aviation at the University of South Australia, (UniSA)
Stephen Phillips, says the academic benet of learning to y at a
university is more to do with the theoretical side than the practical. All
unis would be of the view that we provide a greater depth and require
a better level of understanding than that required by a ying school.
In addition, the non-core study and the academic rigour are aspects
which work to produce a better pilot, he says.
Phillips notes that several airlines around the world require their
pilots to have tertiary qualications, and having a degree has long
been a requirement for pilots in the US Air Force and the majority of
North American airlines. In Australia, he says the benet of a degree
is not seen or supported by all in the industry. Phillips sees distinct
advantages in combining ying training with the academic discipline
of university.
The difference I see is that the degree-qualied instructor would seem
to be better at addressing the issues and providing likely resolutions,
not just the problem, he says. The rigour of study tends to create
someone who assesses the issue from more than just the obvious.
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Grifths course places strong emphasis on
leadership, management and communication
skills, which are developed, among other ways,
by students having signicant involvement in
the running of the Wide Bay Air Show.
Our students learn broad management
skills so that they can integrate with other
aviation disciplines. Traditionally, aviation
professionals have tended to grow up in their
own narrow professional silos. We believe
that all aviation professionals need broader
industry understanding. This will allow
graduates to be better equipped to take on
command and management roles at an earlier
age, Murray says. Teamwork is another
emphasis in Grifths aviation syllabus.
'Working as a team is essential,
and from day one at the university
the students are focused on
teamwork, concentrating
on such areas as developing
communication, assertiveness,
self condence, leadership and
followership'.
However, Grifths aviation department recognises not all student
pilots will take the tertiary pathway. Bates says: we believe that for
many years to come there will be parallel pathways into professional
aviation. Traditionally, in Australia, graduates are under-represented in
aviation compared with other countries, thats both aviation graduates
and graduates in general.
Phillips says the more likely scenario is for a growing number of
tertiary-qualied pilots, which will then further drive demand as
airlines recognise that they get more than just a pilot with a degree.
There will however, still be a place for the non-degree CPL; there may
just not be as many of them around, he says. He also predicts more
degrees among ex-military airline pilots.
A recent innovation in pilot training was the introduction of the multi-
crew pilot licence, (MPL), a competency-based licence which allows
newly-trained pilots to y as rst ofcer on a two-pilot turbine or jet
aircraft. For the moment, universities are sticking to the ab-initio
model and training their graduates to a commercial pilot licence in a
xed-wing piston aircraft. Graduates emerge with about 200 hours of
ight time from university aviation courses.
MPL licensing raises the issue of pilot competency, with supporters of
the traditional approach self-education in a variety of types to build
command hours - claiming there is no substitute for the reality of being
in charge of an aircraft. Phillips expects universities will continue to
follow the CPL licensing model.
The constraints of the MPL regarding the airline/trainer relationship
are likely to militate against a uni going with the MPL, he says. Instead,
he foresees an evolution of CPL licensing: something between the total
crew approach of the MPL and the strictly single-pilot focus of the CPL.
Murray and Bates agree that basic piloting skills are on the agenda
internationally, after a spate of airliner loss-of-control crashes.
Obviously its important to achieve the correct blend of ight
management and '"hands-and-feet skills",' Murray says. While making
no judgement on the merits of MPL versus CPL licensing, he offers the
observation that ongoing evidence-based simulator testing and check
ights are as important to maintaining piloting skills as sound basic
training.
Education, he argues, adds to safety and prociency; it provides both
a philosophical and practical foundation on which graduate pilots
can build their understanding of ying skills, teamwork, knowledge,
compliance and the myriad other attributes required to y safely.
With the internationalisation of the profession, the technology
and the equipment, we believe there is, more and more, a case
for future pilots being educated as well as trained.
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Reach new heights with a degree
in aviation management.
Working in uviufion meuns you huve fo be progressive und lexible. 1euching uviufion
is no dierenf. 1huf's why Griifh Universify oers uviufion progrums purf-fime
or ull-fime, viu fhe lnfernef us well us on cumpus.
Our undergruduufe und posfgruduufe progrums in uviufion munugemenf oer direcf
enfry or uviufion proessionuls wifh or wifhouf previous ormul ucudemic quuliicufions.
1he 8ache|or of Av|at|on Management progrum is designed fo develop eurly uviufion
proessionuls who ure uiming or u cureer in fhe indusfry. lf is speciicully fuilored or
individuuls holding or wifh umbifions fowurds supervisory und munugemenf posifions.
1he Craduate Cert|f|cate and Master of Av|at|on Management progrums ure designed or
more experienced uviufion supervisors und munugers fo underfuke sfudies fhuf will ussisf in
reuching fhe highesf levels o munugemenf. Lnfry muy be bused on ucudemic or proessionul
quuliicufions. Suifubly experienced uirline cupfuins und munugers muy guin direcf enfry.
To reach new he|ghts |n your av|at|on career v|s|t gr|ff|th.edu.auJav|at|on
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The innocent and the beautiful, Have no enemy but time, said the
poet William Butler Yeats. Theres no reason why it shouldnt be the
same for a well-own and well-maintained aircraft. But all good things
have to end sometime and with the average age of Australian general
aviation aeroplanes now more than 30 years, the question how old is
too old? is starting to be asked. The answer is yet to be discovered,
because the impact of ageing aircraft eets, particularly in relation to
commercial operations, is not yet fully understood.
An ageing aircraft can be dened as an operational aircraft that is
approaching the end of its design life. In Australia, the percentage of
multi-engined piston aircraft more than 40 years old is approaching
10 per cent. Who would have thought, when these aircraft rst came
on the register in the 1960s, they would still be ying in the second
decade of the 21
st
century?
Older aircraft are not necessarily a risk to safety, but an ageing eet
has safety implications for the industry and the regulator. There are
two distinct issues at work. One is the effect of time and use on the
aircraft, and the other is the appropriateness of continuing to use
technology designed generations ago.
A useful analogy is to compare the ageing aircraft situation with the
automotive sector. If the equivalent proportion of ageing automobiles
was still in circulation as is the case with ageing aircraft, we could
expect to still see large numbers of Volkswagen Kombis, EH Holdens
and Bedford vans on our roads, with many engaged in commercial
activities.
how
old is
too
old ?
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Those vehicles were leading-edge designs in their day and complied
fully with the roadworthiness standards of their time. But there is no
way they would be considered suitable for daily commercial activities
today - particularly if passengers were involved. No business would
accept their levels of safety, reliability and economy.
Even in as-new condition, a 1960s vehicle would be no match for its
newer equivalent in safety terms. Newer vehicles have safety systems
that were science ction in the 60s, including airbags, anti-lock brakes
and electronic stability control,making them dramatically safer than
old ones. A study by Monash University estimated that if all young
drivers involved in crashes were driving the safest car available, rather
than the cars they usually drove; their road fatality and serious injury
rate could be reduced by more than 80 per cent.
The analogy with general aviation is not exact; many new systems
such as solid-state instruments can be tted to existing aircraft. And
a pessimist might say cabin safety improvements are a moot point
because many aircraft crashes are, by their nature, non-survivable. But
safety improvements such as solid state instrumentation, autopilots
and ballistic recovery parachutes are undeniably more common on
newer aircraft than older ones.
The effects of age are subtly different on aircraft than on cars.
Corrosion or rust is a factor that takes many older motor vehicles off
the road, because it reduces structural strength dramatically. But most
aircraft are made up of a large percentage of aluminium - less subject
to corrosion. However, structural integrity in aircraft is arguably even
more important than in a land vehicle; there is no coming to a stop
at the side of the road in the event of a wing-spar failure. And with a
large number of aircraft now operating long after their manufacturers
anticipated, the Australian eet is moving into uncharted territory
when it comes to the effects of ageing.
Factors on the side of older aircraft are that many of their systems have
been designed to be replaceable, and the cost of new aircraft makes
maintenance of old ones a viable alternative even when it involves
substantial repair and refurbishment work done to a high standard.
The automotive arena has better news when it comes to the use of
old vehicles in a non-commercial context, for instance their private
weekend use by enthusiasts. The risk exposure to both the travelling
public and the drivers and passengers involved is signicantly reduced
under such circumstances. Both government authorities and the
insurance industry acknowledge this reality by offering concessional
registrations and discounted premiums to classic car owners in
recognition of their low-risk prole.
The situation in aviation is likely to be similar (although there are no
promises of discounts) and CASA fully appreciates that there is no one-
size-ts-all approach to the ageing aircraft issue.
The effects
of age
are subtly
different
on aircraft
than on
cars.
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CASA has taken the rst steps in appraising and addressing the
ageing aircraft situation in Australia. On the 25 February 2010, the
CASA Strategic Priorities Committee approved the ageing aircraft
management plan (AAMP) in response to the Government aviation
white paper Flight Plan to the Future released in December 2009. In
the white paper, the Government called for CASA to continue its focus
on the safety of ageing aircraft, particularly in relation to the regional
airline sector.
The ageing aircraft management plan, intended to run over three
stages, will involve signicant industry liaison and consultation.
In addition, risk management techniques will be applied in order
to quantify potential threats to ongoing safety in Australias ageing
aircraft eet. In particular, CASA will focus on issues such as structural
fatigue, corrosion, wiring systems, power plants and mechanical
systems.
The rst stage of the plan will quantify the magnitude of the ageing
aircraft issue in Australia and will recommend strategies to address
any issues raised. Stage 2 will involve the implementation of the stage
1 strategies considered most necessary. Finally, stage 3 of the plan
will involve the annual review of the implementation measures that
may have been put in place in the earlier stage as well as any new
developments.
The Stage 1 report, due in December 2010, will provide CASA with a
co-ordinated overview of the status of ageing aircraft in Australia, the
priorities for addressing any issues that may have been uncovered, as
well as provide recommended strategies for the future to ensure the
ongoing safety of the Australian travelling public. Areas of particular
interest for the AAMP project team are likely to include:

The adequacy of the regional airlines sectors ageing eet
airworthiness programs;

The y-in/y-out sectors use of older jet transport aircraft;

Charter operations that utilise ageing aircraft;

The overall health of private-use ageing aircraft;

The appropriateness of existing systems of maintenance for
supporting ageing aircraft;

The development or implementation of structural inspection
documents (SIDs) and supplemental inspection programs (SIPs);

Reviewing appropriate categories of operation for certain
aircraft types;

The requirement for additional maintenance activities;

The development or cancellation of relevant airworthiness
directives.
The AAMP project is sponsored by Peter Boyd, Executive Director
Standards Development and Future Technology. The project manager
for the AAMP is Continuing Airworthiness Engineer: Pieter van Dijk,
who will work in conjunction with Mike Higgins, Lance Thorogood,
Darren Morris, Larry Russell and external consultants to deliver the
Stage 1 AAMP report.
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The project team will consult with both CASA and industry experts
for inputs into the AAMP. This will include CASA hosting several
Ageing Aircraft Advisory Group (AAAG) meetings in either Canberra
or Brisbane, which will formally draw upon the advice from industry
representative organisations and groups including Aircraft Owners
and Pilots Association (AOPA), Regional Airlines Association of
Australia (RAAA) and the Australian Transport Safety Bureau (ATSB)
among others.
In addition to the AAAG meetings, members of the project team will
also make targeted visits to selected CASA regional ofces to meet
CASA airworthiness inspectors, as well as industry representatives,
aircraft owners and operators in that region. The aim of this exercise is
to workshop the issue with airworthiness inspectors in order to gather
as much information as possible on ageing aircraft issues from around
Australia, as well as harness the collective experience of both CASA
and industry to assist with the study. Members of the public will be
invited to contribute via a CASA website.
Running in parallel with the AAMP, and in conjunction with the Royal
Australian Air Force (RAAF), CASA is co-sponsoring the Australian
Aircraft Airworthiness & Sustainment Conference to be held at the
Brisbane Convention and Exhibition Centre (BCEC) from 1719 August
2010. The conference will bring together representatives from military
and commercial aviation to share their knowledge and experience,
ideas and technologies relating to platform sustainment. An update
on the status and ndings to date of Stage 1 of the AAMP will also be
presented at this forum. For more information on the conference,
contact the event co-ordinator on (07) 3299 4488.
If you have any further questions relating to the AAMP or wish to make
an individual submission or contribution to the study, please contact
AAMP Project Manager: Pieter van Dijk on (02) 6217 1417 or via email
on: pieter.vandijk@casa.gov.au
Australian Aircraft
Airworthiness
& Sustainment
Conference to be
held at the Brisbane
Convention and
Exhibition Centre
(BCEC) from 1719
August 2010.
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SELECTED SERVICE DIFFICULTY REPORTS
1 Apr 2010 14 May 2010
Note: Occurrence fgures not included in this
edition.
AIRCRAFT ABOVE 5700KG
Airbus A319115 Aircraft stair/door proximity
switch sticking. Ref 510010464
Air stair/door indicating system faulty. Intermittent
indication allowed aircraft to taxi with stairs
extended while cockpit indications showed stairs
retracted.
Airbus A320212 Passenger oxygen container
faulty. Ref 510010368
Passenger oxygen system container had no oxygen
generator ftted.
P/No: AH5L3760.
Airbus A320232 Windshield anti-ice system
unserviceable. Ref 510010344
RH windshield unserviceable. Popping sounds
followed by burning odour and ANTI ICE: R
WINDSHIELD message.
P/No: STA320271. TSN: 6,990 hours/3,776 cycles.
TSO: 6,990 hours/3,776 cycles.
Airbus A330202 Angle of attack sensor
suspect faulty. Ref 510010328
Angle of attack sensor suspect faulty.
Airbus A330303 Aft galley circuit breakers
covered by galley ceiling panel. Ref
510010331
Aft galley circuit breakers (2off) covered by aft
centre galley ceiling panel preventing the circuit
breakers from being tripped if needed.
Airbus A380842 Air conditioning odour in
cockpit and cabin. Ref 510010266
Fumes in cockpit and cabin. Investigation could
fnd no cause for the smell. No3 engine had been
recently changed.
Airbus A380842 Floor panels delaminated.
Ref 510010466
Numerous foor panels delaminating. Suspect
manufacturing error. Investigation continuing.
Airbus A380842 Landing gear systems tyres
blew out. Ref 510010275
Main landing gear No5 and No6 tyres blew out on
landing. Wheels and brake assemblies damaged.
Suspect brakes locked up on landing. Investigation
continuing.
Airbus A380842 Seat belt loosens after
tension is removed. Ref 510010314
Seat belt loosens after tension is removed.
Investigation found a mixture of knurled pinch
rollers with different friction settings. Investigation
continuing.
BAC 146200A Cabin rows 2 and 3 oily fumes.
Ref 510010327
Oily fume-type odour in cabin area around rows 2
and 3. Investigation iaw BAE SB 21-150 and AD/
BAE146/86 could fnd no source for the fumes.
Boeing 717200 Air conditioning duct
disconnected. Ref 510010271
RH air conditioning duct disconnected. Duct is
located in rear compartment.
P/No: 59718801.
Boeing 717200 Aux hydraulic pump and case
hoses chafed/leaking. Ref 510010346
Auxiliary hydraulic pump pressure and case drain
hoses chafed and leaking. Pressure hose P/No
AS116-08-0352 and case drain hose P/No AS117-
06-0285. Loss of hydraulic fuid.
P/No: AS117060285.
Boeing 737376 Spoiler actuator faulty. Ref
510010477
No7 fight spoiler actuator faulty. Vibration
experienced when right turn aileron applied.
Actuator rod-end bolt also replaced during actuator
replacement.
P/No: 654456115. TSN: 62,749 hours.
TSO: 62,749 hours.
Boeing 737476 Engine EGT indicator
unserviceable. Ref 510010476
No2 engine EGT indicator unserviceable. Display
blank and pointer incorrect reading.
P/No: WL202EED6. TSN: 57,150 hours.
TSO: 57,150 hours.
Boeing 737476 Engine fuel shutoff valve
failed. Ref 510010484
No1 engine fuel shutoff valve failed in the open
position causing tailpipe fre. Exhaust and turbine
inspected with nil damage found.
P/No: 737M28500011. TSN: 42,778 hours.
TSO: 14,594 hours.
Boeing 737476 IRU failed. Ref 510010414
LH inertial reference unit (IRU) failed.
P/No: HG1050AD05. TSN: 49,345 hours.
TSO: 30,842 hours.
Boeing 7377Q8 Air conditioning aircycle
machine plenum cracked. Ref 510010300
LH aircycle machine plenum cracked.
P/No: 22064002. TSN: 27,737 hours/20,085 cycles.
Boeing 737838 Air conditioning odour in
cockpit and forward galley. Ref 510010396
Mild odour in cockpit and forward galley area during
takeoff. Odour was described as stale/mouldy.
Odour disappeared 3-4 minutes after takeoff.
Investigation could fnd no defnite cause for the
smell.
Boeing 737838 Captains windshield cracked.
Ref 510010416
Captains L1 windshield cracked.
P/No: 5893543135.
Boeing 737838 Landing gear manual
extension switch failed test. Ref 510010490
Landing gear manual extension switch S1060 failed
test. Switch was found to be open circuit at all
times.
P/No: MS250112.
Boeing 737838 Trailing edge ap up switch
faulty. Ref 510010415
Trailing edge fap up switch S1051 faulty
preventing automatic start of the standby hydraulic
motor.
P/No: 426EN108.
Boeing 737838 Wing fuel tank panel leaking.
Ref 510010386
RH wing fuel tank access panel 632CB cracked and
leaking. Crack length approximately 38.1mm (1.5in).
P/No: 112N61014.
Boeing 7378FE Fuselage and engine bird
strike. Ref 510010282
Two bird strikes on takeoff. One strike on fuselage
and one on RH engine. Fuselage inspection and
borescope inspection of engine found nil damage.
Aircraft returned to service.
Boeing 7378Q8 Cockpit window frame
cracked. Ref 510010402
L1 cockpit window frame cracked through C-D post
in area parallel to A-C sill.
P/No: 141A880053.
Boeing 7378Q8 Ground spoiler interlock cable
broken. Ref 510010272
RH ground spoiler interlock cable broken.
P/No: 580250451.
Boeing 747438 Galley oven fumes and white
smoke. Ref 510010420
Fumes and white smoke from upper deck galley
oven. Investigation found oven to be contaminated
with spilled food.
Boeing 747438 Pylon brace forward
attachment tting damaged. Ref 510010277
No4 pylon diagonal brace forward attachment
ftting damaged. Fretting evident and 17 of 18
fasteners P/No BACB30FM14AU were loose
and holes were found to be worn. Investigation
continuing.
P/No: 65B89616.
Boeing 747438 Upper-deck near crew rest
area burning smell. Ref 510010421
Electrical smell evident near upper-deck crew rest
area. Investigation could fnd no cause for the smell
and no electrical burning.
Boeing 767336 Cabin lighting wiring loom
worn/burnt. Ref 510010325
Cabin lighting system wiring loom W1236 worn and
burnt. Loom is located above LH mid-cabin toilet.
Investigation continuing.
Boeing 767336 Engine service panel missing.
Ref 510010315
LH engine RH inner service panel separated from
aircraft during takeoff. Panel was found on runway.
Investigation continuing.
P/No: UL25208.
Boeing 767338ER In-ight entertainment
cooling lter blocked. Ref 510010320
Plastic burning smell in cabin followed by failure
of in-fight entertainment (IFE) and cabin reading
and call lights behaving erratically. Investigation
found the area equipment cooling flter completely
clogged.
Boeing 767338ER Passenger seat separated.
Ref 510010379
Passenger seat 57DEF adrift from seat track.
Investigation continuing.
Boeing 767338ER Wing trailing edge ap
fairing loose and bolts missing. Ref 510010296
No2 trailing edge fap aft fairing loose and two
attachment bolts missing. Inspection found nil
damage.
Boeing 7773ZGER Galley oven dirty
overheated and smoking. Ref 510010441
Mid galley No2 oven overheated and smoking due
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to build-up of oil on oven base under oven insert.
Overheat switch found tripped.
P/No: 820216000001. TSN: 5,195 hours/439 cycles.
Boeing 7773ZGER Thrust reverser cowl
bracket broken. Ref 510010316
LH thrust reverser cowl bracket broken.
P/No: 311W16705. TSN: 4,709 hours/416 cycles.
Bombardier DHC8102 Pitot head anti-ice
faulty. Ref 510010280
RH pitot head anti-ice faulty. Investigation found
high resistance causing circuit breaker to trip.
P/No: PH11001DH.
Bombardier DHC8315 Nose landing gear
cable guide distorted. Ref 510010463
Nose landing gear cable guide damaged (twisted).
Support bracket bushes P/No M81934/2-05A008
worn. Line at transducer support bracket P/
No 8961-1 mounting lug broken. Investigation
continuing.
P/No: 83220087001.
Bombardier DHC8402 Cargo door incorrectly
secured. Ref 510010404
Forward baggage door incorrectly secured. Door
lock was not fully engaged in the locked position
causing the door warning light to illuminate.
Bombardier DHC8402 Engine oil cooler
bypass door nut loose. Ref 510010269
RH engine oil cooler bypass door upper attachment
nut loose on bolt. Investigation found that the
cotter pin had not been installed at factory during
aircraft build.
Bombardier DHC8402 Engine starter-
generator failed. Ref 510010389
No2 engine starter-generator failed.
P/No: 11521063.
Embraer ERJ170100 Engine anti-ice valve
unserviceable. Ref 510010398
No2 engine anti-ice valve unserviceable.
P/No: 32157903. TSN: 4,004 hours/4,040 cycles.
Embraer ERJ170100 Galley burning smell.
Ref 510010323
Burning smell from rear galley area. Investigation
could fnd no defnitive cause for the burning smell.
Investigation found strong odour in galley bin and
RH trolley compartment due to old food and fuids. It
was also noted that the exterior of the aircraft and
engines were covered with dead locusts which may
have caused the smell.
Embraer ERJ190100 Engine IDG failed.
Ref 510010456
No2 engine integrated drive generator (IDG) failed.
TSN: 4,047 hours/2,766 cycles.
Embraer ERJ190100 Landing gear steering
control module unserviceable. Ref 510010401
Landing gear steering control module
unserviceable.
P/No: 1855A000004.
TSN: 1,929 hours/1,313 cycles.
Fokker F28MK0100 Flap control data unit
faulty. Ref 510010479
Flap control data unit (FDCU) faulty. Investigation
continuing.
TSN: 20,088 hours/18,003 cycles.
TSO: 41 hours/23 cycles.
Fokker F28MK0100 Forward oor panel
collapsed. Ref 510010366
Forward entry foor panel collapsed. Panel is
located between front coat locker and galley
cupboards. Investigation continuing.
Fokker F28MK0100 Lift dumper manifold
suspect faulty. Ref 510010305
Lift dumper manifold suspect faulty. Investigation
continuing.
P/No: 1095123.
Saab SF340B Aircraft lightning strike.
Ref 510010293 (photo below)
Aircraft suffered a lightning strike on the captains
side. Double DC generator failure. Lightning strike
inspection revealed numerous areas of damage
including the fn tip and wings.
Saab SF340B Aircraft oxygen system tting
sparking. Ref 510010355
Orange sparks coming from No2 oxygen bottle
outlet port ftting during reconnection. Aircraft was
earthed and power was off. See SDR5100009880
for similar occurrence.
Saab SF340B Tail pipe re detector low
resistance. Ref 510010352
LH tailpipe fre detector 27WG low resistance.
Resistance was approximately 100K ohms.
P/No: 1734362450F.
AIRCRAFT BELOW 5700KG
Beech 200 Pilots rudder pedal failed.
Ref 510010347 (photo below)
Pilots LH rudder pedal failed at LH attachment
bolt hole. Investigation found the bolt hole worn
unevenly followed by failure. The twisting motion
then caused the RH attachment point to fail.
P/No: 355240119.
Beech 58 Engine nacelle wiring chafed.
Ref 510010372
LH and RH engine nacelle wiring chaffng on top
forward sections of main spar. Wiring is used for
alternator and starter motor.
Cessna 152 Alternator brushes worn.
Ref 510010321
Alternator brushes worn out. Alternator failed in
fight.
P/No: ES4118. TSN: 1,018 hours.
Cessna 152 Seat tracks worn. Ref 510010295
Seat tracks P/No MC0410235-1 and P/No
MC0410235-6 worn and cracked.
P/No: MC04102351.
Cessna 172M Rudder attachment bracket
cracked. Ref 510010337
Top rudder attachment bracket worn and cracked.
P/No: 05310186. TSN: 9,264 hours.
Cessna 172N ELT remote switch missing.
Ref 510010491
ELT installed with no remote switch ftted. No G
switch loop installed.
Cessna 208 Engine rear oil pressure tube to
boss elbow unserviceable. Ref 510010383
Engine rear oil pressure tube to boss elbow leaking.
Investigation found wear inside elbow due to oil
transfer tube rubbing. Investigation found o-ring
seal damaged during ftment.
P/No: 3007389. TSN: 8,885 hours/9,321 cycles.
TSO: 1,044 hours/1,459 cycles.
Cessna 210L Control column tube worm/
damaged support bearings failed. Ref
510010311
(photo below)
Control column tube worn and damaged due to
failure of support bearings.
P/No: 12601408. TSN: 4,698 hours.
Cessna 402C Landing gear microswitch wire
broken. Ref 510010451
LH main landing gear microswitch wire broken.
Wire connects between switch and selector valve.
Cessna 404 Aileron quadrant bearing loose.
Ref 510010361
LH aileron quadrant bearing popped out causing
aileron free play.
TSN: 15,015 hours.
SELECTED SERVICE DIFFICULTY REPORTS ... CONT
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Cessna 404 Engine control cable bracket
broken. Ref 510010317 (photo below)
Engine control cable support bracket broken in two.
Engine control travel compromised.
P/No: 501150829. TSN: 32,676 hours.
Cessna 404 Wing panel disbonded. Ref
510010288
LH and RH wing panels disbonded. Found during NDI
iaw AD/Cessna400/108 Amdt1.
Cessna 441 Avionics bus circuit breaker/
switch faulty. Ref 510010462
RH avionics bus circuit breaker/switch faulty.
Switch was broken and had to be held by hand in
the off position for remainder of fight.
P/No: W31X100050.
Cessna 501 Cabin bleed air supply duct
coupling loose. Ref 510010390
Aircraft would not maintain cabin pressure.
Investigation found cabin bleed air supply duct
coupling partially migrated from duct inlet fange.
Outfow valve sense line B nut also found to be
loose.
Cessna 560 Wing aileron hinge brackets
cracked. Ref 510010362
Aileron hinge brackets P/No 6624032-3 and P/
No 6624031-4 cracked. Brackets are located at LH
aileron inboard and RH aileron centre.
P/No: 66240323. TSN: 230 hours.
Extra EA300200 Aileron control rod cracked/
corroded. Ref 510010459 (photo below)
LH aileron control rod cracked and corroded. Crack
length 35mm (1.37in).
P/No: PC43201A4. TSN: 988 hours.
Jabiru 160DLSA Main landing gear leg
delaminated. Ref 510010417 (photo below)
Main landing gear leg delaminated. Aircraft is
registered with RAA.
P/No: 6204023. TSN: 99 hours/70 landings.
TSN: 99 hours/70 landings/11 months.
PAC CT4B Aircraft lighting power leads
incorrectly stowed. Ref 510010470
Elevator momentary restriction. Investigation of
the elevator control system could fnd no faults.
Internal investigation of the tail cone found the tail
navigation light earth and power leads incorrectly
stowed and possibly catching in the elevator
connecting rod bolt.
Pilatus PC12 Landing gear hydraulic motor
unserviceable. Ref 510010467
Landing gear power pack hydraulic motor
unserviceable.
P/No: 9603002104.
TSN: 7,880 hours/10,497 cycles.
Piper PA31350 Landing gear microswitch out
of adjustment. Ref 510010388
Landing gear microswitch out of adjustment. Could
not be duplicated on the ground and was only
evident when air loads present.
P/No: 487862.
Reims F406 Electrical static inverters failed.
Ref 510010304
Phase B and phase C static inverters failed.
P/No: 1B10001G.
Reims F406 Nose landing gear initially failed
to extend. Ref 510010458
Nose landing gear failed to extend on frst attempt.
Gear operated OK on second attempt. Nose landing
gear door bellcrank spring adjusted.
Socata TB20Trinidad Nose landing gear strut
body cracked. Ref 510010374
Nose landing gear strut body cracked at drag brace
attachment.
P/No: TB2042019001. TSN: 3,961 hours.
Swearingen SA227AC Engine mount truss
burnt. Ref 510010471
RH engine mount truss burnt by battery cable which
arced to the frame. Investigation found the cable
incorrectly installed, allowing the cable to rub
on the frame and short circuit. Starter/generator
changed as a precaution. RH generator current
limiter and generator control unit also damaged by
short circuit.
P/No: 2762114095.
Swearingen SA227AT Starter-generator
brushes worn. Ref 510010342
RH engine starter-generator brushes worn.
Swearingen SA227DC Horizontal stabiliser
trim actuator bracket corroded. Ref 510010301
Horizontal stabiliser trim actuator attachment
bracket lugs contained exfoliation corrosion on both
lower brackets.
P/No: 2743060011.
TSN: 16,132 hours/11,968 cycles.
Swearingen SA227DC Passenger door lock
spring retainer incorrect part. Ref 510010475
Passenger door lock assembly diaphragm spring
retainer unapproved part. Suspect part appeared
to be from a bottle cap or tin of unknown origin,
adapted to ft. A search of aircraft records could fnd
no evidence of the repair/modifcation being carried
out. Incorrect/unapproved part.
Correct part number 27-24127-029.
TSN: 16,243 hours/12,575 cycles.
ROTORCRAFT
Agusta Westland AW139 Windshield cracked.
Ref 510010407 (photo below)
Front RH windshield extensively cracked.
Windscreen is constructed from laminated glass.
P/No: 3G5610V00451. TSN: 562 hours/1,417 cycles.
Bell 206B3 Engine/transmission drive shaft
grease boot unserviceable. Ref 510010357
Engine to transmission drive shaft forward
grease boot failed. Grease leaking from boot
and teletemps activated. Following drive shaft
replacement, the forward boot had failed again on
the new drive shaft. Further investigation found the
cause of the failure to be a faulty isolation mount.
P/No: 206040015103.
TSN: 13,408 hours/21,952cycles/21 months.
TSO: 175 hours/184cycles/5 months.
Eurocopter AS350B2 Tail rotor control lever
inner bearing unserviceable. Ref 510010284
(photo below)
Tail rotor control lever inner bearing surfaces worn.
Suspect bushings had been working inside lever
for some time and fell out of lever when pivot bolt
removed.
P/No: 350A33105803.
TSN: 2,002 hours/2,700 cycles.
SELECTED SERVICE DIFFICULTY REPORTS ... CONT
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Eurocopter AS350BA Engine starter-
generator drive shaft fractured. Ref
510010472
Engine starter/generator driveshaft sheared.
Further investigation found the incorrect assembly
of the Belleville washers and incorrect torque on
the retaining nut.
TSO: 618 hours/16 months.
Eurocopter EC225LP Tail boom pylon deck
cracked. Ref 510010334
Tail pylon inclined deck cracked. Broken brackets
in support structure for inclined drive shaft fxed
fairing.
Robinson R22BETA Engine oil cooler cracked.
Ref 510010287
Engine oil cooler cracked and leaking due to
corrosion pitting.
P/No: 1061LTC. TSN: 990 hours.
Robinson R22BETA Engine/transmission
drive belt faulty. Ref 510010286
Engine to transmission drive belt contained a small
bulge on outer surface.
P/No: A1902. TSN: 439 hours.
Robinson R22BETA Main rotor collective
spring rod end broken. Ref 510010350
Collective spring assembly upper rod end broken.
Investigation found rod end bearing extremely tight.
P/No: B2923. TSN: 1,378 hours.
Robinson R44 Main rotor blade skin
delaminated. Ref 510010394
Main rotor blade lower skin delaminated at blade
tip. Delamination was 3.175mm (0.125in) back from
tip and 3.175mm (0.125in) along the spar joint.
P/No: C0162. TSN: 1,922 hours. TSO: 1,922 hours.
Schweizer 269C Fuel system water
contamination. Ref 510010385
Water contamination of fuel system. Investigation
found that although the fuel system had been
drained, the design of the system allows several
areas where water can accumulate and not be
detected during fuel drain. This water can then
affect the engine during fight.
PISTON ENGINES
Continental GTSIO520M Engine fuel injection
fuel ow line worn. Ref 510010489
LH engine fuel injection system fuel fow line
chafed.
P/No: 510010694.
Continental GTSIO520M Engine hydraulic
valve lifter worn. Ref 510010384
RH engine hydraulic valve lifter worn. Found when
changing leaking pushrod seals.
P/No: 653909. TSN: 968 hours.
Continental GTSIO520M Engine turbocharger
non-compliant. Ref 510010302
RH engine turbocharger non-compliant with FAA AD
2010-07-08. Turbocharger ftted at engine overhaul.
P/No: 4659309002. TSO: 939 hours.
Continental IO550D Engine failed suspect
cylinder piston faulty. Ref 510010447
Engine failed. Suspect caused by piston.
Investigation continuing.
P/No: 648046A2. TSN: 120 hours.
Continental IO550N Engine crankshaft
cracked. Ref 510010465
Crankshaft cracked in radius of rear fange. Crack
length 50.8mm (2in). Found using magnetic particle
inspection (MPI) following inspection by an
automotive engine rebuilding company. Crankshaft
serial number N08GA147.
P/No: 649900.
Continental IO550N Magneto bearings heat
damaged/corroded. Ref 510010326
Magneto bearings heat damaged and corroded
especially on the external surface of the capacitor.
Magnetos were incorrect part. Correct P/No
10-500556-1 incorrect ftted magneto P/No 10-
500556-101. Incorrect magnetos had pressurisation
gaskets ftted.
P/No: 10500556101. TSN: 100 hours/16 months.
Continental TSIO520N Engine cylinder
cracked. Ref 510010333
RH engine No5 cylinder cracked.
P/No: TIST714BCA. TSN: 392 hours/10 months.
Lycoming IO540E1B5 Engine camshaft lobes
worn. Ref 510010406
Metal found in oil flter. Investigation found two
camshaft lobes badly worn.
P/No: LW13940. TSO: 1,390 hours.
Lycoming IO540E1B5 Engine crankcase
cracked. Ref 510010364
RH crankcase cracked in area located below No3
cylinder.
TSO: 1,139 hours.
Lycoming IO540E1B5 Engine cylinder
cracked. Ref 510010367
Engine cylinder cracked from top spark plug hole.
TSO: 1,132 hours.
Lycoming IO540E1B5 Engine fuel pipes worn.
Ref 510010408
Engine solid fuel lines severely chafed. Found during
inspection iaw AD/Lyc/90.
Lycoming IO540C4B5 Engine fuel pump drive
gear corroded. Ref 510010380
LH engine fuel pump drive gear corroded on cam
lobe.
P/No: 71652. TSO: 1,447 hours/384 months.
Lycoming O360A1F6 Engine cylinder inlet
valve stem damaged. Ref 510010427
(photo below)
New cylinder found with damaged inlet valve stem
causing valve to stick in valve guide. Valves appear
to be damaged at assembly by manufacturer.
P/No: 17A23938.
Lycoming O360A4M Engine camshaft idler
gear incorrect part. Ref 510010438
Incorrect camshaft idler gear ftted during overhaul.
No drive to engine-driven fuel pump. Engine
stopped when the auxiliary pump was turned off
during aircraft ground run.
P/No: 74996.
Lycoming O360J2A Engine cylinder exhaust
valve guide incorrect part. Ref 510010482
No2 cylinder exhaust valve guide incorrect part.
As a consequence, exhaust valve rocker arm P/No
17F19357 was broken in half due to contact with
the valve guide. Personnel/maintenance error.
P/No: 75838. TSN: 435 hours. TSO: 1 hour.
TURBINE ENGINES
Allison 250C20J Engine FCU unserviceable.
Ref 510010336
Fuel control unit (FCU) unserviceable. Bench testing
found the FCU out of limits. Further investigation
involved removing the ratio lever covers, which then
found the lock nuts on the ratio levers incorrectly
secured, allowing the ratio levers to move out of
calibration (levers were lock-wired).
P/No: 23070606.
Garrett TPE33111U611 Engine compressor
section impeller damaged. Ref 510010485
RH engine frst stage impeller had a substantial
piece missing from vane.
P/No: 31081822. TSN: 10,152 cycles.
TSO: 4,360 hours/4,371 cycles.
Garrett TPE33111U Engine reduction gear
bearing failed. Ref 510010264 (photo below)
RH engine failed. Suspect fuel loss. Metal found in
gearbox chip detector. Investigation found failure
of FCU drive bearing P/No 3103035-1 located in the
accessory gear and drive idler housing assembly.
P/No: 31030351. TSN: 3,205 hours.
GE CF3410E Engine oil system metal
contamination. Ref 510010444
No1 engine oil system magnetic chip detector metal
contamination. Following oil replacement, system
fushing and ground runs, nil further contamination
was evident. Analysis of metal found the engine
was OK for further operations.
GE CF680E1 Engine control alternator drive
adapter bearing failed. Ref 510010322
No2 engine control alternator drive adapter bearing
collapsed. Metal contamination of engine gearbox.
Engine changed. Investigation continuing.
SELECTED SERVICE DIFFICULTY REPORTS ... CONT
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5ervice DifhcuIty Pepcrts
or contact your local CASA Airworthiness Inspector [freepost]
Service Difculty Reports, Reply Paid 2005, CASA, Canberra, ACT 2601
Online: www. casa.gov.au/airworth/sdr
TO REPORT URGENT DEFECTS
CALL: 131 757 FAX: 02 217 1920
GE CFM567B Engine accessory drive bearing
failed. Ref 510010353
No2 engine aft sump chip detector contained three
metal fakes. Analysis identifed fakes as bearing
material.
GE CFM567B Engine air inlet fan blades
damaged - bird strike. Ref 510010399
No2 engine bird-strike. Four fan blades damaged.
Nil evidence of ingestion into engine core.
P/No: 3401613030.
GE CFM563B Thrust reverser failed. Ref
510010455
Both thrust reversers failed to operate when
selected on landing. Investigation found circuit
breakers open. Further investigation found that the
reversers had been deactivated for maintenance
and not reset.
IAE V2527A5 Engine air inlet cone fairing
bolts loose. Ref 510010473
RH engine inlet cone fairing attachment bolts (3off)
loose. Anchor nuts appeared OK.
IAE V2527A5 Engine turbine air seal cracked.
Ref 510010373
Stage 2 high pressure turbine air seal cracked for
approximately 180 degrees in front fllet radius.
P/No: 2A3596. TSN: 18,321 hours/9,309 cycles.
TSO: 18,321 hours/9,309 cycles.
Lycoming LTS101600A3A Engine starter-
generator drive shaft fractured. Ref
510010472
Engine starter/generator driveshaft sheared.
Further investigation found the incorrect assembly
of the Belleville washers and incorrect torque on
the retaining nut.
TSO: 618 hours/16 months.
PWA PT6A67B Engine fuel pump leaking. Ref
510010274
Engine driven low pressure fuel pump leaking due
to internal failure.
P/No: RG9570R1. TSN: 4,726 hours.
TSO: 1,930 hours.
PWA PT6A67B Engine oil lter carbon
contamination. Ref 510010273
Carbon contamination of engine oil flter.
PWA PW123E Engine Compressor bleed
control piston ring sticking. Ref 510010434
No1 engine LH and RH P2.5/P3 switching valves
sticking due to faulty piston rings.
P/No: 3311221801.
PWA PW123E Engine HBOV leaking. Ref
510010433
No2 engine handling bleed-off valve (HBOV) leaking
around dome gasket.
P/No: 311669101.
PWA PW125B Engine bleed valve
intermittent. Ref 510010319
LH engine handling bleed valve intermittent in
operation. Bleed valve had only been ftted prior to
this fight.
P/No: 03R311282601.
PWA PW150A Engine compressor bearing
carbon seal cracked/damaged. Ref 510010454
RH engine high oil consumption. Investigation
found the No5 bearing rear carbon seal cracked
and damaged allowing oil to leak. The compressor
bleed valve was found to be dry and free of oil
contamination.
TSN: 4,668 hours/5,475 cycles.
PWA PW4168A Thrust reverser fairing
missing. Ref 510010289
No1 engine inboard thrust reverser lower
blocker door close out fairing partially missing.
Investigation continuing.
P/No: 74M312004.
Rolls Royce RB211524G Engine failed. Ref
510010270
No3 engine failed. Engine stalled and EGT over-
temp. Investigation continuing.
Rolls Royce RB211524G Engine failed. Ref
510010299
No4 engine compressor stall accompanied by high
vibration, loud bang and fames. EGT peaked at
950 degrees C and vibration at 5.00 units. Engine
removed for further investigation.
P/No: RB211524GT.
Rolls Royce RB211524G Thrust reverser
blocker door separated. Ref 510010468
No1 engine thrust reverser No8 blocker door
separated. Corona P/No LJ32557 located aft of
blocker door damaged. Investigation continuing.
P/No: LJ40613.
Rolls Royce TAY65015 Engine slow
acceleration N2 stagnation. Ref 510010332
No1 engine would not accelerate due to N2
stagnation. Several engine runs were carried out
with normal engine parameters and the aircraft has
fown without further problems.
PROPELLERS
Allison A6441FN606 Propeller solenoid valve/
regulator o-rings misaligned. Ref 510010483
LH propeller feathered and shut down engine.
Investigation found that the propeller solenoid valve
had been changed and that two of three oil transfer
o-rings P/No 6515407 located between the solenoid
valve and regulator were misaligned causing
incorrect governing of the propeller.
P/No: 6506714.
Hamilton Standard 14SF23 Propeller PCU
faulty. Ref 510010397
No2 propeller pitch control unit (PCU) faulty.
Hartzell HDE6C3B Propeller feathered in
ight. Ref 510010486
LH propeller feathered in fight. LH propeller oil
pressure caution message. Investigation continuing.
COMPONENTS
Extinguisher contaminated. Ref 510010279
Lavatory fre extinguisher flled with contaminated
Halon 1211. Found during inspection iaw EASA AD
2010-0062 and FFE ASB 26-116 Issue A.
P/No: BA20509AA4SN037520.
Bendix 1200 Magneto unserviceable. Ref
510010358
Magneto had excessive play in gear shaft bush
causing gear to jump teeth and affect timing.
P/No: BENDIX1200. TSO: 299 hours.
Collins Radio Co SVO65 Servo incorrectly
marked. Ref 510010453
Servo unit incorrectly marked. The servo was
originally marked as P/No 622-5734-002 but
had been over stamped to P/No 622-5734-001.
Investigation found that the unit was still a P/No
622-5734-002 unit internally. The two part number
units are not compatible.
P/No: 6225734002.
SELECTED SERVICE DIFFICULTY REPORTS ... CONT
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12 - 25 March 2010
Part 39 - Rotorcraft
Eurocopter AS 355 (Twin Ecureuil) Series
Helicopters
2010-0023R1 - Engine and Main Gearbox Cowling
Eurocopter BK 117 Series Helicopters
2010-0049 Correction - Cyclic-Stick Locking Device
Eurocopter BO 105 Series Helicopters
2010-0049 Correction - Cyclic-Stick Locking Device
Eurocopter SA 360 and SA 365 (Dauphin)
Series Helicopters
2010-0052-E - Equipment / Furnishings - External
Life Raft Mooring Line Attachment - Inspection /
Rework
Sikorsky S-76 Series Helicopters
2010-06-08 - Metallic Foil Shunt on Floatation
Device
Part 39 - Below 5700kg
Beechcraft 55, 58 and 95-55 (Baron) Series
Aeroplanes
2010-06-02 - Installation of Stand-off Hardware
Part 39 - Above 5700kg
Airbus Industrie A319, A320 and A321 Series
Aeroplanes
AD/A320/210 - 80VU Rack Attachments -
CANCELLED
2007-0276R1 - 80VU Rack Attachments
Airbus Industrie A330 Series Aeroplanes
2010-0042-E - Fuel - Main Fuel Pump System -
Water Scavenge System - Deactivation / Dispatch
Restriction
2010-0048 - Time Limits / Maintenance Checks -
ALS Part 3
Boeing 737 Series Aeroplanes
2010-06-51 - Inspection of the Aft Attach Lugs of
the Elevator Control Tab Mechanisms
Boeing 777 Series Aeroplanes
2010-06-09 - Inadvertent Engagement of the
Autopilot
Boeing 767 Series Aeroplanes
2010-06-16 - Fuselage Skin Scribe Lines
Bombardier (Boeing Canada/De Havilland)
DHC-8 Series Aeroplanes
CF-2010-08 - Electrical Power - AC Wiring Harness
Chafng on Centre Wing Lower Flap Shroud
British Aerospace BAe 125 Series Aeroplanes
AD/HS 125/115 Amdt 1 - NLG Bay Sidewall -
CANCELLED
AD/HS 125/116 - Standby Inverter Cover -
CANCELLED
AD/HS 125/117 - Instrument Integral Lighting
Dimmer Unit - CANCELLED
AD/HS 125/118 - Fire Extinguisher Electrical
Connectors - CANCELLED
AD/HS 125/121 Amdt 1 - Fuel Feed Pipe Joints -
CANCELLED
AD/HS 125/184 - Main Entry Door Frame Pressing
Fokker F100 (F28 Mk 100) Series Aeroplanes
2009-0269R1 - Landing Gear - Main Landing Gear
(MLG) - Modifcation / Replacement
Learjet 45 Series Aeroplanes
2010-06-13 - Flap Actuator Ballscrew Assembly
Sleeves
Part 39 - Turbine Engines
AlliedSignal (Garrett/AiResearch) Turbine
Engines - TFE731 Series
2010-06-11 - Second Stage Low-Pressure
Compressor Rotor (LPCR) Disc Bore
General Electric Turbine Engines - CF6 Series
2010-06-15 - Low Pressure Turbine Stage 3 Disk
International Aero Engines AG V2500 series
2010-06-18 - Vortex Reducers
Pratt and Whitney Turbine Engines - JT8D-200
Series
97-17-04R1 - Front Compressor Hub
Part 39 - Equipment
Radio Communication and Navigation
Equipment
AD/RAD/91 - Rockwell Collins TDR-94/94D
Transponder - Air/Ground Discrete Inputs
AD/RAD/92 - Rockwell Collins TDR-94/94D
Transponder/Honeywell AZ800/810 Air Data
Computer Selected Altitude Data Inputs
AD/RAD/93 - Rockwell Collins TDR-94/94D
Transponders - Aircraft Type Category
26 March 2010 - 8 April 2010
Part 39 - Rotorcraft
Agusta A119 Series Helicopters
2010-0059-E - Tail Rotor Drive - Tail Rotor Gearbox
Assembly - Inspection / Replacement / Re-
identifcation
Eurocopter AS 332 (Super Puma) Series
Helicopters
2010-0043R1-E - Hydraulic Power - Hydraulic Pumps
- Identifcation / Replacement
Eurocopter BK 117 Series Helicopters
AD/GBK 117/19 - Rotor Control Bearing Attachment
- CANCELLED
2010-0045 2nd Correction - Upper Rotor Control
Bellcrank Assembly
2010-0058 - Rotor Control Bearing Attachment
Eurocopter BO 105 Series Helicopters
AD/BO 105/27 - Cyclic-Stick Locking Device -
CANCELLED
Eurocopter EC 135 Series Helicopters
AD/EC 135/16 - Rotor Control Bearing Attachment
- CANCELLED
2010-0058 - Rotor Control Bearing Attachment
Eurocopter SA 360 and SA 365 (Dauphin)
Series Helicopters
AD/DAUPHIN/100 - Fuselage Frame N.9 -
CANCELLED
2010-0064-E - Fuselage Frame N.9
Part 39 - Below 5700kg
Partenavia P68 Series Aeroplanes
AD/P68/43 Amdt 5 - Wing and Airframe - Fatigue
Life Limit - CANCELLED
2010-0051 - Wing Safe Life Fatigue Limits / Wing &
Stabilizers Structures
Part 39 - Above 5700kg
Airbus Industrie A319, A320 and A321 Series
Aeroplanes
AD/A320/225 Amdt 1 - Elevator Servo-Control Rod
Eye-End - CANCELLED
2010-0046 - Elevator Servo-Control Rod Eye-end
Airbus Industrie A330 Series Aeroplanes
AD/A330/90 - Time Limits/Maintenance Checks -
ALS Part 3 - CANCELLED
AD/A330/110 - Fuel Line Inspection
AD/A330/111 - GE Engine - Forward Mount Bolts
Avions de Transport Regional ATR 42 Series
Aeroplanes
2010-0061 - Fire Protection - Halon 1211 Fire
Extinguishers - Identifcation / Replacement
Boeing 717 Series Aeroplanes
AD/B717/4 Amdt 3 - Rudder Trim Control
Boeing 737 Series Aeroplanes
AD/B737/286 - Fuselage Skin Scribe Lines -
CANCELLED
2010-05-13 Correction - Fuselage Skin Scribe Lines
Boeing 747 Series Aeroplanes
2010-07-03 - Sections 41 and 42 Upper Deck Floor
Beams
Boeing 767 Series Aeroplanes
2010-06-10 - Centre Tank Fuel Densitometer
Bombardier BD-700 Series Aeroplanes
CF-2010-10 - Hydraulic Systems Number 2 and 3:
Damage caused by Main Landing Gear Tire Failure
British Aerospace BAe 125 Series Aeroplanes
AD/HS 125/1 - Flight Control Castings -
Modifcation - CANCELLED
AD/HS 125/2 - Fuselage Frame 17 - Modifcation -
CANCELLED
AD/HS 125/3 - Aileron Shroud Clearance -
Modifcation - CANCELLED
AD/HS 125/4 - Cabin Pressure Safety and Inward
Relief Valve - Modifcation - CANCELLED
AD/HS 125/6 - Aileron Upper Hinge Fairing
Attachment Bold - Modifcation - CANCELLED
AD/HS 125/7 - Nose Gear Torque Links -
Modifcation - CANCELLED
AD/HS 125/8 - Engine Mounting Beam -
Modifcation - CANCELLED
AD/HS 125/119 Amdt 1 - MLG Torque Links -
CANCELLED
Dornier 328 Series Aeroplanes
2010-0054 - Tab-to-Actuator Linkage
Part 39 - Turbine Engines
Pratt and Whitney Canada Turbine Engines -
PW300 Series
CF-2010-09 - Engine Impeller in-service Life
Reduction
APPROVED AIRWORTHINESS DIRECTIVES
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Rolls Royce Turbine Engines - Tay Series
AD/TAY/17 Amdt 1 - Low Pressure Turbine Disc
Corrosion - CANCELLED
2010-0060 - Low Pressure Turbine Discs Stage 2
and 3
Turbomeca Turbine Engines - Makila Series
2010-0055 - Engine Fuel & Control - Digital Engine
Control Unit - Replacement
Part 39 - Equipment
Fire Protection Equipment
2010-0062 - Fire Protection - Halon 1211 Fire
Extinguishers - Identifcation / Replacement
Propellers - Variable Pitch - Dowty Rotol
AD/PR/35 Amdt 4 - Propeller Hub Wall Cracking
Radio Communication and Navigation
Equipment
AD/RAD/76 Amdt 1 - Honeywell Primus II RNZ-850
or -851 Integrated Navigation Units - CANCELLED
2010-07-02 - Honeywell Primus II RNZ-850 or
-851 Integrated Navigation Units (supersedes AD/
RAD/76 Amdt 1)
Turbochargers
2010-07-08 - Rebuilt Kelly Aerospace Turbochargers
9 April 2010 - 22 April 2010
Part 39 - Rotorcraft
Bell Helicopter Textron Canada (BHTC) 430
Series Helicopters
CF-2010-11 - Transmission Planetary Pinion Gear
Damage
Part 39 - Below 5700kg
Gippsland Aeronautics GA8 Series
Aeroplanes
AD/GA8/5 Amdt 3 - Horizontal Stabiliser Inspection
Liberty Aerospace XL Series Aeroplanes
2009-08-05R1 - Muffer Cracking
Part 39 - Above 5700kg
Airbus Industrie A319, A320 and A321 Series
Aeroplanes
AD/A320/19 Amdt 1 - Hydraulic Fire Shut-Off Valve
AD/A320/146 Amdt 3 - Airworthiness Limitation
Items - CANCELLED
AD/A320/163 Amdt 1 - Wing Trailing Edge Cable
Routes - CANCELLED
2007-0276R1 Correction 2 - 80VU Rack
Attachments
2008-0051R1 - Fuel / Electrical Power - Prevention
of Fuel Tank Explosion Risks - Electrical Cables -
Modifcation
2010-0071 - Aiworthiness Limitation Items
Airbus Industrie A330 Series Aeroplanes
AD/A330/109 - Pitot Probe Quick-Disconnect Union
- CANCELLED
2009-0202R1 - Navigation - Pitot Probe Quick-
Disconnect Union - Torque Check
Airbus Industrie A380 Series Aeroplanes
2010-0038 - Flight Controls - Outboard Elevator
Electro Hydrostatic Actuator (EHA) - Inspection /
Replacement
Bombardier (Canadair) CL-600 (Challenger)
Series Aeroplanes
CF-2008-35R1 - Angle of Attack Transducer -
Heating Element Degradation and Inaccurate
Calibration
CF-2009-08R1 - Pressurisation System: Cabin
Pressure Control (CPC) uints and Cabin Pressure
Control Panel (CPCP) Defciency
Bombardier (Boeing Canada/De Havilland)
DHC-8 Series Aeroplanes
AD/DHC-8/144 - De-Ice Busbar Sealant -
CANCELLED
CF-2009-01R1 - Dual AC Generator Shutdown
British Aerospace BAe 146 Series Aeroplanes
2010-0072 - Nose Landing Gear Main Fitting Nose
Landing Gear Main Fitting
Part 39 - Turbine Engines
Turbomeca Turbine Engines - Makila Series
2010-0068-E (Correction) - Engine Fuel & Control -
Digital Engine Control Unit - Replacement
Part 39 - Equipment
Radio Communication and Navigation
Equipment
AD/RAD/91 Amdt 1 - Rockwell Collins TDR-94/94D
Transponder - Air/Ground Discrete Inputs
23 April 2010 - 6 May 2010
Part 39 - Rotorcraft
Agusta AB139 and AW139 Series Helicopters
AD/AB139/4 - Fuselage Frame 5700 Middle Section
- CANCELLED
2006-0357R1 - Fuselage Frame 5700 Middle
Section
Eurocopter AS 350 (Ecureuil) Series
Helicopters
2010-0082-E (Correction) - Tail Rotor - Tail Gearbox
(TGB) Control Lever - Inspection / Rework /
Replacement
Eurocopter AS 355 (Twin Ecureuil) Series
Helicopters
2010-0082-E (Correction) - Tail Rotor - Tail Gearbox
(TGB) Control Lever - Inspection / Rework /
Replacement
Eurocopter EC 120 Series Helicopters
2010-0078-E - Electrical Power - Emergency Switch
(EMER SW) Wiring - Modifcation
Part 39 - Below 5700kg
Liberty Aerospace XL Series Aeroplanes
AD/XL/1 - Muffer Cracking - CANCELLED
Part 39 - Above 5700kg
Airbus Industrie A330 Series Aeroplanes
AD/A330/37 Amdt 2 - Elevator Servocontrols -
CANCELLED
2010-0081 - Elevator Servocontrols
2010-0083 - Operational Test of the Fuel Pump Non-
Return Valve (NRV)
Boeing 737 Series Aeroplanes
2010-09-05 - Aft Attach Lugs of the Elevator
Control Tab Mechanisms
Boeing 747 Series Aeroplanes
2010-09-03 - Fuselage Lap Joints at Stringer 6 from
STA 340 to STA 400
Bombardier (Canadair) CL-600 (Challenger)
Series Aeroplanes
AD/CL-600/107 - Angle of Attack Transducer -
CANCELLED
AD/CL-600/120 - Angle of Attack Transducer -
CANCELLED
Part 39 - Piston Engines
Volkswagen Derivative Piston Engines
AD/VW/1 - Assurance Inspection - CANCELLED
Part 39 - Turbine Engines
General Electric Turbine Engines - CF34
Series
2010-01-04 (Correction) - Inspections of Fan Blades
and Actuator Head Hoses
General Electric Turbine Engines - CF700
Series
2010-09-08 - Combustion Liner Cracks
General Electric Turbine Engines - CJ610
Series
2010-09-08 - Combustion Liner Cracks
Rolls Royce Germany Turbine Engines - BR700
Series
2010-0077 - Change of Life Cycle Counting Method
for Touch-and-Go and Overshoot
2010-0076 - HP Turbine Discs Life Limits
2010-0075 - HP Turbine Discs Life Limits
Rolls Royce Turbine Engines - Tay Series
2010-0060R1 (Correction) - Engine - Low Pressure
Turbine Discs Stage 2 and 3 - Inspection /
Replacement
Part 39 - Equipment
Auxiliary Power Units
2010-0079 - Airborne Auxiliary Power - Auxiliary
Power Unit Turbine Wheel Life Limit - Reduction
Instruments and Automatic Pilots
2010-09-04 - APEX Flight Management Systems
7 May 2010 - 20 May 2010
Part 39 - Rotorcraft
Eurocopter AS 350 (Ecureuil) Series
Helicopters
2010-0088-E - Equipment and Furnishing -
Emergency Flotation Gear Wiring - Modifcation
Eurocopter EC 225 Series Helicopters
2008-0007R3 - Limitations - 14Hz Vibrations at Low
Density Altitude
Sikorsky S-76 Series Helicopters
2010-11-52 - LITEF LCR-100 AHRS
continued p42
APPROVED AIRWORTHINESS DIRECTIVES ... CONT
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40
Adhesive bonding has been part of aircraft construction since the
beginning of powered ight when wooden components would be
glued together. It has also been a widely-used construction technique
in metal aircraft for over 40 years.
Many aircraft, whether xed or rotary wing, use bonded components,
some in critical parts of their structures. The advantages of adhesive
bonding over mechanical bonding using fasteners such as rivets, bolts
and screws include greater strength, less weight and, sometimes,
lower cost.
But as aircraft age, the service life of adhesive bonds becomes a critical
issue. The casein glues used in wooden aircraft did not last as well as
they did when used in furniture and musical instruments, where they
can last for hundreds of years. Although waterproof in the short term,
if exposed to high atmospheric humidity over many years, casein-
glued joints in aircraft had the alarming characteristic of dissolving.
The failure is caused by micro-organisms consuming proteins in the
milk-based casein glue. Adhesive bond failure has also affected metal
aircraft. The extraordinary near-loss of Aloha Airlines Flight 243 in
1988, where part of the fuselage blew away on a ight between two
Hawaiian islands, was attributed in part to disbonding of cold-bonded
lap joints that were used on the early model Boeing 737. Again high
atmospheric humidity during production was implicated.
Max Daviss career has been in studying bonded joints in aircraft and
devising techniques to repair them, working with the Royal Australian
Air Force, and recently as a consulting engineer. He presented a
paper at the recent Australian and New Zealand Society of Air Safety
Investigators on the subject. The paper, co-written with New Zealand
forensic engineer, Andrew McGregor, reached the unsettling conclusion
that one form of disbonding was harder to detect and possibly more
common than previously assumed.
Bonds fail in two distinct ways, described by Davis as adhesion failure
and cohesion failure. Adhesion failure is when the glue and the surface
being glued come apart. This happens at less force than the cured
strength of the bond. Cohesion failure is when the glue itself comes
apart. This requires greater force than the cured strength of the bond.
Adhesive bonding has been part of aircraft construction since the
beginning of powered ight when wooden components would be
glued together. It has also been a widely-used construction technique
in metal aircraft for over 40 years.
Many aircraft, whether xed or rotary wing, use bonded components,
some in critical parts of their structures. The advantages of adhesive
bonding over mechanical bonding using fasteners such as rivets, bolts
and screws include greater strength, less weight and, sometimes,
lower cost.
But as aircraft age, the service life of adhesive bonds becomes a critical
issue. The casein glues used in wooden aircraft did not last as well as
they did when used in furniture and musical instruments, where they
Often a cohesion failure will include a bond
coming apart at the carrier cloth, which is
used in construction to facilitate handling of
the adhesive material and becomes a line of
relative weakness in the bond.
The failure mode which is least understood
is mixed-mode failure, where there is a
combination of cohesion and adhesion
failure within the same bond, Davis told
the conference. A mixed-mode failure has
elements of adhesion and cohesion failures. It
leaves behind a component with some traces
of adhesive on it and some bare metal.
Davis strongly supports the use of bonding
as a technique. From his conference paper:
Adhesive bonded structures are rigorously
tested for static strength and fatigue
performance as part of the certication
basis for the aircraft, and also undergo
rigorous quality assurance assessment during
production. Hence it can safely be assumed
that such structures leave the production line
with bonds that demonstrate an adequate
strength.
What worries him is the occurrence of
mixed-mode bond failures in service and the
difculty of detecting them.
Fatigue may usually be excluded from the
causes of mixed-mode and adhesion failures.
The excellent fatigue performance of high-
quality adhesive bonds has been known
for many years. There is only one cause of
mixed-mode failure: the interface produced
by the bonding process was not resistant to
the service environment.
when it all comes
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Because of the comprehensive rigour of
certication and quality assurance, a very
large proportion of these defects are either
adhesion failures or mixed-mode failures
due primarily to degradation/hydration of the
bond interface, Davis told the conference.
Degradation or hydration are engineering
language for breakdown caused by water or
atmospheric moisture. This can react with
the oxides on the metal surface. It is, in
essence, the same problem that made life
difcult, and in some cases short, for pilots of
some wooden aircraft in the 1960s and 70s.
However, degradation of adhesive bonds to
composite materials may be different to that
for metals because of the absence of surface
oxides susceptible to hydration.
Non-destructive inspection (NDI) techniques
are used to check the strength of bonds in
aircraft, but Davis has reservations about the
usefulness of these methods.
Current NDI methods are only generally
effective at nding production voids where
there is an air gap. These are the types of
defect which cause cohesion failures because
the effective area of the adhesive is reduced,
or adhesion failure after the bond interface
has degraded, the paper says.
He says the ability of NDI to interrogate
interfaces, or detect weak bonds such as
kissing disbonds that are typical of the onset
of mixed-mode failure, is extremely limited.
For example, surfaces bonded with double-
sided adhesive tape will pass many NDI
inspection methods, especially the tap-test, despite the obvious
weakness of the bond compared to effective structural bonds. In
effect, NDI can only tell whether or not the bond has a physical defect,
it can not determine the strength of the bond.
A critical factor relevant to the continuing airworthiness of bonded
structures is the fact that using current technologies, NDI can readily
nd cohesion failures and adhesion failures, but can not nd degraded
bonds which are susceptible to mixed-mode failure.
Davis says it is not possible to predict the extent of strength loss due to
mixed-mode and adhesion disbond growth rates, and once hydration
has begun, defects may grow without any ight loads.
Without implying any criticism of air safety investigators, Davis says
mixed-mode failures are difcult to interpret because the investigator
cant be sure if the bond failure caused the crash, or if the bond failed
as a result of the crash. The only certainty is that where mixed-mode
failures occurred, the strength of the bond was less than for bonds
which had not degraded.
He says many adhesively bonded principal structural elements
are managed using damage tolerance methodology, based on an
invalid assumption that the adhesive surrounding a defect maintains
full strength.
There is therefore a signicant risk to continuing airworthiness of
any bonded structures which have been constructed using processes
which are susceptible to mixed-mode or adhesion failure, the paper
concludes. Davis stated that the FAA had recently amended an advisory
circular (AC 20-107) to address adhesive bond durability testing and
suggested that these changes may need to be supported by regulation.
Davis proposes durability testing using the wedge method used for the
RAAFs F-111 eet. A wedge is driven into a sample bonded joint which
is left in hot and humid conditions (50 degrees C and 95 per cent) for
the test period. Any interface that survives such extreme demands
should produce acceptable service durability without mixed-mode and
adhesion failures, he says.
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Part 39 - Below 5700kg
Embraer EMB-110 (Bandeirante) Series
Aeroplanes
AD/EMB-110/54 Amdt 1 - Corrosion of Wing and
Vertical Stabiliser to Fuselage Attachments, Rib 1
Half-ing and Cabin Seat Tracks - CANCELLED
2006-10-01R2 - Wing and Vertical stabiliser to
Fuselage Attachments, Rib 1 Half-Wing and Cabin
Seat Tracks
Gippsland Aeronautics GA8 Series
Aeroplanes
AD/GA8/5 Amdt 4 - Horizontal Stabiliser Inspection
Part 39 - Above 5700kg
Airbus Industrie A330 Series Aeroplanes
AD/A330/98 - Fuel Pump Non Return Valve -
CANCELLED
2010-0086 - Electric and Electronic Common
Installation - Hydraulic Pump Electrical Motor
Connectors - Modifcation
2010-0089 - Indicating & Recording Systems - Flight
Warning Computer (FWC) - Software Installation
Boeing 737 Series Aeroplanes
AD/B737/307 Amdt 2 - Main Slat Track Downstop
Assembly
Bombardier (Canadair) CL-600 (Challenger)
Series Aeroplanes
CF-2010-12 - Wing Leading Edge Thermal
Switches and Wing Anti-Ice Duct Piccolo Tubes -
Airworthiness Limitation Tasks
CF-2010-13 - Angle of Attack (AOA) Transducers -
Resolver Oil Contamination
CF-2010-15 - Main Landing Gear - Piston Axle
Failure
Bombardier (Boeing Canada/De Havilland)
DHC-8 Series Aeroplanes
AD/DHC-8/88 Amdt 1 - Flap Drive Actuator -
Inspection - CANCELLED
CF-2002-26R2 - Flap Drive Actuator Assembly -
Lubrication and Backlash Check
Part 39 - Turbine Engines
CFM International Turbine Engines - CFM56
Series
2010-09-14 - EGT Margin Deterioration
Part 39 - Equipment
Fire Protection Equipment
2010-0062R1 - Fire Protection - Halon 1211 Fire
Extinguishers - Identifcation / Replacement
21 May 2010 - 2 June 2010
Part 39 - Rotorcraft
Bell Helicopter Textron 205 Series
Helicopters
2010-10-16 - Aeronautical Accessories Inc (AAI)
Low Skid Landing Gear Forward Crosstube
Bell Helicopter Textron 212 Series Helicopters
2010-10-16 - Aeronautical Accessories Inc (AAI)
Low Skid Landing Gear Forward Crosstube
Bell Helicopter Textron 412 Series Helicopters
2010-10-16 - Aeronautical Accessories Inc (AAI)
Low Skid Landing Gear Forward Crosstube
Eurocopter BK 117 Series Helicopters
2010-0096 - Airworthiness Limitations Tail Rotor
Intermediate Gear Box (IGB) Bevel Gear - Reduced
Life Limit
Eurocopter SA 360 and SA 365 (Dauphin)
Series Helicopters
2010-0100-E - Navigation - Vertical Gyro Unit
Data Output - Operational Limitation / Operational
procedure / Reinforcement
Sikorsky S-76 Series Helicopters
2010-10-02 - Leaking Servo Actuator
Sikorsky S-92 Series Helicopters
2010-10-03 - Main Gearbox Filter Bowl Assembly -
Failure of Mounting Studs
Part 39 - Below 5700kg
Aerospatiale (Socata) TBM 700 Series
Aeroplanes
AD/TBM 700/52 Amdt 1 - Oxygen - Pilot Operating
Handbook - CANCELLED
2010-0090 - Oxygen - Chemical Oxygen Generator
- Modifcation
Pilatus PC-12 Series Aeroplanes
2010-0093 - Engine Controls - Power Control Lever
Reverse Thrust Latch - Inspection / Modifcation
Part 39 - Above 5700kg
Airbus Industrie A319, A320 and A321 Series
Aeroplanes
AD/A320/224 - Hydraulic Power - Ram Air Turbine
Georotor Pump - CANCELLED
2010-0071R1 - Time Limits and Maintenance
Checks - Damage Tolerant Airworthiness Limitation
Items - ALS Part 2 - Amendment
2008-0034R1 - Hydraulic Power - Ram Air Turbine
(RAT) Gerotor Pump - Replacement
2010-0091 - Stabilizers - Elevators - Inspection
BAe Systems (Operations) Jetstream 4100
Series Aeroplanes
2010-0098 - Time Limits / Maintenance Checks
- Airworthiness Limitations - Amendment /
Implementation
Boeing 747 Series Aeroplanes
AD/B747/142 - Fuselage Skin Lap Joints -
CANCELLED
2010-10-05 - Fuselage Skin Lap Joints
Bombardier BD-700 Series Aeroplanes
CF-2010-14 - Passenger Door - Tensator Springs
Failure
Bombardier (Canadair) CL-600 (Challenger)
Series Aeroplanes
CF-2003-23R3 - Main Landing Gear Door Separation
During Flight
Bombardier (Boeing Canada/De Havilland)
DHC-8 Series Aeroplanes
CF-2010-16 - Cockpit Windshield Lower Frames -
Potential for Corrosion
British Aerospace BAe 125 Series Aeroplanes
AD/HS 125/89 Amdt 3 - Elevator Mass Balance
Sideplate and Spigot
Embraer ERJ-190 Series Aeroplanes
2009-08-02R1 - Deployment Failure - Escape Slide
2006-11-01R5 - Low Pressure Check Valves
2010-01-02R1 - Air Management System Controller
Card
Part 39 - Piston Engines
Teledyne Continental Motors Piston Engines
2010-11-04 - TCM Engine Hydraulic Lifters
Part 39 - Turbine Engines
General Electric Turbine Engines - CF34
Series
2009-26-09 (Correction) - Fan Disk Inspection for
Electrical Arc-Out Indications
Part 39 - Equipment
Compressed Gas Cylinders
2010-11-05 - AVOX Systems and B/E Aerospace
Oxygen Cylinder rupture
APPROVED AIRWORTHINESS DIRECTIVES ... CONT
Book now for the Australian Aircraft Airworthiness
& Sustainment Conference
Brisbane Convention and Exhibition Centre (BCEC)
1719 August 2010
Contact the event co-ordinator on (07) 3299 4488.
Aircraft Airworthiness & Sustainment
2010 Conference
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ever had a
CLOSE
CALL?
Write to us about an aviation
incident or accident that youve
been involved in. If we publish
your story, you will receive
$
500
Articles should be between 450 and 1,400 words. If preferred, your identity will be kept condential. Please do not submit articles regarding
events that are the subject of a current ofcial investigation. Submissions may be edited for clarity, length and reader focus.
Write about a real-life incident that
youve been involved in, and send it
to us via email: fsa@casa.gov.au.
Clearly mark your submission in the
subject eld as CLOSE CALL.
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Each year, CASA surveys holders of air operator
certicates (AOC) to collect detailed information
from them about their activities, types of aircraft,
hours own and other factors impacting on safety.
The survey does not include the 14 largest regular
public transport (RPT) operators.
In February 2010, some 789 Australian AOC holders
(some operators were no longer operating and
non-contactable) completed CASAs AOC holders
survey questionnaire.
A BIG THANK YOU to these respondents,
who provided valuable information that will assist
us in ongoing improvement to safety oversight,
including targeted industry safety education.
QUESTIONNAIRE RESULTS
Some 133 operators either ceased activities, or were
active for fewer months than planned in 2009. Of
operators who were contactable, 37 per cent ceased
to exercise their AOC due to insufcient demand, and a
further 31 per cent ceased operations voluntarily.
In total, the 789 AOC holders operate 3713 aircraft
(with 301 of these being used by multiple operators), or
around a quarter of civil aircraft on the Australian VH-
register. Together, these AOC holders ew 1.3 million
hours, with about a third of these hours being for ight
training (not including the operators internal training
activities), and another third for various charter
operations.
Many operators are relatively small, with the majority
(60 per cent) reporting ying fewer than 1000 hours
per year. In terms of the number of aircraft, 22 per
cent of AOC holders operate a single aircraft, with a
further 20 per cent operating two aircraft. Of the larger
operators, 12 per cent (or one in eight) y more than
4000 hours each, and 16 per cent operate more than
ten aircraft.
The majority of AOC holders (58 per cent) performed
some type of passenger-carrying activity (such as
regular public transport, scenic charter or transport
charter operations).
Fixed-wing aircraft account for three-quarters of
the eet used by AOC holders, with the remainder
comprising 23 per cent rotorcraft and two per cent
balloons. The age prole of aircraft differs markedly
between the three categories, with the majority of the
rotorcraft eet manufactured after 1990, while around
half of the power-driven eet was manufactured
before 1980.
AOC HOLDERS SAFETY QUESTIONNAIRE
Proportion of hours fown
Agricultural work
6%
Training
33%
Medical
7%
Aerial work* 19%
*Aerial work includes aerial advertising and
fre fghting operations
Charter (32%)
Scenic - 7%
Transport - 21%
Freight - 4%
RPT
3%
Why exclude the larger RPT operators?
The larger RPT operators (such as QANTAS and
Virgin Blue) carry the substantial majority of
passengers and perform the majority of combined
passenger and charter ight-hour operation
in Australia. Data which includes these large
operators may therefore obscure important
information.
Whilst these large operators are obviously a
critical part of the industry, the focus of this article
is on the smaller AOC holders. There will be more
on the larger RPT operators in a future article.
Decade of manufacture by aircraft class
Power driven aeroplane
Rotorcraft
50%
40%
30%
20%
10%
0%
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<1970 1970-79 1980-89 1990-99 2000-10
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STABILITY OF OPERATIONS
Whilst change is a natural and often necessary aspect
of the aviation industry, it may result in increased risk
if not managed effectively. When identifying safety
concerns, it is appropriate to discuss and analyse the
rate of change within the industry.
The chief pilot is a key position for an air operator
(and an AOC cannot be exercised without a suitable
appointment). These positions appear to be relatively
stable, with 93 per cent of survey respondents
indicating that their chief pilot has been in the position
for more than six months.
A key risk identied by AOC holders is the ability to
retain and recruit operational staff. The results of the
survey indicate that retaining key staff is currently less
of a challenge than recruiting. The 2009 survey showed
that it was often harder than usual to recruit key staff.
This issue appears to have reduced in 2010, although
40 per cent of respondents still found recruiting more
difcult than usual.
PERCEIVED SAFETY RISKS
In a new and important addition to the 2010 survey,
AOC holders were asked what they consider to be the
current risks to aviation safety in Australia.
Other factors include airmanship and fight crew training, levels of fight crew
experience and also regulatory practices.
The risk identied most often by AOC holders is
adverse economic conditions. These may result from
increases in fuel, maintenance and other costs, and
may place economic pressure on operators to reduce
safety standards.
Despite the identication of these risks, it is important
to note that only two per cent of respondents thought
the Australian aviation industry was not very safe,
whilst 56 per cent thought the industry was either
extremely or very safe. This is consistent with results
from previous years.
SATISFACTION WITH CASA
Of obvious interest to CASA is the industrys perception
of how well we contribute to the safety of each
organisation. Of the 479 AOC holders providing us this
information, 42 per cent thought CASA was extremely,
or very helpful in identifying important safety issues
that organisations had not previously been aware
of, whilst seven per cent thought CASA was not at
all helpful.
Similarly, 45 per cent of AOC holders thought CASA
was extremely, or very helpful in providing useful
information about risk management principles and
concepts, whilst eight per cent thought CASA was not
at all helpful.
The data provided by AOC holders will allow more
detailed and targeted analysis to be performed, and
the comments made by AOC holders will be analysed
further, and, where appropriate, provided to the
relevant CASA business areas. The feedback you have
provided assists CASA to continue improving aviation
safety in Australia.
For further information, please contact the AOC
Holders Survey team at aocsurvey@casa.gov.au
Maintenance of aircraft: 71 per cent of respondents
indicated the maintenance of their aircraft is performed
by maintenance facilities independent of the AOC. Of
these, 78 per cent indicated that there has been no
change in the maintenance provider for at least two
years. Only eight per cent of respondents indicated that
the AOC does not oversee maintenance (for example, all
aircraft are cross-hired).
30%
25%
20%
15%
10%
5%
0%
Operator identifed risks
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Recruiting and retaining staff
Recruit staff
Retain staff
70%
60%
50%
40%
30%
20%
10%
0%
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EASIER than usual Above average HARDER than usual
Recruiting - 2009 and 2010
2009
2010
60%
50%
40%
30%
20%
10%
0%
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EASIER than usual Above average HARDER than usual
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I w
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and of a
trusty w
orkhorse,
a C
essna 206.
Phillip Zamagias found himself having to make a
split-second decision after being fooled by rapidly
changing tropical weather.
a
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Australias north is a training ground for many a new commercial
pilot. Aviation is a way of life, as aircraft are used almost as readily
as taxis to supply essential services and administer government
programs in remote communities.
I was one of many pilots who went north feeling quite chuffed that
I had made it through my companys rigorous fight training and
orientation program. I was now in command of a trusty workhorse,
a Cessna 206.
The company I few with was world-renowned for its experience in
bush fying and had an enviable safety record. I had received much of
the companys collective wisdom during bush orientation; however,
learning to apply this knowledge was another thing.
The wet and dry seasons of northern Australia present two very
different scenarios to pilots. In the dry, the wind is always a south-
easterly and the sky is almost always clear.
In the wet, the winds shift to north-westerlies, and the weather
builds up from isolated cumulonimbus to full monsoonal cloud and
rain. In the transition between the two, anything can happen.
It was my frst wet season and as the isolated cumulonimbus started
to appear, I was mindful of the advice of many senior pilots warning
me about windshear. A general rule of thumb was that landing and
takeoff within fve miles of an active cell should be avoided.
That sounded reasonable enough, but when there is only one cell in
the vicinity and clear skies all-round a single cell doesnt look that
menacing.
After a long day of fying, the last sector was a simple matter of
picking up one passenger from a small aboriginal outstation in
Arnhem Land and taking him back to base.
The outstation landing strip was typical of many in the area.
It was 700m long, reasonably well maintained, and surrounded by
moderately dense bushland with tree-tops around 25m (80 feet)
above the runway elevation.
The parking area was near the western threshold, and the windsock
was beside it so that it could get some clear air and be seen more
readily. There was one minor problem; the strip had a rise in the
centre, making the windsock invisible from the eastern threshold.
As I taxied for takeoff, the wind was a westerly, just as I had
encountered during the landing. I was aware that the thunderstorm
was nearby and to the north-east of the feld. Lining up for departure,
I could not do a fnal check of the windsock as it was obscured by
the rise.
I opened the throttle gently to avoid stone damage and checked for
full power, oil temps and pressures in the green, airspeed rising. All
was good to go.
Reaching the middle of the runway, I could sense that something
wasnt quite right. I was travelling very fast, but the airspeed was
still very low. For a brief moment I could not make sense of it, but I
had the presence of mind to check the windsock as it came into view.
To my horror, it was pointing in the direction I was travelling and
perpendicular to the pole supporting it! I guessed it was showing 30
knots downwind component.
Time seemed to slow down as I tried to evaluate the situation.
Normally, I should have aborted by that point, but with a much
faster groundspeed and a roaring tailwind, I was faced with a tough
decision.
To abort now would mean a defnite overrun into the trees. To
continue the takeoff would be risky. I reasoned that in my favour was
an aeroplane I knew was a good performer (it was the only one that
I few every day) and it was very lightly loaded. The trees were the
only obstacles, as the ground surrounding the strip was fat.
I held the aircraft on the ground until rotate speed and the plane broke
ground easily. I knew that I could not wring any better performance
from my trusty 206 than to maintain Vx (max angle climb speed) and
pray for the best.
The aircraft made it over the trees with little margin; I even checked
for twigs in the landing gear when I arrived home. The climb out was
very shallow and highlighted the effect of the massive tailwind we
were experiencing. It was a very quiet fight home. My passenger
said nothing. I volunteered nothing.
I have thought long and hard about it over the past 20 years. Common
wisdom would say that I should have aborted; maybe I should have.
I know of several others who did abort and ended in the trees with a
plane written off and signifcant injuries to passengers.
What I did was based on split-second reasoning
in a set of circumstances that is not readily
transferable. But I did learn some valuable
lessons.

Be aware of weather in the vicinity of an
aerodrome. Note what is happening when
you arrive and watch for trends while you
are on the ground.

Never underestimate the ability of
thunderstorms to change the local wind
conditions, even if it goes against the
normal seasonal wind.

Be ready to abort every takeoff early
enough if it doesnt seem right - even more
so if you have a short runway. Things
happen fast even at 80 knots (40 metres per
second).

Know your aircrafts V speeds and dont
deviate from them. The makers test pilots
had a vested interest in getting the best
performance fgures to put in the types
publicity material. You wont do better.

Ask for windsocks to be moved to places
where they can be seen from each
threshold, or have additional ones installed.

Know the expected performance of your
aircraft both empty and fully laden. Never
overload!

Be aware of the terrain surrounding the
airfeld. Brief yourself on which direction to
turn for the lowest ground, clear areas etc.
I cannot condone my actions but I still believe
that to have aborted by the time I had worked
out what was happening would have been
disastrous.
In bush fying, I was always taught to use all the
runway available for take-off using short-feld
technique. Operating in a standard, consistent
way will alert you of something being amiss
much earlier than if every departure is
haphazard.
Thankfully, I got away with this one, but I have
not forgotten its lessons. In the subsequent
twenty years of fying I have tried to ensure that
I allow suffcient margins for the unexpected.
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In the mid 1980s I worked in line maintenance for a large, great
Australian airline, sadly now gone.
During this time I worked with some great fellows on a tight-knit
maintenance crew. The age and experience of this crews members
varied from LAMEs and AMEs who had been in the industry since
the days of Australian National Airways, right up to recent ex-
apprentices, including some who were the sons of current and former
airline workers, plus a good spread of LAMEs of various backgrounds
and experience. It mixed in a nice balance of youth and experience.
I was a LAME and as a recent refugee from a competing airline, I had
been made to feel welcome in this crew. I enjoyed my time with this
eclectic group.
On a pleasant, late-spring Saturday afternoon, our line maintenance
crew happened to be rostered for duty on a 14.30 to 22.30 afternoon
shift. Afternoon shift meant that the whole crew would be on the
tarmac at the companys passenger terminal doing turnarounds and
maintenance activities on company and customer aircraft.
I do recall thinking that the weather was so nice that day that it would
have been an ideal afternoon to be at home with the family, or at a
barbecue with friends, but if you must go to work on the weekend, and
in the great outdoors, then the days didnt come much nicer than this;
warm soft sunshine and a gentle breeze.
A young
engineer, w
ho
follow
ed his
training and
stood his ground
w
hen others
assured him

there w
as no
problem
, m
ay
w
ell have saved
his airline from

disaster.
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This companys ying activities on Saturdays were always somewhat
quieter than during the other days of the week. This meant that some
of our line maintenance crew would be looking after the needs of
transiting aircraft, whilst others of the crew would focus on deferred
maintenance - maintenance outstanding on aircraft which had
nished their days ying and were parked at various gates on tarmac
at Melbourne airport.
One such aircraft was a company Boeing 727 that had been parked at
a standoff bay. A young LAME was assigned to check the aircraft over
and put it to bed. This included a visual external check of the aircraft
and its systems.
This young man had joined our crew only in recent months. He was a
keen well-liked ex-apprentice who had previously spent a lot of time
in the aircraft overhaul department working on and getting to know
intricately the inner workings of Boeing 727s. He was enthusiastic and
had a particular like of the type.
During his end-of-the-day ying check he discovered that one of the
four main landing-gear brake assemblies was worn to limits, and this
would require changing before the next days ying.
The 727 brake unit is a line-replaceable one, and although its
replacement would normally be carried out when the aircraft was
positioned in the hangar, it was a task that could be carried out on the
tarmac. It would be no real chore to do it in the open on such a nice
afternoon.
The 727 brake unit is a large and heavy multi-disc assembly that
ts co-axially over the landing gear axle, and the main landing-gear
wheel and tyre assembly ts over, and engages with it. Unlike general
aviation aircraft, the brake unit is not relined with friction material,
but rather the whole module is changed as a complete assembly. This
module is fastened to the landing gear with a dozen or so nuts, which
are tightened onto large studs projecting from the main landing-gear
brake housing through corresponding mating holes in the aircrafts
landing-gear axle ange.
As a fast, heavy aircraft like the 727 generates
a lot of heat, and dissipates a lot of energy
through its wheel brakes, it was a mandatory
company requirement not to reuse the main
landing-gear brake retaining nuts when a
brake assembly was replaced, but to replace
them with new ones.
When our young maintenance worker
travelled to the company parts store and
ordered a serviceable 727 brake assembly,
he diligently ordered a packet of new brake
retaining nuts.
When he received the brake unit retaining
nuts from the storeman, they were correctly
packaged in a vendors bag, which identied
the parts as the items he had ordered. The
package was also supplied as required with a
general release note (GRN) number.
On closer inspection, the nuts
he had just ordered appeared
identical to the ones he had
removed, and while they were
clearly new parts, each new nut in
this packet had a small innocuous
dot of red dye on it.
Although they had come supplied with a GRN
- which is normally proof that maintenance
workers can rely upon to indentify serviceable
aircraft parts, with acceptable history and
traceability - our young LAME was troubled
by the red dye stains. He knew from his
time in the company component overhaul
department that when aircraft parts were
determined to be beyond repair and scrapped
it was normal practice to mark them with
red paint as a visual cue of their soon-to-be-
discarded status.
He decided to confer with some older hands
on the shift about this conundrum. He was
assured by all the maintenance crewmembers
present, including me, that if the parts were
the correct part number, and they had been
supplied with a GRN, then he could rely
on them to be serviceable and he should
use them.
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Our young worker wasnt convinced by the assurances of his more
senior peers. As events unfolded, it was good that he wasnt.
He decided to order more nuts from the store to see if he could get a
set that were not marked with any red dye. As this airline was a large
operator of 727s they had good stock of these parts, and he managed
to nd a set of new fastening nuts that were unmarked with red dye.
He then quarantined the nuts that had dye marks for the quality
assurance (QA) departments attention and submitted a report asking
them to follow up his concerns.
Some weeks later, our young LAME, rather proudly and with more
than a hint of gloating to his more experienced peers, announced
to the crew room that he had been correct about the brake nuts. He
went on to explain that QA had investigated the matter, and they had
discovered that, although the parts came from a reputable and
trustworthy vendor that the airline had used for years, they were
counterfeit.
Further, QA investigations had discovered that the nuts were made by
a reputable overseas aircraft fastener manufacturer with all the correct
part manufacturing approvals. However, during the post-production
quality testing they had been rejected as below the required Rockwell
hardness value and sent to be scrapped - hence the red dye marks.
Around this time, it was believed that person or persons unknown
had taken these rejected parts, forged the paperwork and sold them
back into the aircraft parts supply chain in the USA, from which they
eventually ended up in our young LAMEs hands.
His discovery prompted a company-wide alert
to check other 727s with recent brake changes
to ensure they didnt have any red-dyed nuts
installed. There was also a worldwide alert to
727 operators advising other operators who
may have purchased these nuts from the
same supplier.
Fortunately, this episode did not result in
anything more than some light-hearted
teasing of the more experienced members
of the maintenance crew, but it was a telling
reminder that maintenance workers must
always be vigilant for evidence of bogus
aircraft parts, and always, to follow their
instincts if things dont seem right.
The morals are:

If it doesnt seem right or feel right, dont
just accept it at face value. It pays to check
it out.

You can teach old dogs new tricks.

And thirdly, just because some workers
are young and relatively inexperienced,
it doesnt mean that they cannot bring a
new perspective.
It seems to me that often pilots do not understand the principle of
failsafe design, as it applies to electrical/electronic control of aircraft
systems. To illustrate this, I will describe an incident that almost had
a nasty outcome involving the operation of the hydraulically-boosted
control system in the Bell 205 helicopter.
Because of the heavy forces needed to control the rotor system,
a transmission-driven hydraulic pump supplies pressure to servos that
reduce the stick loads felt by the pilot. In the case of total hydraulic
failure the helicopter can still be own, although with some difculty.
Because hovering in this condition would be virtually impossible,
a run-on landing would be required.
A more difcult failure may occur when one hydraulic servo fails, but
the others continue to work. This means that the controls are boosted
in some parts of their movement, but not in others. Such a failure could
easily result in an aircraft that is unyable by the average pilot. Bell
therefore provides a switch allowing the pilot to disable the hydraulic
system. The pilot still has to contend with a total hydraulic failure, but
all the stick forces are equally high, and the aircraft is still yable.
The hydraulic disable system is failsafe. This means that an electrical
circuit is used to hold the hydraulic system in the disabled condition.
When the hydraulic system switch is in the on position, this circuit
is switched off and the hydraulic boost is switched on. Likewise, if the
electrical system fails, this circuit will be de-energised, or off, and the
control linkages will continue to be boosted, regardless of the position
of the hydraulic override switch. This prevents loss of the aircraft
electrical system from causing a total hydraulic failure. In short: if
electrics off, then hydraulics on; for hydraulics off, electrics must
be on.
I was returning from an offshore sortie one day when the pilot of
another aircraft called on the radio, in a highly-agitated voice, that he
was losing control. He said the hydraulics kept cutting in and out, and
the aircraft was rolling and pitching violently. There was real panic in
his voice and I could hear his passengers shouting in the background.
Another pilot called, Switch off the hydraulics. He responded with,
Ive switched off the hydraulics, and pulled the circuit breaker, I think
were going in. I called out as calmly as I could, Leave the switch in
the off position and push the circuit breaker back in.
After a minutes silence he came back with,
I did that and I have control back with no
hydraulics. What he had done by pulling
the circuit breaker was negate the override
system by de-energising it, which was the
same as turning the hydraulic system back
on. Pushing the circuit breaker in turned the
hydraulics off again. He proceeded back to
base and made a run-on landing on the ight
strip beside the runway.
We all learned from that, about following the
ight manual procedures and not applying
our own overkill additional actions.
The bottom

line is:
Know
your
aircraft.
The devil is in the details of your
aircrafts systems, Lloyd Knight writes

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Chief Commissioners
message
On 12 April I signed a renewed
memorandum of understanding
(MoU) with the President of the
Australian and International
Pilots Association (AIPA),
Captain Barry Jackson.
Representing around 2,500
Qantas ight crew, the AIPA
is the largest representative body of airline pilots in
Australia. The AIPA plays a valuable role in contributing
the expertise of these ight crew to the governments
legislative and regulatory processes. The association
also contributes resources and expertise to a broad range
of local and international initiatives that signicantly
contribute to improving aviation safety.
This MoU strengthens our relationship with AIPA and
articulates how we will work cooperatively to support
aviation safety investigations. With Australian ight
crew being widely regarded as the most experienced and
respected in the world, the ATSB recognises the great
value AIPA adds to our safety investigations.
On 20 April I had the pleasure of addressing the ninth
International Symposium of the Australian Aviation
Psychology Association on the topic Safety Management
Systems: Is there a role for an independent investigator?
Safety management systems (SMS) are increasingly
important in aviation, with ICAO actively requiring
aviation operators to implement an acceptable safety
management system. The progress that Australia has
made in this area is encouraging, although it will continue
to present new challenges for all of us.
From the ATSBs perspective, these developments
emphasise the importance of taking a systems view of
safety occurrences: of looking at what we can learn to
improve future safety each time something goes wrong.
While we encourage everyone in aviation to focus on
learning from errors and problems, we also believe that an
independent investigator brings something important to
SMS arrangements: a dispassionate capability to assess
and identify safety issues and learn and communicate
safety lessons. To be most effective at this, we continue
to rely on comprehensive reporting of safety occurrences
by pilots and others. Your contribution to our knowledge
of what is happening remains essential.


Martin Dolan
Chief Commissioner
The Austra||an
T
he ATSB has just released its aviation occurrence statistics report.
Each year, the ATSB receives reports on aviation accidents and
incidents, collectively termed occurrences. Tese reports are used
by the ATSB to assist with the independent investigation of occur-
rences and for identifying safety trends. Tis report, published twice a
year, provides aviation occurrence data for the period 1 January 1999 to
31 December 2009.
over the reporting period.
For commercial air transport (high capacity regular public transport
[RPT], low capacity RPT and charter), although the accident rate had
climbed in 2007 and 2008, the number of accidents reduced from
registered Airbus A340-500 in Melbourne on 20 March. Most fatal
accidents in commercial air transport are in charter operations, and it
has a similar rate of fatal accidents to all general aviation. Charter has
high capacity RPT.
and (VH-registered] sport aviation), accidents and serious incidents
have remained generally consistent since 2007. In 2009, there were
126 accidents, including 18 fatal accidents, and 95 serious incidents.
reporting period, has an accident rate per million hours that is two
times higher, and private/business has an accident rate that is 2.5 times
training, the fatality rate in aerial work is three times higher, and
private/business is at least six times higher.
in interpreting accidents by the number of engines. In part this may

aviation_statistics.aspx>
Australian aviation accidents and
incidents
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Av|at|on Safety lnvest|gator
O
n 9 May 2008, a Boeing Company
PK-GEF, was being operated on
a scheduled passenger service between
Denpasar, Republic of Indonesia and
six cabin crew and 76 passengers.
established in the cruise, they reviewed
threshold for runway 21 at
Perth was displaced due to
runway works.
On approach to land at
Perth, the aerodrome
crew with the landing
clearance, ... runway 21
displaced threshold, cleared
was about 15 seconds from
questioned the presence
of cars on the runway and
conducted a go-around.
On the second approach,
issued the landing clearance ... runway 21,
aerodrome controller recalled observing
approach to land on the closed section of
to go around and provided information
level over the runway works area prior to
landing beyond the displaced threshold.
At the time of the incident, the permanent
runway 21 threshold and touch-down
markings were unobscured and clearly
works area, which included the threshold
and touchdown markings, was marked by
6 m closed runway crosses.
runway thresholds that were displaced
recommended by the International Civil
Aviation Organization (ICAO). When
compared with the likely visibility of
the ICAO-recommended 36 m closed
runway markings, the Australian 6 m
markings, as used in this case, increased
precise location of the displaced threshold.
As a result, there was an increased risk of
to the permanent threshold/touch-
ICAO Annex 14
Aerodromes, would have been visible to
approach, allowing additional time for
have allowed an early adjustment to their
approach path, ensuring a stabilised
approach and landing.
Despite an apparent awareness of the
crew to conduct consecutive approaches to
the runway works area suggested that the
temporary markings that were used were
vehicles on the runway during the initial
landing approach, they may have landed
within the runway works area.
As a result of this incident, the airport
operator undertook a number of safety
actions and proactively implemented
the use of ICAO compliant 36 m closed
runway crosses.
and retrieving the crosses in
a timely manner, made from
several tonnes of rubber,
was overcome by the use of
specially-designed trailers
that were constructed by the
employed two motorised
drums on a swivel base, to
hold the two 36 m by 1.8 m
lengths of painted rubber.
appropriate location, the
swivel base is unlocked and
deployed as the trailer is
Retrieval is accomplished by reversing the
process and is assisted by electric motors
which drive the rollers. Deployment or
retrieval takes about 10 minutes.
During a recent works programme to
re-surface the entire length of runway 21,
the 36 m crosses were successfully used
to identify the closed runway sections
without reported incident.
by the airport operator in proactively
addressing this safety issue.

ATSB investigation report AO-2008-033, released
on 6 June 2009, is available on the website.
Airport introduces safety innovation
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Investigation briefs
Ambiguous design standards
ATSB Investigation AI-2008-038
Following the construction of a new
hangar adjacent to runway 28 right (28R)
at Archerfeld Airport, Queensland, the
ATSB received a number of submissions
asserting that the building infringed
safety standards or reduced fight safety.
Drawing on an independent third-
party review, the ATSB determined that
the building does not breach obstacle
limitation surfaces. Te ATSB also
conducted an initial examination of
the instrument departure procedure
from runway 28R. Te ATSB found
that the procedure complied with the
extant instrument departure design
requirements, but identifed an ambiguity
in the guidance for designing instrument
departure procedures.
Te ATSB assessed that this ambiguity
could lead to inconsistent expectations
about the extent of clearance from
obstacles provided to aircraf when pilots
were following an instrument departure
procedure. Tis had the potential to
increase the risk of a collision with an
obstacle. In response, on 30 May 2008,
the (then) Executive Director of the ATSB
commenced a safety issue investigation.
As a result of that investigation, the Civil
Aviation Safety Authority and Airservices
Australia have, in consultation, reviewed
their understanding of how the design
standards for instrument departure
procedures should apply in Australia.
Tey have also re-examined the runway
28 instrument departure procedure at
Archerfeld in the light of that review
and have advised that they intend to
amend the requirements for instrument
departures from runway 28R.
Te potential for inconsistent
interpretation of the instrument
departure procedure design requirements
has also been notifed to the International
Civil Aviation Organization instrument
fight procedures panel, which monitors
the international standards for the design
of instrument procedures.
Taxiway takeoff
ATSB Investigation AO-2007-064
On 25 November 2007, a Gulfstream
Aerospace Corporation G-IV aircraf,
registered HB-IKR, with two pilots, a
cabin attendant and fve passengers was
being operated on a charter fight from
Brisbane Airport, Queensland to Sydney,
New South Wales.
At about 2215 Eastern Standard Time
(EST), the crew was issued with an air
trafc control (ATC) clearance to taxi via
taxiway Foxtrot 2, to the east, then right
onto taxiway Bravo for an intersection
departure on runway 01 at Alpha 7. An
intersection departure had earlier been
ofered to, and accepted by the pilot in
command (PIC). Te PIC taxied the
aircraf while the co-pilot conducted
the taxi checks and conducted the radio
communication with ATC. At about
2225 EST, the PIC of the aircraf
commenced the take-of run while on
taxiway Alpha, which was adjacent to
the active runway 01. Te aerodrome
controller (ADC) instructed the crew
to cancel the take-of clearance. Te
crew stopped the takeof and the ADC
instructed them to taxi to the end of the
runway for a takeof using the full runway
length.
Tere were no injuries, or damage to the
aircraf or airport infrastructure. Te
investigation found that a combination of
a cockpit equipment failure, inadequate
pilot rest, defcient cockpit resource
management practices and unfamiliarity
with the airport layout were likely factors
that led to the occurrence. Te time of the
fight and the PICs reported tiredness,
possible jetlag and interrupted sleep
patterns may have impacted on his ability
to make efective decisions. Te PIC did
not use the available means to assist in
guiding the aircraf during the taxi.

Flight instrument reliability
ATSB Investigation AO-2007-047
During the early evening of 17 October
2007, the pilot of a Cessna Aircraf
Company C210M, registration
VH-WXC, was fatally injured when his
aircraf impacted terrain during a fight
from Warburton to Kalgoorlie, Western
Australia. Tat fight was being conducted
at night under the visual fight rules and
the pilot was the sole aircraf occupant.
Te aircraf was seriously damaged by
impact forces. Tere was evidence that the
engine was producing signifcant power
at that time. Te aircraf was inverted
when it collided with terrain, which was
consistent with an in-fight loss of control.
Te accident was not survivable.
Examination of the aircraf wreckage
found evidence that the aircrafs suction-
powered gyroscopic fight instruments
were in a low energy state. Tat was most
probably because the vacuum relief valve
was at a low suction setting. Tere was
no lockwire ftted to the associated lock
nut that would have ensured the security
of the vacuum relief valves adjustment
spindle. Te design of the valve was such
that any in-service loss of friction on the
lock nut could allow the spindle to move
to a lower suction setting. In consequence,
the aircrafs fight instruments may not
have been providing reliable indications
to the pilot.
Te pilot was appropriately qualifed to
conduct the fight. However, dark night
conditions probably prevailed in the
vicinity of the accident site which meant
that the pilot would have had few
external visual cues. In such conditions,
the pilot was reliant on the indications
from the aircrafs fight instruments to
maintain control of the aircraf. Te pilot
would have had limited time to identify
and react to any unreliable indications
from the suction-powered fight
instruments.
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Oxygen masks deployed
ATSB Investigation AO-2007-062
On 17 November 2007 a Boeing Company
737-7Q8 aircraf, registered VH-VBC,
with two fight crew, four cabin crew
and 145 passengers was being operated
on a scheduled passenger service from
Coolangatta, Queensland to Melbourne,
Victoria. During the takeof, the Master
Caution system activated and the right
BLEED TRIP OFF light illuminated. Te
pilot in command elected to continue
the takeof. Once airborne the Bleed Trip
Of non-normal checklist was actioned.
Te right engine bleed could not be reset
with the result that, when above fight
level (FL) 170 (17,000 f above mean sea
level), only the lef engine bleed air was
available for airconditioning and cabin
pressurisation.
At FL318 during the climb, the fight
crew observed the lef PACK TRIP OFF
light illuminate, followed by a rapid loss
in cabin pressure and the cabin rate of
climb indicator showing a rate of climb of
about 2,000 f/min. Te crew ftted their
emergency oxygen masks, commenced
the Emergency Descent checklist and
began a rapid descent to 10,000 f. During
the descent, the cabin altitude exceeded
14,000 f, at which time the passenger
oxygen masks deployed automatically.
Te aircraf was diverted to Brisbane for
landing. Tere were no reported injuries
to passengers or crew and no damage to
the aircraf.
Te investigation found that a
combination of technical faults
contributed to the loss of pressurisation
and identifed a number of safety factors
relating to operational procedures and
cabin crew knowledge of the passenger
oxygen system.
Te operator conducted an internal
investigation of the incident and carried
out a number of safety actions. Tose
actions included the enhancement of a
number of the operators manuals and the
amendment of the operators cabin safety
recurrent training. In addition,
the operators passenger oxygen use
in-cabin brief was enhanced to include
advice that oxygen would fow to
passengers masks even if the associated
bag was not infated.
Te antenna was replaced and the aircraf
was returned to service.
Te maintenance history for the aircraf
operators feet of 38 Boeing 737-800s
revealed that, over the previous
12 months, the operator had removed
and replaced 24 RA antennas. Te
replacements (including for this event)
were as a result of 11 antennas having
failed bonding checks, and 12 antennas
exhibiting RA system faults or alerts.
Tree months afer the occurrence,
a further RA warning fag event was
experienced by another crew in this
aircraf. As a result, the lef and right
RA transceivers were removed and
tested with internal faults found on the
lef unit.
Inaugural Level 5 Bulletin
ATSB Investigation AB-2010-020
The ATSB receives around 15,000 aviation occurrence notications each year, equating to
about 8,000 reportable matters. The Bureau, however, is only resourced to undertake a certain
number of investigations each year, and while professional judgment is required in making
decisions about which are investigated, there are a signicant number of occurrences that are
only entered into the ATSBs data base for future statistical analysis and trend monitoring.
There are times, however, when more detailed information about the circumstances of the
occurrence would have allowed the ATSB to make a more informed decision both about
whether to investigate at all and, if so, what necessary resources were required. In addition,
further publicly available information on accidents and serious incidents should increase safety
awareness in the industry and enable improved research activities and analysis of safety
trends, leading to more targeted safety education.
To enable this, the ATSB established a small team to manage and process short, factual
investigations, the Level 5 Investigation Team. The Team has recently released its rst
quarterly bulletin of level 5 investigations, providing a set of professional-level examinations of
occurrences that would not traditionally have been investigated.
The summary reports in the bulletin were compiled from information provided to the ATSB by
individuals or organisations involved in an accident or serious incident between the period
1 December 2009 and 30 March 2010.
The bulletin covers a range of occurrences, examining the circumstances surrounding a pilot
incapacitation, a ground handling event, an instance of total power loss, a depressurisation, a
situation in which aircraft control was lost, and an in-ight re.
The bulletin, with details of the investigations, can be found on the ATSBs website at
<www.atsb.gov.au>
Bad data represents safety risk
ATSB Investigation AO-2009-013
On 7 April 2009, at about 1210 EST,
the fight crew of a Boeing 737-800
aircraf, registered VH-VYL, received
an enhanced ground proximity warning
system alert while passing through
129 f above ground level during an
autoland approach and landing at Sydney
Airport, NSW. At the same time, the lef
radio altimeter (RA) display reduced
in altitude to minus 7 f, the autopilot
disconnected and the engine thrust levers
moved toward the idle position. Te pilot
in command, who was the handling pilot,
immediately re-positioned the thrust
levers and conducted an uneventful
landing.
Te investigation determined that
spurious data from the lef radio altimeter
(RA) provided an indicated altitude of
minus 7 f, resulting in the autopilot
disconnecting and the thrust lever
movement. An examination found that
the lef RA receive antenna displayed
rubbing wear adjacent to the attachment
screw inserts. A bonding check of the
antenna indicated that its resistance was
outside the aircraf manufacturers limits.
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Australias voluntary condential aviation reporting scheme
REPCON briefs
REPCON allows any person who has an
aviation safety concern to report it to the
ATSB confdentially. Unless permission
is provided by the person that personal
information is about (either the reporter
or any person referred to in the report)
that information will remain confdential.
Te desired outcomes of the scheme are to
increase awareness of safety issues and to
encourage safety action by those who are
best placed to respond to safety concerns.
Before submitting a REPCON report, take
a little time to consider whether you have
other available and potentially suitable
options to report your safety concern. In
some cases, your own organisation may
have a confdential reporting system that
can assist you with assessing your safety
concern and taking relevant timely safety
action. You may also wish to consider
reporting directly to the Civil Aviation
Safety Authority (CASA) if you are
concerned about deliberate breaches of
the safety regulations, particularly those
that have the potential to pose a serious
and imminent risk to life or health.
REPCON staf may be able to assist you
in making these decisions, so please dont
hesitate to contact our staf to discuss
your options.
REPCON would like to hear from you if
you have experienced a close call and
think others may beneft from the lessons
you have learnt. Tese reports can serve
as a powerful reminder that, despite
the best of intentions, well-trained and
well-meaning people are still capable of
making mistakes. Te stories arising from
these reports may serve to reinforce the
message that we must remain vigilant to
ensure the ongoing safety of ourselves and
others.
If you wish to obtain advice or further
information, please contact REPCON on
1800 020 505.
Unsafe practices at an
aerodrome
R200900006
Report narrative:
Te reporter expressed safety concerns
that incidents/accidents are increasing
and operating procedures appear to be
deteriorating at the named aerodrome.
Occurrences and deteriorating operating
procedures include; not restraining
aircraf when unattended, collisions with
other aircraf and structures, dangerous
hand starting procedures, unconventional
circuits being fown, and non standard
radio calls.
Action taken by REPCON:
REPCON supplied CASA with the de-
identifed report and CASA advised that
it was aware of increased activity at the
aerodrome as a result of aircraf operating
from Parafeld Aerodrome. CASA
has recently conducted surveillance
activity on operations in the vicinity
of the aerodrome and is satisfed that
aircraf operators are meeting their
safety obligations in accordance with
the applicable civil aviation legislation.
Further surveillance activity is planned.
Without more specifc information, CASA
is unable to action or comment further on
the issues raised in the REPCON.
Safety of cabin crew in
turbulence
R200900075
Report narrative:
Te reporter expressed safety concerns
about cabin crew not being seated with
seatbelts secured during turbulence
when the seat belt sign illuminated. Te
reporter estimated that over the last
7 years fying with the operator, with an
estimated 300 to 400 sectors, that only
once were cabin crew observed to resume
their seats in turbulence. Tis occurred
when the turbulence was so severe that
crew found it extremely difcult to stand.
During the fights where the crew did not
resume their seats in turbulence, the food
service was continued and cabin crew
moved through the cabin with hot liquids
and food.
Te reporter believes that CAO (Civil
Aviation Order) 20.16.3 requires all
passengers and crew to occupy a seat
during turbulent conditions. On other
airlines that the reporter has fown with,
whenever the seat belt sign is illuminated
due to turbulence, both passengers and
crew are instructed to be seated and
fasten seatbelts.
Action taken by REPCON:
REPCON supplied the operator with the
de-identifed report and the operator
advised that CAO 20.16.3 states:
3.1 Each crew member and each passenger
shall occupy a seat of an approved type:
(a) during take-of and landing; and
(b) during an instrument approach; and
(c) when the aircraf is fying at a height
less than 1000 feet above the terrain;
and
(d) in turbulent conditions:
Te operator advised that the CAO does
not defne the level of severity of the
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turbulence at which crew and passengers
must be seated. Te operator ensures
that passengers are seated at a lesser level
of turbulence than for cabin crew and
this is stated in their procedure manual.
Contained therein are procedures for
dealing with the levels of severity of
turbulence and also included is the
following note:
NOTE: Crew should be seated immediately
if they feel their safety is in jeopardy at any
stage.
Te operator also noted that CAO
20.16.3 and Civil Aviation Regulations
(1988) 251 lists duties for cabin crew
that require certain actions if turbulence
is encountered. Te operator believes
that assumes cabin crew are to perform
functions other than immediately assume
their seat in all cases of turbulence
encounters. Te operator therefore, in
keeping with the drafing of the relevant
CAO, published procedures that detail
duties of cabin crew in turbulence as long
as the overriding embodied intent is to
ensure the safety of both passengers and
crew.
REPCON supplied CASA with the
de-identifed report and a version of the
operators response. CASA provided the
following response:
CASA has reviewed the report and will
request that the operator review their turbu-
lence procedures in accordance with Civil
Aviation Regulation 251 s1(d).
Te operator has subsequently advised that
they are in the process of revising their
turbulence procedures.
REPCON reports received
Total 2007 117
Total 2008 121
Total 2009 118
Total 2010
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a. as of 30 April 2010
What is not a reportable safety concern?
To avoid doubt, the following matters are not reportable safety concerns and
are not guaranteed confidentiality:
(a) matters showing a serious and imminent threat to a persons health or life;
(b) acts of unlawful interference with an aircraft;
(c) industrial relations matters;
(d) conduct that may constitute a serious crime.
Note 1: REPCON is not an alternative to complying with reporting obligations
under the Transport Safety Investigation Regulations 2003
(see <www.atsb.gov.au>).
Note 2: Submission of a report known by the reporter to be false or misleading
is an offence under section 137.1 of the Criminal Code.
REPCON Operation types First quarter 2010
Reported issues First quarter 2010
Who is reporting to REPCON?
a
How can I report to REPCON?
Reporters can submit a REPCON report online via the ATSB website.
Reporters can also submit via a dedicated REPCON telephone
number: 1800 020 505
by email : repcon@atsb.gov.au
by facsimile: 02 6274 6461
or by mail : Freepost 600, PO Box 600, Civic Square ACT 2608
How do I get further information on REPCON?
If you wish to obtain advice or further information on REPCON,
please visit the ATSB website at <www.atsb.gov.au> or call REPCON on
1800 020 505.
a. 29 January 2007 to 30 April 2010
b. examples include residents, property owners, general public.
High capacity air
transport 44% (19)
Sports aviation 2% (1)
All 7% (3)
Charter 5% (2)
Regional airlines 5% (2)
General aviation 27% (12)
Flight training 5% (2)
Aerial work 5% (2)
Operating procedures 26% (11)
Airmanship 12% (5)
Aerodrome safety 12% (5)
Cabin crew fatigue 18% (8)
Cabin safety 9% (4)
Aircraft defects 7% (3)
Maintenance 5% (2)
Radio communications 5% (2)
Ground handling 2% (1)
Flight publications 2% (1)
Organisational safety culture 2% (1)
Flight crew 37% (150)
Others 25% (100)
Aircraft maintenance
personnel 22% (92)
Passengers 8% (33)
Air Traffic controller 4% (14)
Cabin crew 3% (12)
Facilities maintenance
personnel/ground crew 1% (4)
b
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Nearly 10 years after Air Frances Concorde, F-BTFC,
crashed shortly after lift-off, killing all 109 occupants and
four people on the ground, French authorities have brought
manslaughter charges against the US-based Continental
Airlines, two of its employees and three French nationals
closely involved with the development and operation of
Concorde aircraft, writes Macarthur Job.
repercussions of the
CONCORDE
DISASTER
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AirFrance
inaugurated
its supersonic
service, from Paris to
Rio de Janeiro via Dakar,
with the revolutionary Anglo-
French Concorde in January 1976.
Operations across the Atlantic to the
United States were initially delayed because of
noise protests, but fights began to Mexico City via
Washington DC later that year. The following year direct
services to New York and to Washington DC began. The fight
time to New York from Paris was only three hours and 23 minutes,
cruising at about twice the speed of sound.
Air France and British Airways were the only two
airlines in the world to operate regular supersonic
services, continuing daily transatlantic Concorde
ights for two decades.
Air France Flight 4590, departing Paris for New York City on 25 July 2000,
under the command of Captain Christian Marty, was a charter for a German
shipping company, Peter Deilmann Cruises. The 100 passengers, mostly
from the western German town of Monchengladbach, were on their way to
join a 16-day luxury cruise around South America.
There was a delay of about 45 minutes in the aircrafts scheduled departure
from Charles de Gaulle Airport; some of the passengers luggage was
late arriving, and the thrust reverser for the No 2 engine was found to be
malfunctioning and had to be changed. But as the passengers waited in the
VIP lounge, they were in high spirits, singing and chatting to pass the time.
Finally the thrust reverser work was completed and 19 bags of passengers
luggage arrived at the Concordes parking bay. They went in the aircrafts
rear hold, and by 1400 hours the Concorde was ready. The surface wind
was then calm, and the fight crew contacted the control tower to request
the entire length of runway 26R for a take-off at 1430.
Ten minutes later, the towers ground controller
passed the crew their start-up clearance,
confrming that 26R would be available. As the
six cabin crew briefed the passengers pre-fight,
the engines were started, the fight engineers
calculations showing the aircrafts total weight
was 186.9 tonnes with 95 tonnes of fuel on board.
Calculated take-off speeds were V1 at 150 knots,
a VR at 198kt and V2 at 220kt.
At 1434 hours, the ground controller cleared
the aircraft to taxi to the holding point for
runway 26R. Six minutes later, after a US-bound
Continental Airlines DC-10 had taken off from the
runway, the Concorde was cleared to line up, the
fight engineer announcing that the aircraft had
used 800kg of fuel during taxiing - 1.2 tonnes less
than allowed for in the fight plan.
At 1442 the airport controller cleared the
Concorde for take-off, adding that surface wind
was now from 090 degrees at 8kt. The crew
read back the clearance, and Captain Marty,
in the left-hand seat, opened the throttles.
Half a minute later, as the aircraft continued to
accelerate, the co-pilot called 100kt, and nine
seconds afterwards, V1.
Seconds later, the right-front tyre of the port
main undercarriage bogie ran over a strip of
titanium, about 43cm long and 3cm wide, that had
fallen from a thrust reverser cowl door on the
preceding DC-10. The metal punctured the fast-
spinning tyre, which immediately disintegrated,
hurling substantial pieces of rubber forcefully
against the underside of the port wing where fuel
tank No 5 was located.
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The impact, as well as severing a 115V AC electrical cable, propagated a shock
wave through the full tank of jet fuel, rupturing its wall. Fuel pouring from the tank
ignited by arcing from the broken cable, touched off a spectacular confagration
beneath the port wing. In a moment, the two port engines began surging as
hot gases from the fre were ingested into the port side under-wing air intakes.
No 1 engine lost some power, while the No 2 engine lost a substantial amount
of thrust.
At this stage, the Concordes take-off run became directionally unstable, the aircraft
veering to the left side of the runway where one of its port-side wheels demolished
a steel landing light, throwing some of its debris into the No 2 engine air intake. In
danger of leaving the runway altogether and heading directly towards an arriving Air
France Boeing 747 waiting on an adjoining taxiway, the co-pilot called out in alarm,
Watch out!
Having passed V1, the crew had little option but to take off, the captain attempting
to retrieve the situation by pulling the aircraft into the air at 188kt, 11kt below the
recommended minimum VR.
As he did so, the airport controller transmitted an urgent warning of fames behind the
aircraft. The captain acknowledged the towers transmission as the cockpit engine
fre alarm began sounding; and he ordered the shut-down of No 2 engine. The fight
engineer confrmed he was doing so, and the captain called for the engine fre procedure.
The No 2 fre handle was pulled and after about 12 seconds the fre alarm ceased. The
airspeed was still indicating only 200kt, the frst offcer drawing this to the captains
attention, and the fight engineer announced No 2 engine was no longer operating.
The tower controller, thoroughly alarmed by the magnitude of the now-ferce plume
of fame extending behind the Concordes tail for more than 60m, again warned the
crew. The captain ordered the undercarriage up, but 10 seconds later, after the engine
fre alarm again sounded briefy, the frst offcer reported that it was not retracting.
Unable to gain airspeed on the three functioning engines because the undercarriage
would not retract, the aircraft was hardly climbing. Still only 200 feet above the
ground, it would not accelerate beyond 210kt and, as the frst offcer continued to
call out airspeed readings, the fre alarm began sounding for the third time. The frst
offcer transmitted that they would divert to Paris Le Bourget Airport, not far away.
In danger of
leaving the
runw
ay
altogether and
heading
directly
tow
ards an
arriving Air
France Boeing
747 waiting on
an adjoining
taxiway, the co-
pilot called out in
alarm,
61
But with No 1 engine now also failing rapidly and the aircraft pitching up
uncontrollably as the fre affected the port wing structure, asymmetric
thrust lifted the starboard wing steeply. In a vain attempt to regain control,
the crew reduced power on the starboard engines, but with the nose now
up almost vertically, the bank to the left increasing beyond 90 degrees and
airspeed falling rapidly, the crew fnally lost all vestige of control.
Moments later the Concorde stalled as its airspeed fell to zero. Sliding
rearwards and rolling to the left as it fell with the nose dropping, it fell
tail frst on to a small hotel in the village of Gonesse on the outskirts of
Paris. The aircraft exploded, killing all on board as well as four people in
the hotel. The fight had taken less than two minutes.
The aftermath
The most signicant nding from the wreckage
examination was that a spacer was missing from
the undercarriage beam for the port side bogie
assembly. The spacer locates two steel shear
bushes on the pivot connecting the bogie assembly
to the main undercarriage oleo leg, thus keeping
the four wheels of the bogie in correct alignment.
Without the snug t provided by the spacer, the
bogie and its wheels can move up to three degrees
either way.
Four days before the accident, the aircrafts port side undercarriage
assembly had been serviced, and the undercarriage beam changed. Reftting
the spacer to the replacement beam had apparently been overlooked when
the bogie was reassembled. After the accident, the missing spacer was
found in Air Frances workshop, still attached to the old beam.
The point on Charles de Gaulle Airports runway
26R where the Concordes tyre had disintegrated
was clearly evident from the marks and rubber
debris it had left. The riveted titanium strip from
the DC-10 which caused the tyre failure was
found seven metres ahead and 37m to the right
of where the Concordes tyre blew out. It was
found to be a non-standard part, not approved for
use on DC-10 aircraft by the US Federal Aviation
Administration.
Other signifcant evidence found on the runway
were tyre scuff marks near where the aircraft
had veered to the left and hit a landing light before
lifting off. The marks indicated that the port side
bogie had moved out of alignment at or before this
point, and could have been responsible for the
Concordes directional instability on the runway.
It was also possible that if the bogie was out
of alignment earlier in the take-off run, it could
have retarded the aircrafts acceleration on
the runway.
Two highly-experienced, retired Air France
Concorde fight crew members, a pilot and a fight
engineer, believed the bogie was already out of
alignment when the aircraft began its take-off
run. Their detailed calculations showed that,
without the consequent retardation, the aircraft
should have been able to lift off after 1694m -
before reaching the point where the metal strip
had fallen from the DC-10.
Several other factors could have together
contributed to the catastrophe. Indeed, it
appears that even before the Concorde hit the
metal strip on the runway, it could have been
operating beyond the limitations of its safe fight
envelope.
When the 19 bags of overdue passengers
luggage, an additional 500kg not included in
the manifest, fnally arrived at the aircraft, they
were hastily loaded into the rear cargo hold. This
not only raised the Concordes total weight to
186 tonnesa tonne over the types maximum
structural weightit also moved the centre of
gravity further aft than had been calculated.
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Start of take-off roll: 14:42.31
Weight approx 6 tonne over
crews calculated weight.
C of G slightly beyond safe
aft limit.
Port undercarriage bogie
possibly out of alignment
and retarding acceleration.
8kt tailwind
Tyre punctured
by DC-10 debris.
Tyre fragments damage fuel
tank, leaking fuel ignites.
Heading towards B747 on
intersecting taxiway, pilots
pull aircraft into air 11kt
below Vr. Time: 14:43.13
Aircraft veers to left.
Late luggage loaded
into rear hold.
Less fuel burnt
than expected
during taxi.
During development of the Concorde, test pilots
established that its safe aft centre-of-gravity
limit was 54 per cent. But the investigation
showed that the accident aircrafts C of G at the
time it began its take off would have been 54.2
per cent, and possibly as much as 54.6 per cent
with the additional luggage.
As one Concorde authority commented: even
with all four engines working normally, this
was beyond where test pilots would have be
willing to tread. And as fuel gushed from
the breached wing tank, the C of G would
have progressively moved even further
behind the aft limit.
As the aircraft lined up for take-off, it was also carrying 1.2 tonnes more
fuel than allowed for in the fight plan. The crew had expected this fuel to
be consumed during taxiing. And fnally, there was the unexpected tailwind
of 8kt that developed while the aircraft was taxiing to the runway. These
three factors together effectively rendered useless the crews take-off
calculations.
Had they done their calculations again, using the changed data, they would
have found that their new regulated take-off weight (as the determination
is offcially called), was six tonnes less than the aircrafts total
actual weight!
Another experienced Concorde captain commented: Ive probably taken
off overweight after all, you can never be sure because you dont weigh
the passengers or the hand luggage. But not six tonnes! They were already
at the limits of the envelope. Once the wind changed they were beyond it.
The fnal nail in the coffn for the fight was evidently the decision to shut
down the ailing No 2 engine. Experienced Concorde pilots, both French and
British, said it was a disastrous mistake breaching all set procedures. The
engine was not on fre, and its thrust output would probably have recovered,
at least to some degree. The standard procedure for shutting down an
engine requires the fight to be stable at a height of at least 400 feet.
Illustrations: Juanita Franzi, Aero Illustrations
No 2 engine fire
alarm sounds.
No 2 engine shut down.
Airspeed 200kt.
Undercarriage fails to retract.
No 1 engine losing power.
Altitude 200ft above ground.
Unable to accelerate above
210kts, unable to climb.
Aircraft pitching up
uncontrollably and
rolling to left.
Aircraft stalls and crashes
tail-first into hotel-motel
buildings. Time: 14:44.50
Because the crash initially appeared to have come about solely because a
tyre had disintegrated during take-off, all Concorde aircraft were promptly
grounded pending investigation of the accident. An Air France Concorde in
New York at the time was granted a ferry permit to return to Paris without
passengers. The Concorde feets in both France and Britain were modifed
to guard against a recurrence of the problem. The costly changes included
greater impact protection for the electrical wiring looms in the wings, fre-
protective Kevlar lining in the fuel tanks, and specially developed burst-
resistant tyres.
Late in 2001, 15 months after the accident, supersonic trans-Atlantic
services by both Air France and British Airways resumed with the modifed
Concorde. But shortly before they did so, the twin towers terrorist attack
occurred in New York.
The result was a marked drop in custom for the premium-price fights,
contributing eventually to their demise for economic reasons. Air France
discontinued Concorde operations in May 2003, and British Airways
followed suit the following October.
By this time it had become evident that fery end of F-BTFC on the outskirts
of Paris, far from being a single cause accident as frst believed, was, like
so many other aircraft disasters, the fnal result of a chain of errors and
unfortunate circumstances.
Relatives of the victims were granted substantial
fnancial compensation by Air France, Continental
Airlines, and Goodyear, the manufacturer of the
Concordes tyres, provided they agreed not to
take legal action against the companies.
In March 2005, French authorities instituted
a criminal investigation into the part that
Continental Airlines had played in the tragedy.
Several months later, the former head of the
Concorde Division at Aerospatiale, together
with the Concorde chief engineer also came
under investigation for negligence. As a result
of these enquiries, manslaughter charges were
brought against Continental Airlines, together
with one of their maintenance engineers and his
maintenance manager,
Aerospatiales former Concorde Division head
and its chief engineer, and a former Director of
Technical Services at the French civil aviation
authority. If convicted, Continental Airlines
stands to pay a penalty of US$500,000. Its two
employees, together with the French defendants.
could face substantial fnes, or up to fve years
in jail.
The trial opened at the beginning of February
this year, and a verdict is expected late in
the year.
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A new
road for
diabetics?
CASA medical ofcer, Dr David Fitzgerald, writes about
new protocols for pilots with type 1 diabetes.
Diabetes is a condition of the bodys endocrine system (the system
of hormones which controls body processes) and is characterised by
inadequate control of blood glucose levels. Overly high blood glucose,
or hyperglycaemia, damages the body; while overly low blood glucose,
hypoglycaemia, can lead to impaired judgement and coordination,
unconsciousness, seizure, and rarely, death.
There are two distinct types of diabetes. Type 1 diabetes is an
autoimmune condition. It is characterised by inadequate levels of
insulin in the blood, due to destruction of the islets of Langerhans in
the pancreas. These are the structures responsible for the production
and secretion of insulin. Type 1 diabetes tends to present early, often
in childhood, and requires treatment with exogenous insulin, or
insulin administered by injection.
The consequence of a diagnosis of Type 1 diabetes and its relationship
to aviation is an emotive issue. Several issues must be faced when
certifying a pilot who is diagnosed with diabetes. They are:

What is the risk the pilot may be suddenly incapacitated due to the
disease or its treatment?

What, if any complications of diabetes are present, and what is
the risk that they will adversely affect ight performance?

What are the accepted aeromedical standards, and does the pilot
meet those standards?

If the pilot does not meet the standards, can they be issued a
certicate, and if so under what criteria?

What are the monitoring requirements pre-, and in-ight?

What ongoing monitoring of the disease and its consequences are
required to ensure there is no appreciable risk to ight safety?
Hypoglycaemia is the most concerning risk
in the aviation setting for a diabetic. A pilots
in-ight hypoglycaemic episode puts the pilot,
passengers, other aircraft and people on
the ground at risk. To ensure safety, insulin-
dependent diabetic pilots need to satisfy
themselves, and the regulator, that they
are not at risk of becoming hypoglycaemic
in ight; or if they are, that they are able to
recognise the symptoms and can reverse the
situation very quickly by taking either oral
glucose or glucagon.
An additional level of physiological protection
from hypoglycaemia in place in most people
is, unfortunately, reduced or absent in type
1 diabetics. Their adrenalin response to
hypoglycaemia compared with non-diabetics
may be reduced, and therefore of less value.
Hypoglycaemia in a non-diabetic person
causes symptoms such as hunger, tachycardia
and sweating.
However, in people with type 1 diabetes, the
level at which the adrenalin response kicks in
is reset to a lower blood-glucose level, so that
the blood-glucose level has to fall much lower
before they are aware of hypoglycaemia.
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Why did CASA develop its own protocol rather than
use the FAAs?
Firstly, the FAA protocol is fairly old, and there have been signicant
developments in insulins, and their delivery devices since it was
written. Secondly, the FAA protocol bases its measures to determine
success of the program on the number of incidents and accidents
among the insulin-dependent diabetics. This is an unacceptable
measure for Australia, because the Australian Civil Aviation Act
requires the regulator to make ight safety the priority, and waiting for
an incident or accident to occur is unacceptable as a control measure.
The protocol is aimed at keeping blood glucose levels within safe
tolerances during ight (5-15mmol/L) and has strict requirements
with respect to the frequency of pre-ight and in-ight blood glucose
monitoring and glucose loading. Entry to the protocol will require
detailed reports from treating endocrinologists regarding the status
and control of the diabetes, and review of the applicants blood glucose
records and accident records. Key exclusion criteria include poorly-
controlled diabetes, frequent hypoglycaemic episodes, presence of
complications and demonstration of hypoglycaemia unawareness.
Certication is only to be available for Class 2 applicants for day VFR
ight only.
A key difference between the FAA and CASA protocols is that CASAs
involves a discussion between the endocrinologist and the pilot about
diabetes control while ying. This discussion will result in a safety
case being forwarded to CASA, and CASAs experts reviewing the
treatment regime. Only when CASA is satised that the regime is safe,
will the individual be authorised to proceed to the next step.
Another key difference is that CASA will require insulin-dependent
pilots to undertake a number of proving ights (a minimum of 15
ights - details of types of ights and durations will be tailored by
CASA to meet individual requirements) where the pilot will be required
to adhere to the protocol whilst still carrying a safety pilot. Doing this
will give CASA some measure of evidence that the protocol is effective
at maintaining blood glucose levels within safe tolerances in the
individual case. After the 15 ights, these pilots must submit details
of the in-ight monitoring to CASA, as well as an operational check by
a chief ying instructor or approved testing ofcer to document their
ability to comply with the practical issues of monitoring in-ight blood
glucose. CASAs panel of doctors will then review the reports, and if
the individual is deemed to be safe whilst adopting the protocol, the
safety pilot restriction will be removed.
CASA will continue to monitor and review the individuals in the
protocol closely, and if there is evidence that the protocol does not
maintain glucose levels safely, the individual requirements in the
protocol may be modied. CASA will also carry out a periodic group
analysis to review the outcomes of the protocol.
A copy of the protocol is available in the Dame Handbook
Endocrinology [2.4-9] available online at http://www.casa.gov.au/
wcmswr/_assets/main/manuals/regulate/dame/080r0204.pdf
If you have type 1 diabetes and would like to enter the protocol, please
get in touch with avmed@casa.gov.au.
By this time, the diabetic may already be
subtly incapacitated due to the effect of the
low blood glucose on the brain, and may be
experiencing functional impairment without
knowing it. This is even more pronounced in
diabetics who have developed nerve damage.
Ideally, a diabetic would satisfy this
requirement by simply running their blood
sugar levels high enough to virtually make
hypoglycaemia impossible by maintaining an
inadequate insulin regime. However, this is
hard to do because of the many factors which
affect hypoglycaemia. Maintaining high blood
sugars also increases the risk of diabetic
complications.
The most accurate and safest way to minimise
hypos is to have a device that regulates blood
sugar accurately and frequently, such as an
insulin pump which measures blood glucose
constantly, and makes small adjustments as
required to a constant infusion of insulin.
Even more desirable would be a device that
can also give a dose of glucose in the event
of undesirably low levels of blood glucose.
Unfortunately, these devices are not in
widespread use as yet.
While some jurisdictions allow the use of
insulin, (most notably the FAA, which has a
protocol for such pilots), in Australia, insulin-
dependent diabetics have been limited
to ying with a safety pilot as a means of
risk mitigation against incapacity due to
hypoglycaemic episodes.
To review its stance on diabetes in light of
up-to-date evidence, CASA recently convened
a workshop on insulin-dependent diabetes
and aviation, to examine options for relaxing
restrictions on insulin-dependent aviators.
From that workshop a protocol was designed.
In many ways it mirrored the FAA protocol,
but had some very signicant differences.
The protocol was further rened after the
workshop, and is now at a stage where CASA
is satised it can be safely applied.
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FLYING OPS
1. If, after maintaining a ight planned heading of 333(m) in order
to track 322(m), you determined your position as 3nm right of
track having travelled 30nm, you have experienced
(a) left drift.
(b) right drift.
(c) zero drift.
(d) some drift, but the actual amount cannot be determined
from the information given.
2. The cleanliness and security of the base of a VHF antenna,
where it is in contact with the aircraft fuselage, is critical to
the functioning of the antenna because any increased electrical
resistance in this area due to corrosion
(a) severely reduces antenna efciency.
(b) reduces the shielding effect of the fuselage, which is
particularly noticeable on transmit.
(c) reduces the shielding effect of the fuselage, which is
particularly noticeable on receive.
(d) increases the parasitic current losses in the shield of
the feeder cable.
3. In an ATC environment, aircraft acknowledging a clearance
correctly would have the aircraft callsign at
(a) the beginning of the transmission.
(b) the end of the transmission.
(c) either the beginning or the end.
(d) both the beginning and the end and with the word trafc
at the beginning.
4. With respect to horizontal distance, in the vicinity of an
uncontrolled aerodrome is dened as within
(a) 3 nm or less.
(b) 5 nm or less.
(c) 8 nm or less.
(d) 10 nm or less.
5. When operating in the vicinity of a non-towered aerodrome,
other than when joining on base leg or nal, pilots are expected
to make the following minimum broadcasts: intending to takeoff
(taxiing call), intending to enter the runway,
(a) ready to join the circuit, overying.
(b) inbound, ready to join the circuit, base.
(c) inbound, base, nal.
(d) inbound, overying, base, nal, clear of the runways.
6. A broadcast in the vicinity of a non-controlled aerodrome,
for example Snake Gully, should begin with
(a) Snake Gully trafc and end with Snake Gully trafc.
(b) Snake Gully trafc and end with just Snake Gully.
(c) All stations Snake Gully and end with Snake Gully.
(d) All stations Snake Gully and end with Snake Gully trafc.
7. Carriage and use of radio is mandatory at
(a) licensed aerodromes.
(b) aerodromes designated as CTAF(R).
(c) all certied, registered, and military aerodromes and
at certain designated aerodromes.
(d) all security controlled aerodromes.
8. A broadcast relating to a non-controlled aerodrome must
include: the name of the aerodrome,
(a) whether VFR or IFR.
(b) and the distance from or the ETA at the aerodrome
(c) the distance from the aerodrome.
(d) the aircraft type and call sign, the aircraft position and
intentions.
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9. A departure from a non-controlled aerodrome should be
made by
(a) turning 45 degrees from the runway heading when reaching
700ft above the aerodrome elevation.
(b) turning 45 degrees from the runway heading in the
direction of the circuit when reaching 700ft above the
aerodrome elevation.
(c) extending one of the standard circuit legs.
(d) turning 45 degrees in the direction of the circuit when on
any leg.
10. The overy height of a non-controlled aerodrome should
usually be no lower than
(a) 1500ft above aerodrome elevation.
(b) 1500ft above MSL.
(c) 2000ft above the aerodrome elevation.
(d) 2000ft above MSL.
MAINTENANCE
1. Dry nitrogen is often used for tyre ination
(a) to minimise the explosion risk from the combustible gas
which is liberated from the tyre at elevated temperatures.
(b) to reduce the pressure loss due to diffusion through the
tube.
(c) to reduce the change of pressure with temperature.
(d) to reduce the probability of a magnesium re.
2. The structure below a fuselage-mounted VHF antenna is also
termed the ground plane and, for electrical purposes, this can
be regarded as
(a) an antenna element that widens the bandwidth.
(b) an antenna element that narrows the bandwidth.
(c) the other half of the antenna.
(d) a shield that reduces spurious radiation.
3. A typical device for monitoring the current ow into a pitot
head heating element is a
(a) shunt relay.
(b) a current transformer on an AC system.
(c) a current transformer on a DC system.
(d) a voltmeter.
4. Referring to a ball bearing, damage or wear consisting of
circular indentations on the bearing races due to high forces
on installation, or removal, or high static loads, is termed
(a) galling.
(b) brinelling.
(c) skidding
(d) peening.
5. Where a windshield heating system has two elements which
may be connected in series or parallel in order to give a high
and low heat, a failure of one element during parallel operation
(a) may cause windshield cracking due to a high thermal
gradient between the heated and unheated area.
(b) will have no potential consequences, other than heater
failure in the series mode.
(c) will have no potential consequences, other than reduced
visibility through the unheated area.
(d) will have no potential consequences.
6. When an aircraft with a wooden propeller is parked for some
time, the propeller blade should be positioned
(a) vertically to discourage nesting birds.
(b) vertically to minimise the risk of injury.
(c) horizontally to discourage nesting birds.
(d) horizontally to avoid imbalance due to water
accumulating in the lower blade.
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7. Prior to engine start, a rough check of the accuracy of the
manifold pressure gauge may be made by comparing the gauge
reading with the
(a) QFE on the basis that 1013 HPa = 29.5in Hg.
(b) QNH on the basis that 1013 HPa = 29.5in Hg.
(c) QFE on the basis of 1000 HPa = 29.52 or 1016 HPa =
30.00in Hg.
(d) QNH on the basis of 1000HPa = 29.52 or 1016 HPa =
30.00in Hg.
8. A spark plug gap of 0.026 is closest to
(a) 0.015 mm
(b) 0.15 mm
(c) 6.6 mm
(d) 0.66 mm.
9. The apparent drift of a directional gyro heading indicator due
to the earths rotation, if uncorrected, is at a maximum of
(a) 5 degrees per hour at the poles.
(b) 5 degrees per hour at the equator.
(c) 15 degrees per hour at the poles.
(d) 15 degrees per hour at the equator.
10. When two wheels are installed on one undercarriage leg, an
under-inated tyre on one wheel
(a) cannot be reliably detected visually.
(b) can be readily detected by additional bulging of the
inboard wall.
(c) can be readily detected by additional bludging of the
outboard wall.
(d) can be readily detected by comparing the top camber.
IFR OPERATIONS
Radio Phraseology
In each of the following situations (1-10) match from the list of
possible calls (A-U) the appropriate radio report. For simplicity,
use the callsign Alpha Bravo Charlie in each case.
1. You are taxiing for runway 03 at Latrobe Valley (YLTV),
destination Essendon (YMEN). The CTAF broadcast has been
given. What is the content of the taxi report to ATC and on
what frequency?
2. You are ready to taxi at Essendon (YMEN), destination Albury
(YMAY) during tower hours. What is the content of this call?
3. You are airborne from runway 27 at Melbourne (YMML) having
been cleared via DOSEL SEVEN DEPARTURE to 9000ft with
an initial level of 5000ft. Melbourne tower advise you of the
frequency transfer to Departures. What will be in this call to
departures?
4. You are setting course outbound during tower hours from
Alice Springs (YBAS) having been cleared via the SCOTI ONE
DEPATURE to 8000ft. What will be the content of the report to
Alice Tower?
5. You are setting course outbound from Wynyard (YWYY)
tracking via CAMUS en route to Moorabbin (refer ERC L1) and
climbing to 8000ft, presently passing 2500ft. What will be in the
departure report and on what frequency?
6. You have departed Swan Hill (YSWH) tracking along V255 for
Wagga Wagga (YSWG) (refer ERC L2). You have levelled out in
the cruise at your planned level of 9000ft. Is a report required
and if so, what content?
7. You are inbound to Alice Springs (YBAS) along W584 from
Broken Hill (YBHI) at 8000ft and in VMC. Approaching the CTA
step you are instructed to call Alice Tower for clearance. What
will be the content of this call?
8. (Refer to ERC L2). Your position is overhead NEVIS on H345
tracking Melbourne (YMML) to Adelaide (YPAD) at 8000ft. A
position report is required. What will be the content of this
report?
9. You are established on downwind for runway 35 at Echuca
(YECH) and elect to cancel SARWATCH at this time. What is the
content of this call and on what frequency?
10. You are tracking along W188 between Eildon Weir (ELW) and
COLDS, destination Essendon (YMEN), (Refer ERC 2) at 10,000
in cloud. Melbourne Centre have you radar identied and have
issued your clearance. At 35 DME ML, Centre instructs you to
call Melbourne Approach. What will be the content of this call
to Approach?
Contacting Approach
(a) ML Approach, ABC maintaining one zero thousand in cloud,
received (ATIS) .
(b) ML Approach, ABC three ve DME Melbourne north east
maintaining one zero thousand in cloud, received (ATIS) .
SAR cancellation
(c) ML Centre ABC Circuit area Echuca, cancel SARTIME.
Frequency 134.325
(d) ML Centre ABC Circuit area Echuca, cancel SARWATCH.
Frequency 126.8
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Position report
(e) ML Centre ABC, NEVIS at (minutes) 8000ft Bordertown
at (minutes) .
(f) ML Centre ABC, over NEVIS at (minutes) 8000ft next
position Bordertown at (minutes) following point DUKES.
Level maintaining
(g) Report required. It would be ML Centre ABC maintaining
9000.
(h) Report not required.
Departure & airborne reports
(i) ML Centre ABC departed Wynyard at (minutes) tracking
338 passing 2500 climbing 8000, CAMUS at (minutes).
Frequency 122.6.
(j) ML Centre ABC departed Wynyard at (minutes) tracking
to CAMUS climbing 8000. Frequency 122.6.
(k) ABC departed (minutes) via SCOTI ONE DEPARTURE
climbing to 8000, estimating SCOTI at (minutes) .
(l) Alice Tower, ABC departed (minutes) tracking 346
climbing 8000.
(m) ML Departures, ABC passing (altitude to the nearest
100ft) climbing 5000.
(n) ML departures, ABC climbing 5000 passing (altitude
to the nearest 100ft) .
(o) ML departures ABC DOSEL SEVEN DEPARTURE
passing (altitude to the nearest 100 ) climbing 5000ft.
Taxi report
(p) Essendon Ground ABC (persons on board if not RPT)
received (ATIS) IFR to Albury, request taxi.
(q) Essendon Ground ABC IFR to Albury via (tracking point/s)
received (ATIS) request taxi clearance.
(r) ML Centre ABC (aircraft type) I.F.R taxiing Latrobe Valley
for Essendon Runway 03, Frequency 124.0.
(s) ML Centre ABC (aircraft type) (persons on board) IFR
taxiing Latrobe Valley for Essendon Runway 03, Frequency
124.0.
Contacting a procedural (non-radar) tower
(t) Alice Tower, ABC (distance) DME on the 137 radial
maintaining 8000 visual received (ATIS) request clearance.
(u) Alice Tower, ABC (distance) maintaining 8000 visual
received (ATIS) request clearance.
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july
8

Regional Airspace and Procedures
Advisory Committee
Melbourne www.casa.gov.au
16-18

Australian Centenary of
Powered Flight
Mia Mia, VIC Australian Centenary of Powered Flight
Mia Mia Inc.
Jill James secretary: m: 0418 388 919
e: jill@colibanestate.com
august
11

AvSafety seminar Goolwa www.casa.gov.au


17-19

The Australian Aircraft


Airworthiness
& Sustainment Conference
Brisbane Convention &
Exhibition Centre, QLD
AASC/Ageing Aircraft - chairman
Richard Gauntlett
e: richard@ageingaircraft.com.au
september
9

Regional Airspace and Procedures
Advisory Committee
Darwin www.casa.gov.au
14

Regional Airspace and Procedures


Advisory Committee
Cairns www.casa.gov.au
15-17

Regional Aviation Association


Australia annual conference
Hyatt Regency Resert
Coolum, QLD
www.raaa.com.au/convention.html
23

Regional Airspace and Procedures
Advisory Committee
Hobart www.casa.gov.au
30

Regional Airspace and Procedures
Advisory Committee
Canberra www.casa.gov.au
october
7

Regional Airspace and Procedures
Advisory Committee
Sydney www.casa.gov.au
24-28

Australian Airports Association


national conference
Adelaide Convention
Centre
http://convention.airports.asn.au/
25-28

Sixth Triennial Int'l Aircraft Fire &


Cabin Safety Research Conference
Atlantic City,
New Jersey
Register online at www.fre.tc.faa.gov/
or email april.ctr.horner@faa.gov.au
for more information.
28

Regional Airspace and Procedures
Advisory Committee
Adelaide www.casa.gov.au
29

Regional Airspace and Procedures


Advisory Committee
Perth www.casa.gov.au
november
2-5

Flight Safety Foundation


International Air Safety
Seminar 2010
Milan Marriot
Hotel, Italy
http://fightsafety.org
9

Regional Airspace and Procedures


Advisory Committee
Brisbane www.casa.gov.au
10-11

Business Aviation Safety


Seminar-Asia
Singapore Aviation
Academy, Changi Village,
Singapore
http://fightsafety.org
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KEY: CASA events Other organisations' events
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QUIZ ANSWERS
Flying Ops
1. (a) heading 333(m) and TMG
328(m) drift 2 degrees left.
2. (a) the electrical integrity of
the antenna mounting to the
fuselage is critical.
3. (b)
4. (d)
5. (a) CAAP 166-1(0) table 2
6. (b) Traffc is required
at the beginning of the
transmission, but should not
be used at the end of the
transmission.
7. (c) CAR166D, CASR 139.B
and 139.C.
8. (d) CAR166C.
9 (c) CAAP 166-1(0) para. 4.4
10. (c) CAAP 166-1(0) makes this
recommendation.
IFR Operations
Question Answer Reference
1 (s) AIP GEN 3.4-47 Para 5.14.4 Item 1 and AIP ENR
1.1-72 Para 42.2
2 (p) AIP GEN 3.4-47 Para 5.14.4 Item 1
3 (m) AIP ENR 1.1-14 Para 8.1 and AIP GEN 3.4-55
Para 5.14.8 Item 2
4 (k) AIP GEN 3.4-55 Para 5.14.8 Item 3 and AIP ENR
1.1-15 Para 8.2.1 and 8.2.2
5 (i) AIP GEN 3.4-56 Para 5.14.8 Item 4 and AIP ENR
1.1-73 Para 43.3
6 (g) AIP ENR1.1-45 Summary and AIP ENR
1.1-74 Para 44.4
7 (t) AIP ENR1.1-20 Para 12.1.6a and c
8 (e) AIP GEN 3.4-104 Appendix 2
9 (d) AIP ENR1.1-84 Para 52.1.2
10 (a) AIP ENR 1.1-20 Para 12.1.6b
Maintenance
1. (a) the combustible gas
emitted from heated
rubber is called isoprene.
2. (c) the importance
of the ground plane,
and particularly the
cleanliness of the
mounting to it, is often
overlooked.
3. (b) a current transformer
connected to a warning
system is mostly used on
AC systems.
4. (b)
5. (a)
6. (d)
7. (c)
8. (d)
9. (c)
10. (a)
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