March–April 2012
The learning curve | Training for the future
Change in the air | ADS-B and airspace reform
Last year, the series targeted those in rural and regional areas – the 2012 series will feature six
metropolitan venues across Australia.
CASA supports the continued operation of ageing aircraft, as long as it can be done safely.
Come and hear the experts, who will be appearing at the following seminars:
17 March
28 April
12 May
26 May
2 June
16 June
Convention & Exhibition Centre
21 Mounts Bay Road
Waterview Bicentennial Park
Australia Ave, Sydney Olympic Park
Crowne Plaza
32 Mitchell St
Convention & Exhibition Centre
1 Convention Centre Place South Wharf
Convention & Exhibition Centre
Cnr Merivale & Glenelg Streets South Bank
Hilton Adelaide
233 Victoria Square
• Venue space is limited, so bookings are essential and strictly on a first-in,
best-dressed, basis.
• To secure your place, please go to www.casa.gov.au/ageingaircraft and complete
your booking online. Please bring your booking reference to the seminar.
Issue 85 | March–April 2012
08 The learning curve
02 Air mail
Aviation training issues and trends
20 New SMS kit on its way
CASA’s new safety management
systems resource kit
22 New thinking on old
Ageing Aircraft Management
Plan update
24 Change in the air
ADS-B and airspace reforms
28 New year, new look
AvSafety seminars for 2012
Flight bytes
Aviation safety news
16 ATC Notes
18 Accident reports
The dynamics of flight: how the
media took flight with an old story
31 The trouble with cables
The importance of cable
40 Fishing for chips
New data recovery methods from
modern electronic devices
18 International accidents
19 Australian accidents
31 Airworthiness section
46 Close calls
News from Airservices Australia
46 Scud running
48 Born to fly
50 Not very happy returns
52 ATSB supplement
News from the Australian Transport
Safety Bureau
66 Av Quiz
Flying ops | Maintenance
IFR operations
44 Sharing the skies
71 Quiz answers
A new occasional series begins with
a look at ballooning
58 An unnecessary tragedy
Colgan Air Flight 3407
62 The cabin connection
Training cabin crew members
Upcoming events for March-July
72 Coming next issue
Product review
Aviation safety news
The Jan-Feb issue of Flight Safety Australia featured an article
on fuel management and various pitfalls. I have a problem, but
one with a twist.
In 1979 I was flying our homebuilt Pitts S1 VH-SIE when
training at Murray Bridge prior to the Australian Aerobatic
Championships. None of the Pitts owners had starters fitted;
they had been removed to lighten the aircraft. I checked my
fuel with my dipstick. There was a quarter of a tank – ample I
thought for a 15-minute aerobatic flight.
One of the first manoeuvres was a vertical climb followed by a
stall turn, but I was not as far as the stall turn when the engine
quit. I got the nose down immediately, hoping that my speed
would turn the engine over, but I was too low to gain sufficient
speed to turn over the engine and I had to plan an emergency
landing. I had been practising over the cross strip so I did a
steep approach, turned onto finals and side-slipped down to a
rather bumpy landing. I left my aircraft there and went into the
clubhouse for a cup of coffee. After the coffee I returned to my
Pitts with another AAC member and strapped myself in.
The other member gave one pull and my engine fired. I took
off and did one circuit to steady my nerves.
This was a valuable lesson for other Pitts owners and for me.
A quarter tank of fuel was unusable when vertical. I later fitted
a header tank that only had about three litres of unusable
fuel when vertical, but this was OK since it held about 12 litres
in total.
Hilton Selvey
Phone payments ceasing for medicals
In order for the Permissions Application Centre to have
consistency across applications coming into CASA, phone
payments for medicals will cease as of close of business,
16 March 2012.
From Monday 19 March, all medicals will need to have the
payment slip completed and attached to the medical received
from the DAME.
Director of Aviation Safety, CASA | John F McCormick
Manager Safety Promotion | Gail Sambidge-Mitchell
Editor, Flight Safety Australia | Margo Marchbank
Writer, Flight Safety Australia | Robert Wilson
Sub-editor, Flight Safety Australia | Joanna Pagan
Designer, Flight Safety Australia | Fiona Scheidel
Phone 131 757 | Email [email protected]
Advertising appearing in Flight Safety Australia does not imply
endorsement by the Civil Aviation Safety Authority.
Flight Safety Australia GPO Box 2005 Canberra ACT 2601
Phone 131 757 | Fax 02 6217 1950 | Email [email protected]
Web www.casa.gov.au
To change your address online, go to www.casa.gov.au/change
For address change enquiries, call CASA on 1300 737 032.
Bi-monthly to 89,730* aviation licence holders, cabin crew and
industry personnel in Australia and internationally.
Stories and photos are welcome. Please discuss your ideas
with editorial staff before submission. Note that CASA cannot
accept responsibility for unsolicited material. All efforts are made
to ensure that the correct copyright notice accompanies each
published photograph. If you believe any to be in error, please
notify us at [email protected]
The views expressed in this publication are those of the authors,
and do not necessarily represent the views of 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.
Copyright for the ATSB and ATC supplements rests with the
Australian Transport Safety Bureau 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.
© Copyright 2012, Civil Aviation Safety Authority Australia.
Registered–Print Post: 381667-00644.
Printed by IPMG (Independent Print Media Group)
ISSN 1325-5002.
*latest Australian Circulation Audit Bureau figures Sept 2011
This magazine is printed
on paper from sustainably
managed forests and
controlled sources
Recognised in Australia
through the Australian
Forestry Standard
Flight Safety Australia
Issue 85 March-April 2012
2011 – a safer year in the skies
The Aviation Safety Network (ASN) has described 2011 as
a very safe year for civil aviation: the second safest year by
number of fatalities and the third safest year by number of
accidents. The year also marked the longest period without a
fatal airliner accident in modern aviation history.
In 2011, the ASN recorded a total of 28 fatal airliner accidents,
resulting in 507 fatalities and 14 on-ground fatalities. This
number of fatalities is lower than the ten-year average of 764.
The worst accident happened on 9 January 2011, when an Iran
Air Boeing 727 crashed on approach to Orumiyeh, Iran, killing
77 people.
The number of accidents involving passenger flights was
relatively high, with 19 accidents as compared to the ten-year
average of 16 accidents.
Seven of 28 accident aircraft were operated by airlines on
the European Union ‘black list’, as opposed to six of 29 in
2010. The E.U. added a total of nine airlines to the ‘black list’
and removed three airlines, after they achieved improved
safety records.
In 2011, Africa showed a continuing decline in accidents:
14 per cent of all fatal airliner accidents happened there.
However, the continent only accounts for about three per cent
of all world aircraft departures. Russia suffered a very bad
year, with six fatal accidents.
Electronic flight bag approval
American Airlines is the first carrier to allow pilots to use iPad
tablet computers for digital charts and manuals in all phases
of flight. The airline will use the iPad on its Boeing 777s as a
Class 1 electronic flight bag (EFB), described by the FAA as a
‘portable, commercial, off-the-shelf computing device that is
not attached or mounted to the aircraft’.
The approval covers a
Class 1 EFB running
Type A and Type B
software applications
for electronic manuals
and charts.
The FAA requires crew
members to secure or
stow Class 1 EFBs not
attached or mounted to
the aircraft during critical
flight phases. Those
with Type B software,
including ‘dynamic, interactive applications’, may be used, but
must be ‘secured and viewable during critical phases of flight
and must not interfere with flight control movement’. American
Airlines pilots secure the iPad to the forward chart holder with
an FAA-approved securing mechanism.
American has carried out 777 flight evaluations using digital
manuals, gathering thousands of hours and test points in
the process.
American Airlines is not the only commercial carrier to use
iPads as EFBs, a practice that has proliferated in business
aviation. Last spring, Alaska Airlines started issuing iPads to
1,400 pilots to replace paper manuals, largely as a weight
and fuel-saving measure.
British Airways is also distributing iPads to 2,000 senior cabin
crew for customer service applications.
In Australia, Qantas is in a staged trial of EFB. CASA has also
convened an EFB industry working group with representation
from the major players. A draft CAAP will be released shortly
for public comment.
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Aviation safety news
Safety award presentation
Join the RAAF Association
At a recent ceremony, the 2011 Australasian Aviation Ground
Safety Council (AAGSC) Safety Award was presented to
Queensland Airports. They won the gong for producing a
DVD for airside and landside manual handlers, showing
ground handling operations from the perspective of both ramp
and passenger services. The DVD also shows ground staff
performing their roles, highlights ways in which they can
improve their manual handling techniques, and explains the
risks staff expose themselves to by not following good manual
handling techniques.
Very few people engaged in general aviation are aware that
they are eligible to join the RAAF Association. All you need is
a keen interest in aviation.
The DVD will be shown during the induction process for all
new Queensland Airports staff, as well as helping to educate
current staff about improved work practices and correct
manual handling techniques.
‘Here at the northwestern Tasmania branch, for example,
we hold monthly meetings for general business; several
commemorative dinners are held yearly, as well as BBQs and
bus tours. There is also the pleasure of socialising with people
of similar interests,’ writes Derek Padgett, northwestern branch
committee member.
Associate membership allows partners to join, making it
family friendly. And your area of aviation expertise may also be
valuable for volunteer work with such groups as the air cadets.
For further details see http://www.raafa.org.au
Also available online:
All CPL Subjects plus IREX
• Practice exams with fully explained answers
• E-text versions of every book
Full online course for
CPL performance:
With video, audio-visual
lesson presentation,
hundreds of practice
questions with fully
explained answers,
practice exams and a
final assessment exam.
Check out our website at www.bobtait.com.au
or email [email protected]
Home study and full-time courses available
Flight Safety Australia
Issue 85 March-April 2012
New ATM role for EASA
Contemporary Air Safety Investigation
Patrick Goudou, executive director, European Aviation
Safety Agency (EASA) speaking to Air Transport News
in January, discussed the Agency’s new role in overseeing
air traffic management safety, previously the responsibility
of Eurocontrol.
The 2012 Australian & New Zealand Societies of Air Safety
Investigators (A/NZSASI) seminar will be held in Sydney at
the Mercure Hotel, George Street, from 1–3 June.
‘We have the role of everything regarding safety, and it’s
important to know that, because previously it was also
Eurocontrol, which was taking care of safety, of ATM. Now
this task has been transferred to EASA … we now have
under our umbrella all domains of aviation regarding safety.’
Goudou went on to explain that the time frame for
implementing EASA’s air traffic management responsibilities,
would be the end of 2012, at which stage the agency ‘will
start working on real issues, because by then we will have
all the regulatory framework in place’.
The seminar will include wide-ranging presentations and
papers covering contemporary air safety investigation and air
safety issues. This year’s seminar promises to be A/NZSASI’s
biggest and best, so save the date.
There is still a limited number of positions available for
papers and presenters, so if you would like to present a paper
addressing contemporary air safety investigation and air safety
issues, please submit an abstract and short bio to Paul Mayes
by 14 March 2012, at [email protected]
To register, go to http://asasi.org/seminar/rego_main.htm
where you can download a registration form.
You can make seminar hotel reservations directly with the
Mercure, Sydney, George Street by email at [email protected]
accor.com, or phone on 02 9217 6612. The hotel is offering
a special rate of A$170 per night, but you need to book before
1 May to receive this rate. Quote the A/NZSASI seminar
block code of ASA080611. For further information, go to
Aviation safety news
RCAs now NCNs
CASA’s regulatory oversight processes are changing, with
a greater emphasis being given to effectiveness and clear
guidelines for industry and CASA inspectors alike.
One of these changes involves what were formerly known as
Requests for Corrective Action, or RCAs. From 16 April 2012,
RCAs will become Non-Compliance Notices (NCNs).
While neither the substance nor the status of the notice has
changed, the name change to NCN ‘tells it like it is’. It clearly
shows recipients that CASA believes they have breached the
regulations and are expected to take appropriate action to bring
themselves back into compliance.
Non-Compliance Notices also advise recipients to examine
the underlying reasons why the identified breach occurred,
and to take appropriate steps to rectify those underlying
deficiencies.For more information, visit the CASA website at
US Senate Passes FAA Bill A bill to speed the switch from radar to an air traffic control
system based on GPS technology, and to open US skies to
unmanned aircraft flights within four years, received final
congressional approval on Monday.
The bill authorises $63.4 billion for the Federal Aviation
Administration (FAA) over four years, including about $11
billion toward the air traffic system and its modernisation.
The system is central to the FAA’s plans for accommodating a
forecast 50 per cent growth in air traffic over the next decade.
Most other nations already have adopted satellite-based
technology for guiding planes, or are heading in that direction,
but the FAA has moved cautiously. The United States accounts
for 35 per cent of global commercial air traffic and has the
world’s most complicated airspace, with a greater volume and
more varied private aviation than other countries.
Within nine months of the bill’s passage, the FAA must
also submit their plan as to how they will provide military,
commercial and privately-owned unmanned/remotely piloted
aircraft (RPA) safe access to airspace currently reserved for
manned aircraft, to fly in the same airspace as airliners, cargo
planes, business jets and private aircraft.
Flight Safety Australia
Issue 85 March-April 2012
The FAA must then provide these RPA with expanded access
to US airspace currently reserved for manned aircraft by
30 September 2015.
• the aircraft flight manual, or approved flight manual
supplement, or
Currently, the FAA restricts UAS/RPA use primarily to
segregated blocks of military airspace, border patrols and
about 300 public agencies and their private partners.
Those public agencies are mainly restricted to flying small,
unmanned aircraft at low altitudes away from airports and
urban centres.
• the aircraft’s type certificate, or type certificate
data sheet.
Washington Post 6 February 2012
New MTOW exemption
Previous maximum take-off weight (MTOW) requirements
for aircraft operated in a restricted category, or used in aerial
application operations, are now found in one exemption—
Exemption CASA EX01/12—designed to clarify and simplify
the MTOW requirements for applicable aircraft.
If your aircraft is eligible under the exemption, and you wish
to take advantage of it, then you must comply with the
conditions stated in schedule 3 of the exemption, that is:
There is no provision in the exemption to exceed
whichever is the highest applicable MTOW specified in
• an approved placard in the aircraft, or
If you wish to take advantage of the exemption, not only must
you comply with the above, but you must also ensure that:
you operate your aircraft in accordance with the
manufacturer’s or supplemental type certificate holder’s
published operational limits and maintenance instructions
where applicable, you correctly calculate and record
weight related, time-in-service
• In some applicable aircraft types, if they are
operated at MTOW above the baseline used to
establish the service life of the aircraft, the increase
in take-off weight results in increased fatigue
effects and a consequent reduction in service life.
you forward relevant information about the
exemption to anyone involved in operating or
maintaining your aircraft.
If you have any queries about the exemption, please
contact the manager of your nearest CASA regional office,
at GPO Box 2005, Canberra ACT 2601, or phone 131 757.
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Aviation training
The learning curve
Training (and
how best to
do it) is one of
aviation’s big
Flight Safety
examines some
of the issues and
trends involved
For aviation, the good times are back in sight.
The GFC held it at bay; continuing economic
uncertainty in parts of Europe and the United
States is still having an impact, but the pundits
agree – forecast aviation growth will mean a
shortage of trained personnel in the next decades.
The International Civil Aviation Organization
(ICAO), in its publication Global and Regional
20-Year Forecasts: Pilots. Maintenance
Personnel. Air Traffic Controllers. (Doc 9956
Feb 2011), says the shortage will be especially
critical in the Asia-Pacific region.
No one learns to fly without some form of
training. It’s the law that no one can perform
more than minor maintenance on a VH-registered
aircraft without being specifically trained for
it. And, with the exception of the children of a
certain US controller, amateurs are banned from
control towers.
In aviation, as in society at large, the trend is
towards spending more time in formal education
and training. In Australia in the 1930s, for
example, only seven per cent of 16-17 year olds
were at school. In 2010, the Year 12 retention rate
was 79 per cent.
During World War I trainee pilots frequently flew
solo after as little as three hours, and could
be instructing new pilots after 20 hours. In
World War II, about six hours to solo was not
uncommon. Today, any solo in a general aviation
aircraft before about 10 hours raises questions
about whether all the necessary skills have
been taught. Fifteen hours is now considered
an appropriate time before first student solo.
Cabin crew, who began in the 1920s with a
role combining advertising, reassurance and
food service, are now part of an airline’s safety
system and undergo intensive training in this
Pilot attrition comparison: 2010 - 2030
60 000
40 000
Training capacities
20 000
Training needs
-20 000
Graph adapted from ICAO report
America East
Flight Safety Australia
Issue 85 March-April 2012
area. Engineers must now meet the challenges of
rapidly evolving technology in materials, avionics
and propulsion.
Several common themes emerged as Flight
Safety Australia spoke to pilots, engineers,
academics, air traffic controllers and cabin crew
about aviation training in its broadest sense.
They were: the impact of supply and demand
on training and safety standards, resilience,
competency and experience, practical learning
and theoretical or simulated learning, and the
importance of continual learning.
Supply and demand
The big issue is that we’re going to be facing
another global pilot shortage, says Roger Weeks,
CASA manager, flying standards branch.
ICAO’s global and regional forecast for pilots,
maintenance engineers and air traffic controllers
predicts the aviation growth rate is going to
exceed four per cent per annum for each decade
until 2030. It shows the Asia Pacific region will
have the highest growth rate, with that region’s
fleet projected to grow by 9.1 per cent annually.
By 2030, that region will equal North America in
size. The most likely scenario, ICAO says, is a
training deficit worldwide of about 8000 pilots,
18,000 maintenance personnel and 2000 air
traffic controllers every year – a grand total of
560,000 personnel over the next two decades.
‘Couple that with the age demographics – 30
per cent of pilots worldwide are aged over 50 –
in 15 years they’ll be in their retirement phase.
We’re certainly going to see a major issue,
which we got a taste of in 2007-08 before the
GFC, when the industry at all levels was under
significant pressure. Schedules were being
curtailed and aeroplanes were being parked
because there were not enough crews to
fly them.’
While supply and demand is not the regulator’s
bailiwick, the challenge for us as a regulator is
that if a shortage occurs that there’s no potential
for any reduction in standards. We will need to be
vigilant to ensure that does not occur.’
Weeks’s analysis is that, overall, pilot supply is
squeezed by both boom and bust.
‘During the GFC, flying schools closed down; for
example, in the Sydney basin three or four closed,
and our figures show a 38 per cent reduction in
the number of instructors being trained.’
‘This level of infrastructure is not going to meet
the increased training demand.
‘I think what we’ll see is two strong pathways
in Australia, the traditional pathway of CPL,
building your hours and approaching the airlines.
Then there’s the new cadet model, with Rex
establishing an academy in 2008 and Jetstar
recently establishing a program.’
We won’t see the end of the standard direct entry
model, but I believe we will see increased use of
cadets’, Weeks says, adding that ‘cadet programs
are not new, having been used by both Qantas
and Ansett in the past and in widespread use
The mystery of what makes the perfect pilot,
engineer, controller or executive is summed up
in one of aviation’s most celebrated clichés –
the right stuff. And, as with all clichés, it contains
a grain of truth – there appear to be attributes
that define the best in each of these areas. But
research suggests that the actual right stuff is
different from the popular perception.
In a study published in 2001, US Air Force
psychologist Raymond E. King, and academics
Paul D. Retzlaff and Daniel R. Orme compared
pilot psychological profiles to safety outcomes.
Aviation training
Their method was to examine the psychological
assessments of air force pilots who had had
accidents or incidents. They found: ‘Pilots who
had received high scores on subscales related to
self-assurance and devotion to duty were 3.75
and 2.39 times, respectively, more likely to have
pilot-error mishaps/incidents. No relationship
was found between mishaps/incidents and
orderliness, achievement striving, self-discipline,
and deliberation.’
How then
do you train
for this
‘While counter-intuitive, it may be that these traits
represent a lack of flexibility of the pilots such that
they are less able to meet novel demands in crisis
situations’, the authors wrote.
They added a note of caution: ‘alternatively, those
with higher feelings of competence, particularly
in this relatively inexperienced sample, may have
over-stretched their ability. Or, perhaps pilots with
these traits are more likely to report significant
incidents that fall short of a mishap. These
interpretations are preliminary; more cases need
to be collected and analyzed.’
Their findings correspond with a 1991 study
by Charles L. Lardent, who found that pilots
who had been involved in a crash were more
conscientious, on average, than those who had
not been involved in a crash. Lardent mentioned
unrealistically high standards and reluctance to
quit, even in the face of adversity, as potential
dangers of excessive conscientiousness.
The flexibility mentioned in King and Lardent’s
studies is similar to what Professor James
Reason in his most recent book, The Human
Contribution, calls resilience. It is the factor
that allows pilots, engineers and controllers to
recognise, reduce and recover from the mistakes
that are an unavoidable part of being human.
Former airline executive engineering manager,
Mark Sinclair, is now CASA’s executive manager
of safety education and promotion. He says
resilience is related to the ability to think laterally
under stress.
‘It’s the capacity to join the dots and get to the
real technical issue – to understand that the
problem is not necessarily what it appears to be.’
And, you have to combine that lateral thinking
with technical creativity to come up with an
innovative solution to the problem’, he adds.
Rodd Sciortino, Airservices Australia ATC
academy training manager, describes resilience
in the ATC context as the ability to make solid
decisions under intense time pressures. It also
involves continual assessment of those decisions
and a willingness to adapt or abandon them if
Former air traffic controller, Peter Cromarty, is
now CASA’s executive manager of airspace and
aerodrome regulation. He says humility is part of
‘You need to be decisive, with the self-confidence
to stand by your own judgement. But you’ve
also got to be flexible enough not to die in a ditch
to make a plan work. You’ve got to be humble
enough to change a plan if it’s not working,’
Cromarty says.
Engineer Stuart Hughes, Australian managing
director of human factors and safety management
consultants, Baines Simmons, says confidence
is essential. ‘You need be able to say, “I’m not
happy with the condition of this aircraft. This is
not right”.’
James Reason’s analysis of resilience in The
Human Contribution uncovers more paradoxes.
Some of the examples he quotes, such as the
crash of United Airlines Flight 232, or the Air
Canada ‘Gimli Glider’, involve improvisation, while
others involve disciplined application of basic
principles, such as the by-the-book sang-froid
of captain Eric Moody and the crew of British
Airways Flight 9 when volcanic ash stopped all
four engines over Java.
How then do you train for this flexibility and
Anthony Petteford, managing director of Oxford
Aviation Academy, based at Moorabbin, says
there is one factor that much pilot traditional
training does not address: the ability to work as
part of a team. This is essential for airline pilots,
he says.
Flight Safety Australia
Issue 85 March-April 2012
‘An airline pilot’s is a highly sophisticated role. It’s
a specialist job that’s not just about flying skills
any more,’ he says. ‘It’s a team management
activity involving high degrees of automation in
a hostile, dense environment. An airline pilot has
to be trained for the profession from the outset,
and that training must be ongoing. You wouldn’t
train a doctor, dentist or lawyer to gain a basic
qualification, and then go out into the world and
work it out as they went along.
Crew resource management is (or should be!)
a well-known concept to commercial pilots, but
Hughes says something similar is essential in the
maintenance hangar.
‘There needs to be communication between
management and maintenance people, asking,
“how can we do this together?” Too often there is
a disconnect between the maintenance function
and planning, leading to unrealistic deadlines,
which compromise safety’, he says.
Dr Peter Bruce teaches aviation and aviation
management subjects at Swinburne University in
Melbourne. He argues that while pilots comprise
probably 10 per cent of the aviation industry, the
concepts of CRM, safety management systems
and human factors are essential knowledge for
anyone working in aviation, whether they be
baggage handler or chief executive.
Swinburne aviation students, whether in the
pilot or management streams, all study many
common subjects – including basic aeronautical
knowledge and human factors – in their first year,
‘because we see it as an important part of the
Rodd Sciortino says close cooperation is central
to the ATC system of aircraft being handed on
from one sector to the next.
‘One thing that’s not negotiable is teamwork.
Every controller looks after the aircraft in their
airspace and they need to ensure they progress
safely through that volume on to the next volume,’
he says.
But Petteford says embracing the team approach
raises further questions about potential gaps
in training. ‘Here’s something that has really
raised a flag; there’s so much emphasis on “the
pilot flying”. But do we really train pilots in the
monitoring mode? What do we mean by that?’
he says.
The question is as basic as where the pilot
monitoring should be looking, Petteford says.
‘Everyone understands you’ll be doing the radio,
monitoring systems, navigation logs and so on;
stuff that supports the pilot flying. But during the
final phases of approach should you be placing
greater emphasis on monitoring the primary flight
display, on looking out, or on the engines? Where
should your eyes be and what should you be
doing?’ This is such a primary question that the
UK Civil Aviation Authority has commissioned a
research study into the matter.
‘There are no answers yet, but I think there’s an
awareness that we may have followed a standard
model for too long.’
Oxford Aviation Academy - students in the briefing room
Aviation training
Competency and experience
Well-publicised incidents involving Australian
carriers and media interest have put pilot training
in the spotlight. Some reporting has made much
of the comparative lack of hours that some newly
qualified airline pilots have when they first sit in
the cockpit.
A thousand
hours of
flying may
involve 1000
flights or
the same
flight 1000
times – the
that results
can be very
Multi-crew licensing, which trains ab-initio
candidates to take the first officer’s seat in an
airliner, is now throughout Europe and Asia, but is
not yet offered in Australia. In this country, airline
cadets are trained from having little or no aviation
experience to a direct first officer role. Some
schemes, such as the Jetstar cadet program
administered by Oxford Aviation Academy, offer
an additional module of multi-crew cooperation
(MCC) in their training.
Petteford is aware that some in Australia, with
its stronger GA sector than Europe, see Oxford’s
model as controversial. (Oxford’s model has
operated in Europe since 1964.) ‘What we’re
not saying, and what we’ve never said, is that
you should completely rubbish other means of
training,’ he stresses, ‘provided that when pilots
are trained for their licence qualification that the
training they undergo is structured, good quality
and that, ideally, they do not enter into it without
being pre-assessed’.
‘Some people go in with predetermined ideas
that we’re not teaching people to fly, but both
our ab-initio ATPL and (overseas) MPL courses
have a mandatory upset avoidance and recovery
component. The primary emphasis is avoidance,
not just recovery. We’re trying to develop an
intuitive thinking that they should constantly be
evaluating threats and errors to avoid being upset
in the first place.’
Flying instructor Steve Pearce, a holder of the
Royal Federation of Aero Clubs Australia Master
Instructor award, is among the voices that say
nothing replaces time in command of an aircraft
– of any size.
‘My personal view is that I want someone in the
right-hand seat who’s done the hours, the hard
yards, and has the experience to draw on.
Oxford Aviation Academy - King Air used for training
The concept of someone who’s got the
experience in the simulator, but not in the real
world, is hard for me to get my head around.’
However, Petteford argues that structured ab-initio
training can respond to safety trends in a way
that individual pilots working their way through
the informal progression system of night freight,
charter and low-capacity regular public transport
operations cannot do easily.
‘During our second Flybe MPL course, the airline
has asked us to increase the amount of handflying on instruments – power plus attitude –
partly as a result of the Air France accident,’ he
says, as an example.
CASA’s Roger Weeks says both experience
and competency are necessary, but ‘there
is some exclusivity to the two.’ Experience
doesn’t necessarily guarantee competence and
competency-trained low hours pilots are by
definition inexperienced.
Flight Safety Australia
Issue 85 March-April 2012
‘Experience does count, but competency also
counts,’ Weeks says. ‘A thousand hours of flying
may involve 1000 different flights or the same
flight 1000 times – the competency that results
can be very different.’
However, Pearce firmly believes there is ‘no
substitute for command hours, regardless of type.
It’s in the subconscious, for you to draw on.’
Practical vs simulation
The competency vs experience debate sometimes
merges into a discussion of the merits of
simulator vs real-world training. (Flight Safety
Australia looked at this topic in ‘When to Sim?’
November-December 2010.)
What is not as widely appreciated is how
simulation is being applied to fields other than
pilot training. Swinburne’s aviation and aviation
management students continue to encounter
safety in the second and third years. The bachelor
of aviation and bachelor of aviation management
courses use an airline business simulation to
teach airline management to senior students.
‘They buy aircraft, set up route structures,
schedules, and make decisions about fares,
advertising, staffing, catering and seat
configurations’, Bruce explains.
Swinburne aviation senior lecturer, Dr David
Newman, says simulation teaches the relationship
between safety and organisational culture in a
way that classroom lectures cannot.
‘The same things happen in simulation as in
the real world. We get fare wars, mergers and
alliances, requests for bailouts’, he says.
The simulation reinforces that safety underpins
profit, he adds. ‘Safety is an emphasis throughout
the whole course and students are well aware of
how the brand is affected by safety.
‘If they don’t do maintenance properly, the aircraft
become unreliable and may crash. Then people
won’t travel with their airline, no matter how much
they discount.’
Bruce continues: ‘Through subjects like SMS,
the course tries to prepare students to be aware
of the safety systems and culture in aviation,
not only in airlines but in airports, and the system
Newman adds, ‘If you have a safety issue in a
retail business, you might get a fine from the
occupational health and safety authorities. But in
the airline, a safety issue can threaten the viability
of the business, not to mention people dying. It’s
a commodity-based business, selling seats; but
it’s also volatile, dynamic, safety critical and very
much in the public eye.’
Airservices Australia and its predecessors have
used simulators for many years in ATC training,
but Sciortino says they are now of a standard
that can deliver highly sophisticated scenarios in
high fidelity.
Top to bottom: Swinburne University’s fixed-wing simulator;
inside Swinburne’s helicopter sim: Hong Kong at night; and on
approach to Bankstown
Aviation training
‘There are still the core competencies and things
we need to instruct. Our tower visual simulator is
a 360-degree simulator that can be loaded with
any scenery in Australia,’ he says. Airservices
also has a radar simulator and Eurocat en-route
ask “what
can I learn
next?” You
never stop
‘[Simulators] were more rudimentary in the
old days. In the ’80s, the tower simulator was
watching a slide show. The dot above the Mt
Macedon range was meant to be an F-27 on final.
Now we can press a button and create rain, low
cloud, night or fog. We can thoroughly test the
Sciortino says the simulators allow an integration
of theory and practice that was much more
difficult in the days of classroom-only instruction.
ATC trainees study in a sandwich structure
beginning with theory, simulation, further theory,
a second round of simulations and, finally on-thejob training under supervision.
CASA’s director of aviation safety, and former
Cathay Pacific flying training manager, John
McCormick, says simulators are good predictors
of successful pilots. ‘Piloting is first and foremost
a psychomotor skill. If you cannot think and fly
the aircraft at the same time you are in the wrong
occupation’, he says.
‘When I look at my logbook of the pilots I checked
in simulators, there is an absolute 100 per cent
correlation between people who could fly the
simulator well and those who went on to senior
positions in the company.’
Lifelong learning
Although there are some sharp differences of
opinion about training there is one common point
of agreement: it should never stop. All the experts
interviewed stressed the importance of lifelong
learning for anyone making aviation their career,
or hobby.
‘An American writer, Richard S. Drury, said we’re
all student pilots until we retire, I think that sums
it up perfectly’, says Pearce.
‘We’re in a learning environment for the whole of
our careers.’
Part of lifelong learning is mentoring, which Pearce
finds valuable because it often allows two-way
learning: the teacher learning from the student as
well. ‘I’m only ever a phone call away’, he tells his
former students.
CASA director, John McCormick, emphasises
the importance of contextual knowledge. ‘If you
say, “I’m going to be a pilot,” that doesn’t mean
you never read anything again about general
business or management. You’ve got to have an
understanding of how your occupation fits into
the grand scheme of that’, he said.
Petteford says pilot training should not just be
ongoing and set against regulatory minimum
requirements; it should be tailored to a ‘training
needs’ profile (pilot and airline). ‘One should take
training records and evaluate the strengths and
the potential threats/errors and use them as a
means to tailor ongoing training design.’
Weeks says the key thing is to look at the big
picture. Where are the accidents happening and
what is being done to address these issues in
training? Training for the big three killers: loss
of control, runway in/excursions, and controlled
flight into terrain should not just be the domain
of airlines and air forces.
This philosophy extends into the hangar, the office
and the tower.
Sciortino says the cycle of assessment and
training in ATC is, in effect, continuous learning.
‘I tell our students, “Get used to being under
scrutiny, whether it be with an instructor behind
you every day for the next 15 months or, once you
get your licence, having a check controller behind
you every six months”.’
Hughes says ‘Good engineers ask themselves
“what can I learn next?” You never stop learning.’
Flight Safety Australia
Issue 85 March-April 2012
CASA Training Centre
CASA is setting up a new training centre at its Brisbane offices, due to open in the second
half of this year. ‘The Centre’, CASA executive manager education and safety promotion,
Mark Sinclair, explains, ‘is not teaching the basics of how to be a pilot or an engineer’.
Rather, its focus is squarely on ‘helping to build a baseline of regulatory skills, so that
CASA delegates, or key personnel in an aviation organisation, understand the core
regulatory competencies associated with that function and know what we expect of them’.
At the Centre, people in key positions, such as accountable managers, safety managers,
delegates, responsible managers, approval personnel (and those aspiring to be), will
develop an understanding of their regulatory obligations, and the expectations CASA has
of such roles.
‘As we progress to the outcome-based style of legislation, organisations will have the ability
to better self-manage,’ Sinclair explains. ‘But at the same time, with that flexibility comes
responsibility, and a certain required level of maturity.
The Centre is about assisting key individuals in these organisations to develop that level
of maturity.’
CASA flying training and education managers
are contributing to ICAO’s global effort to
address the forecast shortage of aviation
personnel, and build training capacity. ICAO is
holding a series of regional conferences and
global symposiums focusing on the issue,
under the title of the ‘Next Generation of Aviation
Professionals’ (NGAP).
The first NGAP symposium was held in Montreal
in early 2011, followed by a round of regional
conferences. The second symposium will be
held in Montreal in April of this year (2012).
Online Human Factors training
Practical, cost effective and flexible Human Factors
training for flight operations, engineering, cabin
crew and ground handling.
For more information, visit www.hfts.com.au
email [email protected] or phone 0412 542 859.
The smarter way
Accident reports
International accidents | Australian accidents
International accidents/incidents 17 December 2011 – 26 January 2012
17 Dec Cessna 208
Caravan 1
Mesquite Airport,
Nevada, USA
20 Dec Boeing
YogyarkartaAdisutjipto Airport,
28 Dec Tupolev
Osh Airport,
Kyrgyzstan, Kyrgyz
Written off
Orense, Buenos Aires 2
Province, Argentina
Witchford, near Ely,
Cambridgeshire, UK
Written off
Skydiving plane landed, skidded off the runway, crossed a road and slid down
a slope into a golf course, stopping on its belly at the 17th hole. The pilot and
passenger only suffered minor injuries.
Passenger jet (first flight 1996), with 131 occupants, damaged in a runway
excursion. The aircraft landed in strong rain, failed to stop, and veered
onto the grass, where the RH main gear and nose gear collapsed. Several
passengers were injured in the evacuation. The IJOG localiser for ILS
approaches to the runway was NOTAMed out of use.
Passenger jet (first flight 1979) landed hard in dense fog and rolled over,
causing the right wing to separate. A fire erupted but was quickly contained.
All six crew members and 19 of the 82 passengers were taken to hospital
for medical treatment.
Ultralight crashed killing the pilot and his son, who were observing the
Dakar Rally.
Helicopter came down in a field near a business park. Witnesses said they
heard a bang and saw the helicopter plummeting to the ground from about
500ft, landing upside down and breaking into pieces. Pilot killed on impact.
Balloon on a scenic flight clipped HT powerlines, caught fire and crashed,
killing everyone on board.
1 Jan
6 Jan
R22 Beta
7 Jan
7 Jan
8 Jan
8 Jan
10 Jan
11 Jan
15 Jan
15 Jan
16 Jan
18 Jan
19 Jan
23 Jan
24 Jan
26 Jan
Written off
Clareville, near
Carterton, Wairarapa,
Cessna 150L
Fyfergat Farm, near
Uitenhage, Kruisrivier,
South Africa
Bowers Fly
Jackson County
Baby 1A
Airport, Georgia, USA
Cessna 152
Near EnghienMoisselles Airfield,
Piper PA-31-350 North Spirit Lake
Navajo Chieftain Reserve, Ontario,
Robinson R44
Mosjøen, Nordland,
Raven II
Piper PA-24-180 St Landing’s Beach,
near Brewster,
Massachusetts, USA
Robinson R22
San Liberato, Italy
Written off
Written off
Madiba Bay School of Flight aircraft crashed, killing both occupants.
Written off
Written off
Experimental aircraft crashed shortly after take-off when the engine failed
while performing test take-offs and landings. Pilot killed.
Aircraft crashed shortly after take-off, killing the 22-year-old pilot and his
13-year-old passenger.
Written off
Written off
Written off
Written off
Whitianga Airfield, NZ
Bell 206L-4 Long Auyantepui Mountain,
Ranger IV
Canaima National
Park, Venezuela
Wax Lake, Louisiana,
R44 Raven II
Timona Park, near
Feilding, NZ
Villa Hayes, Chaco,
R44 Raven
near Bushehr, Iran
F-14A Tomcat
Written off
Written off
Helicopter crashed into Wax Lake, killing the pilot and passenger.
Written off
Written off
According to witnesses the pilot was performing aerobatic manoeuvres before
the aircraft made a strange noise and crashed.
During instruction in the landing phase, the pilot apparently performed a bad
landing procedure and broke the National Police aircraft’s tail cone.
The vintage American-built fighter plane crashed after what was described as
a ‘technical malfunction’, killing the pilot and co-pilot.
Aircraft crashed and caught fire on approach, 500 yards from
North Spirit Lake Airport in a blinding snowstorm. Five people
were on board.
Helicopter used for herding deer was reported missing. Pilot and passenger
found dead at the scene.
Emergency crews began searching for the aircraft after the pilot reported
smoke in the cabin and then lost contact with ATC.
Helicopter clipped high-voltage cables and crashed near a highway, killing
both occupants.
Aircraft crash landed with no wheels.
Helicopter crashed in rough weather in mountainous terrain, killing all five
people aboard.
International accidents
Compiled from information supplied by the Aviation Safety Network (see www.aviation-safety.net/database/) and reproduced with permission.
While every effort is made to ensure accuracy, neither the Aviation Safety Network nor Flight Safety Australia make any representations about its accuracy, as information is based on preliminary
reports only. For further information refer to final reports of the relevant official aircraft accident investigation organisation. Information on injuries is not always available.
Australian accidents
compiled from the Australian Transport Safety Bureau (ATSB).
Disclaimer – information on accidents is the result of a cooperative effort between the ATSB and the Australian aviation industry. Data quality and consistency depend on the efforts of industry
where no follow-up action is undertaken by the ATSB. The ATSB accepts no liability for any loss or damage suffered by any person or corporation resulting from the use of these data. Please note
that descriptions are based on preliminary reports, and should not be interpreted as findings by the ATSB. The data do not include sports aviation accidents.
*indicates ‘investigation continuing’
Flight Safety Australia
Issue 85 March-April 2012
Australian accidents/incidents 03 December 2011 – 29 January 2012
03 Dec
Piper PA-28-161
PZL-Bielsko 48-3
Jantar STD 3
Cessna 182E
West Sale Aerodrome, Vic Nil
Bathurst Aerodrome, 270° Nil
M 13km, NSW
Lower Light (ALA), SA
03 Dec
04 Dec
05 Dec
05 Dec
06 Dec
07 Dec
11 Dec
15 Dec
20 Dec
23 Dec
24 Dec
25 Dec
28 Dec
29 Dec
30 Dec
30 Dec
Damage Description
During landing, the aircraft landed hard on its nose landing gear before bouncing
a number of times.
During the turn onto final, at low level, the wing struck the ground and the
glider crashed.
During landing roll on the short strip, the aircraft did not decelerate as expected.
The pilot attempted to turn onto the crossing strip, resulting in the aircraft sliding
off the runway.
During landing roll, the aircraft encountered a willy willy before leaving the runway,
colliding with a fence and coming to rest upside down.*
During flying training, the helicopter rolled over and hit the ground.
The two occupants were uninjured.*
During take-off, the aircraft hit a gusting crosswind and was pushed off the runway,
hitting a bank and stopping among trees.*
The aircraft crashed, killing the pilot.*
While aerial spraying, the aircraft struck a power line and made a precautionary
landing at Moree.
During take-off roll, the aircraft hit an obstacle and came to rest inverted.*
During the take-off run, the aircraft ran off the end of the airstrip and hit a mound
of dirt.*
During the hover, the left skid hit the ground, resulting in a dynamic rollover.*
A helicopter crewman was killed while attempting to retrieve an injured bushwalker
by winch.*
During final approach, the pilot received a stall warning and applied full power, but
the aircraft continued to descend, landing on the soft wet surface before the runway.
The landing gear dug into the wet grass.*
During the landing, the nose landing gear collapsed. The engineers could not find
any faults with the system.
During the landing, the aircraft groundlooped.
Taylorcraft BC12-D near Gunnedah
Aerodrome, NSW
Schweizer 269C-1 Moorabbin Aerodrome,
Rockwell 114
Meekatharra Aerodrome,
Cessna 210M
Roma Aerodrome, Qld
Air Tractor
Moree Aerodrome, NSW
Auster J5F Aiglet near Tyabb (ALA), Vic
Cessna A188B/A1 St George Aerodrome,
Robinson R22 Beta Caloundra (ALA), Qld
Agusta AW139
Nowra Aerodrome, 012° T
36km, NSW
Cirrus SR22
Warnervale (ALA), NSW
(a/c tail)
Piper PA-31-350
Cessna A188B/A1
Cessna 172R
PZL WarzawaOkecie M-18A
Cessna A188B/A1
Robinson R22 Beta
Scone Aerodrome, NSW
Gunnedah Aerodrome,
Cambridge Aerodrome,
Dirranbandi Aerodrome,
225° M 36km, Qld
Substantial After starting the engine, the instructor left the aircraft to replace the headset.
The aircraft taxied forward and struck a hangar.
Substantial During agricultural operations, the engine failed and the pilot made a forced landing
in a paddock.
Forbes Aerodrome, NSW Minor
Richmond (Qld)
Aerodrome, 067° M
45km, Qld
Happy Valley (ALA), Qld
Substantial After take-off, the helicopter lost power and the pilot made a forced landing.
The helicopter rolled onto its side and was destroyed in a post-impact fire.*
Cessna 172N
Schweizer G-164B Goondiwindi Aerodrome,
Air Tractor AT-502 near Collarenebri (ALA),
Aero Commander Warrnambool Aerodrome,
500-S Shrike
Nanchang CJ-6A near Parafield Aerodrome,
Substantial During initial climb, the aircraft lost power and crashed.*
09 Jan
Eagle X-TS 150
Yarrawonga Aerodrome,
12 Jan
Beech 23
Renegade Spirit
Mildura Aerodrome, Vic
ICA Brasov
Ayres S2R-R1820
Turbo Thrush
Schweizer 269C
near Benalla Aerodrome,
Condobolin Aerodrome,
W M 41km, NSW
Long Hill (ALA), Tas
de Havilland DH82A Tiger Moth
de Havilland
DHC-1 MK 22
Pitts S2-ZZ
Maryborough Aerodrome, Fatal
Goulburn Aerodrome,
NW M 2km, NSW
Substantial During an aerial agricultural spray run, the aircraft struck a powerline and the pilot
made a precautionary landing in a nearby field.
Substantial During the take-off run, the aircraft did not accelerate normally. The pilot attempted
to dump the load but the left wing stalled and the aircraft veered left and crashed.
Substantial During approach, the pilot forgot to lower the landing gear, resulting in a
wheels-up landing.
Substantial During approach, the nose landing gear did not extend. The crew did a non-normal
checklist, but this did not rectify the problem. They retracted the landing gear and
landed wheels up. Engineering inspection did not reveal any faults, but it was
suspected that the nose landing gear-up lock had jammed.
Substantial During landing, a strong wind gust lifted the aircraft, blowing it to the side of the
runway. The pilot applied power to go around, but due to the proximity of the fence
rejected the take-off. The landing gear collapsed when it struck the soft ground
at the side of the strip.
Substantial During landing, the aircraft ballooned and landed hard on its nose landing gear,
which collapsed. The passenger suffered minor injuries. Investigation continuing.
Substantial During cruise, the engine failed and the pilot made a forced landing in scrub.
The main landing gear hit a tree stump, causing the aircraft to cartwheel.
The pilot escaped the aircraft uninjured before it was destroyed by fire.
Substantial During approach, the glider lost lift. The pilot attempted to land in a paddock,
but collided with a fence.
Substantial During initial climb, the aircraft lost power and the pilot made a forced landing
in a field.
Destroyed During return from crop spraying operations, the engine lost power, resulting
in a forced landing.*
Destroyed It was reported that the aircraft had crashed.*
01 Jan
03 Jan
04 Jan
04 Jan
05 Jan
05 Jan
07 Jan
14 Jan
15 Jan
21 Jan
25 Jan
27 Jan
29 Jan
29 Jan
near Whyalla Aerodrome, Nil
near Murray Bridge
The aircraft crashed during aerial agricultural operations.*
Substantial During initial climb, the engine failed and the pilot made a forced landing.
Substantial It was reported that the aircraft had crashed, killing the pilot.
Safety management systems
New SMS kit on its way
As a regulator CASA deals with the common and known areas
of potential hazard—training standards; airworthiness controls;
certification and entry control; operational issues such as loads
and balances and fuel management, for example.
‘Just obey the rules and nothing bad will happen.’ If only.
For aviation safety to continue to improve, aviation
organisations not only have to comply with the rules,
but then move beyond that basic (and fundamental)
compliance to a new level. At this next level, every person
in an aviation organisation strives for safety by identifying
hazards, evaluating risks, communicating them and taking
steps to mitigate them.
As the regulator for the Australian aviation industry as a whole,
it is appropriate that CASA does this. But CASA cannot regulate
against the unique and ‘unknown unknowns’ hazards that may
reside with individual operators. They must observe, analyse
and improve their own safety. That’s where safety management
systems (SMS) come in. New regulations in place and underway,
mean that organisations will need to have SMS in place.
But what are the hazards? A safety management system
is an approach to safety that shares its logic with former
US Secretary of Defense, Donald Rumsfeld’s, sometimes
derided ‘unknown unknowns’ phrase of 2002. Rumsfeld
said: ‘There are known knowns; there are things we know
we know. We also know there are known unknowns; that is
to say we know there are some things we do not know. But
there are also unknown unknowns – there are things we do
not know we don’t know.
CASA is working on a resource kit, SMS for Aviation—a Practical
Guide, to assist organisations with SMS, whether they are
updating and improving an existing system, or developing and
implementing a new one from scratch.
It is practical, written in plain English, and takes a jargon-busting
approach. The set of six booklets outlines the structure of an
SMS, following the global ICAO framework. The kit includes:
1.An introductory booklet: Safety Management System
Basics – why have an SMS? What’s in it for me? What is
the difference between an SMS and a quality management
system? Safety Management System Basics also
includes jargon busters: a list of useful definitions and
Similarly, in aviation there are hazards that we don’t know
about and we don’t even realise that we don’t know them: a
flight management system inundating a crew with more than
fifty error messages, for example. There are no rulebooks
and checklists to guard against these so-called ‘black swan’
hazards (from Taleb’s 2007 book, The Black Swan, where
he talks about ‘black swan’ events as being undirected and
unpredicted). Only a safety management system based
on constant alertness, reporting, analysis and mitigation
can hope to discover and address them. Hazards may be
latent in new aircraft types, buried in new or time-honoured
procedures, or inherent in certain destinations.
Safety Mana
Safety Mana
Safety Mana
2. Four booklets (nos. 2–5) covering each of the four main
parts of the global ICAO safety management system
framework. Each of these contains useful checklists and
templates, which organisations can adapt to suit their
individual needs.
Safety Mana
Safety Mana
Safety Mana
Flight Safety Australia
Issue 85 March-April 2012
• SMS for Aviation—a Practical Guide.
Safety policy, objectives and planning
Good safety management is not about having an SMS
manual on your shelf, outlining each of the elements you
have in place. Safety policy, objectives and planning
looks at the vital role of management in having an effective
SMS, setting up roles and expectations, clear policy
guidelines, and making sure everybody in the organisation,
whether it’s big or small, knows about and supports
the SMS.
• SMS for Aviation—a Practical Guide.
Safety risk management
With policies and people in place, the next step in an SMS
is to identify the hazards in your organisation, and to make
sure you have controls to manage risk. This booklet looks
at managing risk, the idea of reducing risk to be ALARP (as
low as reasonably practicable) and ALoS (acceptable level
of safety) and provides templates and checklists such as a
sample risk register and hazard ID.
• SMS for Aviation—a Practical Guide.
Safety assurance
Safety assurance is the way you show that your SMS
works, so this booklet looks at ways to monitor and
record your safety performance. It includes investigation,
reporting and auditing; as well as important things to
consider in managing change.
• SMS for Aviation—a Practical Guide.
Safety training and promotion
Good communication is vital for an effective SMS. If the
boss keeps everyone in the loop on safety issues, and
in turn, listens to what employees have to say, the SMS
will be much more effective. Equally, part of an effective
SMS is ensuring employees have the skills and knowledge
they need. This booklet therefore focuses on the ‘safety
training and promotion’ part of an effective SMS.
3.Booklet 6 in the SMS for Aviation—a Practical
Guide kit is Human Factors, dedicated to promoting
an understanding of humans—our behaviour and
performance. Then, from an operational perspective,
we apply that human factors knowledge to get the best
fit between people and the systems in which they work,
to improve safety and performance.
4. A DVD containing all the checklists and templates is
included so that organisations can adapt these to suit
their individual needs.
The kit is due for release by mid-2012,
and will be widely publicised.
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Ageing aircraft management plan
Flight Safety Australia reviews the state of play in the Ageing Aircraft Management Plan
with project manager, Pieter van Dijk
The first stage of CASA’s Ageing Aircraft Management
Plan is complete and the true scale of the issue discovered.
The Stage 1 report reached three main conclusions:
CASA fully supports the continued operation of ageing
aircraft in Australia – providing it can continue to be
done safely.
Aircraft owners may not be able to continue operating
the existing fleet of ageing aircraft indefinitely, with only
a minimal amount of the existing type of maintenance,
and expect the inherent risks to remain at an acceptable
Identified ageing issues are affecting the continuing
airworthiness of aircraft.
Stage 1+ took place in 2011 and involved providing
feedback to industry on the findings of Stage 1 and
delivering an aircraft owner awareness program on the
science of aircraft ageing. This was done via the CASA
website and through a series of seminars around the
country in metropolitan and regional venues.
Stage 2 includes further seminars this year following the
successful 2011 round. These seminars will be fewer in
number but larger in scale than those that took place
across the country last year. ‘We’ll go for larger venues,’
van Dijk says.
Stage 2 also involves preparing a discussion paper and
developing ageing aircraft training programs, both of which
are scheduled for release in mid 2012.
A prototype online matrix tool is also under development
to allow aircraft owners to assess the degree to which
the many factors in aircraft ageing affect their aircraft.
‘We want to have this facility available for industry to
trial so owners can run some “what-if” scenarios on the
airworthiness status of their aircraft,’ says van Dijk.
‘The online tool leads the person through a series of
questions about their aircraft, based on engineering
and scientific facts—nothing subjective. At the end, the
answers to each question will produce a likelihood index
number, which will give an indication of the likelihood that
their aircraft is affected by ageing issues. The questions
include a range of objective data fields including the type
of aircraft, its certification basis, whether it has ever been
damaged, how it has been repaired, how it has been
operated and where it is usually kept (in a hangar, on
grass, or near the coast).
‘You can enter your individual aircraft’s details and get
some idea of whether you should be making some
fundamental changes to it, or its maintenance system.’
Later this year CASA intends to publish a notice of
proposed rule making, after the responses to the ageing
aircraft discussion paper have been assessed. A notice
of final rule making should follow in mid to late 2013.
All interested industry parties are invited to comment on
CASA’s proposed initiatives to manage ageing aircraft.
One trend that has emerged in the Stage 1 investigation
is that ageing aircraft are primarily a general aviation
Flight Safety Australia
Issue 85 March-April 2012
Aircraft in the airline transport sector are more heavily used
than most GA aircraft, but they also tend to be both newer and
more comprehensively maintained.
‘We’re less worried about airline transport aircraft,’ van Dijk
says. ‘They are very intensively used, but that’s fine, as
their systems of maintenance are continuously monitored
and improved.’
‘That’s a different situation to GA, where the systems of
maintenance haven’t necessarily been adapted over the years
to include ageing-related issues.’
Stage 1 was somewhat reassuring in that it confirmed what
we know about the issue of metal fatigue as part of ageing.
For details of the
2012 seminars,see the
full-page ad on the
inside front cover of
this issue.
‘Corrosion has turned out to be a more significant issue than
fatigue,’ van Dijk says. ‘It seems we’ve managed fatigue
reasonably well over the years, but corrosion is a lot more
prevalent than we anticipated.
‘If you have a hard-to-get-to bit of the aircraft, chances are
it’s not been looked at for decades, and chances are also
that it will have corrosion damage. That’s significant because
corrosion damage compromises the structural strength of
the aircraft.’
Wiring emerged as another significant factor in ageing. Some
GA aircraft more than 40 years old were seen by the ageing
aircraft team to be still flying with their original circuit breakers
and wiring.
‘Original wiring in a 40-year-old aircraft is not going to be
reliable,’ van Dijk says. ‘To fly in IMC with ageing wiring is to
put your life in the hands of some cracked-up, ageing wiring
insulation that could easily be your undoing.’
The schedule of maintenance, known as CASA Maintenance
Schedule 5, calls for aircraft wiring to be inspected,
but does not provide any guidelines for its replacement.
Therefore wiring often goes unreplaced for decades.
‘Schedule 5 was never intended as a catch-all for large
fleets of aircraft that are twice as old in age and hours as
manufacturers originally expected them to be,’ van Dijk
says. ‘It was initially designed several decades ago as a
schedule of maintenance for a few orphan aircraft that did
not have adequate maintenance data available from their
The concept of a minimum maintenance standard is obviously
valid, but there is a strong case that its current content needs
to be updated into some sort of enhanced Schedule 5.’
All these concepts will be discussed in full in CASA’s
upcoming discussion paper and notice of proposed rule
making on the topic.
Air traffic management reforms
in the air
After a long period of consultation and
development, which began in 2010 with an initial
discussion paper, CASA is close to finalising
important air traffic management (ATM) reforms.
Broadly, the proposed changes involve requiring operators of certain
aircraft to fit avionics equipment to enable safe and efficient utilisation
of new technologies supporting future ATM and satellite navigation. The
proposed changes come at a time of increasing global harmonisation of
ATM and satellite navigation standards. Historically, these changes have
been developed in a co-operation with ASTRA* members as an acceptable
compromise between the various industry sectors. The changes mainly
affect IFR and do not affect Class G airspace below 10,000 feet.
(*ASTRA, the Australian Strategic Air Traffic Management Group, is an
aviation industry body dedicated to developing an optimum air traffic
management system for Australia. ASTRA members include the airlines,
CASA, Airservices, the Aircraft Owners and Pilots Association, the
Regional Aviation Association of Australia, the Australian Sport Aviation
Confederation, the Australian & International Pilots’ Association and others.)
In Australia, too, there are powerful drivers for change. Australia is at a
watershed in its ATM, with many legacy ground-based navaids, such as
non-directional beacons (NDB) and VHF omni-range (VOR) equipment,
approaching the end of their useful life. The intention is to complete the
transition to satellite navigation, which commenced in 1995, by early 2016,
while retaining selected navaids to back up and mitigate any problems
with GPS. Airservices is also providing new Mode S radars, multilateration
at major city airports, wide area multilateration (WAM), and more ADS-B
ground stations are being commissioned to provide improved services,
coverage and increased safety.
... for ongoing safety
and efficiency, CASA
is proposing a number
of changes to avionics
Another factor is increased air traffic: Western
Australia’s growing mining activity, for example
can mean that aircraft are unable to enter or leave
Perth controlled airspace when they request. The
fact that en-route ATM outside radar is presently
handled by procedural methods, with a 50nm
procedural limitation, affects the amount of traffic
in the airspace around Perth.
Consequently, for ongoing safety and efficiency,
CASA is proposing a number of changes to
avionics equipment. These changes apply
especially to satellite-based IFR navigation;
fitting of Mode S/ADS-B (automatic dependent
surveillance – broadcast) transponders; and
fitting of the updated version of the traffic
collision avoidance system—TCAS II version 7.1.
Flight Safety Australia
Issue 85 March-April 2012
Comments of the Notice of Proposed Rule Making 1105AS,
circulated in January 2012, close on 13 March. No rule
changes will be undertaken until feedback received by this
date has been considered.
– For aircraft operating in controlled airspace—A, B, C
and E, and above 10,000ft in class G—mandatory for
new transponder installations and new aircraft placed on
the Australian register on/after 6 February 2014
Broadly, the proposed changes are:
– All aircraft operating at Brisbane, Melbourne, Perth and
Sydney airports must be Mode S transponder-equipped
by 4 February 2016.
Mandatory avionics equipment—GNSS navigation/
IFR aircraft
– New* RPT and charter aircraft must be equipped for
GNSS navigation under instrument flight rules (IFR)
6 February 2014 (*placed on the Australian register
on/after 6 February 2014)
– Existing* RPT and charter aircraft must be equipped
for GNSS navigation under instrument flight rules
(IFR) 4 February 2016 (*placed on the Australian
register before 6 February 2014)
– New* private and air work category aircraft
undertaking IFR flight, must be equipped for GNSS
navigation 6 February 2014 (*placed on the Australian
register on/after 6 February 2014)
– Existing* private and air work category aircraft
undertaking IFR flight, must be equipped for GNSS
navigation 4 February 2016 (*placed on the Australian
register before 6 February 2014)
Mandatory Mode S ADS-B transponders (with ADS-B
out capability*) (*transponder must be ADS-B capable,
but the aircraft does not necessarily need to have GPS to
support ADS-B)
Mandatory ADS-B out capability
– New* aircraft flying IFR must be equipped to transmit
ADS-B 6 February 2014 (*placed on the Australian
register on/after 6 February 2014)
– Existing* aircraft flying IFR must be equipped to transmit
ADS-B 2 February 2017 (*placed on the Australian
register before 6 February 2014)
– Any aircraft flying IFR in classes A, C or E airspace
in the area bounded by a 500 nautical mile arc north
and east of Perth Airport must be equipped to transmit
ADS-B by 6 February 2016
Mandatory fitting of TCAS II v7.1 avionics equipment
– Before turbine-powered aeroplanes used in public
transport, with
• maximum certified take-off weight over 5700kg, and
• certified to carry more than 19 passengers, and
• first placed on the Australian register on/after 1
January 2014 (ICAO-determined compliance date)
– can fly, they must be fitted with a serviceable, approved
TCAS II v7.1
Another ADS-B mandate is even closer—in fact it’s happening next year
By 12 December 2013, operators of aircraft flying at and above 29,000ft (FL290) must have ADS-B equipment installed
and operating correctly. CASA mandated this mandatory fitting of ADS-B in 2009.
‘We are now seeing over 70 per cent of all international flights in our flight information region getting the ADS-B service,’
said Airservices senior engineering specialist and ADS-B program manager, Greg Dunstone, in December last year.
‘A small number of airlines and business jet operators appear not to have made the move to have ADS-B installed.
They need to get a move on, because the effective date is fast approaching,’ Dunstone added. CASA is not expecting to
issue exemptions.
After 12 December, 2013, non-ADS-B equipped aircraft will have to operate below FL290, with the corresponding
disadvantage of less operational flexibility and potential delays because of procedural separation standards applied
outside radar airspace.
Air traffic management reforms
What is ADS-B?
Using ADS-B
Simply, automatic dependent surveillance - broadcast, or ADS-B, is
aircraft automatically sending flight information to air traffic control and
to each other.
ADS-B systems typically broadcast two means of
identifying the transmitting aircraft. The first is a
technical means called the aircraft address (also
known as the 24-bit code) and the second is the
flight identification (FLTID)—the visual equivalent
of a call sign—used to identify targets on a
display and link them to their flight plans.
ADS-B broadcasts information about an aircraft, including its:
altitude (barometric and/or geometric)
The system also broadcasts technical information, such as position
This data is automatically sent about every half-second. The system
takes its information from other aircraft systems: a barometric encoder
for altitude, and global navigation satellite system (GNSS) equipment for
speed position and direction data.
The initials ADS- B describe the main characteristics of the system:
Automatic—the system requires no human input. No radar is needed
to interrogate it.
Dependent—the system relies on information from aircraft systems.
Surveillance—the system allows ATC, and individual aircraft with
cockpit displays of traffic information (CDTI), to see a picture of air
traffic in an area.
Broadcast—the system is a broadcast to all listeners, rather than
directly to a known receiver.
Airservices Australia completed the installation and commissioning of
its nationwide automatic dependent surveillance-broadcast network
in December 2009, with Australia becoming the first in the world to
provide nationwide ADS-B coverage.
ADS-B is available to suitably-equipped aircraft at all flight levels
within coverage of ground stations at 29 sites throughout the country,
providing radar-like coverage over continental Australia for the first
time. ADS-B data is also received by wide area multilateration (WAM)
systems in Tasmania and at Sydney. The accuracy of the information
displayed on air traffic controllers’ screens allows separation standards
to be reduced from 30nm to 5nm.
Level off! Level off!
TCAS stands for traffic collision avoidance
system, which has evolved through several
versions since first introduced in 1990.
TCAS II V7.1 is an enhancement that
verifies pilot response to a resolution
advisory (RA) and may generate a TCAS
resolution reversal, and changes the
verbal advisories from ‘adjust vertical
speed, adjust’ to ‘level off, level off’. This
enhancement came in response to the
Uberlingen mid-air collision of 2002.
In that accident, 71 people were killed
when a Boeing 757 and a Tupolev 154
collided over southern Germany. The
Tupolev crew had followed conflicting
directions from the controller instead of
obeying TCAS alerts.
ICAO is mandating TCAS II V7.1 on/after 1
January 2014. All public transport, turbinepowered aircraft above 5700kg certified
to carry more than 19 passengers, first
placed on the Australian register on/after
1 January 2014, must have TCAS II V7.1
before they can fly.
Flight Safety Australia
Issue 85 March-April 2012
Aircraft identification
The aircraft identification (sometimes called the flight
identification) is the equivalent of the aircraft call sign and
is used in both ADS-B and Mode S-SSR technology.
It is up to seven characters long, and is usually set by
the flight crew using a cockpit interface. It enables air
traffic controllers to identify an aircraft on a display and
to correlate a radar or ADS-B track with the flight plan data.
Airline aircraft should use the three-letter ICAO airline
code used in flight plans, not the two-letter IATA codes.
For aircraft using registration, the code should exactly
match the flight plan. For Australian domestic flights the
preceding ‘VH’ should not be included.
Aircraft identification is critical information, so enter it
carefully. Punching in the wrong characters could lead to
ATC confusing your aircraft with another. It is important
that the identification exactly matches the aircraft
identification (ACID) entered in the flight notification.
Intuitive correlation between an aircraft’s identification
and radio callsign enhances situational awareness and
Each aircraft has a unique aircraft address, which consists
of a 24-bit code allocated by CASA. This code is usually
entered into the unit by a LAME at installation. The code is
on the aircraft registration letter sent to aircraft owners by
CASA. If your aircraft is not registered by CASA, you can
get a code from the aircraft registry.
S for safety
ADS-B broadcasts are made using Mode S, the same
standard as used on Mode S transponders, which
are replacing the Mode A/C transponders used in
radar surveillance. ADS-B enables automatic safety
alerting within the ATC system including short term
conflict alert and cleared level adherence monitoring.
This is already active across the whole continent for
equipped aircraft.
Mode S has less signal garbling, less erroneous data,
and allows aircraft call signs to be displayed on the
ATC radar screen. Mode S transmits a unique 24-bit
aircraft address to greatly reduce the probability of
identification errors.
Aircraft address
AvSafety seminars
CASA’s successful AvSafety seminar series returns in 2012
with two new topics added to the line-up. And … you can now
register online to attend the next seminar in your area.
AvSafety seminars are aimed at everyone in the aviation
community, and are held in regional centres, as well
as in capital cities. In 2011, more than 5000 people attended
120 AvSafety seminars run by CASA across the nation.
The 2012 seminar program continues with a new focus on
two key issues: aviation safety resources on the internet
and human factors in aviation.
There is a wealth of official and unofficial information
on aviation to be found on the internet, but the key is
understanding where to find the official information you need.
The ‘aviation resources on the internet’ seminar will guide
attendees on how to find information on the official websites
most people in aviation need to use: CASA (www.casa.gov.
au), Airservices Australia (www.airservicesaustralia.com),
the Bureau of Meteorology (www.bom.gov.au) and the
Australian Transport Safety Bureau (www.atsb.gov.au).
The seminar will demonstrate how to find training materials,
general information, advice and regulations, as well as how
to lodge reports (such as SDRs—service difficulty reports)
and access self-learning resource centres. The aim of the
seminar is not to explain each of the websites in detail, but
to give attendees an understanding of the sort of information
they contain and to encourage attendees to explore them on
their own.
(*A new companion kit, Safety Behaviours—Human Factors
for Engineers, is in production, due for release in June 2012.
To ensure consistency of the two kits, the Safety Behaviours—
Human Factors for Pilots is being reprinted. It is therefore not
available from the CASA online store until late April; however,
until then, it can be downloaded from the resources section of
the Skybrary website – www.skybrary.aero)
Both topics are applicable to all members of the wider aviation
The safety seminar program also covers a wide range of other
topics, from airmanship to glass cockpits, and maintenance to
fuel management.
Go online to the ‘Seminars and Workshops’ section of the CASA
website (which you can find via the Education dropdown menu
on the top navigation bar) to request a seminar in your area.
All seminars are sponsored by CASA, and are free to attend.
Seminars 2012 … New Year, New Look
The ‘human factors’ seminar looks at how an understanding
of human performance is important to the safety of all aspects
of aviation operations. The seminar uses the kit, Safety
Behaviours—Human Factors for Pilots*, produced by CASA,
as its major resource. There will be a focus on the major
elements that make up the study of aviation human factors
and a demonstration of how they can be applied in a practical
way to everyday operations. People attending this seminar will
be provided with resources so they can research in greater
detail the aspects of human factors relevant to their operations.
This topic is vital as human factors is fast becoming a major
safety focus for both CASA and the International Civil Aviation
Organization (ICAO), and a required part of new aviation
Flight Safety Australia
Issue 85 March-April 2012
Alternatively, you can follow this link:
to see the 2012 schedule for a seminar in your area.
This year, if you wish to attend an AvSafety seminar, you register online. Simply follow the link above, click on the ‘Register’
option and follow the instructions. You do not need a user name or password to register for seminars, and there is no cost
involved. Once you register, you will receive a booking reference, which you should print out and bring to the seminar.
Informing and entertaining pilots for over 20 years.
$40 (4 ISSUES)
Use coupon code: FSAFY
Offer valid for print subscriptions of Australia only.
36572_2_HN Flight Safety TPH.indd 1
6/02/12 11:07 AM
The dynamics of flight
Lift-off: how the media took flight with
an old story
To those who know aerodynamics intimately
it’s not exactly news, but a viral video on
YouTube has revived the public discussion on
how a wing creates lift.
‘Cambridge scientist debunks flying myth’ proclaimed the
London Daily Telegraph of 24 January. ‘Engineer debunks
theory of flight,’ trumpeted The Sydney Morning Herald on
26 January. Er, not quite—the truth has been available for
years. But any chance to revisit the fundamentals of lift is
worth taking …
Professor Holger Babinsky, of Cambridge University has been
mildly annoyed at the persistence of the ‘equal transit time’
fallacy for many years. This is the sentence that persists in
popular explanations, including some aviation theory textbooks
(Babinsky found one at his daughter’s school). It says that
when the airflow separates to go over and under a wing,
Bernoulli’s principle dictates that the upper and lower streams
will meet at the same time at the trailing edge.
So when Cambridge University proposed he contribute to a
series of Science in a Minute videos he had a ready topic.
‘The university wanted to accompany this by a press release
and it all took off from there,’ he told Flight Safety Australia.
‘In the university statement we have been very careful to avoid
giving the impression that this is new.’
Photos: Screen captures from Cambridge University’s video
His video, posted on YouTube, (and at http://preview.tinyurl.
com/6wyfea6) uses interrupted smoke streams to show that
the top stream arrives at the wing’s trailing edge much sooner
than the lower stream.
Under this explanation there is no prediction that air from
above and below the wing must rejoin at the same time at the
trailing edge. ‘There is no need even to introduce Bernoulli’s
equation,’ Babinsky concludes.
A 2003 paper by Professor Babinsky in Physics Education
(at http://preview.tinyurl.com/72bnyeq) explains what is
CASA engineer, Neville Probert, does not believe Bernoulli’s
principle should be thrown out. But he agrees that equal transit
time is a demonstrable fallacy.
Air moving over a wing can be thought of as layers of
streamlines—and smoke streams in a wind tunnel can
illustrate these. Babinsky says ‘the wing’s airfoil shape causes
curved streamlines, centripetal force acting on the air, and a
progressive drop in pressure towards the centre of curvature
of the streamlines’. This accounts for the lower pressure on
the upper surface of a wing. There is a also a downwards flow
of air as it leaves the wing (as any student pilot who has tried
to land a low-wing aeroplane can attest).
‘It is important that pilots accept the practicalities of lift
and have a sound understanding of the implications for
drag, stalling and spinning,’ he says. ‘There are a number
of suitable explanations to choose from. Pilots should
choose the explanation of lift that they find most satisfactory
and that matches their background knowledge.’ Babinsky
is philosophical too. ‘Clearly Wednesday (25 January)
was not a big day for news but the response has been
overwhelmingly positive.’
Flight Safety Australia
Issue 85 March-April 2012
The trouble with cables
Aircraft owners have had a timely reminder of the importance of flight control cable
maintenance. The basics of cable maintenance are as important as ever, particularly
given the ageing of some of the Australian general aviation fleet
Flight Safety Australia’s January 2012 story about a control
cable failure turned out to be only the first chapter in CASA’s
response to the issue. Between printing and distribution of
the magazine more cases of control cable wear or failure in
some Beechcraft aeroplanes were discovered, prompting a
series of airworthiness directives for mandatory inspections
of the cables on Beechcraft Debonair, Bonanza and Baron
models. Seven cases of frayed or broken cables have been
found so far in response to the directives.
But no aircraft owner can afford to be smug. Cables are
critical maintenance items on any aircraft that uses them
because of their obvious importance to flight control.
Regardless of age, cables require close attention. They are
a maintenance sensitive item.
There are five major points about cable maintenance
aircraft owners and maintainers should revisit, particularly
at this time.
1. Wear
Under normal use cables wear, unavoidably, in two ways.
External wear comes from the abrasion of the cable’s
individual wires, coming into contact with pulleys,
guides, rubbing strips or, sometimes with poorly installed
wiring or other fittings. A recent service difficulty report
describes an egregious piece of mis-rigging. The elevator
trim cables on a single engine aircraft had been replaced,
but mis-routed, which brought them into contact with
an electrical wiring loom. Someone who should have
known better wrapped the electrical cables in tape in
an effort to prevent the cables from cutting through the
electrical wiring.
An unusual feature of external wear is that it seems
to affect cables that make small direction changes
at pulleys more so than cables that make sharper
direction changes. Lightly loaded pulleys, for example,
may revolve slowly during flight in response to engine
vibration, wearing the cables.
Cable wear patterns
Source: Figure 7-17, Advisory Circular 43.13-1B
Internal wear is much more difficult to detect, and comes
from wires and strands in the cable rubbing against each
other at the point where the cable changes direction over
a pulley. Internal wear is greatest at the point where the
cable changes direction, and is related to the radius of the
direction change. A small radius produces more internal
wear, as the cable has to bend more sharply.
The trouble with cables
2. Fatigue
Related to wear is fatigue, which can take the form of work
hardening and brittleness of individual wires, or strands of
wires, in a cable. Fatigue is an inevitable consequence of a
cable doing its job over several years, but can be accelerated
when aircraft are parked in the open with their flight controls
locked in the cabin and the control surface still free to move.
The movements caused by wind on the ground take a toll on
the cables that may be the equivalent of hundreds of hours
extra flying time.
To combat the effects of corrosion on coated carbon steel
cables, some manufacturers have introduced stainless steel
cables. While this seemed a good idea at the time - stainless
steel is a very effective material in marine use - they have been
found to wear far more rapidly than plain old, plated carbon
steel. An FAA special airworthiness inspection bulletin (SAIB:
CE-12-01) says manufacturers are now moving away from
stainless steel. This is backed up by CASA’s considerable
case log of wear-related failures in stainless steel cables.
However, the effects of fatigue can be minimised, or at
least brought to acceptable levels, by correct maintenance
of cables.
The FAA now recommends that stainless steel cables
only be used in marine environments where corrosion is
a major problem.
3. Corrosion
4. Tension
Corrosion is another enemy of cables. The extent and rate of
corrosion is affected by where the aircraft is flown and stored.
Cables that run near batteries, toilets and galleys, or that are
exposed in wheel wells, or other open areas, are particularly
susceptible to corrosion. Corrosion pitting on the cable acts
as a stress raiser and significantly reduces the fatigue life of a
cable. Another characteristic of cable corrosion is that it can
be insidious. Cables can be riddled with it while appearing
sound from the outside.
The literature on cable wear and maintenance dates well
beyond 1957, but in that year, an airworthiness directive was
brought out for Auster A61 aeroplanes following a series
of rudder cable failures. The AD required that the cables be
removed and inspected every 100 hours. The cables had failed
mostly due to fatigue, it seems, after vibrating in response
to frequency generated by the aircraft’s engine, propeller or
There is at least one well-documented anecdote of an
apparently serviceable looking cable with a very sound coating
of anti-corrosive compound which snapped when an engineer
accidentally leaned on it. The commuter aircraft’s flight control
cable was riddled with corrosion beneath its covering of
anti-corrosive compound. The compound had served to retain
moisture: as well as keeping water out, it also kept water in.
If cables were improperly tensioned, in effect, they behaved
like guitar strings becoming more sensitive than they should
be to the vibrations from the engine and propeller.
As a general rule, under-tensioned cables are subject to lowfrequency vibrations, and over-tensioned cables are subject to
high-frequency vibrations. This is in addition to the problems
of loose control feel that result from under-tensioned cables
and tight control feel, sometimes coupled with restricted range
of motion, that accompanied over-tensioning.
The solution is tensioning the cable to manufacturer
specifications, using an accurate and calibrated tensiometer
and thermometer.
7 x 19
7 x 19
Internal end view of cable wear
Source: Figure 7-19, Advisory Circular 43.13-1B
6 x 19
7 x 19
6 x 19
Flexible cable cross section
Source: Figure 7-8, Advisory Circular 43.13-1B
6 x 19
Flight Safety Australia
Issue 85 March-April 2012
Pulley wear patterns
Source: Figure 7-20, Advisory Circular 43.13-1B
5. Temperature
The cable tension is frequently specified by the manufacturer
for a certain temperature range. This is because an aluminuim
fuselage expands and contracts at a different rate to the steel
cables. If cables are not correctly tensioned it can result in the
cables going slack in cold weather or at high altitude. It can
also result in cables becoming too tight during hot weather.
The need to check
It is to be expected that there will be more cable changes
done this year in response to CASA’s series of airworthiness
directives. When cables are changed, duplicate inspections for
correct run and correct response to control surface are critical.
But cable replacement has its own hazards. It has been known
for aircraft to have passed through these inspections, and still
have their controls rigged incorrectly - even backwards.
As in so many areas of aviation you, the pilot, are your own
last line of defence. One thing you can tilt in your favour is
your daily/pre-flight inspection. Take advantage of the quiet,
Cable inspection technique
Source: Figure 7-16, Advisory Circular 43.13-1B
before the engine starts and gyros start running up, to really
listen when you move the controls. Is there any unusual noise
or binding when you move the control column or surfaces?
Later, at the threshold, check again, and not just a cursory
glance. Do the controls really move in the right direction? Do
they really feel free? A few moments of sensitive observation
before you commit to the sky could save you from being the
victim of a cable catastrophe.
Pull-out section
19 Nov 2011 – 6 Feb 2012
Note: Similar occurrence figures not included
in this edition
Aircraft above 5700kg
Airbus A320212 Elevator, spar/rib rib corroded.
SDR 510014117
LH elevator No10 rib corroded and cracked at aft end.
P/No: D55281546200.
Airbus A320232 Escape slide cable frayed.
SDR 510014160
LH aft door slideraft assembly deployment wire cable
frayed. Found during slideraft removal.
Airbus A320232 Hydraulic system, main hose
ruptured. SDR 510014195
RH main landing gear inboard lock stay hydraulic
hose ruptured. Loss of green system hydraulic fluid.
P/No: 201655146. TSN: 9,723 Hours/5,846 Cycles.
Airbus A320232 Landing gear retract/extension
system hose sheared. SDR 510014184
Upon selection for gear up after take-off the landing
gear did not retract with various ECAM messages.
Green hydraulic system failure. Upon landing and
inspection the R/H main landing gear lockstay
actuator hose was found to have sheared from its
P/No: 201655147. TSN: 9,719 Hours/5,844 Cycles.
Airbus A321231 Public address and
entertainment system battery overheated.
SDR 510014137
IPad external battery overheated with electrical smell.
Investigation continuing.
Airbus A330202 Wing, miscellaneous structure
cover missing. SDR 510014047
LH outboard flap cover missing on the fairing for No3
flap track. Suspect that the panel detached during
flight. The panel was sighted (fitted) prior to flight.
P/No: F5757416100000.
Airbus A330301 Landing gear brake system
hose ruptured. SDR 510014228
Aircraft returned to gate due to green hydraulic system
failure.L/H main landing gear green hydraulic system
brake supply line found to be ruptured.
P/No: AE2463936G0265.
ATR 72212A Fire detection system fire warning
system suspect faulty. SDR 510014146
No1 engine fire warning. Investigation could find no
evidence of fire. Further investigation found that the
engine fire warning system is susceptible to tail winds
when engine is feathered.
Bae 146300 pitot tube fod. SDR 510013906
Rejected takeoff due to ASI failure. Investigation found
Captain’s pitot tube blocked by a bug.
Bae JETSTM4101 Cargo/baggage doors roller
separated. SDR 510013957
Aft cargo door upper forward roller separated from
door rails. Incident occurred while door was open
during loading.
P/No: 1415206091. TSN: 23,107 Hours/27,605
Cycles. TSO: 23,107 Hours/27,605 Cycles.
Beech 1900D Elevator, spar/rib fitting cracked.
SDR 510014040
RH elevator torque tube adapter/fitting contained
circumferential cracking between two of six rivet holes
in the fitting flange.
P/No: 1016100171.
Boeing 737376 Fuselage main, longeron/stringer
stringer cracked. SDR 510013911
Stringer splices located at BS 907 stringer 4L and 4R
cracked over butt strap splice.
Boeing 737476 Aircraft fuel crossfeed valve
failed. SDR 510014213
Fuel crossfeed valve failed to close.
Investigation found crossfeed valve actuator
and gate unserviceable.
P/No: 737M28500011. TSN: 57,802 Hours.
TSO: 14,522 Hours.
Boeing 737476 Air distribution fan
recirculation fan failed. SDR 510014002
Electrical smell in area of rear galley.
Investigation found LH recirculation fan extremely hot.
P/No: 6454051. TSN: 64,478 Hours.
TSO: 64,478 Hours.
Boeing 737476 Passenger station equipment
system seat separated. SDR 510014114
Passenger seat 14ABC separated from seat track.
Investigation found the forward RH fitting had
migrated out of the frame. Investigation continuing.
Boeing 7377BK Pneumatic distribution system
bleed air contaminated. SDR 510014174
Bleed air system system contaminated with oil smell.
Suspect caused by overnight engine wash.
Boeing 7377FE Cabin cooling system actuator
failed. SDR 510014235
Warning light during flight “ram door full open”.
No change in air conditioning when tried cooling and
warming. Defect confirmed, MEL applied.
P/No: 5416744. TSN: 22,526 Hours/12,776 Cycles.
Boeing 7377FE Hydraulic pump, (electric/
engine) unserviceable. SDR 510014038
RH engine driven hydraulic pump seized and drive
sheared. Metal debris completely blocked case
drain filter.
P/No: 66087. TSN: 22,026 Hours/12,530 Cycles.
Boeing 7377Q8 Fuselage main, structure window
frame cracked. SDR 510014205
RH No1 cockpit window frame cracked on C-D post.
Crack confirmed using FPI inspection.
Boeing 73782R Brake unserviceable.
SDR 510014170
No2 main landing gear brake assembly damaged
and partially disintegrated. Damage also to wheel
hub and heat shield.
P/No: 26123121. TSN: 20,674 Hours/10,842 Cycles.
TSO: 7,447 Hours/4,326 Cycles.
Boeing 73782R Galley station equipment system
galley odour. SDR 510013912
Burning smell in aft galley. Investigation found a
smouldering cleaning cloth on the G4 coffee maker
hotplate at location 407.
Boeing 737838 Drag control actuator ratio
changer unserviceable. SDR 510014109
No8 and No9 spoilers floating. Investigation
found a faulty spoiler ration changer. Spoiler mixer
P/No:251A1741-5 also changed.
P/No: 654637026.
Boeing 737838 Navigation system navigation
sys failed. SDR 510014011
No1 and No2 VHF nav panels failed. Loss of
navigational capability. Circuit breakers reset. Half
hourlater No1 VHF nav panel failed again. Aircraft
diverted to another airport. Investigation continuing.
Boeing 737838 pitot line disconnected.
SDR 510014149
Auto throttle disconnected during take-off.
Investigation found the piton connection to
Captain’s Air Data Module not properly connected.
Investigation continuing.
Boeing 7378BK Fuselage main, structure
window frame cracked. SDR 510014218
RH No1 cockpit window frame cracked in upper
outboard corner. High Frequency Eddy Current
(HFEC) inspection confirmed cracking.
P/No: 141A8800Y54.
Boeing 7378FE Brake pad separated.
SDR 510014016
LH main landing gear brake pads separated from
rotors causing wheel to jam.
TSN: 20,627 Hours/11,632 Cycles.
TSO: 9,740 Hours/5,861 Cycles.
Boeing 7378FE Elevator tab control system
spring sheared. SDR 510013924
RH horizontal stabiliser elevator tab control
mechanism spring (1off4) sheared and displaced.
Suspect manufacturing fault.
Boeing 7378FE Flight compartment lighting
reminder unit contaminated. SDR 510013964
Captain’s control wheel reminder aid unit smoking.
Investigation found electrical contacts contaminated
with “fluff” causing smoking and burning smell.
P/No: 3103.
Boeing 7378FE Fuselage main, bulkhead skin
cracked and corroded. SDR 510014238
Cracking and corrosion found in fuselage skin
(section 47, pressurized non-crown) in the location
of rear pressure bulkhead. Crack is approx 0.40”
long through entire skin thickness and corrosion
is intergranular. Swelling has caused the skin to
lift and crack. Temporary repair carried out under
CAR 35.Aircraft ferried unpressurized for further
assessment and permanent repair.
Boeing 747438 Ac power distribution system
cable worn. SDR 510014061
No2 and No3 engine Integrated Drive Generator
feeder cables rubbing on cable support brackets.
Investigation continuing.
Boeing 747438 Hydraulic pump, (electric/
engine), main pump cracked and leaking.
SDR 510014261
No2 engine driven hydraulic pump cracked
and leaking.
Boeing 747438 Passenger compartment lighting.
SDR 510013990
Upper deck LH rearmost mood light located above
seat 18AC sparking. Investigation found one wire
pulled from pin1 on the light connector DL9874 and
shorting against pin2. Investigation continuing.
P/No: 0203521001.
Boeing 747438 tyre failed. SDR 510013962
Main landing gear No14 tyre failed on takeoff
causing damage to RH wing landing gear fixed door.
Investigation continuing.
Boeing 747438 Waste disposal system waste
water leaking. SDR 510013987
Water leaking into Main Equipment Centre. Initial
investigation found major water leakage from galleys.
Investigation continuing.
Boeing 747438 Windshield de-ice short circuit.
SDR 510014107
Window 2L heating switch short-circuiting between
connector and airframe causing sparking and smoke.
Suspect caused by chafing of heat shrink.
P/No: 9750002002.
Boeing 767336 Wing, longeron/stringer stringer
cracked. SDR 510014180
During inspection in R/H dry bay stringer found to
have 2.25 inch crack.
Boeing 767338ER Adf system receiver failed.
SDR 510014044
No1 ADF receiver internal failure. Unable to reset
circuit breaker. LH ADF receiver and control panel
replaced. Investigation continuing.
P/No: 6225222102. TSO: 63,840 Hours.
Flight Safety Australia
Issue 85 March-April 2012
Boeing 767338ER Apu doors door separated.
SDR 510014108
APU inlet door separated in flight.
Investigation continuing.
TSN: 79,793 Hours. TSO: 26,003 Hours.
Boeing 767338ER Fuselage main, plates/skin
bracket failed. SDR 510014029
Hydraulic Motor Generator (HMG) power panel
P65 support attachment brackets failed. Initial
investigation found “lightning strike” burn marks on
the brackets. Investigation continuing.
Boeing 7773ZGER Escape slide reservoir
failed test. SDR 510014093
Door 1 LH slideraft reservoir assembly failed
hydrostatic test. Found during inspection iaw AD/
Gas/1. Investigation found damage to the reservoir
assembly at the threaded area of the “O” ring
sealing surface.
P/No: 660421. TSN: 13,134 Hours/1,133 Cycles.
Boeing 7773ZGER Tyre separated.
SDR 510014162 (photo below)
RH main landing gear No8 tyre tread separated.
Damage caused to RH engine stator case
acoustic liner.
P/No: APR07700R2. TSN: 1,749 Hours/129 Cycles.
TSO: 1,749 Hours/129 Cycles.
Bombardier DHC8102 Drag control actuator
unserviceable. SDR 510014092 (photo below)
LH outboard spoiler actuator unserviceable.
Investigation found actuator cracked and leaking.
P/No: A44700009.
Bombardier DHC8402 APU engine compressor
blade failed. SDR 510014112
APU impeller blade separated due to bending forces.
Investigation also found engine mount P/No:40012651-1 cracked. Exhaust silencer also cracked.
Investigation continuing.
TSN: 11,422 Hours/13,254 Cycles.
Bombardier DHC8402 Engine oil pressure
transducer failed. SDR 510014230
Main engine oil pressure transducer failed causing oil
pressure fluctuations. Following replacement of the
transducer, the oil pressures were indicating high and
were adjusted.
P/No: CPW312244801. TSN: 758 Hours/734 Cycles.
Bombardier DHC8402 Engine oil temperature
regulator bypass valve failed. SDR 510014214
LH engine oil cooler bypass valve failed.
TSN: 1,966 Hours/2,163 Cycles.
Bombardier DHC8402 Wheel nut loose.
SDR 510013945
LH main landing gear outboard wheel had 9 loose
nuts (finger tight). Investigation also found one
bolt sheared.
P/No: 42FLW720. TSN: 7,009 Hours/7,731 Cycles.
TSO: 28 Hours/40 Cycles.
British aerospace BAE1251000 aircraft
structures aircraft lightning strike.
SDR 510013954
Aircraft sustained two possible lightning strikes
during descent. Lightning strike inspection found the
following: LH aileron burnt, secondary burn to the top
tail cap, various rivets down the fuselage burnt.
Doug DC3CR1830 Engine oil cooler oil cooler
leaking. SDR 510014018
LH engine indicated low oil pressure and was
shut-down in flight. Upon landing oil was found on
LH nacelle and oil level in tank was low. LH engine
oil cooler replaced. Suspect oil cooler bench tested
for leaks and found to be leaking from centre core.
Possible centre core damage from last landing when
LH main wheel was off sealed runway.
P/No: V16011.
Embraer ERJ170100 Pneumatic distribution
system gasket unserviceable. SDR 510014068
No1 bleed air system leaking. Investigation
found an unserviceable interface gasket at the
LH wing precooler.
P/No: 17016603001.
Bombardier DHC8102 Power lever friction
brake faulty. SDR 510014065
Power lever friction brake leave assembly interfering
with flight idle gate allowing power levers to be pulled
through the gate without stopping.
Bombardier DHC8106 Hydraulic pressure
sensor pressure switch failed. SDR 510013936
Engine driven standby hydraulic pump pressure
switch failed allowing standby pressure to turn
the propeller.
P/No: 7G733. TSN: 14,982 Hours/13,856 Cycles.
TSO: 2,958 Hours/1,937 Cycles.
Bombardier DHC8202 Fuel transfer valve
check valve incorrect fit. SDR 510013963
Fuel transfer check valve incorrectly fitted 180
degrees out with the check valve hinge in the
lower position.
Bombardier DHC8315 Engine oil pressure
indicator faulty. SDR 510014142
LH engine oil pressure fell below 50psi limit.
Investigation found No1 engine oil pressure
indicator faulty.
Embraer ERJ190100 Aircraft structures fuselage
lightning strike. SDR 510014186
Lightning entered the nose of aircraft travelled along
the lower side of fuselage and the wing to body
fairing. Lightning exited at rudder tip cap and ejected
the upper most static wick. Caused dual HF comms
system failure.57 maintenance defect entries raised in
relation to this lightning strike.
Embraer ERJ190100 Escape slide support
cracked. SDR 510014268
LH aft entry door escape slide support board
centre attachment bracket cracked.
P/No: 4A402047.
Embraer ERJ190100 Flight compartment
windows windshield lightning strike.
SDR 510014204
RH windshield damaged by lightning strike.
Further investigation found multiple entry points
on the forward and centre fuselage and the exit
point on the LH stabiliser trailing edge.
P/No: NP18730116.
Embraer ERJ190100 Fuselage floor panel panel
corroded. SDR 510013978
Aft cabin floor structure RH shear panel PNo 17091919-001 corroded along forward edge upper
surface. Corrosion depth was beyond repair limits.
Aft cabin floor structure centre shear panel P/No
170-65928-001 also corroded. Depth of corrosion
approximately 0.203mm (0.008in).
Embraer ERJ190100 Hydraulic pump, (electric/
engine) unserviceable. SDR 510014073
No3 hydraulic system electric hydraulic pump failed.
P/No: 5116603. TSN: 7,244 Hours/6,663 Cycles.
TSO: 6,301 Hours/5,646 Cycles.
Fokker F28MK0100 Apu core engine aux
power unit surged. SDR 510014273
APU surging with intermittent low bleed pressure.
Boroscope inspection found evidence of black goo
and oil coming from the front of the compressor.
APU replaced. Investigation continuing.
TSN: 28,913 Hours.
Fokker F28MK0100 Auto throttle system
servo unserviceable. SDR 510013928
No1 engine thrust lever stuck. Thrust lever became
free when the auto throttle was disengaged.
Investigation found No1 autothrottle servo
Fokker F28MK0100 Brake brake disc cracked.
SDR 510014173
RH inboard brake assembly carbon discs contained
numerous hairline cracks. Crack lengths less than
25.4mm (1in).
TSN: 1,796 Hours/9,922 Cycles.
Fokker F28MK0100 Flight compartment windows
windshield cracked. SDR 510014001
Pilot’s windshield contained extensive cracking.
Caused by moisture hitting an electrical heating
element in the windshield. Suspect faulty seal
allowing moisture ingress.
Fokker F28MK0100 Main landing gear attach
section pintle incorrect fit. SDR 510014183
During scheduled maintenance of MLG change the
pintle pins P/N D12031-001 and D12030-001 were
found to be installed incorrectly between fore & aft.
It was noticed that these pins are able to be locked/
secured in their wrong positions even though there is
4mm difference in length.
Fokker F28MK0100 Pitot/static system pitot
head contaminated. SDR 510014155
System 1 pitot probe contaminated by wasp nest.
Fokker F28MK070 Landing gear actuator
actuator cracked. SDR 510014266
Main landing gear retraction actuator eye end cracked
in threaded area. Found during Magnetic Particle
Inspection (MPI). Suspect eye end incorrectly fitted
with the grease nipple pointing down.
Aircraft below 5700kg
Beech 200BEECH Power lever arm migrated.
SDR 510014015
FCU input arm found to have moved on shaft.
Unable to reduce engine power below 80% Ng.
Arm repositioned and secured.
P/No: 509440763.
Beech 200BEECH Trailing edge flap track broken.
SDR 510014060
RH outer flap inboard track broken away from the rear
spar structure. Further investigation found failure
of the lower attachment clips P/Nos 35-115393-1,
35-115393-3. Track to spar attachment angles also
pulled out of rear spar. Rear spar and adjacent wing
internal structure also damaged.
Beech 35C33 Elevator control system cable
unserviceable. SDR 510014154
Elevator down cable frayed with broken strands in area
located behind instrument panel.
P/No: 3352400061.
Pull-out section
Beech 36BEECH Elevator control system cable
frayed. SDR 510013966
Elevator down cable frayed and ready to fail at
pulley PNo 18754-6. Cable is located forward of the
instrument panel. Found following discovery of a
failed cable on a similar type aircraft (Beech E33)
with the same part number (PNo 33-524000-23).
P/No: 3652400023.
Beech 58 Mixture control cable failed.
SDR 510014236
LH engine mixture control cable failed at flexible to
solid joint.
P/No: 5038901229.
Beech A36 Elevator control system cable frayed.
SDR 510014203
Front elevator cable frayed in area around pulley
located behind instrument panel. Found during
inspection iaw AD/Beech36/54.
P/No: 3657400023.
Beech A36 Rudder control system cable frayed.
SDR 510014269
Rudder forward RH cable frayed. Cable is located in
the same area mentioned in AD/Beech35/74.
P/No: NAS304351696.
Cessna 172R Aileron control system aileron
system incorrect rigged. SDR 510014179
Ailerons found to be incorrectly rigged with 17
degree’s up travel but should be 20 degree’s +/- 1
degree. Aircraft has been recently imported to
Australia with 24.8 hrs total time.
Cessna 172S Main landing gear strut/axle/truck
axle corroded. SDR 510014226 (photo below)
During tyre change severe pitted corrosion found at
wheel axle underside and also on axle nut threads.
P/No: 0541191. TSN: 3,021 Hours.
Cessna 210L Landing gear position and warning
system wire broken. SDR 510013955
Main power wire for landing gear indicator lights
broken at first terminal board in nose wheel well.
Cessna 310R Landing gear system drive rod
sheared. SDR 510013902
Nose landing gear drive rod attachment fork failed and
sheared approximately halfway down the shank where
it attaches to the drive collar.
P/No: 52435182.
Cessna 402C Antenna corroded. SDR 510014051
Marker beacon antenna contained heavy exfoliation
corrosion. Minor corrosion also found found on
fuselage skin.
P/No: CI102.
Cessna 404CESSNA Wing spar spar web
cracked. SDR 510013939
RH wing main spar web cracked. Found following
removal of RH main landing gear actuator bracket
PNo 5841141-2 for cracking.
TSN: 11,473 Hours.
Cessna R182 Horizontal stabilizer structure
hinge corroded. SDR 510014189
RH horizontal stabiliser hinge assembly corroded.
P/No: 12324002. TSN: 4,353 Hours.
TSO: 4,353 Hours.
Cessna R182 Landing gear door actuator pin
migrated. SDR 510014166
Nose landing gear actuator downlock pin migrated
approximately 2mm (0.0078in) inboard to rest on
the nose landing gear actuator pushrod, preventing
full retraction. Pin is held in place by a small split pin
which had broken. Aircraft landed with nose gear not
fully extended and nose gear collapsed on landing.
P/No: 12802091. TSN: 2,611 Hours/372 Months.
Cessna U206G Wing, control surface attach
fittings bracket cracked. SDR 510013959
(photo below)
LH and RH aileron brackets PNo 1220052-17 and
PNo 1220052-18 cracked.
P/No: 122005217. TSN: 5,723 Hours.
Giplnd GA8 Horizontal stabilizer, spar/rib
rib cracked. SDR 510014006
Horizontal stabiliser rib flange cracked in area near
RH inside attachment bolt hole. Found during
inspection iawSB-GA8-2002-02 issue 6.
P/No: GA855102123.
Cessna 208B Engine air intake system lever
cracked. SDR 510014190
Inertial separator lever cracked at middle
attachment point.
P/No: 265805713.
Gulfstream 500S Trailing edge flap
control system cable failed. SDR 510013922
Trailing edge flap cable failed.
Investigation continuing.
Gulfstream 500S Trailing edge flap control
system cable frayed. SDR 510014219
Flap control cable when removed found to be frayed
through 30% of cable strands. Cable failure would
lead to assymetric flap condition. Defective cable
was found as result of company directive to replace
all primary flight control cables on AC50 fleet.
This is 2nd cable failure of same type. It is believed
that the flap cable is failing in an area that is not
readily accessible for visual inspection.
P/No: 50000439. TSN: 7,032 Hours/145 Months.
Jabiru SP470 Nose/tail landing gear strut/axle
suspension rubber deteriorated. SDR 510014120
(photo below)
Nose landing gear suspension rubbers deteriorated
and collapsed causing propeller to contact the
ground. Aircraft is registered with Recreational
Aviation Australia.
TSN: 212 Hours.
Pac CT4B Ac alternator unserviceable.
SDR 510013994
Alternator rotor driveshaft sheared.
P/No: ER28C. TSN: 50 Hours.
Parten P68B Aircraft fuel system filter
contaminated. SDR 510014222
L/H engine reported to be intermittently running
rough. Upon investigation severe corrosion and water
contamination found in fuel system at inlet fuel filter
(FCU) and airframe fuel filters both L/H and R/H.
Cessna 182Q Horizontal stabilizer, plates/
skin skin incorrect repair. SDR 510014239
(photo below)
Repair patch on horizontal stabilizer skin is
found not to comply with Cessna 182 structural
repair manual.
P/No: 123260032. TSN: 4,403 Hours.
Cessna 208B Aileron tab structure hinge seized.
SDR 510014052
Aileron trim tab hinge seized.
TSN: 7,947 Hours/8,734 Cycles.
Gulfstream 500S Fuel wiring wiring burnt.
SDR 510014224
L/H fuel Boost pump wiring found Burnt and
exposed at connector during troubleshooting of
a separate fault.
Defect entered on maintenance release.
Piper PA23250 Elevator tab control system cable
incorrect routed. SDR 510014249 (photo below)
Trim cable incorrectly routed. Adjacent wire
bundle had been shielded with electrical tape to
prevent damage.
P/No: 151310.
Giplnd GA8 Horizontal stabilizer, rib cracked.
SDR 510014138
Horizontal stabiliser RH rib cracked in rear lower area.
Further cracking found in area of attachment bolt and
spar doubler. Attachment bolt also found to be loose.
P/No: GA85510111. TSN: 2,952 Hours/84 Months.
Grob G115C2 Engine air intake system frame
cracked. SDR 510014212
Induction air filter cage aft lower frame cracked and
separated. Piece of frame entered the carburettor and
partially restricted butterfly valve movement.
P/No: 115C6601.
Piper PA31350 Navigation system navigation
sys failed. SDR 510013914
KNS81 navigation system failed with smoke coming
from component. Investigation found a blown
P/No: 066401000.
Flight Safety Australia
Issue 85 March-April 2012
Reims F406 Brake brake failed. SDR 510013900
RH brake failed during taxi. Brake pedal hit the floor.
Investigation continuing.
Reims F406 Non standard equipment system
inverter faulty. SDR 510013981
Electrical fumes in cockpit. Investigation found faulty
mission system radar inverter.
P/No: 1B10001G.
Seabrd SB7L360A2 Ailerons doubler cracked.
SDR 510014049
Aileron hinge doubler cracked in area of mass balance
attachment. Investigation found similar cracking on
another aircraft.
Swrngn SA227AC Aileron control system cable
unserviceable. SDR 510014041
Pilot reported autopilot would not hold heading or
make commanded turns.
P/No: 9923166001.
Swrngn SA227DC Cargo/baggage doors handle
incorrectly stowed. SDR 510013898
Cargo door warning activated. Investigation
found door handle not correctly stowed in recess.
Investigation continuing.
Swrngn SA227DC Control column section
bearing cap unserviceable. SDR 510014037
Pilot reported aileron controls felt stiff and binding.
Engineering investigation confirmed the fault.
P/No: KP16B.
Swrngn SA227DC Dc power distribution system
switch unserviceable. SDR 510014252
Bus tie switch intermittent in operation.
Switch had been fitted iaw Fairchild SB CC7-24-12.
P/No: 8781K11.
TSN: 628 Hours/486 Cycles/8 Months.
Swrngn SA227DC Pitch Trim actuator actuator
faulty. SDR 510014216
Stabiliser trim actuator slow in operation followed by
increasing requirement for forward control pressure.
Investigation continuing.
P/No: DL5040M8. TSN: 4,653 Hours.
TSO: 4,653 Hours.
Jabiru JABIRU2200B Reciprocating engine
internal oil system dipstick incorrect length.
SDR 510014122
Oil dipstick approximately 38.1mm (1.5in) too short.
Engine had just been overhauled. Aircraft is registered
with Recreational Aviation Australia.
Lycoming IO360L2A Reciprocating engine
cylinder section exhaust valve stuck.
SDR 510013935
No4 cylinder exhaust valve stuck open.
P/No: LW19001. TSN: 3,202 Hours.
Lycoming IO540K1A5 Engine fuel pump pump
damaged. SDR 510014089
Engine driven fuel pump failed. Spline failed.
Agusta Westland AW139 Ac power distribution
system relay unserviceable. SDR 510013940
Main battery relay (K3) failed. Investigation found
evidence of heat damage on the external surfaces
of the relay.
P/No: 11526203. TSN: 1,620 Hours/4,442
Cycles/4,442 Landings/48 Months.
Agusta Westland AW139 Fuselage main,
plates/skin cowling cracked. SDR 510013998
(photo below)
Top forward cowl cracked on internal surface at
Stn 6445 located above the No1 engine air intake.
P/No: 3G7106P08431. TSN: 464 Hours/834
Landings/12 Months.
Lycoming IO540K1A5 Engine fuel pump failed.
SDR 510014014
Engine driven fuel pump internal failure.
Investigation continuing.
P/No: 201F5003R. TSO: 434 Hours/8 Months.
Lycoming LTIO540J2BD Reciprocating
engine power section crankcase cracked.
SDR 510014147
RH engine Rh crankcase half cracked from No3
cylinder base. Crack length approximately
100mm (4in).
P/No: 11F20022D3. TSO: 1,045 Hours.
Lycoming O360J2A Fuel control/reciprocating
engines arm broken. SDR 510014208
Carburettor mixture control arm broken at cable
attachment bolt hole.
TSN: 427 Hours/10 Months.
TSO: 427 Hours/10 Months.
Lycoming O540F1B5 Reciprocating engine
cylinder section plug failed. SDR 510014248
(photo below)
Piston pin plug failed causing major damage
to piston.
P/No: 72198. TSN: 1,008 Hours.
Agusta Westland AW139 Hydraulic system,
main hose failed. SDR 510013961
(photo below)
No1 Pressure Control Module (PCM) hydraulic
pressure hose ruptured. Loss of hydraulic fluid.
Hydraulic pump replaced due to suspected
dry running.
P/No: A494AE3E00E0580X.
TSN: 1,434 Hours/3,812 Landings/35 Months.
Swrngn SA227DC Trailing edge flap actuator
actuator cracked and leaking. SDR 510014099
RH flap actuator casing cracked and leaking.
P/No: 2736053001.
TSN: 19,486 Hours/24,379 Cycles.
Piston Engines
Continental IO520C Reciprocating
engine internal oil system contam-metal.
SDR 510013923
Engine oil system contaminated with metal.
Low compression also found in No6 cylinder.
Engine returned to manufacturer under warranty.
Continental IO520L Reciprocating engine power
section nut split. SDR 510014135 (photo below)
Engine No4 cylinder through bolt nut cracked/split.
TSN: 686 Hours.
Lycoming TIO540A2B Reciprocating
engine power section crankshaft broken.
SDR 510014101
RH engine crankshaft broken through No6 connecting
rod journal/counterweight cheek.
P/No: 13F17776. TSO: 486 Hours/64 Months.
Lycoming TIO540J2BD Reciprocating engine
power section stud sheared. SDR 510013952
No5 cylinder bottom rear holddown stud sheared
flush with cylinder base.
P/No: 5015. TSO: 520 Hours.
PWA R985AN14B Reciprocating engine
cylinder section engine cylinder separated.
SDR 510014042
No2 cylinder head separated from barrel. Cylinder
stamped UT10 (ultrasonic inspection 2010).
P/No: 126742. TSO: 183 Hours.
Continental TSIO520VB Reciprocating engine
low oil pressure. SDR 510014072
RH engine oil pressure low. Investigation found oil
filter and pressure relief valve contaminated with a
large amount of carbon pieces as well as scoring of
the oil pressure relief valve seating surface.
Agusta-Bell A109E Exterior lighting wire worn.
SDR 510014034
Position light wire insulation worn through and short
circuiting where unsupported wire passes through
internal lightening holes in the stabilator.
Agusta Westland AW139 Hydraulic system, main
hose leaking. SDR 510013970
No2 main servo system hydraulic hose fire shielding
ruptured and hose leaking from the edge of the
swaged fitting.
P/No: A494AD2C00C0496X. TSN: 1,634 Hours/4,477
Cycles/4,477 Landings/48 Months.
Eurocopter EC135T2 Engine egt/tit indicating
system probe broken. SDR 510014090
(photo below)
No2 engine thermocouple probe broken.
Probe is located at the 4 o’clock position.
P/No: TC26801.
TSN: 458 Hours/537 Cycles/1,338 Landings.
Pull-out section
Eurocopter EC225LP Aircraft fuel distribution
system jet pump blocked. SDR 510013905
Forward fuel tank jet pump blocked preventing
fuel transfer.
P/No: 332A5211610001. TSN: 2,824 Hours.
Sikorsky S76C Main rotor gearbox gearbox
corroded. SDR 510014260
Main rotor gearbox No2 hydraulic pump mount
bore corroded.
P/No: 7635109600044. TSN: 8,383 Hours/15,002
Cycles. TSO: 2,575 Hours.
Sikorsky S76C Rotorcraft servo system servo
unserviceable. SDR 510014258
Aft main rotor servo feedback linkage drive pin
displaced by approximately 40mm (1.57in).
P/No: 7825001. TSN: 9,561 Hours/52,774 Cycles.
Sikorsky S92A Tail rotor gearbox gearbox
damaged. SDR 510014088
Tail rotor gearbox damaged by screw holding
two hydraulic hose clamps together. Damage
approximately 4.76mm (0.185in) diameter by
3.175mm (0.062in) deep. Investigation found
clearance when static but vibration can cause the
screw to contact the gearbox.
P/No: 9235806100043. TSN: 2,860 Hours/2,372
Cycles/2,372 Landings/48 Months. TSO: 2,860
Hours/2,372 Cycles/2,372 Landings/48 Months.
GE CFM567B Fuel controlling system
HMU suspect faulty. SDR 510014237
Aircraft returned from taxi due No#2 “ENG
CONTROL” light illuminated. No#2 engine hydro
mechanical unit replaced.
P/No: 5416744. TSN: 7,098 Hours/4,236 Cycles.
PWA PW150A Fuel control/turbine engines
fadec failed. SDR 510014063
LH engine Full Authority Digital Engine Control
(FADEC) failed. Investigation continuing.
P/No: 8193007008. TSN: 6,574 Hours/7,534 Cycles.
GE CFM567B Turbine engine compressor
section fan blade bird strike. SDR 510013984
No2 engine birdstrike. Investigation found significant
damage to No 10 and No 11 fan blades.
P/No: 3400010260.
PWA PW150A Turbine engine accessory drive
drive failed. SDR 510014004
No1 engine failed. Preliminary boroscope inspection
found the drive between the core engine and the
accessory drive gearbox failed causing loss of fuel
supply. Investigation continuing.
Lycoming LTS101750B1 Fuel control/
turbine engines fcu faulty. SDR 510013941
(photo below)
No2 engine N1, N2 and torque decreasing to zero.
Investigation found a faulty Fuel control Unit (FCU).
FCU removed.
P/No: 430128308. TSO: 444 Hours.
Rolls Royce BR700710A220 Turbine engine
accessory drive bearing suspect faulty.
SDR 510014167 (photo below)
Engine chip detector contaminated with a large
amount of metal filings. Suspect caused by
failure of the generator drive shaft bearings.
Generator also failed.
Turbine Engines
Allison 250B17C Fuel control/turbine engines
fcu faulty. SDR 510013907
LH engine Fuel control Unit (FCU) faulty. FCU had
been returned from overhaul but caused hot starts
during engine ground runs following SDRit.
P/No: 23065107. TSO: 861 Hours.
Allison 501D13 Turbine engine oil system pump
cracked and leaking. SDR 510014250
LH engine oil quantity diminishing. Investigation
found the rear turbine scavenge pump cracked.
P/No: 6821270.
Garrett TPE33111U611 Engine (turbine/
turboprop) turbine engine inflight shutdown.
SDR 510014031
Aircraft suffered an uncommanded yaw to the left.
This was accompanied by an oil pressure warning
light, sudden change in engine noise and a loss of
airspeed. Left engine failure. Initial investigation by
engineer found a quantity of metallic particles on
the LH engine magnetic chip detector and some
unusual noises from the LH engine gearbox when the
propeller was rotated by hand. Last oil filter and
SOAP sample 02Dec2011 with no unusual remarks.
Further investigation and details to follow.
Garrett TPE33112UH Engine (turbine/turboprop)
turbine engine contam-metal. SDR 510014256
LH engine chip detector illuminated. Initial
investigation found metal contamination. Engine
removed for further investigation.
GE CF680E1 Turbine engine turbine section
sleeve incorrect part. SDR 510013972
Engine High Pressure Turbine (HPT) damper
sleeve incorrect part for this model engine.
Damper sleeve PNo 1327M75P02 should be fitted
instead of PNo 1327M75P01.
P/No: 1327M75P01. TSN: 28,464 Hours/5,040
Cycles. TSO: 28,464 Hours/5,040 Cycles.
GE CFM567B Engine fuel pump leaking.
SDR 510013985
No2 engine fuel pump leaking from 50.8mm
(2in) blanking plug located on the top of the
pump resulting in pump replacement.
P/No: 8283005. TSN: 28,162 Hours/14,517 Cycles.
TSO: 8,948 Hours/4,650 Cycles.
Lycoming LTS101750B1 Fuel control/turbine
engines fcu seized. SDR 510014100
No2 engine Fuel Control Unit (FCU) drive seized.
FCU to fuel pump coupling internal splines stripped.
Investigation continuing.
P/No: 430128308. TSO: 2,050 Hours.
PWA PT6A112 Fuel control/turbine engines
fcu suspect faulty. SDR 510014077
During taxi after landing, No1 engine low oil
pressure and generator warning. Engine shutdown.
Smoke/fumes smelt so No2 engine shutdown
and aircraft evacuated with fire services called.
Investigation found No1 engine had flamed out
due to a faulty Fuel Control Unit (FCU).
P/No: 32447454.
TSO: 270 Hours/131 Cycles/3 Months.
PWA PT6A114A Fuel control/turbine engines
fcu suspect faulty. SDR 510014078
Engine parameters all rose beyond take-off limits
during cruise. Nil response to power lever and engine
eventually cut at 11,000 feet with aircraft gliding to a
successful landing. Suspect faulty Fuel Control Unit.
Engine had only 2.2 hours operation since overhaul.
Investigation continuing.
PWA PT6A42 Turbine engine reduction gear
damaged. SDR 510014053
Engine chip detector indication. Investigation found
substantial sun gear, planetary gear and bearing
damage in the reduction gearbox.
PWA PW120A Fuel control/turbine engines
plug dirty. SDR 510014175
No1 engine suffered a momentary power loss for
approximately 2 seconds. No1 engine ECU plug
cleaned. Slight fuel flow fluctuations during
ground run but cleared when fuel flow transmitters
were transposed.
PWA PW150A Engine fuel distribution
o ring deteriorated. SDR 510013956
LH engine leaking fuel from fuel heater transfer
tubes. Investigation found deteriorated “O” ring
seals PNo M83461-1-116 and PNo AS3209-126.
P/No: M834611116.
Rolls Royce TAY65015 Fuel control/turbine
engines FFR failed. SDR 510014030
LH engine failed to accelerate. Investigation
found Fuel Flow Regulator (FFR) unserviceable.
Investigation continuing.
P/No: CASC509. TSN: 10,810 Hours/9,364 Cycles.
TMECA ARRIUS2K Engine fuel distribution
pipe worn and damaged. SDR 510014209
Main engine fuel supply line between HMU and fuel
valve worn halfway through on 90 degree bend in
area where the line passed through the fire shield.
P/No: 0319739500.
TMECA MAKILA1A Fuel control/turbine engines
ecu unserviceable. SDR 510014069
No1 engine N1 rpm deteriorated accompanied by
a large bang and yawing. Engine eventually stabilised.
Investigation found a faulty Electronic Control
Unit (ECU). P/No: 0177698350.
Fuel pump TRW Hartzell propeller inc
201F5003R Pump damaged. SDR 510014089
Engine driven fuel pump failed. Spline failed.
Load frame cracked. SDR 510013969
Balloon burner load frame cracked in two places.
P/No: KLF201088CBS. TSN: 199 Hours/228 Cycles.
Sleeve incorrect part. SDR 510013972
Engine High Pressure Turbine (HPT) damper sleeve
incorrect part for this model engine. Damper sleeve
P/No 1327M75P02 should be fitted instead of
P/No 1327M75P01.
P/No: 1327M75P01. TSN: 28,464 Hours/5,040
Cycles. TSO: 28,464 Hours/5,040 Cycles.
Flight Safety Australia
Issue 85 March-April 2012
2 - 15 December 2011
Agusta A109 series helicopters
2011-0236 Main landing gear (MLG) actuator bracket
attachment bolts - replacement/inspection
Agusta AB139 and AW139 series helicopters
2011-0226-E Flight control collective control system
– inspection/installation
Bell Helicopter Textron Canada (BHTC)
206 and Agusta Bell 206 series helicopters
CF-2011-19R1 Incorrect assembly of hydraulic
servo actuators
Eurocopter AS 355 (Twin Ecureuil)
series helicopters
2011-0244-E Lights - position strobe light inspection/deactivation
Above 5700kg
Piston engines
Airbus Industrie A330 series aeroplanes
2011-0242 Windows - fixed windows/windshield
heating connectors - inspection/replacement
Teledyne Continental Motors piston engines
2011-25-51 Replacing CMI starter adapters due to
fractures in shaft gears
Airbus Industrie A380 series aeroplanes
2011-0248 Fuel - feed tank 1 and/or 4 main
and standby pump fault light flickering operational procedure
Turbine engines
International Aero Engines AG V2500 series
2011-25-08 High-pressure turbine (HPT)
Eurocopter AS 350 (Ecureuil) series helicopters
2011-0237 Engine controls - twist grip assembly adjustment/functional check/replacement
Below 5700kg
Aerospatiale (Socata) TBM 700
series aeroplanes
2011-0235-E Nose landing gear (NLG)/actuator
axle attaching bolt - check/replacement
Pratt and Whitney turbine engines - JT9D series
2011-25-10 High-pressure compressor
Pratt and Whitney turbine engines PW4000 series
2011-25-09c High-pressure turbine stage air seal
Boeing 767 series aeroplanes
AD/B767/243 Engine indication and crew alerting
system - CANCELLED
Boeing 777 series aeroplanes
2011-26-03 Prevention of electrical arcing on
the fuel tank boundary structure or inside the
main and centre fuel tanks
Airbus Industrie A319, A320 and A321
series aeroplanes
2011-0229 Forward fuselage frame (FR)
24 - inspection/repair
2011-0231 Fuselage - windshield central lower
node continuity fittings - inspection/repair
Emergency equipment
2011-25-01 Apical Industries emergency float kits
Bombardier (Canadair) CL-600 (Challenger)
series aeroplanes
CF-2011-45 Horizontal stabiliser trim actuator
attachment pins and trunnions not serialised
15 - 31 December 2011
Boeing 737 series aeroplanes
2011-24-12 Fuselage skin at stringers S1 and
S2 right, between STA 827 and STA 847
Bombardier (Boeing Canada/De Havilland)
DHC-8 series aeroplanes
CF-2011-46 Burnt alternating current wire bundle
under floor - cockpit door area
Bell Helicopter Textron Canada (BHTC) 206
and Agusta Bell 206 series helicopters
AD/BELL 206/130 Amendment 3 Main landing gear
cross tubes - CANCELLED
CF-1995-17R1 Main landing gear cross tubes
Boeing 767 series aeroplanes
2011-25-11 Operating program software for
engine indication and crew alerting system
Fokker F27 series aeroplanes
2011-0228 Wing main tanks - modification
(fuel tank safety)
2011-0234 Fuel - main wing tank - inspection/
Embraer ERJ-170 series aeroplanes
2011-12-01 Escape slide deployment failures
Bell Helicopter Textron Canada (BHTC)
407 series helicopters
CF-2011-17R1 Incorrect assembly of hydraulic
servo actuators
Fokker F28 series aeroplanes
2011-0227 Wing and integral centre wing tanks modification (fuel tank safety)
2011-0233 Fuel - wing and integral centre wing
tanks - inspection/modification
AMD Falcon 50 and 900 series aeroplanes
2011-0246 Time limits and maintenance
checks - airworthiness limitations - amendment/
Boeing 737 series aeroplanes
AD/B737/297 Amendment 2 - de-icing fluids and
main wheel well electrical connectors
Rolls Royce Germany turbine engines BR700 series
2011-0232 Engine - low-pressure (LP) compressor
booster rotor - inspection/rework
Above 5700kg
Fokker F50 (F27 Mk 50) series aeroplanes
2011-0228 Wing main tanks - modification
(fuel tank safety)
2011-0234 Fuel - main wing tank - inspection/
Fokker F100 (F28 Mk 100) series aeroplanes
2011-0227 Wing and integral centre wing tanks modification (fuel tank safety)
2011-0233 Fuel - wing and integral centre wing
tanks - inspection/modification
Embraer ERJ-190 series aeroplanes
2011-12-02 Escape slide deployment failures
Learjet 45 series aeroplanes
2011-25-03 Main landing gear actuator end
cap fatigue cracking
Bell Helicopter Textron 427 series helicopters
CF-2011-17R1 Incorrect assembly of hydraulic
servo actuators
Bell Helicopter Textron 412 series helicopters
2011-0247 Main Rotor - collective lever - inspection/
Eurocopter AS 350 (Ecureuil) series helicopters
2011-0244-E Lights - position strobe light inspection/deactivation
Piston engines
Engines - general
2011-26-07 Champion Aerospace (formerly Unison
Industries) (slick) magneto
SMA piston engines
AD/SMA/4 Air inlet manifold hose clamps CANCELLED
2008-0078R1 Engine air - air inlet manifold hose
clamps - inspection
continued on page 42
CALL: 131
02 6217 1920
or contact your local CASA Airworthiness Inspector [freepost]
Service Difficulty Reports, Reply Paid 2005, CASA, Canberra, ACT 2601
Online: www.casa.gov.au/airworth/sdr/
Data recovery
Fishing for chips
Modern electronic devices are giving accident
investigators a new way of investigating aircraft crashes
Flight data recording is no longer the exclusive preserve of airline
transport operations. It is entering general and sport aviation almost by
stealth, as accident investigators exploit the data-recording potential built
into modern consumer electronics.
‘There’s some digital data in almost every crash now,’ says Alex Talberg,
technical investigator with the Australian Transport Safety Bureau (ATSB).
‘Most electronics these days uses flash memory, whether it’s for
processing data or for storage of dates or last known information.’
‘Flash memory can withstand huge impact loads and fairly high
temperatures. I’ve seen research that says that data is only completely
lost at 450 degrees Celsius. It’s generally a stable and robust recording
Recreational Aviation Australia (RA-Aus) operations manager, Zane Tully,
says some modern GPS units automatically record and store a history
of height and track data of the aircraft’s most recent travels. In older
versions this function may need to be enabled, he notes.
‘In many cases a GPS unit’s memory was downloadable and when
analysed, provided valuable information about the fateful flight.’
‘The ATSB generously assists RA-Aus (and the police for that matter) with
data recovery from all types of devices like: GPS, EFIS, iPad and even
engine management systems that have inbuilt data recording software
and memory,’ Tully says.
Flight Safety Australia
Issue 85 March-April 2012
Among the devices that cross Talberg’s desk after a crash are
smartphones GPS receivers, (‘we see a lot of them, often damaged’), fuel
computers, engine monitoring units and engine management systems.
Engine electronics contain flash memory for data logging, or to store the
maps of engine fuel, ignition and spark configurations.
‘We get on average now two or three devices to work on from any
aviation accident. We’ll often get a portable GPS or a phone. There was
one accident where there were four people on the aircraft and three
smartphones were recovered,’ Talberg says.
We had another accident where we had a GPS and an iPad. The GPS
recorded up to five minutes before the accident because of buffering,
which is where it records to volatile memory and then transfers that on
to its non-volatile memory. Because of that buffer we lost the last five
minutes of data on the GPS, but the iPad we analysed had exactly the
same track, but continued all the way to impact.’
The electronic devices that end up on Talberg’s desk fall into two
categories: undamaged units, from which information is relatively easily
downloaded; and damaged units, which require one of three techniques
to extract their secrets.
‘First, we try to fix the device,’ says Talberg.’If that doesn’t work, we
transfer the memory on to a “golden chassis” unit and download from
it that way, substituting a working unit for the damaged one. The third
alternative is to download raw binary data from the flash memory itself.
You get binary data of zeroes and ones that has to be interpreted. We then
either work with the device manufacturer to decode it, or reverse engineer
the information by downloading known data on an identical device.’
Clues to a Spitfire mystery
On 22 October 2010, a replica Supermarine
Spitfire MK26 recreational/light sport aircraft
crashed near Gympie authorised landing
area, in Queensland, killing the pilot, Barry
Uscinski, 75. A former defence scientist
and academic, Uscinski was also a highlyregarded, aerobatic-rated GA pilot.
Recreational Aviation Australia (RA-Aus)
assisted the Queensland Police in their
investigation of the crash. Although it had
no flight recorder, the Spitfire replica had
an automotive engine with a Motec M600
engine management system.
The ATSB undertakes about three investigations annually involving this
level of in-depth data recovery from damaged electronic devices. Talberg
says a global community of investigators is developing, based around
sharing information on how to extract data from electronic devices.
RA-Aus asked the Australian Transport
Safety Bureau (ATSB) for technical
assistance to recover data from the M600’s
flash memory.
‘One of the first things we’ll do is ask several international agencies if
they have had any experience with similar units,’ he says. A complicating
factor is the rapid evolution of consumer electronics, which means that
different models of the same device may use different components
behind a similar interface.
ATSB technical investigators removed
conformal coating from the circuit board and
removed the flash memory from the circuit
board using a hot-air rework station.
Talberg says the increasing presence of flash memory devices can
have a positive effect on safety, provided they are set to record data.
He encourages pilots who carry and use handheld or built-in flash
memory equipment to set it up to record flight data.
‘No-one sets out to have a crash, but if the worst does happen, this is
a way to help investigators find out what happened - and contribute in a
small way to aviation safety,’ he says.
Tully says; ‘It goes without saying that ATSB’s assistance is a valuable
and integral affiliation that RA-Aus is thankful for.
‘This type of information is invaluable to RA-Aus investigators as it can
add a major piece to the accident puzzle.’
The investigators practised on a sample
circuit board provided by the manufacturer
before attempting the operation. On 2 May
2011, they successfully recovered binary
data from the flash memory.
The data allowed conclusions to be drawn
about engine rpm, manifold pressure and
throttle position during the Spitfire’s final
flight, which it logged at 16 minutes and 44
seconds. This information has been sent to
the Queensland state coroner.
Pull-out section
continued from page 39
Teledyne Continental Motors piston engines
2011-26-07 - Champion Aerospace (formerly Unison
Industries) (slick) magneto
Turbine engines
Engines - general
2011-26-07 Champion Aerospace (formerly Unison
Industries) (slick) magneto
AlliedSignal (Garrett/AiResearch) turbine
engines - TFE731 series
AD/TFE 731/33 Amendment 1 - LPT stage 1 nozzle
and disks
Bombardier (Boeing Canada/De Havilland)
DHC-8 series aeroplanes
CF-2012-01 Beta warning horn system failure
CF-2012-02 Rudder control system - seizure of
the rudder feel trim unit
CF-2012-03 Electrical power - wire chafing within
the alternating current contactor box
British Aerospace BAe 146 series aeroplanes
2012-0003 Ice and rain protection - wing leading
edge anti-icing piccolo tube end cap - inspection
Embraer ERJ-190 series aeroplanes
2012-01-01 Main landing gear (MLG) side stay
Rolls Royce turbine engines - RB211 series
2011-0243 Engine - low pressure (LP) fuel tubes and
clips - inspection
Fokker F28 series aeroplanes
2011-0227R1 Wing and integral centre wing tanks modification (fuel tank safety)
Turbomeca turbine engines - Arriel series
2011-0249 Engine fuel and control - digital engine
control unit (DECU) - identification/replacement
Fokker F100 (F28 Mk 100) series aeroplanes
AD/F100/34 Amendment 2 - nose landing gear main
fitting - CANCELLED
2011-0227R1 Wing and integral centre wing tanks modification (fuel tank safety)
2012-0002 Landing gear - nose landing gear main
fitting - inspection/modification/replacement
Radio communication and navigation equipment
2011-0239 Navigation - radio altimeter
indicator- modification
1 - 12 January 2012
Bell Helicopter Textron 212 series helicopters
2012-0001 Main rotor - main rotor blades inspection/replacement
Enstrom F-28 series helicopters
2011-26-10 Modification of the lateral and
longitudinal trim actuator assembly
Eurocopter SA 360 and SA 365 (Dauphin)
series helicopters
AD/DAUPHIN/94 - main rotor drive - CANCELLED
2007-0288R1 Main rotor drive - main gearbox (MGB)
planet gear carrier - inspection/replacement
Kawasaki BK 117 series helicopters
TCD-7805A-2011 Flight manual temporary
revision - generator failure
Below 5700kg
Beechcraft 55, 58 and 95-55 (Baron)
series aeroplanes
2011-27-04 Airspeed indicator - STC SA1762SO
Beechcraft 200 (Super King Air)
series aeroplanes
AD/BEECH 200/67 Amendment 6 - fuselage rear
pressure bulkhead
Above 5700kg
Airbus Industrie A330 series aeroplanes
2012-0005 Fuselage - belly fairing rods - inspection
Beechcraft 1900 series aeroplanes
2011-27-51 Elevator bob weight (stabiliser weight)
Boeing 737 series aeroplanes
AD/B737/297 Amendment 3 - de-icing fluids and
main wheel well electrical connectors
2011-26-09 Replacement of the thumbnail fairing
edge seals
2011-27-03 Horizontal stabiliser trim actuator
(HSTA) - inspections/lubrication/overhaul/
Piston engines
Lycoming piston engines
AD/LYC/90 Amendment 2 - fuel injection
supply lines
Teledyne Continental Motors piston engines
AD/CON/60 Amendment 3 - fuel injection
supply lines
AD/CON/81 Amendment 1 - Unison Industries
(slick) magnetos - CANCELLED
Turbine engines
General Electric turbine engines - GE90 series
2009-25-14 Stage 6 LPT blades
2011-26-11 Inspection of stages 1-2 seal teeth of
the HPC stages 2-5 spool
Rolls Royce Germany turbine engines BR700 series
AD/BR700/10 Amendment 1 – high-pressure turbine
(HPT) time limits - CANCELLED
2007-0152-CN engine – high-pressure turbine (HPT)
disc assembly - reduction of the time limits manual
maximum approved
13 - 26 January 2012
Agusta A109 series helicopters
2011-0236 (correction) Main landing gear (MLG)
actuator bracket attachment bolts - inspection/
Below 5700kg
Beechcraft 33 and 35-33 (Debonair/Bonanza)
series aeroplanes
AD/BEECH 33/48 Beechcraft forward elevator
cable - replacement
Beechcraft 35 (Bonanza) series aeroplanes
AD/BEECH 35/74 Beechcraft forward elevator
cable - replacement
Beechcraft 36 (Bonanza) series aeroplanes
AD/BEECH 36/54 Beechcraft forward elevator
cable - replacement
Beechcraft 50 (Twin Bonanza)
series aeroplanes
AD/BEECH 50/34 Beechcraft forward elevator
cable - replacement
Beechcraft 55, 58 and 95-55 (Baron)
series aeroplanes
AD/BEECH 55/98 Beechcraft forward elevator
cable - replacement
Beechcraft 56TC (Turbo Baron)
series aeroplanes
AD/BEECH 56/36 Beechcraft forward elevator
cable - replacement
Fairchild (Swearingen) SA226 and SA227
series aeroplanes
AD/SWSA226/43 Amendment 7 - supplemental
inspection program and life limited items
Above 5700kg
Airbus Industrie A319, A320 and A321
series aeroplanes
AD/A320/147 Amendment 2 - life limited and
monitored parts - CANCELLED
2012-0008 Time limits and maintenance checks safe life airworthiness limitation items - ALS Part
1 - Amendment
2012-0012 Flight controls - flap interconnecting
strut - identification/modification/ replacement
Airbus Industrie A330 series aeroplanes
2012-0009 Flight controls - spoiler servo controls
(SSC) - Identification/operational test
Airbus Industrie A380 series aeroplanes
2012-0010 Indicating and recording systems - flight
data recording system (FDRS) - software installation
2012-0011 Auxiliary power unit (APU) air intake
duct access cover cut-out - inspection/repair
2012-0013 Wings - wing rib foot - inspection
Airbus Industrie A330 series aeroplanes
2012-0015 Flight controls - flap interconnecting
strut - identification/modification/ replacement
Boeing 767 series aeroplanes
2011-25-05 Main fuel tank boost pumps and centre
auxiliary tank override and jettison pumps
Bombardier (Boeing Canada/De Havilland)
DHC-8 series aeroplanes
CF-2012-04 Hydraulic accumulators - screw cap/
end cap failure
CF-2012-05 Chafing of the wire harness at the
wing leading edge
British Aerospace BAe 146 series aeroplanes
2012-0004 Time limits/maintenance checks
- airworthiness limitations - amendment/
Piston engines
Teledyne Continental Motors piston engines
AD/CON/60 Amendment 4 - fuel injection
supply lines
Turbine engines
General Electric turbine engines - CF34 series
2012-01-10 CVD support assembly removal
from service and determination of fan drive shaft
Flight Safety Australia
Issue 85 March-April 2012
IATA Training Centre
Now Open in Australia
ASSET Aviation International has partnered with
IATA to offer the highest-calibre commercial
aviation training in the world, right here in
Australia. Courses will be taught by IATA instructors
from around the globe. Courses include:
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Emergency Planning and Response Management
Aviation Internal Auditor
Internal Audit Implementation and Control
Training Needs Assessment
For course details and bookings:
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Instructional Technique
Instructional Design
Management of Training
Effective Communication Skills
2012 Courses are held in Brisbane. Qualifications gained are
internationally recognised.
Visit www.aviationclassroom.com for course details and
bookings or contact ASSET Aviation on 07 3103 6870 or
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Sharing the sky
Sharing the sky ... balloons
Aerostation (the art of ballooning) in Australia began in 1964,
more than 200 years after the first manned balloon flight in
the skies above Paris. There are currently over 400 registered
(but not necessarily active) hot air balloons in Australia, mostly
flying along the east coast, with a few in Western Australia and
South Australia.
These balloons operate under two distinct Australian
organisations: the sport balloonists (represented by the
Australian Ballooning Federation [ABF]); and commercial
balloonists, (represented by the Professional Ballooning
Association of Australia [PBAA]).
About 230 of Australia’s 400-plus balloons belong to the
ABF’s 290-or-so members, who fly over 1100 hours annually.
There are about 30 commercial operators in Australia, most
of whom belong to the PBAA. Together these commercial
operators fly for about 10,000 hours and carry 150–200,000
fare-paying passengers annually. The larger commercial
balloons can carry up to 24 passengers in ideal conditions.
Balloons in Australia range in size from 19,000 to 450,000
cubic feet, and can be up to 130 feet tall. Generally, sport
balloons are smaller and less expensive than those operated
commercially. Sport balloons are not permitted to carry farepaying passengers.
Australia has a significant record in international competition
and achievement, per capita and size, in comparison to the
rest of the ballooning world.
Where do they fly?
Recreational balloons cannot operate in controlled airspace
(unless authorised by CASA), but can access registered
aerodromes, as long as they carry and use radios and
transponders, as appropriate.
They usually fly below 3,000 feet, but the current Australian
(hot air) altitude record is 37,839 feet (11,533 metres), and
the world (gas) altitude record 113,740 feet (34,668 metres).
When flying over populated areas balloons currently must be
at or above 1,000 feet above ground level, but this is about to
change to 500 feet.
Photos 1-5, 7-8: courtesy of Andrew Chapman, photo 6, courtesy of Paul Gibbs
Balloons tend to fly in the early morning to take
advantage of decoupled catabatic or drainage
winds, temperature inversions and stable
atmospheric conditions. Experienced balloon pilots
have an impressive knowledge and understanding of
micrometeorology and regularly navigate their aircraft to
exact predetermined points. Balloons travel with the wind,
and vertical control is extremely precise. Nine fare-paying
passenger balloons recently flew from Bundoora in Victoria to
Moorabbin aerodrome and landed, as pre-arranged, between
the runways.
Equipment carried
Altimeter, variometer, envelope temperature indicator,
timepiece, compass, fire extinguisher, ground handling drop
line, GPS, UHF air-to-ground radio, VHF radio, and transponder
where required. There is no air speed indicator because there
is no airspeed in a balloon.
Recreational or sport ballooning refers to pilots who hold a
private balloon certificate issued by the Australian Ballooning
Federation and who do not carry fare-paying passengers.
The ABF is responsible for the day-to-day administration of
recreational ballooning in Australia, and under arrangements
with CASA, carries out safety and surveillance duties.
These include:
Safety issues
Landowner relations
Production of operations manual
Training and issuing certificates for pilots, instructors
and examiners
The Professional Balloon Association of Australia has three
classes of membership: AOC holders, commercial pilots and
associates (manufacturers, maintainers, legal and insurance
advisors etc.)
Some commercial operators run training courses for aspiring
commercial pilots. For a private licence from a zero hours
starting point, you need about two weeks, during which you
would have a minimum of 16 hours flight instruction and,
provided your progress is satisfactory, a flight test.
An Australian commercial licence requires a minimum of
Flight Safety Australia
Issue 85 March-April 2012
75 hours flying experience plus
eight hours of advanced training.
Australian licences are much
respected (and sought after) in
commercial operations internationally.
This may partly be due to ballooning being
taken up by people who are already involved in
other forms of aviation, but also because licensing
here is taken more seriously by operators and the
regulator than in many other nations around the world.
Sharing the skies with … balloons
Balloons are very visible and move very slowly. If an
aircraft comes out of cloud and sees them, it will be easier
for it to avoid them than vice versa.
Balloon envelopes are made in contrasting colours, to help
others to see them even better.
Below 500 feet, balloonists exercise extreme caution, care
and vigilance.
They always do downwind landings.
They do not do circuits on landing.
They carry and use radios and transponders, as required.
Please keep in touch.
Balloons are registered and subject to regular
airworthiness checks and maintenance.
Optical illusions can make balloons look closer and
higher than they actually are. Balloons have been reported
to be in one location, but tracked on radar somewhere
quite different.
They are courteous and polite to land occupiers and
respectful of landowners’ rights, and make reasonable
efforts to obtain permission prior to entering private
They leave launch and landing areas in the same
condition as they found them, with gates, fences and
locks as they were.
They fly in a manner that does not unduly disturb residents
or animals.
They always ascertain the location and dimensions of,
and any restrictions associated with, sensitive zones prior
to flying.
They avoid known sensitive zones, and communicate
information about new or changed sensitive zones to all
other pilots and operators.
Safety and balloons
Australia’s last hot air ballooning fatalities were in 1989. In
October of that year, four people were killed in two separate
accidents (both involving wirestrike), and earlier in 1989,
13 people died near Alice Springs in a mid-air involving two
balloons. The chief pilot and flying instructor at Brisbane
Hot Air Ballooning, Steve Griffin, was quoted in The Sydney
Morning Herald in January 2012 as saying most power line
incidents occurred in good weather, ‘when people were relaxed
and the flight was going beautifully.
‘It’s very important that when conditions are very benign you
don’t let your guard down, because that’s when these types of
incidents tend to happen and they happen to pilots of all levels
of experience.’
CASA has developed draft guidelines requiring commercial
balloon operations to implement a safety management system
that includes low-flying procedures. The new rules will be
released for public comment later in 2012. CASA has also
advised the ABF on developing
a coordinated training package
Cost of ballooning
for instructors.
A complete type-certified
Damian Croc, chief executive
sport balloon for private
of Professional Ballooning
operators, with two to
Association, quoted in
four people on board
January 2012 in a WA regional
(POB),costs $50–70,000
newspaper, said Australia had
new, or around $20,000
an exemplary ballooning safety
for a good second-hand
record. ‘Australian commercial
aircraft. An average
hot air balloon companies
charter balloon with
operate under strict regulations
eight to 11 POB costs
… [with] extensive operations
from $160,000 new. The
manuals subject [to] regular
envelope (specialised
audit by CASA. Commercial
nylon/Nomex fabric) lasts
balloon pilots here are also
400 to 600 hours and the
subject to regular supervised
basket (wicker/stainless
flight reviews to ensure safety,’
steel) lasts at least 1500
Croc concluded.
hours. LPG/propane fuel
is 65c per litre (60 to
Further reading
150 litres used per hour).
One or two people with a
CAAP 157-1(0) – Balloon
4WD and trailer follow the
flight over populous areas
balloon as retrieval crew.
CAO 95.54
Scud running
In the late 80s I was working at a flying school in Parafield, as
a junior grade 3 instructor – the lowliest of the staff – building
my hours and experience in the way everybody seems to have
to. It was my first job since obtaining my rating, and at first I
was grateful - there were plenty of aircraft and students, and
the weather was generally excellent. What more could I want?
Well pay, for one thing. Sadly, this was in short supply as
I was only paid for flight time – no retainer, and no briefing –
and was expected to be available seven days a week and
24 hours a day (how I ran my logbook was my business
I was told!).
I did what I was told, when I was told, and accepted the
instructions of my boss. This was almost my downfall one
day, when I was tasked with a two-hour navex with a student
in one of the Cessna 172s we had on line. It was to be part
of a multi-aircraft exercise, where three students would fly
the same basic route, leaving at 10-minute intervals, with the
middle aircraft (mine) doing the route in reverse. Normally, this
would have been fine, and it wasn’t the first time I’d done this,
but the weather was deteriorating, and the forecast was for low
cloud and rain, just when I would be trying to come back in
over the Adelaide hills via the lane of entry. As it was, much of
the route would need to be flown at low level, as the pre-frontal
Scud running
A junior instructor does as he is told and lives
to regret his über obedience
Name withheld by request
cloud was already down to 2-3000 feet. The aircraft departing
before and after me were planned to fly initially out to the east,
and then track northwards, eventually completing a huge loop
– almost up to Port Pirie – and returning to Parafield via the
coastal training areas. This would have them potentially scud
running along the coast, but that was much more acceptable
than trying to come in over the ranges with the same cloud
base – the path I was assigned.
I was concerned about this and approached the chief flying
instructor suggesting that I too should take the anti-clockwise
route. It wouldn’t have been any problem to replan, and the
student was already working on that anyway. He wouldn’t
give me a reason, just a firm ‘no’. This was not what I’d
anticipated, but I was just the junior, so my student and I
dutifully boarded our trusty steed and departed.
The navex went quite well for the first forty minutes or so, as
we flew along the coast past Dublin and Long Plains, and then
across to Clare and Burra before turning southwards for the
lane of entry and then Parafield. All the way, I was monitoring
the developing weather, and eventually decided that I needed
to cut the navex short, so had my student divert as early as
possible and track around the Edinburgh control zone and
training areas so that we could arrive at South Para reservoir
Flight Safety Australia
Issue 85 March-April 2012
in a timely fashion. In spite of this, we found that the low cloud
and rain had beaten us there and we were now – as predicted –
stuck on the wrong side of the ranges.
Since there was clearly no way we could get through the lane
of entry, we continued southbound in the forlorn hope that the
weather might improve sufficiently to allow a VFR transit of
Adelaide’s control zone and back to Parafield that way. We got
all the way to Murray Bridge without a single opportunity to
cross the ranges. Eventually, we turned northwards again and
found ourselves about 35 miles northeast of South Para, with
nowhere else to go.
Our options were now limited, and for a while it looked as if we
might have to divert to Waikerie or Renmark to land, leaving
us without transport, or funds, in a remote airfield on a Friday
afternoon! Not a particularly inviting prospect, but one we had
to consider.
The other option was to call Adelaide Approach and ask for
a low-level transit of Edinburgh’s control zone to arrive into
Parafield from the north. We did this, and after a little dodging
around low cloud, managed to weave our way overhead
Edinburgh. I had also dialled up the NDB as additional
navigational assistance, but insisted that my student maintain
visual contact with the ground, even if we got a little low.
Otherwise, we would turn around and head back for Waikerie.
Just north of Edinburgh, we encountered a very low band of
cloud – around 300 feet – but it was only narrow. The visibility
below it was good enough to see Parafield, so we continued,
calling visual with the airfield and being transferred to the
tower frequency.
We flew a normal, low-level circuit, followed by a very
welcome landing. Home at last. Needless to say, the other two
aircraft were already parked and everybody had gone home for
the weekend. Even the CFI had departed – even though I still
required direct supervision as a junior. Thanks a lot boss!
My student and I put the aeroplane to bed, and I sent him
home after a thorough debrief. Once alone, I took out an
incident report form, and documented everything for the
(then) DoT examiner who was likely to require some answers.
I placed the completed form on the boss’s desk and went
home. Next morning, I got a very irate phone call from him,
telling me that it was none of the DoT’s business, and that
he would not be submitting the report as he didn’t need the
interference that would result. It was interesting to see his
attitude, as I had been told when I joined the company that
‘we do things the right way – no exceptions!’
I phoned the local inspector to talk over the situation anyway.
He was concerned about the attitude of my boss, but together
we worked out that I had acted appropriately in the end, even
though I should never have departed Parafield in the first place.
I had learned several very valuable lessons that day:
1. Even though you may be junior in experience, you must
use that experience and your judgement to keep you out
of situations that could ultimately be dangerous or difficult
to recover from. Always leave yourself an escape route, or
plan for an early termination of the flight – even if it means
you have to wait it out a long way from home.
2. Never be frightened to stand up for what you believe
to be the right course of action. If it doesn’t feel right, it
probably isn’t right! Don’t be bullied by superiors or peers
into doing something you know to be foolhardy, wrong or
illegal. (See rule number 1)
3. Having found yourself in a difficult situation, never give
up. Work carefully and find the best solution, and don’t be
afraid to ask for help from the air traffic controllers. They
don’t want you in trouble any more than you do, so they
will work with you.
4. Don’t be afraid to own up to the authorities if you feel
the safety of the flight was in doubt, or you broke some
rules. Generally, you will find a willing listener, and sage
advice. You may still be punished or cautioned, but it will
be worse if they have to come looking for you!
5. Embarrassment – contrary to popular belief – is not
fatal. Foolhardiness however, can be.
Born toFl y
Born to fly
Name withheld by request
Experience and recency: fuelling the debate
After a few precious and very nerve-wracking seconds we
managed to land smoothly and safely before we taxied off
the active runway. We came to a complete stop, breathed a
sigh of relief and my instructor began to examine the cockpit.
After a few moments he stopped and stared, his head
looking down at the fuel valve and his eyes wide open.
‘The fuel valve is off!’
The gentle hum of the large turbo jet engines nursed me to
sleep on my way back to Hong Kong. I was one month old
in my first log book entry and my father, a Cathay Pacific
captain, was proudly bringing me home on my first flight
from Brussels, Belgium, arriving in Kai Tak at precisely 0115
on 27 Oct 1984. I know that he was already hoping I would
become a pilot like him some day.
Twenty-three years later I found myself working towards my
private pilot licence. I was sitting in the left seat of a Cessna
172, a bit nervous, but very excited about my first flight in
this new type after graduating from the Cessna 152.
The dangers of flying a new type of aircraft are found in
unexpected places. Thanks to standardisation of instrument
cluster layouts and engine control levers, some of the traps
and confusions are gradually being eliminated.
I began to go through the checklists and asked my instructor
if the fuel switch was in the on position. After a quick glance
and an ‘OK’ from him, we completed the rest of our checks
and taxied down the runway for the pre-flight take-off
checks. I took another quick glance at the fuel valve and all
was looking good to go for my first flight as pilot in a C172.
In this case the fuel valve on a C172 is quite different to that
on a C152. The rotary type of valve on the C172 can be
selected to left, right, off, or both tanks, with no separate off
switch in earlier models.
It had been six months since my last flight, and I caught
myself trying to remember all the important safety steps.
The run-up checks say that the fuel valve should to be set
to ‘both tanks’. The valve is similar looking to a pool pump
valve lever, which I had used only a few days earlier while
doing routine pool maintenance at our house. Perhaps my
familiarity with this system had affected my judgement as
to where the lever should be positioned for the selection
desired. I have since learned that a C172 is nothing like
a pool pump, even though it had me swimming in my
own juices.
My head was full of V speeds for this first C172 flight. At
that early point in my career I also knew I wasn’t familiar
enough with the sound of the engine, or how the aircraft was
handling to diagnose any problems. We finished our pre-flight
take-off checks and began to line up for the take-off.
I started to give the aircraft more power as we rolled down
the runway. So many things were running through my head,
Ts Ps green, airspeed live, no fire. Everything was looking
good as we lifted off the ground, but, without any warning,
the engine started to sputter and cough. Before I knew what
was happening my instructor cut in and said ‘I have control’.
I replied ‘You have control’ and he began to turn us around in
preparation for an immediate landing.
The tension was clear, and I could tell by the sound of his
voice that we were not safe, as he alerted the tower to our
return for a low-level circuit for immediate landing. That fear
in his voice was nothing compared to the sound our engine
was making as we began our descent, and prepared for our
emergency landing.
The C152 fuel switch is much simpler, with just an option for
on or off.
I set the C172’s valve to what I thought was both tanks. I had
my doubts and because I had never operated this system
before I asked my instructor whether I had indeed switched
the valve to the on position. He glanced down and nodded in
acknowledgement. He might have misheard my question and
probably didn’t imagine that anybody could make a mistake
with such a simple system. He might have also not realised
how confusing a fuel valve could be to someone who had
just graduated from the C172’s little brother, which was
almost identical in operation. Further research has shown
that I am only one of many who have fallen into this trap.
Flight Safety Australia
Issue 85 March-April 2012
After a few moments he
stopped and stared, his head
looking down at the fuel valve
and his eyes wide open.
In run-up and pre-take-off checks we both glanced down and
saw what we thought was a fuel gauge set to ‘both tanks’.
We had checked this valve three times and seen ‘off’ without
realising it. If our subconscious had a voice it would have
been screaming ‘ Look! It’s off!’
The aircraft took off and climbed to about 300ft before it
protested that it was starving. How could we have done all
our checks, taxied all the way across the airport and taken
off without any fuel being fed to the engine?
‘The fuel valve is off!’
Instructor-student trust is important so that the student can
gain confidence and autonomy in their flying.
Too much trust can cause dangerous situations, as we both
found out.
Also, trusting your instructor to know everything about you
and your level of knowledge can create potential crises.
My lack of knowledge of the fuel system could have been
our downfall, as I had spent all my study time learning the
C172’s limitations, speeds and procedures.
My questions should not have been ‘is the fuel on?’ but
rather, ‘ - how do I operate the fuel system?’ which would
have necessitated a full answer with undivided attention
rather than a quick nod.
People have told me since that this is an impossible situation,
but the aircraft had just been fully fuelled and must have had
enough fuel in her lines to take us up and very quickly back
down again.
If the fuel had been exhausted just seconds later we would
have been over factories and houses with very limited
landing options, if any. It is lucky in a way that the active
runway was so far from our starting point, and that our
engine starting quitting when it did.
My instructor was very quick to recognise the problem and
immediately acknowledged the need to land as quickly as
possible. My flying instincts had become dormant in the
months preceding the flight and I was not able to recognise
the problem as rapidly as he did – a wake-up call about the
importance of experience and recency to safe flying.
19 gal
Ask for an elaborated answer to questions relating to
important systems and procedures.
Instructors should look out for student mistakes in even
the simplest tasks.
Checklists should be vigilantly checked by all, especially
the ones that are carried out so routinely that we
sometimes forget to actually verify the item being
19 gal
Not very happy returns
Not very happy returns
Name withheld by request
... In that split second he had suffered deep cuts to
four fingers on his right hand.
I was 18-years-old, and each day I drove past the airport
heading to work. From the road you can see the hangars and
the aircraft parked on the apron, with at least two or three
aircraft flying circuits above. Sometimes I counted up to six
aircraft, sometimes more.
My birthday was a few months away. What better present to
give myself than flying lessons?
The following weekend I went to the airport, where in those
days every second building housed a flying school. For no
particular reason I chose a school that used Beechcraft
Sundowners–four-seat, low-wing, fixed undercarriage, with
a Lycoming 0-360 engine.
The staff were friendly, and after a brief chat, we scheduled
a trial instructional flight for the next day. Less than 24
hours later, I was back at the school meeting the instructor
who would take me for the flight, and just minutes after I
was airborne and heading towards the local training area.
Yes, I thought, this is definitely for me.
In the next few weeks I attended the necessary aviation medical,
filled in forms, bought text books and booked my first lesson.
Then the morning arrived.
The weather was calm, blue sky, and a mild temperature for
that time of the year. It looked like a great day for flying. I was
scheduled for the first lesson of the day and it was the first time
that day the aircraft would be used.
I met my instructor and we had a pre-flight briefing. Then it was
out to the aircraft, where I was shown how to perform the preflight inspection and check the fuel for water. My anticipation
and excitement were growing with every passing minute.
Finally we climbed into the aircraft and I sat in the left seat.
We made ourselves comfortable, adjusting seats and seatbelts.
My instructor then commenced the start-up procedure, while
talking me through it. I sat as an interested observer taking in
as much as I could.
Flight Safety Australia
Issue 85 March-April 2012
Everything was going to plan. My instructor flicked the
master switch on and turned the key. I expected the dials
to come alive, lights flash and the engine burst into life, but
nothing happened. Everything was quiet and the dials were
still. No response from the aircraft at all … silence.
‘Dead battery’, said the instructor. My anticipation and
excitement evaporated in an instant.
Just as he spoke, another aircraft from the school was taxiing
into a parking position close to our aircraft. Its pilot was a
student who was about to obtain his PPL. My instructor then
said, ‘I will show you how to hand start an aircraft’, and called
the other student pilot over. He explained the dead battery
situation and his intentions to hand start the aircraft and asked
for help to start our disabled aircraft.
I was now an interested spectator with absolutely no idea of
what was about to occur.
The student pilot sat in the aircraft and instructor gave him
instructions about the start-up procedure.
The instructor stood directly in front of the aircraft, grabbed
hold of the propeller blade on his left-hand side and proceeded
to turn the propeller several revolutions opposite to its normal
direction. He gave more instructions to the student pilot in the
aircraft and then, with his right hand, pulled down forcefully on
the right propeller blade in the normal direction. The propeller
turned and the engine coughed briefly but did not start.
More instructions to the student pilot, and the process was
repeated. The instructor performed his previous procedure of
turning the propeller in the opposite direction, then grabbing
the right-hand blade of the propeller with his right hand and
forcefully pulling down on it.
What happened next took place in a split second at high speed.
When the propeller blade was at about four o’clock, the engine
spluttered then backfired, and the propeller blade went in the
opposite direction to the instructor’s forceful pull.
The suddenness and speed of this change of direction caught
him completely by surprise and he was still hanging onto the
leading edge of the propeller.
His arm extended upwards and he only managed to release his
hand when he appeared to be at full stretch.
He was still able to stand, but was pale and slumped over,
grabbing at his bleeding right hand with his left one and
grimacing in intense pain. In that split second he had suffered
deep cuts to four fingers on his right hand.
His right arm was hanging limp and he said he thought that
his arm was broken, indicating an area close to the shoulder.
Blood was dripping through his fingers onto the tarmac and his
pain level appeared to increase. He did remain conscious and
was able to make his way to the office some 25 metres away
with the assistance of the student pilot. The staff gave him
first aid help and an ambulance was called. I stayed with the
aircraft until another instructor came over to lock it up.
Needless to say, my lesson and the instructor’s other lessons
for that day were cancelled.
This incident certainly did not put me off learning to fly, or off
that flying school. My first lesson was rescheduled for the
following week with another instructor, who turned out to be
the CFI.
I never saw the injured instructor again and the incident wasn’t
discussed with me or ever spoken about again.
I have often wondered why the instructor decided to show
a brand-new student a complicated, high-risk, dangerous
procedure that had claimed many victims. Why didn’t he just
ask the LAMEs who shared the school’s hangar to investigate
the flat battery?
Fast forward to the present day: had this accident occurred
now, I imagine I would have been debriefed, required to fill in
incident reports and offered access to counsellors. How times
have changed.
ever had a
Write to us about an aviation incident or
accident that you’ve been involved in.
If we publish your story, you will receive
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The Australian
If in doubt, notify the ATSB
Most people know the ATSB as
Australia’s national transport
investigator—the agency that
investigates aviation and other
transport accidents to find the
cause and prevent them from
happening again.
To help us do our safety job
in aviation, we are also the
notification point for all aviation
safety occurrences in Australia. This means that
whenever there’s an aviation incident or accident—no
matter how seemingly minor—you should notify us.
We use this information in two ways: to decide whether
to investigate an occurrence; and to make real practical
improvements to aviation safety. The data we get from
notifications helps us analyse trends, find patterns in
aviation safety and alert the relevant people to any
ongoing problem or risk.
But to do this effectively, we need to be told about these
occurrences. This is where we rely on the people at
the fore of the aviation industry: the operators, pilots,
engineers, and safety managers. Besides being a legal
requirement, your notification to the ATSB is invaluable
to helping prevent another accident. Ultimately your
notification could save a life.
If you’re not sure if an incident or accident is ‘notifiable’,
the best rule of thumb is to report it to the ATSB anyway.
That includes recreational and sports aviation as well.
We know that people are generally pretty good at
reporting already. But it could be even better. One
example: we’ll soon be publishing a safety investigation
report that reveals that at least 40 per cent of aviation
wirestrikes are not reported to the ATSB. This is a
startling find and we strongly encourage everyone
involved in a wirestrike to tell us about it.
We’re currently finalising some changes to the rules
for notification to make them clearer and simpler. In
the meantime, you can find more information on the
notifications process by calling 1800 011 034 or by clicking
the ‘Submit a mandatory accident or incident notification’
icon on the ATSB website www.atsb.gov.au.
Rare software glitch causes
sudden pitch down
sudden pitch down of a Qantas A330
Perth in October 2008, according to the
ATSB report into the incident.
At least 110 of the 303 passengers and
nine of the 12 crew members were injured.
Of these, 51 received hospital medical
was a unique event and extremely unlikely to
suddenly pitched down, due to a combination of problems involving two
air data inertial reference units (ADIRUs).
incorrect angle of attack data from one of the ADIRUs.
ATSB Chief Commissioner, Mr Martin Dolan, said that Airbus had taken
prompt action to reduce the likelihood of another similar accident.
Dolan said.
happen again.’
An extensive investigation into what triggered the ADIRU failure mode
concluded that it was very unlikely to have been caused by electromagnetic
interference from the Harold E. Holt Naval Communications station at
Exmouth or from a personal electronic device such as a laptop or mobile
phone. A range of other possible mechanisms were also discounted.
Mr Dolan stated that the ATSB investigation covered a range of
complicated issues, including some that had rarely been considered in
depth by previous accident investigations.
systems,’ Mr Dolan said.
Martin Dolan
Chief Commissioner
www.atsb.gov.au ■
Aviation Safety Investigator
Buckle up
Potentially catastrophic data error
9 January 2012.
three times. It then overran the runway
before hitting infrastructure more than
170 metres away.
assengers on board a Sydneybound Qantas A380 Airbus were
reminded of the importance of
About three hours from Singapore, the
Captain switched on the seat belt lights
to keep clear of thunderstorms. Ninety
two very short, but severe sets of
Despite the severity of the turbulence,
only seven passengers were injured in the
incident. None of these passengers were
wearing seat belts—most of the injured
were believed to be walking through the
cabin when the turbulence struck.
likely because the vast majority of
passengers were seated with their seat
belts fastened before the turbulence hit.
In fact, media coverage of the incident
quotes several passengers who noted how
fortunate they were for having their seat
belts fastened during the event.
accident where a Qantas Airbus A330
en route from Singapore to Perth that
due to a rare technical problem in the
who were seated without their seat belts
fastened, were injured.
Although some of those wearing a
seat belt were also injured, most of the
injuries occurred when unrestrained
much greater for those who were not
wearing a seat belt. ■
resulted in a near catastrophe for an
Emirates A380 Airbus at Melbourne
Airport on 20 March 2009. While taking
serious safety consequences,’ said ATSB
Chief Commissioner, Mr Martin Dolan.
been a number of other accidents and
incidents that involved similar errors in
‘All of those events had two basic elements
in common: the error in entering the
was not detected until well into the take-
Mr Dolan noted that, currently, the only
checks in place to prevent these types of
safety action that is occurring as a
accidents are procedural and vulnerable
result of the ATSB’s
to human error. ‘But
‘The aviation industry as a whole a lot of work is being
Mr Dolan was
realises the seriousness of these done to minimise the
speaking about the
risk of similar events in
issues and is working towards
release of the ATSB’s
future,’ he said.
a solution.’
EK407, with 18 crew and 257 passengers,
sustained a tailstrike on departure from
Melbourne Airport, Victoria.
result of the crew using incorrect takeerror was likely due to mistyping, when
a weight of 262.9 tonnes, instead of the
intended 362.9 tonnes, was entered into
subsequent checks without detection.
a number of systemic safety issues
investigation was supported by an
ATSB research report titled
performance calculation and entry errors:
A global perspective.
‘We now understand what caused the
error and why it wasn’t picked up,’ Mr
Dolan said. ‘We also know there have
developing technological aids to assist
aviation industry as a whole realises the
seriousness of these issues and is working
towards a solution.’
To stress that further action is still
needed with technological aids, the ATSB
has issued a safety recommendation
to the United States Federal Aviation
Administration. It has also issued
safety advisory notices to a number of
international aviation organisations.
the meantime of managing the problem
pilots face in deciding whether the
parameters calculated for a particular
A full copy of the investigation report
AO-2009-012 is available on the ATSB
website www.atsb.gov.au ■
Poor fuel management remains a safety risk
Is there enough left in the tank?
An avoidable tragedy
A fatal helicopter accident in the
Northern Territory has highlighted
the importance of pilots and operators
using consistent, reliable procedures to
independently verify the fuel quantity in
their aircraft’s tanks.
On 4 October 2010, the pilot of a
Robinson Helicopter R22 Beta was
mustering cattle on a station property
about 170 km east of Katherine, NT.
When the station owner was unable to
make radio contact with the pilot he
immediately conducted an aerial search.
The search found that the helicopter had
crashed heavily into the ground and the
pilot did not survive the impact.
The ATSB’s investigation found that the
helicopter’s engine had stopped while
operating at low altitude. The cause of
the engine stoppage was most likely due
to fuel exhaustion, which happens when
there is insufficient useable fuel to supply
the engine.
To maximise the performance of the R22
during mustering, the station’s pilots
generally minimised the helicopter’s
weight by only uplifting enough fuel for
the expected duration of the flight. If the
pilot took off with less than a full tank of
fuel he may have thought that there was
more fuel on board the helicopter than
was actually the case.
Accident site of VH-THI
On the day of the accident, neither the
fuel uplifted and consumed, nor the flight
time was formally recorded by the station
Safe flight depends on reliable
Fuel exhaustion and fuel starvation are
the two main reasons for the interruption
of fuel supply.
Fuel exhaustion and starvation incidents
and accidents have led to forced landings,
diversions to other aerodromes and, in the
worst cases, fatal crashes. And it’s not just
single pilot operations that are at
risk—all pilots, including those flying
with multiple crew, are vulnerable to
human error and its consequences.
The ATSB urges all pilots and operators
to review their fuel management practices
and procedures to ensure they are
effective, consistent and reliable.
The ATSB’s latest Avoidable Accident
report, Starved and exhausted: Fuel
management aviation accidents, helps
pilots and operators better understand
and manage the risk of fuel exhaustion
and starvation. You can download the
report free of charge from the Safety
Awareness section at www.atsb.gov.au or
request printed copies by emailing
[email protected] ■
Preventing fuel exhaustion
and starvation
Poor fuel management in some
aircraft operations continues to pose
a serious risk to aviation safety.
Fuel exhaustion
Many accidents involving fuel
exhaustion and starvation are
avoidable through good fuel
management practices and
Pilots and operators can reduce the
chance of fuel exhaustion by:
• using more than one source of
information to obtain consistent
results about the fuel on board
before flight
• implementing a consistent
procedure, and checking it
regularly, to establish and monitor
the exact rate of fuel consumption
• monitoring the flight to ensure that
sufficient fuel will remain on board
in the event of unplanned delays.
Fuel starvation
Fuel starvation usually happens
when the selected tank is run dry.
The chance of fuel starvation can
be reduced by following procedures
and by:
• ensuring the pilot is familiar with
the operation of their aircraft’s
fuel system during normal and
abnormal operations
• adhering to pre-flight procedures
and checks to ensure the correct
tank is selected before takeoff
and landing
• using a fuel log during flight to
provide a record of the fuel usage
from each tank
• selecting the appropriate tank
before descending and ensuring it
has adequate fuel for landing. ■
Your notification improves safety, saves lives
f you were involved in a serious car
accident, one of the first things you’d
do is alert the authorities (if you were
able to do so). After all, that important
phone call could save a life and prevent
notifications, we can make tangible
improvements to safety through safety
advisory notices, recommendations and
further safety investigations.
In 2011, for instance, the ATSB began
a safety issue investigation into the
In the same way, by notifying the ATSB of
Robinson Helicopter R22 drive belt system
aviation accidents and incidents you could following several notifications of accidents
make a real difference to the safety of your and incidents involving the R22 V-belt.
fellow pilots.
While the investigation is still ongoing,
the ATSB has already found key factors
As the national transport safety
that can affect the reliability of the drive
investigator, the ATSB is the Australian
belt system and directly
alerted R22 pilots and
agency you
operators on how to
should notify
manage the issue.
for all aviation
accidents and
Besides the obvious safety
to under reporting.
incidents. While
benefits of reporting
we use your notification to determine
an occurrence, there are also legal
whether to investigate an occurrence,
requirements to report certain accidents
looked at as a whole, notifications also
and incidents to the ATSB. Even if there
give us a bigger picture of aviation safety
are no injuries or there is minimal aircraft
trends and patterns.
damage, you should still let the ATSB
Like a jigsaw piece in a bigger puzzle,
certain notifications can often be joined
together to reveal a broader, systemic
safety problem. Once we’ve identified
an accident or incident trend from your
Also, when considering whether to report
or not, remember that the ATSB does
not investigate to lay blame or apportion
liability. We investigate to improve safety
and prevent an accident from happening
The best rule of thumb is to report any
accident or incident to the ATSB. We
much prefer over reporting to under
You can find more information on
accident and incident notifications—
including when, what and how to notify—
on the ATSB website or by calling the
ATSB notifications number on
1800 011 034. ■
Notify the ATSB of an accident or
You can report an accident or serious
incident (an Immediately Reportable
Matter – IRM) to the ATSB 24 hours a
day, seven days a week.
• call 1800 011 034 (you can also use
this number if you need advice or
clarification on reporting matters)
• submit written reports by any
means—but online notifications
are preferred by the ATSB if
possible. Simply click the ‘Submit a
Mandatory Notification’ button on
the homepage of the ATSB website
ATSB encourages installation of audible cabin pressure warning systems
The Australian Transport Safety Bureau has
reinforced its call for operators of singlepilot, turbine-powered, pressurised aircraft
to consider installing an aural cabin altitude
pressure warning system that operates
separately from their aircraft’s visual
warning system.
In response to Safety Advisory Notice
AO-2009-044-SAN-068 (Flight Safety
Australia Issue 84) the ATSB has had a
number of requests from operators to help
locate vendors of alarm systems. While not
endorsing any particular product, the ATSB
is aware of the following suppliers:
Unrecognised hypoxia in an unpressurised
cabin continues to pose a serious safety
threat. In many cases, pilots have either not
noticed existing visual warning systems, or
those systems failed to operate correctly.
Electric Force Measurement
P: 03 9859 8356
W: www.electricforcemeasurement.com.au
Audible warning systems provide a voice
prompt warning through the aircraft’s
cockpit speakers and the pilot’s headset.
Considering the potential outcome if an
aircraft’s existing visual depressurisation
warning is missed, or fails to operate, an
additional and independent warning system
could prove invaluable.
Anders Sundström
P: +46 703 180 712
E: [email protected]
The ATSB’s investigation report
AO-2009-044 and Safety Advisory Notice
can be found on the ATSB website
www.atsb.gov.au ■
Typical King Air C90 cabin pressurisation
controller with adjacent three-position cabin
pressure control switch indicated by arrow
Investigation briefs
Importance of pre-flight planning
Investigation AO-2011-051
A fatal helicopter accident on the NSW
south coast has again highlighted the
importance of thorough pre-flight
planning and informed in-flight decisionmaking.
On 24 April 2011, the owner-pilot of
a Robinson R44 helicopter departed
Nerrigundah, with one passenger on
board, for a private flight to a property
near Berry, NSW.
Takeoff was delayed and by the time the
flight departed, there was not enough
daylight left for the pilot to complete the
flight under the day visual flight rules.
During the flight, the pilot observed
cloud, moderate rain and low visibility
along the planned track and decided to
divert to a private helicopter landing
site to maintain visual meteorological
The pilot reduced airspeed and descended
over water to what he believed to be
100 feet. Now flying in darkness, the pilot
lost visual reference and the helicopter
collided with the sea in Lilli Pilli Bay.
The pilot survived and the passenger was
fatally injured.
The safety lessons from this accident have
relevance to every flight:
• pre-flight preparation and planning is
• always check the weather forecast and
other operational details before takeoff
and in-flight
• have a backup plan and be prepared to
use it
• make decisions early—if there’s any
doubt, turn about.
The booklet Accidents involving Visual
Flight Rules pilots in Instrument
Meteorological Conditions and
investigation report AO-2011-051 are
available on the ATSB website at
www.atsb.gov.au ■
Recording service life in
overweight operations
PT6A-67 series engine bolt
Investigation AO-2008-084
Investigation AO-2010-006
On 29 December 2008 the pilot of a
PZL-M18A Dromader aircraft was
conducting agricultural spraying near
Nyngan NSW. Witnesses reported seeing
something detach from the aircraft before
it rolled and crashed into the ground.
The pilot was killed in the accident. The
ATSB’s investigation found that during the
flight a 1.8 metre section of the aircraft’s
right wing had detached from the aircraft.
Bolts that had not been cold rolled during
manufacture and overhaul on PT6A-67
series engines caused total power loss for
the pilot of a medical evacuation flight in
While not directly related to the inflight breakup the ATSB also identified
that a number of operators of PZL-M18
Dromader aircraft were not calculating
the correct flying hours when the take-off
weight was over 4,700 kilograms.
That resulted in the overestimation of
those aircrafts’ remaining service life
and meant that it could not be assured
that they were being operated within
their safe service life.
The investigation has prompted the
following safety actions:
• the operator examined its fleet and
retrospectively applied the correct
service life factors and adjusted their
processes to apply correct service life
factors to all future flights
• CASA contacted operators of M18
Dromader aircraft to ensure that
procedures are in place to record
aircraft time-in-service for overweight
operations and that overweight flight
time is factored into the calculation of
Dromader airframe service life.
The final report is available on the ATSB
website at www.atsb.gov.au ■
On 29 January 2010, during a flight in a
single-engine Pilatus PC-12/45 aircraft
with four people on board, the pilot felt
a shudder and heard a loud noise as the
aircraft passed through flight level 180.
Subsequently, the engine CHIP light
illuminated indicating the detection of
metal chips in the engine oil. The pilot
continued the climb and immediately
turned back towards Derby.
The engine lost oil pressure, engine
torque decreased and the inter-turbine
temperature increased. The aircraft’s
rate of climb began to reduce and the
pilot established into level flight before
further reducing engine power. The pilot
shut down the engine when the OIL QTY
warning light came on.
The ATSB’s investigation found that the
engine propeller reduction gearbox had
seized when four of the six reduction gear
assembly carrier bolts failed due to fatigue.
The engine manufacturer determined that
a quantity of assembly carrier bolts had
not undergone the necessary cold rolling
during manufacture. Service bulletins
were issued that identified affected
gearboxes and provided recommended
compliance times for the removal from
service of suspect carrier bolts.
The investigation also found that
the Society of Automotive Engineers
specification AS7477D was ambiguous in
relation to the need to cold roll the headto-shank fillet radius of MS9490-34 carrier
bolts. The Society published a revised
specification in October 2011, clarifying
the need for cold rolling of those bolts.
The final report is available on the ATSB
website at www.atsb.gov.au ■
REPCON briefs
Australia’s voluntary confidential aviation reporting scheme
REPCON allows any person who has an aviation safety concern to report it to the ATSB
confidentially. All personal information regarding any individual (either the reporter or any
person referred to in the report) remains strictly confidential, unless permission is given by
the subject of the information.
The goals of the scheme are to increase awareness of safety issues and to encourage
safety action by those best placed to respond to safety concerns.
REPCON would like to hear from you if you have experienced a ‘close call’ and think others
may benefit from the lessons you have learnt. These reports can serve as a powerful
reminder that, despite the best of intentions, well-trained people are still capable of making
mistakes. The stories arising from these reports may serve to reinforce the message that we
must remain vigilant to ensure the ongoing safety of ourselves and others.
New company procedure
Report narrative:
The reporter expressed safety concerns
over a new procedure being trialled at
Sydney Airport which involves taxiing the
aircraft to the arrival gate without starting
the auxiliary power unit (APU). The new
procedure requires flight crew to listen
to both company radio frequency as well
as the ground frequency after landing,
to monitor the status of ground power
serviceability. Both these frequencies are
reported to get very busy at this airport.
The reporter is concerned that there is an
increased risk of a runway incident with
this increase in monitoring workload.
Response/s received:
REPCON supplied the operator with the
de-identified report. The following is a
version of their response:
A limited trial associated with APU
management is being conducted. The
purpose of the trial is to quantify the
benefits and identify any issues associated
with the APU management procedure.
Based on feedback from flight crew
and review during the trial period, the
requirement to monitor the company radio
frequency for this procedure has since
been removed.
ATSB comment:
Two days after the de-identified report
was sent to the operator, the reporter
advised REPCON that the requirement
to monitor both company and ground
frequencies was removed from the new
The operator also advised that since their
previous response, the procedure to taxi
to the arrival gate without starting the
APU was cancelled after four weeks of
trials. Now the APU is kept running
to the gate and there is no need for
monitoring of additional frequencies for
this purpose.
Flight crew and cabin crew
Report narrative:
The reporter expressed a safety concern
regarding the increase in fatigue levels in
both flight and cabin crew members.
The reporter stated that it is common for
crew members to be rostered on for the
maximum duty time, but in reality this
means that the crews will have to extend
due to normal delays. It is expected that
crews will be ‘happy’ to extend their duty
to complete the flight. The reporter also
stated that the work load is increasing
constantly with a trend for 6-day weeks,
multiple sector days, long duties and
extensions appearing. The operator
is currently using the dispensation to
Civil Aviation Order (CAO) 48 to the
maximum extent, with the result being an
increase in crew fatigue levels.
Response/s received:
REPCON supplied the operator with the
de-identified report. The following is a
version of their response:
I have carried out a random audit of our
fatigue management system and Flight
and Duty times recorded and rostered.
My findings are as follows:
• The average 14 day duty cycle for the
High Capacity crews are ranging from
60 – 85 hours well within the 100 hour
limit. It is very rare for a crew member
to have cumulative duty in excess of 90
hours on this fleet.
• The average 14 day duty cycle on the
Low Capacity is approximately 75
• We do fly seven days per week although
there is only one scheduled flight
on Saturdays and one scheduled
flight on Sundays. Crews very rarely
do a weekend flight on subsequent
• The Flight and Duty exemption
restrictions are adhered to at all times.
I have reinforced to crews that fatigue
management is both the pilot’s and the
company’s responsibility and if a flight
crew member is not adequately rested and
in a physically and mentally fit state to fly,
then they must inform their fleet manager
or myself who will remove them from the
Operations do not expect pilots to
automatically accept duty extensions. It is,
and always has been, the decision of the
pilot to extend a duty in accordance with
the fatigue management system.
I do not believe the author is correct in his
REPCON supplied CASA with the
de-identified report and a version of
the operator’s response. The following
is a version of the response that CASA
This matter has been reviewed by CASA
with the operator’s Chief Pilot. CASA is
satisfied with the operator’s response and
its internal investigation. ■
How can I report to REPCON?
Online: www.atsb.gov.au/voluntary.aspx
Telephone: 1800 020 505
Email: [email protected]
Facsimile: 02 6274 6461
Mail: Freepost 600
PO Box 600, Civic Square ACT 2608
Colgan Air crash Flight 3407
An unnecessary tragedy
It was a cold and icy night, but the crash of Colgan Air Flight 3407 was due more to mishandling,
a poor training system and ignoring procedures than the weather, as Macarthur Job writes
On a night ILS approach to Buffalo Niagara International
Airport and in icing conditions, a Bombardier Dash Eight
stalled and crashed into a house. The 50 occupants in
the aircraft, and one person in the house, were killed.
Although light snow was falling, night VFR conditions
prevailed at the time.The twelfth day of February 2009
was a rotten day for flying in the northwest United States.
A 74-seat, Bombardier Q400, owned by Colgan Air of
Newark, New Jersey, was operating a daily commuter
flight to Buffalo in New York State, under contract to
Continental Airlines but the crew’s first two scheduled
flights for the day had been cancelled because of high
winds. Their planned departure for Buffalo was now
7.10pm, with an estimated flight time of 53 minutes,
cruising at 16,000 feet.
Flight Safety Australia
Issue 85 March-April 2012
But, as often happens after a long day of dirty weather in
crowded airspace, taxi clearance was delayed. The 50 people
on board had to wait in the aircraft until 8.30pm.
At 10.12pm, the controller cleared them to descend and
maintain 2300 feet but, as they followed ATC’s instructions,
they continued their conversation.
The first officer was not feeling well. Suffering from a cold
and sneezing, she remarked to the captain as they were
taxiing, ‘I’m ready to be in the hotel room … we’ll see how
it feels flying’.
Less than three miles from the outer marker, the captain
reduced engine power to minimum thrust to slow the aircraft
for final approach, and the controller instructed them to call
the tower. The first officer’s acknowledgement was the last
transmission from the aircraft.
The tower cleared the aircraft for take off at 9.18pm, the
captain indicating he would fly the leg himself. During the
climb to cruising level, with the weather typical of winter, the
crew turned on the propeller and airframe de-icing equipment.
They also engaged the autopilot. The cruise was uneventful,
and although the crew engaged almost continuously in
conversation, they did not at this stage contravene the sterile
cockpit rule.
At 9.50pm, the first officer reported the wind at Buffalo was
from 250° at 15 knots, gusting to 23 knots, and the captain
said they would use runway 23. The first officer briefed the
airspeeds for landing, with flaps 15 as 118 knots for their
reference landing speed, and 114 knots for go-around speed.
The first officer said it might be easier on her ears ‘if we start
going down sooner’, and the captain told her to ‘get discretion
to 12,000 feet.’ Cleveland ATC cleared them to descend to
11,000 feet, and instructed them to contact Buffalo approach
The captain began the approach briefing, but was interrupted
by the controller clearing them to descend and maintain
6000 feet. Resuming, the captain repeated the airspeeds the
first officer announced for a flaps 15 landing. The aircraft
descended through 10,000 feet; from that point, the crew was
required to observe the sterile cockpit rule.
After approach control cleared the aircraft to descend and
maintain 4000 feet, the captain asked the first officer how her
ears were. She said they were ‘stuffy’ and ‘popping’ and asked
him if ice was accumulating on his side of the windscreen.
He replied that it was. She told him her side had, ‘lots of ice,’
and the captain said, ‘That’s the most ice I’ve seen on the
leading edges in a long time.’
The first officer commented she had accumulated more flight
time in icing conditions in her first days of experience with
Colgan Air than she had before she joined the company. She
also remarked that she ‘wouldn’t mind going through a winter
in the north-east before becoming a captain.’ Before she
joined the company, she explained, she had ‘never seen icing
conditions … never de-iced … never experienced any of that.’
The crew extended the undercarriage, and advanced the
propeller levers to maximum rpm. The autopilot applied noseup pitch trim, and the airspeed decreased to 145 knots. As the
autopilot applied more nose-up pitch trim, an ‘ice detected’
message appeared on the cockpit engine display. At almost
the same time, the captain called for flaps 15 and for the prelanding checklist. The first officer selected the flaps to 10°, and
the airspeed fell to 135 knots, but suddenly the stick shaker
activated and the autopilot disconnect horn began sounding.
Caught completely by surprise, the captain began wrestling
with the control column, at the same time advancing the
engine power levers to about 70 per cent.
With the airspeed at 131 knots when the autopilot disengaged,
the aircraft pitched up sharply as the engine power responded,
rolled left 45°, and then rolled right. As it did so, the stick
pusher attempted to lower the nose, but the captain fought its
action. On her own initiative, the first officer selected flaps up.
The airspeed fell to about 100 knots, and the right roll reached
105° before the aircraft began rolling back to the left.
The stick pusher activated a second time but, now grunting
with exertion, the captain continued to fight the nose-down
force. From about 25° nose down and banked 100° to the
right, the aircraft finally entered a steep descent, and as the
flaps became fully retracted, the stick pusher activated a third
time. The captain called out, ‘We’re down!’ and a moment later
the CVR recorded the noise of impact as the aircraft crashed
into the house.
Fourteen investigators from the National Transportation Safety
Board were assigned to examine the circumstances of the
accident. The aircraft had sheared off the tops of two trees
before striking the southern side of the house near ground
level, and exploding into flames. Only its empennage remained
The captain, aged 47, received his command on the Q400 four
months before the accident and three years after joining the
company. His total flying experience was around 3400 hours,
of which 111 hours were on the Q400. He also had experience
on Beech 1900 and Saab 340 aircraft.
Colgan Air crash Flight 3407
Federal Aviation Administration records indicated he had failed
flight tests on four occasions during his training.
The first officer, 24, had been with the company for a little over
a year and had accumulated 2244 hours flying time, including
774 hours on turbine aircraft. She was considered above
average for her level of experience.
When the crew turned on the de-icing equipment, the captain
would also have turned the reference speeds switch on the ice
protection panel to the ‘increase’ (icing conditions) position.
This would have lowered the angle of attack reference,
increasing the speed for activation of the stick shaker by
about 15 knots. Although the aircraft did encounter snow and
light-to-moderate icing during its approach, and some ice had
accumulated on its surfaces, flight recorder data showed it
was responding normally and the ice was not affecting the
crew’s ability to control the aircraft.
But because the reference speeds switch was selected, the
aircraft was not close to stalling at the time, and because stick
shakers provide a 5-to-7-knot warning of an impending stall,
the crew actually had a 20-to-22-knot warning.
When the autopilot disconnected as the stick shaker activated,
the captain’s response was a heavy pull on the control
column. At the same time he added substantial power,
causing the aircraft to nose-up sharply. This did produce
an aerodynamic stall, with a roll to the left that reached 45°,
despite the captain’s opposing control inputs. This was
followed by several roll oscillations, during which the captain
repeatedly fought the stick pusher’s attempts to lower the nose
by pulling back on the control column with forces of up to
160 pounds.
When the controller informed the crew they were three
miles from the outer marker and cleared them for the ILS
approach, their airspeed of 184 knots was too fast for their
position. The captain had to slow the aircraft quickly, probably
because, distracted by his conversation, he had lost positional
awareness. He did so by extending flaps to 5°, reducing
power to near idle, lowering the undercarriage, and moving the
condition levers to maximum rpm.
Because autopilot altitude hold mode was engaged, the
autopilot continued to add nose-up trim to maintain altitude
after the aircraft levelled off at 2300 feet. But neither pilot
remarked on the increasing pitch, even though it should have
indicated that the airspeed was continuing to slow.
FAA ILS/LOC approach plate to runway 23 at Buffalo Niagara International Airport (KBUF).
The crash site occurred about five nautical miles from the threshold of Rwy 23.
Source: Wikimedia
In addition to other instrument indications, the numbers on the
IAS display changed from white to red as the aircraft reached
the higher stick shaker activation speed.
The captain had the primary responsibility for monitoring the
instruments, with the first officer responsible for providing
backup. The investigation believed that explicit cues that the
aircraft’s attitude was becoming excessively nose-up and that
the onset of the stick shaker was impending, should have been
evident in adequate time to take corrective action. But neither
pilot responded.
Furthermore, the crew failed to consider the position of the
reference speeds switch when the stick shaker activated. After
the accident, another Colgan crew had a similar experience
when the stick shaker activated during a night VMC approach
to Buffalo. Again they had forgotten that the reference speeds
switch, set to ‘increase’, had raised the stick shaker activation
speed, and failed to realise the stall warning was impending.
Flight Safety Australia
Issue 85 March-April 2012
It was evident that Colgan’s approach procedures for setting
airspeed bugs did not adequately remind crews of the
reference speeds switch position, creating an opportunity
for confusion.
When the stick shaker activated, the aircraft was not in an
aerodynamic stall, and there was sufficient airspeed to correct
the situation, but the captain inexplicably pulled back on the
column rather than pushing it forward to reduce the aircraft’s
angle of attack. As a result, its airspeed decreased further, and
it stalled, and because the airspeed remained low after the
stall, the stick shaker remained active.
Even though the captain added power in response to the stall
warning, he did not add full power as required. The first officer
also did not tell him it had not increased to the rating detent,
or advance the power to the detent when the captain failed to
do so. The captain did not call for the flaps to be retracted, yet
about seven seconds after the stick shaker activated, the first
officer raised the flaps, only telling the captain afterwards.
The investigation was concerned that the captain pulled
against the stick pusher three times, and that his control inputs
repeatedly fought the stall protection system’s attempts to
reduce the severity of the situation. His actions were entirely
inconsistent with any procedure or basic requirement for
recovering from a stall.
Had the captain not overridden the stick pusher, it would
have forced the nose of the aircraft down. If the captain had
responded correctly to this nose-down input, the aircraft might
have recovered flying speed in time to avoid the impact. But
the first officer’s raising of the flaps reduced the lift produced
by the wings and increased the stalling speed when the aircraft
was already stalled.
The captain’s response to the stick shaker should have been
automatic, but rather than responding from well-learned habit,
his reaction was one of surprise and startled confusion,
and his control inputs were totally inconsistent with basic
flying training. He did not recognise the stick pusher’s action
to decrease the aircraft’s angle of attack and his efforts to
override it only exacerbated the situation. Although the stall
recoveries he had practised did not involve an autopilot
disconnect, or an element of surprise, his experience should
have allowed him to react correctly. His history of failure
during training showed weaknesses throughout his career with
instrument flying, with heavy reliance on autopilots, and this
could have contributed to his deficient performance.
Research has shown it can be difficult for pilots to recognise
and recover from quite unexpected unusual attitudes, and the
poor night visibility at the time precluded any reliable visual
reference. Also, the aircraft’s G loadings and its proximity to
the ground would have increased the stress of the moment.
Fatigue might also have been a contributing factor. Both pilots
lived a long distance from Newark and regularly commuted by
airline from their homes for their tours of duty. Both had been
at Newark Airport overnight and all day before their 9.18pm
departure, without adequate rest facilities.
Reasons for incorrect recovery procedures
Did the captain respond incorrectly to the stick shaker because
he was applying techniques appropriate to a tailplane stall?
Both the captain and the first officer had watched a NASA
video on icing that explained that tailplane stalls were most
likely with regional and corporate turbo-prop aircraft with ice
on the tailplane.
The recommended tailplane stall recovery procedure entailed
pulling back on the control column and reducing flaps,
which the crew did. However, the video also said that typical
tailplane icing symptoms were a lightening of control forces,
pitch excursions, difficulty in pitch trim, control buffeting, and
sudden nose-down pitch, none of which occurred in this case.
Furthermore, the stick shaker activation was a clear warning
of an impending conventional stall, not a tailplane stall, and the
change in the IAS numbers to red was a conspicuous signal
inconsistent with a tailplane stall.
Flight management
Although the captain was responsible for managing the flight,
he and the first officer engaged in irrelevant conversation
throughout much of it. During cruise this did not conflict
with regulations or company policy, but probably contributed
to delays in performing checklists. Once the aircraft had
descended through 10,000 feet, sterile cockpit procedures
should have been observed. They were not, and the crew
squandered time that should have been spent monitoring,
maintaining situational awareness and preventing errors.
The National Transportation Safety Board attributed the
accident to the captain’s inappropriate response to the
activation of the stick shaker, producing an aerodynamic stall
from which the aircraft did not recover. Contributing factors
were the crew’s failure to monitor airspeed and adhere to
sterile cockpit procedures, the captain’s failure to manage the
flight effectively, and Colgan Air’s inadequate procedures for
selecting airspeeds during approaches in icing conditions.
Cabin crew training
Cabin crew members are the
eyes and ears of the flight crew.
Training them well is vital.
Aviation is an information-rich industry and
training programs may be the first exposure that
aspiring cabin crew members (and their fellow
aviation professionals) have to all the safetycritical information that will potentially save their,
and others’, lives.
Cabin crew members are the eyes and ears of
the flight crew. The best available training and
regular recurrence, in facilities that allow for
realistic simulation of all the emergency situations
that might arise (including the occasional dirty
nappy scenario) are important in developing
Australia has
a mandate for
annual recurrent
testing. Further,
all cabin crew
must be CASAapproved.
The U.S. Federal Aviation Administration
(FAA) has encouraged airlines to implement
an advanced qualification program (AQP) for
flight attendants as ‘an alternative method for
developing training and testing materials for
…flight attendants… based on instructional
systems design, advanced simulation equipment
and comprehensive data analysis to continuously
validate curriculums’. Jargon aside, the FAA
expects this standardisation to ‘require flight
attendants to complete hands-on performance
drills every 12 months, using emergency
equipment and procedures, with trained and
qualified flight attendant ground instructors and
Bringing cabin and flight crew together in training,
assists in ironing out inconsistencies which
have arisen in cockpit-cabin communication and
coordination, especially in these times of locked
flight deck doors. Crew resource management
training, and pre-flight briefings that include both
pilots and cabin crew, allow the entire team to
work together more effectively and safely.
What qualities make for the best cabin
crew members?
Having a cool head under pressure,
diplomacy, flexibility, resilience, common
sense, the ability to think on your feet,
efficiency and time management, good
problem-solving abilities, friendly, sociable,
able to make conversation easily – and
caring. You need to care about your guests,
care about your teammates, care about
improvement and care about safety!
Domestic cabin crewmember and cabin
safety officer
Exceptional face-to-face customer service,
attention to detail, punctuality, sense of
humour, real communicator, procedure
based, team player, ability to be a quick
thinker and follow directions.
Team leader, cabin crew training
A genuine team player, a skilled follower as
well as leader, a clear communicator,
considerable patience and understanding
of others, strong assertive skills, high
emotional and social intelligence, strong
time management skills, able to cope with
shift work.
Safety systems inspector
The ideal CCM has that balance of service
and safety that allows both elements to
be implemented at all times. Cultural
issues can crop up from time to time. For
example, the cultural backgrounds of some
passengers may clash with the background
of the CCM. As a stereotype and with my
tongue firmly in my cheek, I’d say that the
ideal CCM is a waiter in a Michelin-starred
restaurant, a clothes hanger in a fashion
show, a sheepdog when it’s time to round
the passengers up and an old-fashioned
drill sergeant in an emergency.
Quality and safety manager
Photos courtesy of Sue Rice and Emirates Aviation College
Flight Safety Australia
Issue 85 March-April 2012
What did you learn/wish you had learned in your training?
I had mixed emotions about my training. I was very excited and my expectations were high, as
it was my first flying job and I was with a large airline.
Unfortunately I found that from day one we were treated like children. We were lectured by the
trainers, who basically read from the manual word for word. It was death by PowerPoint, and
the usual teaching techniques – role plays, group activities and multiple choice exams – were
used and overused. Surely there is room for more creative techniques and individuality?
It was a six-and-a-half-week course which covered aviation first aid and CPR, fire training,
security training, dangerous goods, manual lifting, emergency procedures, standard operating
procedures and service. The security training was basic and although I’d love to tell you more,
if I did I’d have to kill you.
Disappointedly we hardly touched on service, which set no expectations for those new to the
company. But after all was said and done, I walked away from my training with a warm feeling
of camaraderie and an endorsement on an RPT aircraft.
Having said all that I feel lucky that my training was paid for and I was paid during my training.
I’ve heard much worse stories.
Domestic cabin crew and cabin safety officer
I wish that I had been given more practical
negotiation tools and strategies to deal
with working under pressure within tight
timeframes; with different personality types
and within the tight commercial pressures
versus safety environment.
Safety systems inspector
Crowd control, aviation language and
acronyms, how to remain calm under
pressure, follow procedures to the letter
and open aircraft doors, non-verbal
communication skills.
Cabin crew trainer
Cabin crew training
What skills do cabin crew need
to learn?
Emergency procedures / fighting fires
Emergency drills / evacuations / ditching
Equipment location on various aircraft
Safety briefings
Aircraft systems and components
Customer service essentials / service
sequences / responsible service of alcohol
Company knowledge
Human factors / crew resource management
Leadership / assertiveness
Time management
Handling difficult passengers
SMS – including reporting systems
Security / threat and error management /
dangerous goods
Occupational health and safety
First aid / aviation medicine / CPR – British
Airways also trains its crew to deliver babies
Airport codes
Over 2,600 China Eastern Airlines flight attendants
are being trained in kung fu. All Hong Kong Airlines
staff have also been invited to undergo training
in wing chun – a form of kung fu used in close
combat – with compulsory training for cabin crew,
as a means of dealing with unruly passengers and
even terrorists.
The basis of what trainees need to know
will always be the SOPs, emergency
procedures and crowd control. Their
technical knowledge can be quite limited,
as long as the basics are addressed e.g.
snow and ice contamination on the wing
(my airline is in northern Europe). The
ability not to show fear and thereby create
panic in unusual/emergency situations is
important. Equally, pretending that as a
CCM you know it all is a bad thing. Years
ago, travelling as a passenger, I pointed
out to a CCM that the engine’s magnetic
chip detector panel door was open and
the chip detector was possibly not in
(risking total oil loss from that engine).
I did this during pushback and just prior
to engine start. Her (it was a female CCM)
reaction was that it was normal and if the
panel was open the flight crew wanted it
that way. Her view was that no passenger
knew more about the aeroplane than
she did.
I did eventually convince her - by showing
my crew card - to inform the flight deck.
Immediate action was taken to put the
plug back and shut the panel.
In short, she needed to know that if you
don’t understand the situation go and ask!
Quality and safety manager
iStock Photo
Flight Safety Australia
Issue 85 March-April 2012
Emirates Aviation College
Emirates opened a state-of-the art, multi-million dollar training centre
in 2007 to provide training for its cabin crew members. The centre
houses two full-motion emergency evacuation cabin simulators –
a B777 and an A330/340 – and an A380 full-height static simulator;
a ditching platform into a freezing pool; and a purpose-built firefighting
facility all for safety and emergency procedures training. A further 14
cabin service simulators, replicating every cabin in the Emirates fleet,
form part of the service training equipment, with specialised classrooms
for image and uniform, medical and security training, and a Majilis in
which students explore and experience the all-important Arabic culture
of hospitality.
In 2010 the airline carried 31.4 million passengers. Emirates has more
than 14,000 cabin crew and will almost double its crew numbers within
the next decade. Cabin crew members come from over 130 nationalities
and speak over 50 languages, with some individuals speaking three,
four and even seven languages fluently!
Only five per cent of applicants are selected to commence training.
Every Wednesday, up to 120 aspiring cabin crew members arrive in
Dubai to begin their ab-initio course. Students complete seven and a
half weeks of intensive training and assessment, including induction,
safety and emergency procedures, service, image and uniform,
aviation medicine, security and CRM, culminating in a simulated flight
with unexpected challenges.
How do our Gen Y students like to
learn? Research states they are socially
aware, tolerant, tech savvy, team
oriented and good at multi-tasking.
Our training reflects a brain-friendly
learning approach that is multi-sensory,
facilitative, honours our multicultural
students’ unique qualities, and ‘keeps
it real’, ensuring they are competent
and confident when they leave. We do
not ‘hose’ them with information, but
instead allow them to explore through
a mix of visual, auditory and other
kinaesthetic learning, while emphasising
the context in which they are operating.
Integrating our safety and service
training ensures that our cabin crew
have safety at the heart of everything
they do, whilst delivering an exceptional
customer experience.
Catherine Baird, Emirates senior vice
president – cabin crew training
Flying ops | Maintenance | IFR operations
1. With respect to a jet engine, ‘core lock’ refers to a
situation where, after a flameout, the rotating portion of
the engine seizes due to:
5. Airframe icing is:
(a) possible below 0ºC because, in some circumstances,
water can remain liquid below that temperature
(a) reduced internal clearances aggravated by a
high airspeed
(b) not possible below 0ºC
(b) reduced internal clearances aggravated by a
low airspeed
(d) most likely around 4ºC.
(c) most likely around 13ºC if the humidity is high
(c) increased internal clearances aggravated by a
high airspeed
6. The indicated airspeed at which a given aircraft stalls:
(d) increased internal clearances aggravated by a
low airspeed.
(b) for a given weight, is the same at all altitudes, but the
corresponding true airspeed increases with altitude
2. In a TAF, the term FU VV030 means:
(a) smoke and a visibility of 3000m
(b) smoke and a vertical visibility of 3000ft
(c) fumes and a visibility of 3000m
(d) fumes and a vertical visibility of 3000ft.
3. The appropriate care procedure for lead-acid batteries
if there is a long time interval between flights is to:
(a) let the battery go completely flat
(b) empty out the electrolyte
(c) give the battery a fast charge just before use
(d) charge the battery at least every 30 days to replace
the energy lost due to self discharge.
4. For VFR flights, an alternate must be provided for flights
where the distance from the point of departure will be
more than:
(a) for a given weight, increases with altitude
(c) increases with weight and reduces with altitude
(d) increases with weight and altitude.
7. If a tailwheel aircraft bounces on the main wheels
during landing, the subsequent rebound will be:
(a) assisted by the increased lift resulting from the
increased angle of attack due to the position of the
main wheels ahead of the centre of gravity
(b) assisted by the increased lift resulting from the
increased angle of attack due to the position of the
main wheels behind the centre of gravity
(c) opposed by the reduced lift resulting from the reduced
angle of attack due to the position of the main wheels
ahead of the centre of gravity
(d) opposed by the reduced lift resulting from the reduced
angle of attack due to the position of the main wheels
behind the centre of gravity.
8. The VFR alternate minima for a helicopter are:
(a) 1500ft ceiling and visibility of 8km
(c) 50nm when the forecast conditions are below the VFR
alternate minima of 1500ft ceiling and 8km visibility
(b) 1500ft ceiling and visibility of 8nm
(d) 50nm when the forecast conditions are below the VFR
minima of 1000ft ceiling and 3NM visibility.
(d) 1000ft ceiling and visibility of 5000m.
(c) 1000ft ceiling and visibility of 3000m
Flight Safety Australia
Issue 85 March-April 2012
9. In approaching, on the runway extended centre line, for
a landing in a left crosswind using the ‘crab and kick’
method (no side slip on the approach), the aircraft is:
(a) drifting right and the balance ball will be centred
(b) drifting left and the balance ball will be centred
(c) not drifting and the balance ball will be offset right
of centre
(d) drifting right and the balance ball will be right of centre.
10.On aircraft with vacuum-driven gyro instruments,
the need to replace or clean the inlet filter to the
instruments will be indicated by:
(a) a low vacuum gauge reading
(b) a high vacuum gauge reading
(c) erratic instrument performance and a low vacuum
gauge reading
(d) erratic instrument performance and a normal vacuum
gauge reading.
1. An aircraft mode S skin code or mode S address is:
(a) allocated and unique to a particular aircraft
4. Chromate passivation during the plating process of
a metal is used to:
(b) allocated by ATC and set by the pilot
(a) provide further protection to a plated finish
(c) only used by ADSB-in systems
(b) prepare the base metal for an improved adhesion of
the subsequent plating
(d) only used by ADSB-out systems.
2. The skin code is verified:
(a) when ATC requests it
(b) when an aircraft is issued with a C of A and also on
each occasion when AD/RAD/47 is carried out
(c) during the transponder self-test at start-up
(d) during the transponder self-test at shutdown.
3. Algae in jet fuel:
(a) cannot live long enough to present a problem
(b) are, in most cases, not an issue because of the
filters in the boost pumps
(c) require water for multiplication and as well as blocking
filters can cause electrolytic corrosion of fuel system
(d) will multiply in proportion to temperature in jet fuel,
regardless of the presence or absence of water.
(c) enhance subsequent paint adhesion
(d) place the metal surface under slight compression in
order to reduce the likelihood of fatigue cracking.
5. With reference to steel, martensite is:
(a) a carbon-rich compound formed when steel is cooled
rapidly, such as when normalising
(b) a carbon-rich compound formed when steel is cooled
rapidly, such as when quenching
(c) alternate zones of ferrite and pure carbon
(d) where carbon is precipitated out as a heavy deposit
around the grain boundaries.
6. When an AC supply is half-wave rectified, the resulting
waveform is:
(a) at the same frequency as the supply
(b) at twice the frequency as the supply
(c) at half the frequency of the supply
(d) DC with a slight ripple.
Flying ops | Maintenance | IFR operations
7. A wild frequency engine-driven AC generator produces
power at a:
10.MIL-W-5086 refers to:
(a) 50-ohm coaxial cable
(a) frequency that follows the engine RPM
(b) a 75-ohm coaxial cable
(b) frequency that remains constant because of the
integrated drive
(c) an unshielded, insulated copper airframe wire
(c) voltage that always increases with engine RPM
(d) a shielded, stranded copper airframe wire.
(d) voltage that always decreases with engine RPM.
8. A ‘P lead’ is the:
(a) magneto control wire. Grounding this lead switches
the magneto off.
(b) magneto control wire. Grounding this wire switches
the magneto on.
(c) high voltage wire from the magneto to the spark plug.
(d) high voltage wire from the magneto to the
cockpit switches.
9. The main function of a coalescer in an air-conditioning
pack is:
(a) to filter dust particles from the incoming bleed air
(b) to filter dust particles from the incoming cabin air
(c) to filter water vapour from the air leaving the air
cycle machine
(d) to increase the size of the water droplets in the air
leaving the air cycle machine so that they can be
inertially separated.
The circling approach
1. You are inbound on the final approach of the Bendigo
(YBDG) runway 17 NDB.
You are at the minimum descent altitude (MDA) for your
category B aircraft with 0.5nm to run to the beacon when
you become visual, with the aerodrome in sight.
The AWIS wind is 030/20kt. Which of the following would
be the correct circling manoeuvre to conduct?
(a) A slight ‘sidestep’ to the left to join upwind for runway
17, left-hand circuit
(b) Break left to join a right downwind for runway 35
2. You are inbound on the final approach of the Lismore
You are at the MDA for your category B aircraft with 2nm
to run to the beacon when you become visual with the
aerodrome in sight.
The AWIS wind favours a landing on runway 15.
Which of the following is correct concerning your
circling area?
(a) You must remain within the circling arcs of
1.68NM from the thresholds of runway 15/33
joined by tangents
(c) A slight ‘sidestep’ to the right to join a left downwind
for runway 35
(b) You must remain within the circling arcs of
2.66NM from the thresholds of runway 15/33
joined by tangents
(d) Break right to join an oblique downwind to base for
runway 05.
(c) You are restricted to a 1.5nm arc area to the west of
the aerodrome due to terrain restrictions
(d) You are restricted to a 1.5nm arc circling area
joined by tangents for the whole circling area due to
terrain restrictions.
Flight Safety Australia
Issue 85 March-April 2012
3. Refer to the Georgetown (YGTN) Queensland NDB
(a) 670ft and descent on base
What is the size of the circling area for this
approach plate?
(b) 720ft and descent on base
(a) 3nm radius centred on the aerodrome reference
point (A.R.P)
(d) 570ft and descent late base to final.
(b) 3nm arcs from the thresholds of the runway 06/24
joined by tangents
(c) 1.68nm arcs (category A) and 2.66NM arcs
(category B) from the thresholds of runway 06/24
joined by tangents
(d) 1.68nm radius (category A) and 2.66NM radius
(category B) centred on the A.R.P.
4. You are on final approach of the Griffith (YGTH)
NDB-A approach
You are at the MDA for your category B aircraft with 0.5nm
to run to the beacon when you break visual.
Where do you expect to see the aerodrome as you
establish cloud break?
(a) Directly in front of the aircraft
(b) In front and to the right of the aircraft’s nose
(c) Off the right wingtip
(d) Off and behind the left wingtip.
5. Which of the following is a true statement concerning
the minimum obstacle clearance during a circling
manoeuvre on a ‘new-style’ chart.
(a) 300ft for category A and 400ft for category B
(b) 300ft for categories A and B
(c) 400ft for categories A and B
(d) 400ft for category A and 300ft for category B.
6. Which of the following is a true statement concerning
the minimum obstacle clearance during a circling
manoeuvre on an ‘old-style’ chart.
(a) 300ft for category A and 400ft for category B
(b) 300ft for categories A and B
(c) 400ft for categories A and B
(d) 400ft for category A and 300ft for category B.
7. You have established cloud break at the MDA on the
Moorabbin (YMMB) NDB-A approach. It is night and
you have received the AWIS (outside tower hours).
The AWIS wind is 180/25kt. Since the cloud break was
close to the beacon, you elect to overfly and position for
a left circuit to runway 17.
What is the cloud ceiling at your MDA and when would
you commence descent from this height for the approach
to land?
(c) 570ft and descent turning base
8. You are inbound on final approach of the Albury (YMAY)
NDB-A approach at night. You are at the MDA for your
category B aircraft with 1nm to run to the beacon when
you establish cloud break with the runway lights in
sight. The wind favours a landing on runway 07. Due to
lower scattered cloud north of the aerodrome you elect
to overfly for a right circuit to runway 07.
When can you descend from the MDA to set up the
approach to land?
(a) Continual visual descent during the overfly and
on downwind to achieve ‘normal profile’ turning
base at circuit height
(b) Continual visual descent ensuring the minimum
obstacle clearance of 300ft until turning final
(c) Only when established on the base leg for
runway 07
(d) Only when established on final approach for
runway 07.
9. Refer to the Nhill (YNHL) Victoria NDB-A approach.
You are established clear of cloud and with the threshold
of runway 27 in sight at the MDA for your category B
aircraft. On the left downwind leg for runway 27 you
re-enter cloud.
What actions must you now take?
(a) Descend to re-establish visual reference, being aware
of the obstacle clearance requirement of 300ft until
turning final
(b) Execute a missed approach, turning left to the NDB
and then tracking 050 while climbing to 2400ft
(c) Execute a missed approach, manoeuvring to
immediately intercept a track outbound of 050 while
climbing to 2400ft
(d) Maintain the M.D.A. whilst turning left to the NDB
then execute the missed approach, tracking 050 and
climbing to 2400ft.
10.If the weather conditions are such that you establish
visual reference at the MDA and with the specified
circling visibility, there is no minimum number of legs
of a circuit to fly, or any requirement to fly the specified
circuit direction.
True or false?
March-July 2012
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Bankstown www.casa.gov.au
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To have your event listed
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Copy is subject to editing.
May 26
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March 17
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Education Seminar
(open to public) – Bunbury
Organiser and more info: Susan Ward
[email protected]
April 2-5
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Conference – Baltimore, Maryland, USA
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Tradeshow, Orlando, Florida, USA
May 7-8
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Please note that some CASA seminar dates may be subject to change. Please check the Education and Avsafety sections of
the CASA website for final details and booking arrangements.
CASA events
Other organisations’ events
Flight Safety Australia
Issue 85 March-April 2012
AOPA National Airfield
Directory 2012
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Ph: 02 9791 9099 Email: [email protected] Web: www.aopa.com.au
Flying ops
1. (b) a minimum airspeed is required to
maintain rotation and therefore a cooling
airflow through the core
2. (b) AIP GEN 3.5 12.12.8
3. (d) lead acid batteries slowly discharge in
service and, if left in place but partially
discharged, any unused capacity will
be lost due to sulphation
4. (c) AIP ENR 69.2
7. (a) (d) applies to nose-wheel aircraft
8. (c) VFRG page 358
10.(d) the instrument reading will be regulated
to normal values even if there is no flow
at all through the instruments
IFR operations
1. (b)
2. (c)
3. (a)
4. (d)
5. (b)
6. (c)
7. (d)
1. (a)
7. (a)
8. (a)
9. (d)
AWB 34-015 and AD/RAD/47
8. (a)
9. (b)
10. (a)
There is no CSD
The wire to the cockpit switches
It is more effective to inertially separate
larger water droplets
YBDG NDB approach plate. Note the ‘no circling’ west of 17/35 centreline.
This also precludes the use of runway 05.
YLIS-A approach plate. Answer B is ordinarily correct for category B aircraft, but at
Lismore there is a further 1.5nm restriction to the west. Remember also that these
circling area distances are the maximum surveyed area for the category of aircraft.
On poor-visibility days or nights you will be ‘tucked in’ closer to the field to maintain
the flight visibility required, while (and this is vitally important!) keeping the approach
end of the runway in sight.
DAP EAST.DAP 1-3 i.e. ‘old’ chart. Note that answer B is correct if the runway is
longer than 1800m.
YGTH-A approach plate. This is vital to be aware of, pre-flight, so that you can
smoothly transition from instruments to the visual manoeuvre at the cloud break.
DAP East or West DAP 1-3
DAP East or West DAP 1-3
YMMB-A Approach plate.
AIP-ENR 1.5-33 para 5.3.2
AIP-ENR 1.5-3 para 1.7.6
This descent from a position on the ‘normal profile’ is vital to achieve obstacle clearance
and is strongly recommended, both day and night, even though daytime regulations
might allow a clearance of 300ft (new) or 400ft (old) until on final. The question is –
above what? You might not have this information available, so maintaining the MDA to
that position for a descent from normal circuit height will ensure clearance.
YMAY NDB-A approach plate AIP-ENR 1.5-8 Figure 1
YNHL NDB-A approach plate.
AIP-ENR 1.5-9 para 1.10.1 e para 1.10.3
A good point to note here is that the NHL NDB is a significant distance (1.3nm) north
of the aerodrome.
AIP-ENR 1.5-4 para 1.7.6 note 1
Ideally, left hand is better while conducting the visual circling manoeuvre, since this
will give the (single) pilot in the left seat the best view. Once cloud break occurs,
it is vital to place the heading bug on the runway heading to help maintain orientation,
particularly in conditions of low visibility and at night.
Essential aviation reading
Product review
Helicopter safety
The Heathrow Trident crash
Sharing the skies ... trikes
... and more close calls
Sunshine Coast Airport is the
latest addition to OnTrack,
CASA’s interactive guide
to operating in and around
Australia’s controlled airspace.
OnTrack now covers 10
Class D aerodromes.
OnTrack includes explanations
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infringements and multimedia on how to fly the aerodromes’ inbound/
outbound tracks. Visit OnTrack: www.casa.gov.au/ontrack
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on (08) 8234 3244 or visit www.airsouth.com.au
2012 CPL and ATPL Examinations Scholarship
Applications are invited for the 2012 CPL and ATPL Examinations Scholarships.
Two scholarships will be awarded. One will cover the CASA/ASL examination fees
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The Guild of Air Pilots & Air Navigators (GAPAN)
Assessment Services Limited (ASL)
For further details and application form visit
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Applications close 26 March 2012
Mia Angus and Chris Lee were the successful GAPAN/ASL applicants in 2011. Mia has successfully
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