Flight Safety

JANFEB 2008
ISSUE NO. 60
FINAL
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HUMAN FACTORS
CLOSE CALL
ISSUE NO. 60, JANFEB 2008

CHIEF EXECUTIVE OFFICER, CASA
Bruce Byron
GENERAL MANAGER,
AVIATION SAFETY PROMOTION
David Pattie
EDITOR, FLIGHT SAFETY AUSTRALIA

Margo Marchbank
DESKTOP PUBLISHING
P Markman
LET IT BE ... SOMEBODY ELSE!
You wouldnt wish this on anyone...
39
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ph: 131 757
CORRESPONDENCE
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email: fsa@casa.gov.au
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Safety Analysis
61
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AIRWORTHINESS PULL-OUT SECTION
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Contributions
Stories and photos are welcome. Please
discuss your ideas with editorial staff before
submission. Note that CASA cannot accept
responsibility for unsolicited material.
PROP DROP
The prop stops here
4o
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copyright notice accompanies each published
photograph. If you believe any to be in error,
please notify us at fsa@casa.gov.au
Notice on advertising
Advertising appearing in Flight Safety
Australia does not imply endorsement by the
Civil Aviation Safety Authority.
Warning: This educational publication does not replace
ERSA, AIP, airworthiness regulatory documents
manufacturers advice or NOTAMs. Operational
information in Flight Safety Australia should only be
SDRs ... TO LODGE OR NOT TO LODGE?
29
SELECTED SERVICE DIFFICULTY REPORTS
31
AIRWORTHINESS DIRECTIVES
35
used in conjunction with current operational documents.

Information contained herein is subject to change. The views
AVMED
expressed in this publication are those of the authors, and

do not necessarily represent the views of the Civil Aviation
Safety Authority.
FUEL CAP MISHAP
Fuel flows over the Nullarbor
41
Copyright 2008, Civil Aviation Safety Authority,

Australia. Copyright for the ATSB and ATC supplements rests
with the ATSB and Airservices Australia respectively these
supplements are wrriten, edited and designed independently
of CASA. All requests for permission to reproduce any
articles should be directed to FSA editorial
(see correspondence details above).
Registered printpost: 38166700644. ISSN 13255002.
Cover photo courtesy of

www.AirTeamImages.com
Photographer:
Martin Boschhuizen
CLOSE CALL FOLLOW-UP
Why we encourage our readers stories
43
PROSTATE CANCER AND CERTIFICATION
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A BUMP ON THE HEAD
46
AOD TESTING INFORMATION
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FINAL FLIGHT: SILKAIR MI 185
Building 78, Mick Borzi Drive,
A look at the sequence of events leading to the tragedy 10 years ago
18
Cairns International Airport, Cairns Qld

PO Box 280N North Cairns Qld 4870
Darwin
Reservations House
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FLIGHT BYTES Aviation safety news
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RULES WATCH Regulatory developments
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A
Aerial firefighting
death
FLIGHT SAFETY ran a small
news item on page 9 in the
November-December issue.
The first pilot to die fighting bushfires in Australia had
less than five hours experience f lying the modified aircraft that crashed and killed
him, the ATSB says. Readers
contacted us querying that
Brad Pead was indeed the first
pilot to die while aerial firefighting.
Further investigation by
Flight Safety unearthed a news
release dated Monday 31 January 1994, from the office of the
Victorian Minister for Natural Resources. This expressed
condolences to the family of a
pilot after his untimely death
while engaged in fire bombing a lightning-strike-caused
outbreak of fire at Mt Murray
in the recent NSW bushfires.

Robert Newton, a very experienced pilot, was fire-bombing in a Weatherly 620, when
it crashed after he apparently
encountered severe turbulence
in the Mt Murray region of the
Snowy Mountains. (ATSB Occ.
No. 199400232)
Thank you to those readers
for correcting the record, and
the memory of Robert Newton.
Editor
Blind Faith
IT MAY HAVE been described
in the article as an act of blind
faith (Flight Safety Australia
Nov-Dec 2007 pp. 4649),
but according to two readers
recollections, it was not fully
dark when the DC-3 ditched
into a lake at the Eastlakes
Golf Course on 4 November
1957. This is contrary to the
investigators findings at the
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Agent declares interest
time. Ted Baker, now in his

mid-80s, but then newly-married and living at Eastlakes
almost directly in line with
the east-west runway at Mascot airport also queries the
involvement of a boat, and
the shutting down of the port
engine.
Ian Ward, now in his early
60s, was a boy at the time of
the accident, living almost due
south of the ditching site. He
insists the flight path shown
in the Flight Safety Australia
diagram is incorrect, and
supports Ted Bakers assertion that it was still light.
Macarthur Job, writer of the
article, says that the Department of Civil Aviation investigators, Lum and Yeend, had
reputations for being meticulous, and both were experienced ex-RAAF pilots. And,
after fifty years, it is difficult to
know the detail of what really

happened.
Again, thank you to eyewitnesses, Ted Baker and Ian
Ward, for contacting Flight
Safety with their stories.
Editor
Write to FSA
We encourage feedback from our
readers on this edition of FSA, and
let us know what youd like to see
in future issues. Specify if your
letter is not for publication, or if
you wish to have your name withheld. Due to space constraints,
not all letters received can be
published.
Email: fsa@casa.gov.au
Icy blue yonder

ONE OF NEW federal environment
minister,
Peter
Garretts, first official duties
was to touch down in an
Airbus A319 jet on the new
4-km long blue-ice Wilkins
Runway in Antarctica, on 11
January. According to the
Antarctic Division, the runway
opens a new era in scientific
exploration of the ice.
CASA gave the all-clear for

the first permanent air link
between Australia and Antarctica. In early January, CASA
approved a licence for airline
Skytraders to fly passengers
from Hobart to the blue-ice
runway of Wilkins aerodrome,
near the Australian Antarctic Divisions Casey Station.
Skytraders will carry scientists
and other Antarctic personnel

on a twin-engine Airbus 319
on behalf of the federal government.
A CASA spokesman said the
authority made the decision
after considering a number of
safety issues. These included
the aircraft having sufficient
fuel capacity to safely make the
return journey or turn back
mid-flight, and being able to
complete the trip if one engine
failed.
The aircraft cannot refuel in
Antarctica. CASA also considered contingency plans to fly to
Christchurch, New Zealand,

in case of an emergency, pilot
training and the Antarctic
runways condition.
The runway is carved out of
the ice, and according to CASA
inspector, Bill Hilliger, posed
some interesting challenges.
How do you paint white
lines on ice? he says, and the
logistics of a runway on ice
which moves approximately
12 metres a year.
However, being involved in
the project, and his trip south
he says were one of the highlights of his career.
PHOTOGRAPH COURTESY AUSTRALIAN ANTARCTIC DIVISION
US passengers barred from

taking spare batteries
From left: Matt Filipowski and Stuart McFadzean, from the Australian
Antarctic Division, with the Civil Aviation Safety Authoritys aerodrome
inspector, Bill Hilliger, and aerodrome coordinator, Richard Allen, on Wilkins
Runway, near Casey Station, in Antarctica in early January.
AVIATION MEDICINE
Southern NSW & NE Victoria
DR ANDREW MILLIKEN
M.B.B.S (Monash) Dip. Obst. R.C.O.G.
Dip. Occupational & Environmental Health
CASA Approved Medical Examiner
Aviation and General Medicine
Electrocardiography Audiometry Blood Tests
Border Occupational Medicine Service
645 David Street ALBURY 2640
Ph: (02) 60215555 dsmcalb@bigpond.net.au
Coming next issue:
CASAs aviation safety training initiative for Indonesia.
FLYING well-equipped for

business and pleasure gets a
little more complicated with
new US Department of Transportation rules that bar travellers from packing loose lithium
batteries in checked luggage.
The move is designed to help
minimise the risk that batteries
could overheat and catch fire
on board, the agencys Pipeline and Hazardous Materials
Safety Administration says.
The new rules say travellers
can bring a laptop computer,
digital camera, mobile phone
and other equipment on board
or in checked luggage if their
lithium batteries are installed
in the items.
And passengers can bring
spare batteries in carry-on
luggage if they are stored in
plastic bags or if they are in the
original retail packaging. But
travellers can bring only two
such spare batteries, and each
must be packed separately.
From The Wall Street Journal, Robert

Daniel - January 04, 2008
The International Civil Aviation Organization (ICAO)

also plans to implement heavy
limitations on lithium batteries, particularly for carriage
on passenger aircraft, but there
will also be changes to the
requirements for carriage on
cargo aircraft.
The Federal Aviation Administration of the USA (FAA) has
begun a program publicising
the safety implications for the
air transport of lithium batteries. The FAA has concerns
that aircraft fire suppression
systems have great difficulty
controlling lithium battery
fires.
CASAs dangerous goods
inspectors support the FAAs
program publicising safety
issues and lithium batteries;
Australia has had a number
of incidents involving lithium
battery fires.
2007 worldwide aviation safety statistics

ACCORDING TO recent
figures from the Geneva-based
Aircraft Crashes Record Office
(ACRO), 2007 was the safest
year in aviation since 1963 in
terms of the number of accidents.
It also says there were 25 per
cent fewer fatalities last year
than in 2006. The worst accident last year was the crash of a
TAM Brazil Airbus A320 flight
in Sao Paolo in July, where 199
people died.
Historian in Aircraft Accidents and head of the Record
Office, Ronan Hubert, said this
and other aviation accidents
are tragic, but they must be

put in perspective. He says 965
people lost their lives in plane
crashes last year, compared to
more than one million who
were killed in road accidents.
In 2007, more than two
billion were travelling worldwide: and we have thousands
and thousands of aircraft,
airplanes flying every day
worldwide. It means that aviation is one of the safest transport modes in the world, said
Hubert.
There were 136 accidents
registered (compared to 164
in 2006), resulting in a total
of 965 deaths (compared to

1,293 in 2006). This compares
to 2004, which registered the
lowest number of fatalities
since the end of World War II,
with 766 deaths. The year with
most fatalities was 1972, with
3,214 deaths.
North America accounted
for 32 per cent of all accidents
in 2007, Asia 23 per cent, Africa
14 per cent, South America
and Europe both 10 per cent,
Central America 9 per cent and
Oceania 1 per cent.
Fifty-one per cent of accidents recorded occurred during
the landing phase; 27 per cent
during flight; and 20 per cent

during takeoff. Thirty-seven
per cent of accidents concern
scheduled passenger flights;
12 per cent military flights; 11
per cent cargo flights; and 8 per
cent private flights.
The ACRO is a privately-run
organisation which compiles
statistics on aviation accidents
of aircraft capable of carrying
more than six passengers, not
including helicopters, balloons
or fighter airplanes.
ACRO media release, Voice of
America News 2/108, The Australian
3/1/08
198
198
179
187
184
173
164
165
136
1,567 1,535
1,399
1,130
1,454
1,224
1,293
965
NUMBER OF
ACCIDENTS
766
NUMBER OF
FATALITIES
1999
8
2000
2001
2002
2003
2004
2005
2006
2007
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Concrete start for new airport

THE NEW MINISTER for
Infrastructure,
Transport,
Regional Development & Local
Government, Anthony Albanese, performed his first official
duties in the role on Tuesday 15
January, 2008.
Melbourne Airport played
host to the minister as he acti-
vated a 20-tonne concrete crane

and removed a half-metre deep
3 x 3 metre sized chunk of
airfield concrete, marking the
first step in the largest upgrade
to Melbournes international
terminal since its construction
in the late 1960s.
The first step in the construc-
tion is an entirely new

outbound passenger processing zone, including new security and Customs precinct, due
for completion in early 2010.
Staged expansion over five
years means that the airport
can ensure operations continue
as normal, with an emphasis
and a new tower visual simulator

AIR TRAFFIC controllers, as
well as airport safety officers
and pilots on awareness training now have access to a new
360-degree tower visual simulator opened by the Minister,
Anthony Albanese, at Airservices Australias training
establishment at Melbourne
Airport.
The A$6 million simulator
will provide training scenarios
that an ATC may rarely, if ever,
experience in the real world -such as airport or aircraft emergencies, or unusual weather
10
such as snow in Australia. By

expanding the range of training options, and allowing
instant replays, the simulator
is expected to improve training and safety while reducing
training time.
Photo shows (left to right)
Airservices instructor Iain
Martin, Chairman Nick
Burton Taylor, Maria Vamvakinou MP, Minister Anthony
Albanese, and instructor
Trevor McKeon experiencing
the realism of the new simulator.
on worksite safety. The safety

of our staff and our passengers
has been, and always will be,
our absolute number one priority, Melbourne Airport CEO,
Chris Woodruff said.
For a tour of the future international terminal, see www.
melbourneairport.com.au/t2/
A very CASA Christmas

MEMORIES OF Christmas
and New Year have faded,
with the pressures of the new
working year.
However, whilst most of us
enjoyed a few days of rest and
recreation between Christmas
and New Year, a small team
of volunteers in the Personnel, Licensing, Education and
Training (PLET) Group at
CASA continued to provide
flight crew and maintenance
licensing, aircraft registration and aviation medicine
services.
Over the stand-down period,
PLET staff responded to 50 60 calls and emails requiring

action to help someone obtain
a licence or certificate. These
were mostly aviators who had
overlooked milestone dates,
resulting in a last minute cry for
help. Some were due to operate
commercial flights with expiring medical certificates if the
PLET staff werent on-hand,
they would not have been able
to operate these flights.
On 31 December, a young
man from Sydney turned 16
and was therefore eligible to
be issued with an SPL and fly
solo the flight crew licensing

team were able to accommodate the request, much to his
satisfaction.
In aviation medicine, just
prior to Christmas, there
were several calls asking staff
to process medicals urgently
because they wanted to fly
over the Christmas/New Year
period staff managed to push
them through on time with
some considerable effort.
Similarly, in aircraft registration, there was a considerable
rush to register and de-register
aircraft some of these belong-
ing to major airlines. Calls

continued during the week
between Christmas and New
Year for aircraft registration
services.
In maintenance licensing,
several approvals and one
cancellation were effected.
Those who volunteered to
provide these services over the
break reported that the aviation
community warmly welcomed
and appreciated the assistance
provided to them, and have
received several phone calls
and emails which praised the
CASA volunteers.
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Amateur builders approved for

maintenance on their own aircraft
A NEW CASA legal authorisation (general instrument
CASA 451/07) allows amateur
builders of aircraft under
Amateur Built Acceptance
Aircraft (ABAA) (refer 1998
CASR 21.190) to maintain
their aircraft and issue a maintenance release.
Issued in December 2007,
this authorisation demonstrates the ongoing cooperation
between a Queensland-based,
Sport Aircraft Operations
Group (SAOG) and CASA. The
Sport Aircraft Group provides
support to amateur builders, especially ABAA builders, during the construction
phase.
The Group has several
Instrument of Approval (IoA)
holders who issue manufacturing approval, stage and final
inspections prior to issue of a
special certificate of airworthiness.
One challenge facing sport
aviation is the rising cost and
availability of maintenance
organisations at traditional
locations such as Bankstown
and Archerfield. Sport aviation
has been relocating to airfields
such as Gatton and Jacobs
Well, airfields with limited
or no CAR 30 maintenance
organisations.
Regulations require ongoing
maintenance of ABAA aircraft
to be carried out by CAR
30 organisations unless the
builder has a maintenance
authority (MA).
The Sport Aircraft Operations Group looked at maintenance authorities versus
12 FLIGHT SAFETY AUSTRALIA JANFEB 2008
instruments of approval, and

identified a need for training
in regulatory and continuing
airworthiness.
Mindful of CASAs focus
on passenger-carrying aviation, and limited resources
for sport aviation, the Group
approached Greg Vaughan
(CASAs
Group
General
Manager, General Aviation
Operations) earlier in the year
with a request for an IoA for
ABAA builders.
The Sport Aircraft Operations
Groups
request
included:
a draft of the training procedures manual
a syllabus of the training to
meet (or better) the MA standard

nominated training personnel
a timeframe and commitment to deliver.
Greg Vaughan accepted the
proposal and sponsored the
project under the guidance
of the CASA Service Centre
(CSC).
The Sport Aircraft Operations Group delivered the
training, and provided recommendations to CASA which
drafted the general instrument
for signature.
The training involved:
pre-classroom exercises
focusing on research skills
eight hours of classroom

activities
a hangar field trip of about
four hours
an assignment which formed
part of the assessment.
Feedback from students has
been very positive.
The Sport Aircraft Operations Group delivered over
90 per cent of the work, with
CASA providing the sponsorship, guidance and review.
This project demonstrates
how recognised sport aviation
organisations can work with
CASA to deliver well informed,
cost-effective, safe and compliant outcomes to the sport aviation community.
Student Neil Bell (third from left) highlighting a point during a periodic maintenance check on his RV6a, watched by
Adrian Le Gassick, Airworthiness Inspector, (second from right) who volunteered his time for the hangar field trip.
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Call for nominations

Non-Destructive Testing Board
The National Aerospace Non-Destructive Testing Board

of Australia (NANDTB) is an independent organisation
representing aerospace industry and recognised by CASA,
to provide or support non-destructive testing qualification
and examination services in accordance with Australian and
international standards.
All board members terms expire in March 2008, and the
board is calling for nominations from interested Australian
aerospace industry representatives.
Nominations should be sent to the board secretary,
Colin Hockings
agenda of work to be progressed during the next two years.

The Board acknowledges the time and expense to individuals
and companies to attend a meeting to elect the Board
members, so the election will be conducted online, via the
NANDTB website (www.ndtboard.com) during March 2008.
The Board is made up of 12 full members representing the
various sectors in Australian aerospace which use nondestructive testing. The proportional representation is:
Manufacturers 3 maximum
Training organisations 3 maximum
by email (chockings@qantas.com.au) or
Major airlines 2 maximum
posted to:
Regional airlines 2 maximum
Colin Hockings
QS&RM, SAB2/8 Qantas
Mascot NSW 2020
If youre considering nominating for the board you should keep
in mind that all positions are honorary and the board receives
no funding. Any expenses related to attendance at meetings or
the preparation of board documents are the responsibility of
individual members. It is also worth noting that there is a full
Maintenance and repair organisations / NDT service

providers 3 maximum
General aviation operators 2 maximum
Others 1
Each aerospace company with a discrete ARN number, and
which uses NDT or contracts NDT services, may vote to elect
members to the board.
For enquiries, please contact board secretary, Col Hockings on 02 9691 9035 or chockings@qantas.com.au
A C C I D E N T S
&
I N C I D E N T S
INTERNATIONAL ACCIDENTS/INCIDENTS NOVEMBERDECEMBER 2007

DATE
AIRCRAFT
LOCATION
FATALITIES
DAMAGE
DESCRIPTION
4 NOV
Learjet 35A
Brazil
Destroyed
After takeoff in heavy rain, the Learjet turned and began to descend. The crew
did not respond to tower communications, and the plane crashed into several
houses. Two people were killed on the ground in addition to all six on board
the plane. The pilot may have been attempting to return to the airport due to
heavy rain.
7 NOV
Boeing 737-230
South Africa
Substantial
Right hand engine separated from wing after take-off. The aircraft returned to
Cape Town Airport and landed safely.
8 NOV
Antonov 12
Sudan
Written off
After take-off, a birdstrike caused an engine failure. The cargo plane crashed
onto a military base, killing two soldiers on the ground.
9 NOV
Airbus A340-642
Ecuador
Substantial
The Airbus overshot the runway when one or more of the aircrafts tyres burst
on touchdown.
11 NOV
Bombardier BD-700
Nova Scotia, Canada
Substantial
The aircraft touched down 7 ft short of runway, incurring significant landing

gear damage.
15 NOV
Airbus A340-642X
Toulouse Airport, France
Substantial
During ground performance tests, wheels were not chocked and the aircraft
moved forward into a concrete barrier. The nose was damaged and five
people were injured.
30 NOV
McDonnell Douglas
MD-83
Turkey
57
Substantial
The passenger plane crashed into mountains a few minutes before it was due
to land at Isparta Airport. The cause of the crash has not yet been determined,
although pilot spatial disoriention has been suggested.
05 DEC
Cessna 208B Grand

Caravan
Ohio, USA
Written off
During instrument meteorological conditions, the plane lost altitude and

crashed into terrain.
10 DEC
Let 410
Guyana
Written off
The aircraft was severely damaged after a take-off on an illegal airstrip. It was
later found to have been deliberately burned out alongside an abandoned
camp.
12 DEC
Cessna 208B Grand

Caravan
Nairobi Airport, Kenya
Substantial
The Cessna collided with a DHC-5 Buffalo on the taxiway, damaging both
aircraft and causing injuries to six occupants.
16 DEC
Canadair CRJ200LR
Rhode Island, USA
Substantial
The passenger carrier skidded off the runway on touchdown, incurring

considerable damage to the landing gear and wings.
17 DEC
Beechcraft C.99
Utah, USA
Substantial
The aircraft landed short of the runway, sustaining significant damage to

propellers and landing gear.
18 DEC
Cessna 208B Grand

Caravan
Alaska, USA
Substantial
Immediately after takeoff, the Cessna hit a tundra hill and skidded 100 yards,
leaving a trail of parts and cargo. Both occupants were injured in the incident.
20 DEC
Cessna 208B Grand

Caravan
Alaska, USA
Substantial
The cargo plane lost engine power at 12,000 ft over the Bahamas. The pilots
performed an ocean ditching and were rescued by by a sailboat.
26 DEC
Canadair CL-600-2B16
Challenger 604
Kazakhstan
Destroyed
The Challenger veered off the runway on take-off, slammed into a wall and
caught fire. The sole passenger was killed, but the three crew members
survived.
30 DEC
Boeing 737-38J
Bucharest, Romania
Substantial
While accelerating for take-off, the airliner hit a maintenance workers vehicle.
Visibility was poor due to thick fog.
Notes: Compiled from information supplied by the Aviation Safety Network (see aviationsafety.net) 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 factual information refer to final
reports of the relevant official aircraft accident investigation organisation. Information on injuries unavailable.
14
AUSTRALIAN ACCIDENTS/INCIDENTS NOVEMBERDECEMBER 2007

DATE
AIRCRAFT
LOCATION
INJURIES
DAMAGE
DESCRIPTION
5 NOV
De Havilland DH-82A Tiger

Moth
Aldinga (ALA), SA
Nil
Substantial
During the taxi, the aircraft struck a PA-28.
7 NOV
Piper PA-25-235 Pawnee
Near Leongatha
Aerodrome, Vic.
Nil
Substantial
During agricultural spraying operations, the aircraft was unable to out climb rising
terrain, impacted the side of a hill and was destroyed.
8 NOV
Robinson R44
Flemington (VFR), Vic.
Nil
Substantial
Soon after takeoff at 800 ft, a pelican collided with the helicopter, impacting the
cabin and tail rotor. The pilot conducted an autorotation due to severe vibrations and
immediately landed the aircraft at Port Melbourne.
10 NOV
Cessna 172N Skyhawk
Elliott (ALA), N 37 km, NT
Fatal
Destroyed
The aircraft impacted the ground on or adjacent to the Stuart Highway. The investigation is continuing.
11 NOV
Piper PA-28R-180 Arrow
Gulgong (ALA), NSW
Minor
Substantial
During the initial climb, the aircrafts engine lost power and the pilot elected to land
on the remaining runway. On touchdown, the aircraft veered off the runway, the left
main landing gear collapsed and the aircraft slid into a fence. The pilot sustained
minor injuries but the aircraft was substantially damaged.
11 NOV
Cessna 182T Skylane
Bendigo Aerodrome, Vic.
Nil
Substantial
While conducting a touch-and-go landing on runway 35 the pilot lost directional

control when take-off power was applied. The aircraft left the runway and came to
rest in a ditch.
17 NOV
Cessna 337G Skymaster
Inverloch (ALA), 155

24 km, Vic.
Fatal
Destroyed
The aircraft collided with the sea and was destroyed. The pilot and passengers
received fatal injuries. The investigation is continuing.
17 NOV
Cessna 72M Skyhawk
Uaroo Station, WA
Fatal
Destroyed
The aircraft collided with the ground. The pilot received fatal injuries. The investigation is continuing.
17 NOV
ICA Brasov IS-28B2
Bond Springs (ALA), NT
Minor
Destroyed
During the turn on to base, the glider stalled and went into a spin. The aircraft was
destroyed when it hit the ground.
23 NOV
Cessna 210L Centurion
Snake Bay Aerodrome, NT
Nil
Substantial
After joining crosswind for runway 31, the pilot inadvertently retracted the landing
gear and landed with wheels up.
28 NOV
Cessna A188B/A1 Agtruck
Charters Towers Aerodrome, 320 50 km, Qld.
Nil
Substantial
During the initial climb, engine suffered a partial power loss. Height could not be
maintained and the aircraft collided with trees and terrain.
1 DEC
Amateur Built Spitfire MK

26 Mini replica
Heck Field (ALA), Qld.
Nil
Substantial
During a go around, the aircraft stalled at low level and landed heavily off the
runway. The main landing gear collapsed and the aircraft sustained damage to the
fuselage and the right wing.
1 DEC
Cessna 72M Skyhawk
Latrobe Valley Aerodrome,

Vic.
Fatal
Minor
The Cessna 172M (C172) collided with an ultralight in midair. The ultralight collided
with the ground and the pilot sustained fatal injuries. The C172 landed safely. The
investigation is continuing.
4 DEC
Cessna 152
Bacchus Marsh (ALA), Vic.
Nil
Substantial
During landing, the student pilot landed with excess power and the brakes applied
and the aircraft porpoised down the runway. The aircraft then left the runway, the
nose wheel dug into the soft ground and the aircraft flipped onto its back.
7 DEC
Air Tractor AT-802
Liddell (ALA), 330 6 km,

NSW.
Fatal
Destroyed
The aircraft was reported to have flown into the surface of the lake. The
investigation is continuing.
10 DEC
Piper PA-31 Navajo
Eucla (ALA), WA
Nil
Substantial
During the landing roll on runway 08, the aircraft struck a kangaroo causing nosewheel
lto detach . The pilot held the nose up for as long as possible until the aircraft came to rest
on the nose. Inspection revealed minor damage to trailing edge of the left flap and dent
on lower section of cabin door, from the impact with the nose wheel or kangaroo.
13 DEC
Hughes Helicopters 269C
Devonport Aerodrome, Tas.
Nil
Destroyed
During takeoff while still on the ground, the helicopter entered ground resonance
and broke up.
13 DEC
Piper PA-28-161 Warrior
Tyabb (ALA), 244 38 km,

Vic.
Minor
Destroyed
During cruise, the aircrafts engine lost power and the pilot made a forced landing.
16 DEC
Cessna 150M
Near Eneabba (ALA), WA
Serious
Destroyed
During a low level fly-by in gusty wind conditions, the aircraft struck a powerline and
impacted the ground. The two occupants received serious injuries..
18 DEC
Beech 76 Duchess
Scone Aerodrome, NSW
Nil
Substantial
During the approach to runway 11, with the left propeller feathered and a crosswind
from the right, the pilot was unable to maintain directional control and the aircraft
landed in a paddock outside the aerodrome boundary. The nose landing gear and
left main landing gear collapsed on touchdown.
21 DEC
Cessna A188B/A1 Agtruck
Surat (ALA), NW 43 km, Qld.
Nil
Substantial
During the take-off run, with a quartering tailwind, the aircraft failed to gain sufficient
height and collided with a fence before impacting the ground.
29 DEC
Boeing 737-229
Norfolk Island Aerodrome
Nil
Substantial
During a missed approach at Norfolk Island, the aircraft experienced increasing

airframe vibrations and control difficulties. The aircraft was diverted to Noumea
where a safe landing was completed. The investigation is continuing.
29 DEC
Robinson R44
Near Westgate Bridge

(VFR), Vic.
Fatal
Destroyed
Shortly after takeoff, the R44 helicopter departed normal flight and impacted the
water. One crew member was fatally injured and another sustained minor injuries.
The investigation is continuing.
Text courtesy 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 followup 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. 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.
ATC.MRCQ
ATC OPERATIONS
The intent of this article is to raise awareness of two major
control tower functions and associated workloads, in order to
provide an insight into day-to-day tower activity with the aim
of increasing pilot and vehicle operator ATC understanding.
t is often stated that ground frequency is overloaded and that tower frequency is relatively
quiet and ordered. Contrary to what is heard
PWFSUIFSBEJP UIF"FSPESPNF$POUSPMMFS "%$

BOE4VSGBDF.PWFNFOU$POUSPMMFS 4.$
DBOCF
equally busy at any given time.
adjacent taxiways to detect and prevent runway

incursions and to monitor clearance compliance.
The ADC is also is responsible for scanning surrounding airspace and monitoring navigation aids
and the monitoring and activation of runway and
approach lighting.
AERODROME CONTROL (ADC)
SURFACE MOVEMENT
CONTROL (SMC)
The primary function of the ADC is to regulate

and provide separation to aircraft and vehicles
operating on active runways and in the airspace
in the vicinity of the aerodrome.
This involves managing aerodrome traffic and
providing runway separation standards to aircraft
BOEWFIJDMFTBOEDPPSEJOBUJOHXJUI4.$ XIFSF
FTUBCMJTIFE
GPSUIFDPOUSPMPGHSPVOENPWFNFOUT
entering, vacating and crossing active runways.
ADC is responsible for scanning runways and
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and provide information to aircraft and vehicles
operating on taxiways to enable collision avoidance and provide information on aprons to effectively regulate movements on taxiways.
This involves coordination with ADC for the
control of ground movements entering, vacating
BOEDSPTTJOHBDUJWFSVOXBZT4.$JTSFTQPOTJCMF
for scanning of runways, taxiways and apron areas to detect and prevent runway incursions and
NPOJUPSDMFBSBODFDPNQMJBODF4.$DPPSEJOBUF
BJSFMEXPSLTBFDUJOHUIFBQSPOBSFBT UBYJXBZT
and runways and issue approvals for engine starts
on bays and similar requests. They are responsible
for maintaining regular contact with airfield safety
officers over a broad range of issues and coordinatJOHHBUFDIBOHFTGPSBSSJWBMT XIFSFFTUBCMJTIFE

and monitoring taxiway lighting.
TASKS APPLICABLE TO ADC AND

SMC
Besides their individual tasks both controllers
perform a number of other important functions
including, updating the air situation display (where
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UPFOTVSFUIBUBDDVSBUF
Flight Data information is presented to other conUSPMMFST*TTVJOHJOTUSVDUJPOTUPBJSDSBBOEWFIJDMFT
and recording information and manipulating
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*OBEEJUJPOUPUIJTUIFZNBJOUBJOBXFBUIFSXBUDI
and provide an alerting service. Both positions
are responsible for obtaining correct readbacks of
clearances and instructions and maintaining an
adequate level of situational awareness.
RTF DISCIPLINE
Controllers are regularly called upon to repeat
instructions due to incorrect readbacks or over
USBOTNJTTJPOT1JMPUTBOEWFIJDMFESJWFSTDBO
greatly assist controller workload by being mindful of what is occurring on the radio and behind
the microphone and in doing so, potentially reduce RTF workload and in turn contributing to
flight safety.
16
A Reduced Vertical Separation Minimum within the height band Flight Levels
290 to 410 inclusive has been used within Australian Flight Information Regions
(FIRs) for a number of years. As part of the implementation of this separation minimum, significant monitoring and assessment of aircraft and airspace errors, both
technical and operational, was undertaken. Monitoring of the airspace continues
in accordance with requirements established by the International Civil Aviation
Organisation (ICAO).
5PFOBCMFUIFPOHPJOHNPOJUPSJOHPG374.PQFSBUJPOT *$"0BQQSPWFTTQFDJDPSHBOJTBUJPOT
UFSNFE3FHJPOBM.POJUPSJOH"HFODJFT 3."T

to undertake monitoring activities relative to
BOVNCFSPGBTTJHOFE'*3T8JUIJOUIF"TJB
1BDJD3FHJPO UIFSFBSFGPVSBQQSPWFE3."T
POFCFJOHUIF"VTUSBMJBO"JSTQBDF.POJUPSJOH
"HFODZ ""."
SVOCZ"JSTFSWJDFT"VTUSBMJB
F""."JTSFTQPOTJCMFUP*$"0GPSUIFNPOJUPSJOHBOESJTLBTTFTTNFOUPG374.PQFSBUJPOT
XJUIJOUIF#SJTCBOF .FMCPVSOF )POJBSB /BVSV
BOE1PSU.PSFTCZ'*3T
1BSUPGUIFNPOUIMZBTTFTTNFOUQSPDFTTJOWPMWFT
reviewing large height deviation reports which
are sourced from pilot reports as required by
"*1&/3 PSGSPN
the Airservices Australia
incident reporting system.
These reports are categorised using a regionally
agreed methodology. There
are reports of flight crews
failing to climb or descend
the aircraft as cleared as
well as reports of deviations
due to aircraft contingency
events leading to a sudden
inability to maintain assigned flight level and an
aircraft being provided with
374.TFQBSBUJPOUIBUJTOPU
374.BQQSPWFE FHJHIU
QMBOJOEJDBUJOH374.BQQSPWBMCVUBJSDSBOPU
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3FDFOUBTTFTTNFOUTVOEFSUBLFOCZUIF""."
have identified a number of significant reports
where flight crews or operators have provided
flight notification to air traffic control that incorSFDUMZJOEJDBUFTUIF374.BQQSPWBMTUBUVTPGUIF
JHIU*ODPSSFDU374.BQQSPWBMJOGPSNBUJPODBO
impact significantly on the safe provision of air
USBDTFSWJDFTBTXFMMBTBEWFSTFMZBFDUJOHUIF
risk levels within the airspace. Flight crews and
operators are reminded of the requirements of
"*1&/3JOSFMBUJPOUP374.PQFSBUJPOT
BOEBTLFEUPFOTVSFUIF374.TUBUVTJTDPSSFDUMZ
notified to air traffic control.
Did you know?
Airservices Australias area of operations covers the Australian Flight

Information Region which includes the nations sovereign airspace and
international airspace over the surrounding oceans including the FIRs of
the Solomon Islands and Nauru.
Airservices is responsible for an area of 19,995,070 sq nautical miles
(51,786,992 sq kms) - or some 11 percent of the worlds total airspace.
General
Aviation Survey
At Airservices Australia we value our
customers and wish to better our
flight planning and enroute support
services as well as terminal area and
tower clearances. A few minutes of
your time will help us to improve
our procedures and services that
are aimed at getting you where you
want to go, via the route you wish,
with minimum delay.
The scope of the GA Survey includes
seeking your feedback regarding:
s how you prefer to flight plan;
s which maps and publications that
you prefer to use; and
s are your preferred airways
clearances routinely available?
Your responses will remain confidential and we will provide feedback on
the results through the AOPA Magazine and Flight Safety Australia.
PRIZES
In appreciation, participants who complete the survey will have a chance to
win a Personal Locator Beacon (PLB)
or $500.00 worth of publications. Winners will be selected on a random
basis.
The survey can be accessed and completed at the following link:
http://www.airservicesaustralia.com/
gasurvey/
If you require a paper copy please
contact 1300 301 120.
Your participation will greatly assist
us to understand your needs and to
improve our services.
1IPUPTDPVSUFTZ1IJM7BCSF
Correct notification of RVSM

approval status
Final flight: SilkAir

It is now ten years since the crash of
SilkAirs 19 December 1997 Flight MI 185.
There was considerable controversy
surrounding the cause of the crash at the
time, and the uncertainty continues.
Macarthur Job looks at the sequence
of events; readers can draw their own
conclusions.
mong the flights departing

Jakartas
Soekarno-Hatta
International Airport on
Friday afternoon, 19 December 1997, was SilkAirs service to Singapore, flight MI 185, flown by the 73736N, 9V-TRF. The 80-minute trip was to
leave at 3.30 pm.
Under the command of Captain
Tsu Way Ming, 41, the crew consisted
of First Officer Duncan Ward, a New
Zealander; and five flight attendants.
Shortly before 3.15 pm, 97 passengers
boarded the aircraft.
The wind at the planned cruising
level of 35,000 ft was easterly at 1015 kt, and the weather was expected to
remain generally fine, with thunderstorms expected only around Sinkep
Island, 120 nm south of Singapore. The
737 took off at 3:37 pm, and was cleared
18
direct to PARDI, a reporting point north

of Palembang, Sumatra, where control
responsibility would be transferred to
Singapore.
When abeam Palembang half an hour
later, Jakarta instructed the aircraft to
call Singapore on reaching PARDI. The
first officer acknowledged this instruction normally.
This transmission at 4.10 pm proved
to be the Boeings last. For the following two minutes, Jakarta radar, relayed
from Singapore, showed the aircraft
maintaining FL 350. But only eight
seconds later, the radar showed it to be
400 ft below this level.
An extremely rapid descent followed,
its last radar return at 4:12:41 pm
showing it to be down to FL 195
(19,500 ft). The return then faded,
as Singapores radar, still more than
MI 185
IT APPEARED TO
BE UPSIDE DOWN
BEFORE PLUNGING
INTO THE WIDE,
MUDDY RIVER WITH
INDESCRIBABLE
FORCE.
PHOTO COURTESY JOACHIM BONGERS (WERNER FISCHDICK COLLECTION)
SilkAirs Boeing 73736N 9VTRF

On the runway in Singapore, October 1997, two months before the disaster.
COVER FEATURE
REPORTS OF EXPLOSIONS LED TO SOME EARLY

SPECULATION OF A TERRORIST BOMB, BUT
THAT WAS SOON RULED OUT.
240 nm distant, lost contact with the

aircraft.
At this time, villagers in the Musi
River delta on the south-eastern coast
of Sumatra, 60 km north-north-east of
Palembang, heard the scream of a fastflying jet rapidly increasing in intensity. Rising to a crescendo, the noise was
suddenly overlaid by two thunderous
booms. Further away, several people heard
what they thought was thunder, although
the sky was clear.
Seconds later, villagers near the river
caught a glimpse of an airliner plummeting earthwards. Diving steeply at
incredible speed on a westerly heading, it
appeared to be upside down before plunging into the wide, muddy Musi River with
indescribable force. Horrified fishermen
at once scoured the river for survivors,
but in vain.
INVESTIGATION
The investigation was led by Indonesias
National Transportation Safety Committee (NTSC). Representatives from Singapore, the American National Transport
Safety Bureau (NTSB), Boeing, and
General Electric participated. Australias
Bureau of Air Safety Investigation (BASI,
now ATSB) was also involved.
The crash site was 15 km from the
Sumatran coast, where the river is 700 m
wide and 8 m deep. So steep was the
aircrafts descent that it covered a horizontal distance of only 3.4 nm from its
last observed position at 35,000 ft. The
aircraft was completely fragmented, much
of its wreckage penetrating several metres
into the mud of the river bed.
When it became obvious that recovering the wreckage might be impossible for
the Indonesian authorities, the US Navy
offered its most sophisticated recovery
20
equipment. They believed they would be

able to retrieve all of the wreckage. But to
the bewilderment of the NTSB, the offer
was declined.
Instead, divers from the Indonesian and
Singapore navies, using sonar equipment,
set about the work. Despite strong currents
and almost nil visibility in the muddy
water, and with much of the wreckage
embedded in mud, they found that most
of the wreckage, including the battered
digital flight data recorder (DFDR), lay
within an area of 60 by 80 metres.
Its very dark down there. We cant see
anything, but we can touch things, an
Indonesian army diver said.
The biggest piece was a section of
wing two metres long. The remains of
the engines confirmed that the aircraft,
although diving steeply, was inverted
when it plunged into the water.
A dredge enabled smaller pieces of
wreckage to be extracted from the mud
to a depth of several metres. A number
of watches, all severely damaged, were
found, four showing times consistent with
the time of the aircrafts descent. Little of
the 104 occupants could be identified.
Recovered wreckage included the
centre section of the horizontal stabiliser
(tailplane), together with its adjusting
jackscrew. The jackscrew was jammed at
its full nose-down manual electric trim
limit of 2.5 units. Yet the remains of all
the other control surfaces, together with
their actuators and systems, revealed
nothing that could have caused the highspeed dive. One of the last items recovered
from eight metres of mud was the cockpit
voice recorder.
Ground and air searches conducted up
to several kilometres from the crash site
yielded parts of the empennage that had
failed structurally in the latter stages of
the high speed descent. They comprised

the rudders upper balance weight,
outboard sections of the tailplanes and
elevators, the elevator tabs, and pieces of
skin. The wreckage was distributed in an
easterly direction up to 6.4 km from the
crash site.
There was no evidence of fire, explosion
or electrical overload, and damage to the
remains of seats and cabin fittings exhibited nothing of significance.
None of the recovered oxygen canisters
had been activated.
ENGINES
Both CFM 56 engines were severely fragmented, but about 85 per cent of each
was recovered. They had been running
at high rpm on impact. Damage to the
blades, resulting from their rotation and
the severity of the impact, was such that
the manufacturers representatives said
they had never seen anything like it.
The main engine control governors were
in their positions for high fuel flow, high
engine speed. This finding was confirmed
when the flightdeck throttle box was also
recovered, with one power lever still in
its forward, high power position, and one
fuel shut-off lever in the run position.
THE AIRCRAFT
Delivered new in February 1997, the
Boeing had flown only 2,238 hours, and
at the time of departure was fully serviceable. Up to the time of its acknowledgement of Jakarta ATCs instruction at
4.10.26 pm to call Singapore Control on
reaching PARDI, its transmissions were
perfectly normal.
FLIGHT RECORDERS
The recordings of both the DFDR and the
CVR were read out with the assistance of
the American NTSB and Australias BASI.
All but six seconds of the DFDR record
was recovered, and the CVR record, analysed by the NTSB in Washington DC, was
recovered in its entirety.
For reasons not apparent, both recorders
had ceased to function before the aircraft
began its fatal dive; the CVR shortly after
4:05 pm, and the DFDR just over six
4.04:57pm: Cockpit conversation

Captain: Go(ing) back for a while, finish your plate, F/O: I am...
CVR stops recording 8.6 seconds later.
4.10:26pm: Last communication with ATC
F/O: Silk Air 185 Roger...
4.08pm
4.11:27pm: Last readable data from DFDR before it ceased operation

Cruising flight FL350, autopilot and autothrottle engaged
4.10pm
4.12:09pm: Radar return indicates aircraft at 35,000ft
4.12pm
Flight trajectory determined

from flight simulator
experiments and analysis of
known data and parameters
The unfolding tragedy

The final minutes of SilkAir Flight MI 185, 19 December 1997.
DIAGRAM: JUANITA FRANZI, AERO ILLUSTRATIONS
minutes later. This was only 35.5 seconds

before the aircraft began its precipitous
descent. The CVR readout included the
aircrafts preparation for flight, taxiing
and take-off, and climb to cruising level.
The recording continued until the CVR
stopped suddenly at 16.05.15.6 (i.e. 15.6
seconds after 4.05 pm).
At 16.04.55, with the aircraft established in cruise on autopilot, the captain
remarked, Go(ing) back for a while,
finish your plate. He was telling the first
officer he was leaving the cockpit and to
finish eating. A series of metallic snaps,
consistent with the removal of a seatbelt,
followed. Sixteen seconds later, the CVR
abruptly ceased recording.
The last readable data from the DFDR,
before it also ceased to operate, was at
16.11.27.4 (27.4 seconds after 4.11 pm),
with the aircraft in cruising flight on
autopilot at FL 350 and the autothrottle engaged. This was only 50 seconds
before the aircraft began its extremely
rapid descent.
WHAT STOPPED THE FLIGHT

RECORDERS?
There was no evidence to suggest any
mechanical failure had caused either
unit to cease recording, and no apparent
reason for the six-minute difference in

their stoppage. Indeed, it seemed impossible to account for the stoppages in the
way they occurred.
And while the cessation of the CVR
could go unnoticed from the control
seats, this could not occur with the
DFDR, an annunciator light on the
instrument panel drawing attention to
another on the overhead panel indicating the DFDR had failed.
Because the CVR stopped at the
very time the captain was preparing to
leave the flightdeck, the manufacturer
conducted tests to verify if its stoppage
could have been the result of the circuit
breaker being pulled manually. Other
practical tests were performed aboard
a Boeing 737-300 similar to the crashed
aircraft.
Carried out firstly in the 737 on the
ground with its engines shut down,
these showed the cockpit area microphone did record the sound of the circuit
breaker being pulled, because the CVR
continues to run from its capacitor for
250 milliseconds after its power source
is interrupted. This is to prevent interrupting the recording when its source of
power is transferred from the aircrafts
power supply to external ground power
4.12:41pm: Radar
contact lost at
19,500ft
Approx 12,000ft
Pieces of tail assembly
separate, consistent with
forces incurred at a high
Mach number
North
Musi River delta
COVER FEATURE
and vice versa.

In a second series of tests, both on the
ground and in flight, the circuit breaker
was actuated by introducing short circuits
and overloads. During the short circuit
tests, a distinctive 400 Hz tone or hum
was recorded. Yet the CVR recording
from the crashed aircraft contained no
corresponding tone.
The same tests found the area microphone picked up the distinctive snap
the circuit breaker makes when violently
tripped by a short circuit or overload. But
again, no corresponding sound could be
found on the crash recording. On the
ground without the engines and airconditioning running, the snap of the
circuit breaker being pulled manually
was identifiable. But background noise
obscured the sound when it was pulled in
flight.
INFLIGHT STRUCTURAL
FAILURES
To determine the altitude at which pieces
of the tail assembly separated, trajectory
studies were carried out by BASI. These
showed the rudder balance weight separated at a significantly lower altitude than
35,000 ft. The distribution of the remaining pieces showed they separated near
or below 12,000 ft while the aircraft was
diving at a high Mach number.
An NTSB computer simulation
provided a more complete picture of the
aircrafts trajectory and the break-up of its
tail assembly. All the major fractures had
resulted from numerous excessive reverse
loadings, such as would occur in highspeed aerodynamic flutter.
DESCENT PROFILE
INVESTIGATIONS
Exhaustive flight simulator tests were
carried out to explore the combination of control inputs and engine power
selections that could have resulted in the
aircrafts extreme high-speed descent
profile, not only as indicated by Jakartas
ATC radar, but also by the rapidity with
which the aircraft lost height, the failure
of the empennage, and the mode and
violence of its impact with the river.
22
Eyewitness accounts of two explosions

ultimately suggested sonic booming, indicating that the aircraft had broken the
sound barrier. The reports of explosions
led to some early speculation of a terrorist
bomb, but that was soon ruled out.
Conducted in Boeings full-motion
engineering simulator in Seattle, 21 different flight situations were firstly explored
involving extreme control inputs, engine
failures, yaw damper and autopilot aberrations, and autopilot disconnections.
None was found to match 9V-TRFs crash
trajectory.
A further 20 flight situations and efforts
to recover from them were then explored,
together with manual attempts to replicate the observed crash trajectory. No
trajectory resulting from any single failure
matched the Jakarta radar observations,
and the aircraft could be effectively recovered from any single failure.
A third test, carried out in Garudas
simulator, explored descent times from
35,000 ft resulting from a runaway horizontal stabiliser trim, hard over rudder,
hard over aileron, combinations of these
control inputs, and a combination of
sustained manual inputs of rudder, aileron
and elevator control.
Only in the case of the manual control
inputs did the timing match the 32
seconds 9V-TRF took to descend from
cruising level to the last recorded radar
observation at 19,500 ft.
A computer simulation by the NTSB
examined the Boeing 737-300s responses
to various pitch control, rudder, autopilot
and yaw damper failures. None matched
the radar record of the aircrafts descent,
unless accompanied by adverse, active
pilot control inputs.
Informal tests by a group of experienced airline pilots in another full-motion
Boeing 737-300 simulator found it a very
difficult aircraft to fly into the ground
from the height and speed at which the
SilkAir Boeing was cruising. It required
a very positive and sustained effort, with
full-forward control column and nosedown trim applied all the way down.
Releasing hard-forward control column
while the aircraft was diving at high speed,
even with full nose-down trim applied,

resulted in the aircraft pitching up into
a nose-up attitude. With the simulator
forcibly held in the dive, a maximum of
Mach 1 was reached after 25 seconds at an
indicated 455 kt.
The pilots also found that the only way
to reproduce the height lost in the distance
travelled and in the time elapsed, was to roll
the aircraft inverted and pull hard back on
the control column to place the aircraft in
a near-vertical dive. Maintaining the steep
dive then required hard- forward elevator,
as well as full nose-down trim.
THE FINDINGS SO FAR

The entire circumstances of the aircrafts
dive, during which it evidently became
supersonic, seemed to defy logic. Equally
inexplicable was the stoppage of its flight
recorders six minutes apart, before the
dive began.
And the fact that ATCs last instruction to the aircraft when it was abeam
Palambang evoked an apparently normal
response from the first officer five minutes
after the CVR had ceased recording, only
added to the mystery.
No attempt had evidently been made
to recover from the dive, high engine
power being maintained up to the
moment of impact. And although at
least one minute elapsed between the
onset of the dive and impact with the
river, no emergency transmission came
from the aircraft.
Also questionable were the settings
of the stabiliser trim and autothrottle at
impact. Both in their normal cruising
settings when the DFDR ceased functioning, the trim had been moved to its
full electrical nose-down setting, and
the autothrottle, which would have automatically reduced engine power when the
aircraft entered its dive, had been disengaged.
To the investigation team, only human
intervention could begin to explain the
extraordinary sequence of events. And
as the work progressed, accumulated
personal data clearly warranted further
investigation.
COVER FEATURE
THE CAPTAIN
Tsu Way Ming joined the Republic of
Singapore Air Force (RSAF) in 1975.
Flying fighter and training aircraft, he
achieved senior flying and instructing
positions, and later became a member of
the RSAFs Black Knights aerobatic team.
In 1992, with over 4,000 hours experience, Tsu joined SilkAir. He was found
to be highly skilled and decisive, and his
six-monthly checks were above average.
He was promoted to captain in 1996, and
a year later appointed a line instructor
pilot. Although there were some reservations on his character, it was felt that
his competence would enable him to fulfil
the role. Even so, his future performance
should be monitored.
But between early 1997 and the crash
in December, Tsu was involved in three
serious incidents.
During a routine approach, though
prompted by the first officer to go round
when the aircraft was too high and too
fast, he threw it into a series of S turns in
an attempt to lose height. The first officer
later described the manoeuvres as violent
rolls, left and right, very disturbing.
I was scared, he added.
Even so, the Boeing still crossed the
threshold at 700 ft, finally necessitating
the go-around. Tsu then did so contrary
to procedures, carrying out a tight visual
circuit at 170 kt within the hills surrounding the airport, with the undercarriage
and five units of flap still extended.
After the passengers disembarked, the
cabin crew told the first officer it had made
them feel sick. Captain Tsu did not report
the incident as required. Discussion of it
led to speculation that he was unsafe, and
the first officer was requested to submit a
report.
On the next flight on which they were
rostered together, the captain raised the
matter of the incident as they were preparing for departure. He voiced his frustration at the rumours he was hearing, about
nearly crashing, and about not being suitable for command.
The first officer assured the captain the
rumours had not come from him. This
seemed to satisfy Tsu, but after they began

to taxi, he suddenly swung around in his
seat and pulled the CVR circuit breaker,
located on a panel behind the command
seat.
When the incredulous first officer
demanded to know what he was doing.
Tsu replied that he wanted to preserve
their conversation to present it to management as evidence. The first officer angrily
protested, insisting he would not continue
with the CVR inoperative. The captain
then declared they would return to the
terminal to download the recording.
But when the tower asked why, the
captain changed his mind and reset the
circuit breaker. The flight continued,
but the flightdeck atmosphere remained
strained. As a result of this incident,
Captain Tsu was relieved of his line
instructor pilot status.
Other pilots said that Tsu would often
push his aircraft beyond its economy
speed of .74 Mach. And there were reports
of him performing excessively steep
approaches, and exploring other ways
of varying normal procedures to reduce
flight times.
Four months after his demotion, and
less than four weeks before the crash,
Captain Tsu again exhibited a cavalier attitude while taking off. Despite one engine
showing a low power indication before the
aircraft reached 60 kt, he pressed on, firewalling the power lever. There were other
indications that the engine was faulty, and
20 minutes into the flight, Tsu finally had
doubts about continuing.
After discussing the problem with an
engineer on board, they returned to Singapore. But with no fuel dumping facility,
the landing was considerably overweight.
The engine had to be changed before the
aircraft flew again. Tsu failed to report the
overweight landing as required.
Two days later, Captain Tsu called on
the flight operations manager to discuss
the overweight landing. He was concerned
that the company was being negative
about a minor issue. The flight operations
manager told him to outline his concerns
in a letter. But no letter came, and eight
days later the crash occurred.
Captain Tsus financial background

was examined to see if this could have
affected his conduct. At the time of the
crash, he was experiencing severe financial difficulties. He had operated a securities trading account in Singapore for eight
years, trading millions of shares in high
risk activity, and his losses had increased
between 1993 and 1997.
For two periods during 1997, his trading
had been suspended because he had not
paid his debts from early April to midAugust, and again from 9 December until
the day of the crash. On the morning
of the 19th, he had promised to make a
payment on his return from Jakarta.
Yet although the amount was substantial, he had no liquid assets from which
to pay it. Tsu also had several loans and
other debts and, at the time of the crash,
his monthly income was a little less than
his familys monthly expenditure. There
was also a number of credit card debts.
Tsu had several insurance policies
providing benefits in the event of his
death. Most were taken out years before,
but a recent one, recommended by the
financial institution that provided the
loan on his house, was approved only a
week before the crash. Its commencement
date was 19 December the day of the
crash itself.
THE FIRST OFFICER

Duncan Ward, 23, a New Zealander, had
2,500 hours experience, having joined
SilkAir 15 months before, with experience
with Garuda Airlines. Rated as above
average, with very good handling skills,
he was keen to advance his career and was
planning to complete his ATPL. He was
financially stable, and there was nothing
to show he was experiencing any personal
problems.
ANALYSING THE
INVESTIGATION FINDINGS
As to be expected, the three-year investigation, in which the American NTSB
played a major part, was painstaking and
thorough. The evidence developed was
enhanced by the experience and expertise
of the various accredited representatives
COVER FEATURE
seconded to the investigation.

Final drafts of the different aspects of
the investigation were collectively agreed
to by the participants before they were
submitted to the Indonesian NTSC for
incorporation in the final report.
The NTSCs final report, published
on 14 December 2000, shocked not only
the participants but the airline industry
worldwide. In contrast to the reports
coverage of the operational circumstances
of the crash and its investigation, its
Analysis, Conclusions and Recommendations sections ignored or refuted many
of the indications of the investigation.
To the astonishment of most who had
participated, as well as many industry
observers, the NTSC report concluded
that the technical investigation has
yielded no evidence to explain the cause
of the accident.
The British aviation weekly, Flight
International, in an editorial headed An
unsatisfactory report in its first issue for
2001, reported: Indonesias conclusions
on the SilkAir crash ... have done nothing
to dispel the controversy ... The Indonesian NTSC has produced an evasive and
worthless report ...
UNPRECEDENTED CRITICISM
BY NTSB
But the most damning criticism came
from the American NTSB. Normally
diplomatic about the findings of other
nations investigations, the NTSB unambiguously declared: Of greatest concern
are the statements that the NTSC is
unable to find the reasons for the departure of the aircraft from its cruising level
of FL 350 and the reasons for the stoppage of the flight recorders and that the
investigation has yielded no evidence to
explain the cause of the accident.
The examination of all of the factual
evidence is consistent with the conclusions that:
(1) No
airplane-related
mechanical malfunctions or failures caused or
contributed to the accident.
(2) The accident can be explained by
intentional pilot action; specifically, (a)
the flight profile is consistent with
24
sustained manual nose-down flight

control inputs, (b) the evidence suggests
that the cockpit voice recorder was intentionally disconnected, (c) recovery of the
airplane was possible but not attempted,
and (d) it is more likely that the nosedown flight control inputs were made by
the captain than by the first officer.
Throughout the report, the NTSB was
repeatedly forced to take serious issue
with wording and misleading inferences.
The following paragraphs summarise the
NTSBs principal comments:
A significant amount of pertinent factual
information developed during the threeyear investigation is either not discussed
or not fully considered in analysing the
cause of the accident.
There was no evidence of any pre-impact
mechanical malfunctions or failures.
Further, the pilots did not report any
problems or make any distress calls.
Finally, engineering simulations of
flightpath data were conducted to determine the motion of the aircraft from the
time it departed cruise flight until the
end of recorded data.
No single mechanical failure of the
aircraft structure or flight control systems
would have resulted in movement of the
aircraft through recorded radar data
points. Further, there was no evidence of
any combination of systems failures.
The flight profile is consistent with
sustained nose-down manual flight
control inputs. The horizontal stabiliser
trim was set at the maximum nose-down
main electric trim limit (2.5 units) at the
time of impact.
On the basis of the engineering simulations, it is very likely from the time it
departed from cruise flight until the end
of the recorded data, that the aircraft was
responding to sustained flight control
inputs from the cockpit.
The NTSC report states that no reason
could be found for the stoppage of the
flight recorders and recommends that
a comprehensive review and analysis of [DFDR and CVR] systems design
philosophy be undertaken to identify
and rectify latent factors associated with

the stoppage of the recorders in flight.
This implies the NTSC believes the flight
recorders stopped because of mechanical
malfunction.
This is not supported by evidence.
Rather, the evidence suggests that the
CVR was intentionally disconnected.
There is also no evidence to indicate the
DFDR stopped as a result of mechanical
malfunction.
The first indication of an anomaly in the
flight occurred when the CVR ceased
recording. The stoppage of the CVR was
consistent with the removal of power
to the unit through pulling of the
circuit breaker, rather than as a result
of a mechanical malfunction or a short
circuit.
Evidence from the last recorded minutes
indicates that only the captain and first
officer were present in the cockpit. The
CVR also recorded sounds consistent
with seat movement and removal of a seat
belt. The sequence is consistent with the
captain preparing to leave the cockpit.
The circuit breaker panel directly behind
the captains seat contains the circuit
breakers for both the CVR and DFDR.
Thus it is evident that the captain would
have been in the best position to manually pull the CVR circuit breaker at the
time it stopped.
The DFDR stopped recording approximately six minutes after the CVR did so.
There was no evidence of any malfunction of the DFDR until the moment it
stopped It can be concluded that the
DFDR stoppage was not due to a loss of
power. However, the stoppage could be
explained by someone manually pulling
the circuit breaker.
The NTSC suggests that the cessation of
the CVR and FDR could in each case be
explained by a broken wire. Although
technically correct, the probability of
two such unrelated wire breaks occurring several minutes apart and affecting
only the CVR and DFDR is so highly
improbable that it cannot be considered
realistic.
COVER FEATURE
Regardless of the reason for its departure

from cruise flight, the aircraft could have
been easily stabilised using conventional
techniques that were within the capabilities of both pilots. There was ample
time for the pilots to take such corrective
action.
Both had training in unusual attitudes,
and the captain was an accomplished
fighter pilot adept at aerobatic manoeuvres. It is apparent that, had the pilot
attempted to recover by initiating immediate corrective action, the aircraft would
have recovered to a straight and level attitude with a minimum loss of altitude.
The simulations indicate that from the
time it departed cruise flight, a sustained
nose-down flight control input was
necessary to manoeuvre the aircraft
through the recorded radar points. Additionally, impact damage to the engines
was consistent with a higher-than-cruise
power setting. Without pilot input, the
autothrottle system would have reduced
engine power to idle when the descent
began; therefore, the high power setting
must have been input by the pilot.

Further, there was no evidence that any
other measures, such as deploying aerodynamic drag devices, were taken to
slow the aircraft. The wing leading-edge
devices and trailing-edge flaps, the speed
brakes and the landing gear were found
in positions consistent with cruise flight.
The simulation results, in combination
with the evidence of a high engine-power
setting, a horizontal stabiliser trim
setting positioned for maximum nosedown attitude, and the absence of any
indication of an attempt to reduce the
aircrafts speed, are clearly inconsistent
with an attempt to recover from a dive
and return to cruise flight, and strongly
suggest the manoeuvre was intentional.
The investigative findings strongly
support the conclusions that no aircraftrelated mechanical malfunctions or failures caused or contributed to the accident, and the accident can be explained
by intentional pilot action.
* * *
As soon as the circumstances of the
disaster became generally known, many

in the airline industry drew their own
conclusions. It would be a simple matter
for a captain to surreptitiously disable the
CVR, find some pretext for asking the
first officer to go back to the passenger
cabin, then lock the flightdeck door before
finally shutting off the DFDR.
That this could all have been done
between the actions of the aircraft
completing its last radio exchange with
Jakarta and calling Singapore at PARDI,
and was in effect in ATC no-mans-land,
also seemed significant.
In the weeks and months that followed
the SilkAir crash, various accounts in the
world press speculated on its true cause,
pointing to the obvious conclusion. As
well, a forthright New Zealand TV documentary left its viewers in little doubt as to
what the investigators believed happened.
Readers, having studied the circumstances of the tragedy, may wish to form
their own conclusions.
Macarthur Job is an aviation writer and
historian.
SilkAir Flight MI 185 ongoing controversy

1992
Tsu Way Ming joins SilkAir with 4,000 hours experience
1996
Tsu Way Ming promoted to Captain
19/12/1997 Abrupt descent of Boeing 737-300 registration 9V-TRF into Musi River, Palembang,
Sumatra. All 104 on board killed
14/12/2000 Indonesian NTSC report released. American NTSB report released

24/10/2001 Six families lose their lawsuit against the carrier when a Singapore High Court judge
rules that the onus of proving that flight MI185 was intentionally crashed has not been
discharged.
7/2004
Los Angeles Superior Court finds that defects in the rudder system caused the crash,
apportioning sole blame to the Parker Hannifin Corporation, the worlds leading
manufacturer of motion and control systems.
2005
Parker Hannifin appealing the verdict

COVER FEATURE
Aviation and mental health

Mental health is an issue which
United Nations World Health Orga-
lian organisation beyondblue says
reaches into all aspects of society
nization) highlight how widespread
that around one million Australian
around the world. There is no reason
mental health problems are, and the
adults live with depression each
to think that aviation is immune. The
danger of allowing conditions to go
year.
subject of mental health is still a
untreated.
On average, one in six men, and
taboo for many, who would prefer
Depression, often described as the
one in four women, will experience
instead to sweep the issue under
invisible illness, is the second-
depression over their adult lifetime,
the carpet. However, the statistics
most common mental health issue,
with varying degrees of severity.
for depression and anxiety (e.g.
second only to anxiety. The Austra-
Risks commonly associated with depression

include:
for Disease Control reports, men in the USA

are about four times more likely than women to
commit suicide.
primary risk: suicide.

secondary risks: low functioning, poor
quality of work, poor interpersonal relationships, unhappiness, low productivity, longterm self-esteem issues.
Among men there is a connection between
heart disease and depression.
Men with depression are more than twice as
likely to develop coronary heart disease, and
are 2.34 times more likely to die of heart disease
than their non-depressed counterparts.
Symptoms of heart disease typically occur 15
years after the first episode of depression,
suggesting that untreated depression can have
an insidious effect on general health similar to
that of unremitting stress.
Depression and men

Although 80 per cent of people with depression who have sought help will find relief
through therapy or medication (or both), fewer
than one in three people who are depressed
seek help. Because many men grow up believing that depression is primarily a womens
illness, and perhaps a sign of weakness, they
are much less likely to admit to depression or
to seek help for it.
Men have a tendency to deal with their
symptoms by using alcohol and other drugs
which can often make the symptoms worse.
Men are not as likely to show the typical
signs of depression. They do not usually cry,
show sadness, loss of will, or state an intention to hurt themselves. As a result their
depression is hidden from caring friends and
family who might insist that they seek help. For
this reason, according to unpublished Center
26
Men who experience the loss of a significant supportive relationship are at serious risk
of depression. This type of loss can be either a
romantic relationship or, as is often the case,
the loss of a father who has been particularly
supportive of them.
Job loss is another trigger for depression,
as is physical illness such as cancer, heart
disease, and low thyroid function. The link
to depression is a feeling of loss in terms of
earning potential, virility, strength, control,
and self-definition. For example, of the 33,000
people who committed suicide in Japan in
1999, 50 per cent were unemployed.
Age: suicide in men peaks in the 20s and
again in the 60s and 70s. With a history of
depression, the risk of suicide increases
substantially.
Sources:
www.uc.edu/cc/Depression_in_men.html
www.beyondblue.org.au
Bipolar disorder &

aeromedical certification
Bipolar disorder is a psychiatric condition
characterised by the potential for mood
swings such as mania, hypomania or major
depression. A person with bipolar disorder will
have symptoms of both mania and depression
at different times.
Episodes of mania may consist of symptoms
including:
inflated self-esteem or having grandiose
ideas
decreased need for sleep
rapid speech being more talkative than
usual, or showing pressure to keep talking

racing thoughts having a flight of ideas
or subjective experience that thoughts are
racing
being easily distracted
increase in goal-directed activity, either
socially or at work or school, or sexually,
making individuals often very productive, at
the expense of their quality of work
excessive involvement in pleasurable activities with a high potential for painful consequences, such as engaging in unrestrained
spending sprees; sexual indiscretions; or
foolish business investments.
Hypomanic episodes consist of similar symptoms, but last for shorter periods and/or may
be less severe.
Major depressive symptoms may also intersperse
with manic symptoms in bipolar disorder.
The consequences of someone being in
control of an aircraft during a manic or hypomanic episode could be significant, particularly due to:
their distractibility and difficulty in concentrating
being reckless, or taking unnecessary risks
e.g. aerobatics when untrained
inflated self-esteem leading to overconfidence e.g. flying into adverse weather conditions without the appropriate training, or flying
the aircraft beyond its design limits
the poor judgement associated with the
flight of ideas and lack of sleep.
It is for this reason that bipolar disorder is
generally disqualifying for aircrew, as despite
treatment or medication, recurrences of the
disorder are still possible.
COVER FEATURE
Flying and anti-depressants

Most international air-safety authorities ban
pilots from flying while taking anti-depressant medication. However, an Australian
study released last November found that
taking anti-depressants did not increase the
risk of accidents, and banning flying may be
counter-productive, by discouraging pilots
from seeking treatment.
Aviation medicine specialist James Ross led
the team, which examined records of pilot
safety from 1993 to 2004.
Over this time, 481 pilots who were prescribed
antidepressants had 11 accidents due to pilot
error and 22 near misses. According to the
researchers, this was not significantly different to from the five accidents and 26 near
misses of the similar number of pilots who
did not take antidepressants, but who were
matched by age, sex, and flying experience.
Team member Kathy Griffiths, from the
Australian National Universitys Centre
for Mental Health Research, presented the
findings at the World Psychiatric Congress
in Melbourne last year.
According to David Powell, of the Occupational and Aviation Medicine Unit, Otago
University, New Zealand, Many aviation
doctors have maintained that the side effects
of anti-depressants present far less risk to
aviation safety than the problem of untreated
or undeclared depression.
Its encouraging to see that the Australian
evidence supports this.

Depression is common and treatable, so
surely the best way to manage it in aviation is
to bring it out of hiding, he told New Scientist
(29 November 2007)
Final flights
Suicide rates around the world show a great
variation, with male rates exceeding those for
women. Male rates range from Egypt 0.1 per
100,000 population; Kuwait 2.5; Australia 17.1;
USA 17.9; New Zealand 19.8; Sri Lanka 44.6;
to the Russian Federation 61.6 per 100,000.
(WHO data 2007)
Men account for 20 per cent of all suicides in
the United States, but this rate triples in men
aged 4060, and increases seven-fold in men
aged over 65.
The NTSB listing describes the intentional flight

into terrain of various small aircraft: dives at full
power into frozen lakes, runways and fields.
Such final flights are relatively rare.
While these small single-pilot suicides are tragedies, they pale against the horrifying possibility
of a commercial airliner pilot intent on death.
For more information

NTSB incident/accident database
www.ntsb.gov/NTSB/Query.asp
UN World Health Organisation information on
depression
www.who.int/mental_health/en/
Data from Americas National Transportation Safety Board (NTSB) spanning 1993
to 2007 show that pilots are not immune to
these trends. According to pilot and journalist Peter Garrison, who examined the NTSB
data, Suicide is the official probable cause of
perhaps two accidents a year.
University of Cincinnati website counselling
It is also implicated in, but not blamed for, a few

unexplained collisions with terrain involving
pilots with histories of depression or previous
suicide attempts, but who did not leave notes
or otherwise express an intention to take
their lives. Final flights are often though not
always made in small planes, according to
Flying magazine (February 2005).
www.newscientist.com /article /dn12981-
centre page
www.uc.edu/cc/Depression_in_men.html
New Scientist article Anti-depressants and
flying study
pilots-on-antidepressants-pose-no-safetyrisk.html
Australian site with fact sheets on anxiety,
depression, bipolar disorder
www.beyondblue.org.au
EgyptAir Flight 990
he SilkAir crash is one case in

which uncertainty about its cause
continues. Another is EgyptAir Flight
990. EgyptAirs Boeing 767-366ER SUGAP dived steeply into the Atlantic off
the coast of Nantucket, Massachusetts,
on 31 October 1999, killing the relief first
officer, who was at the controls, and 216
passengers and crew.
According to the NTSB, the probable cause of the Flight 990 crash is the
airplanes departure from normal cruise
flight and subsequent impact with the
Atlantic Ocean as a result of the relief
first officers flight control inputs. The
reason for the relief first officers actions
was not determined. (NTSB report 13
March 2002)
Reports in Egyptian newspapers at
the time reflected a very different view:
it is not possible that anyone who would
commit suicide would also kill so many
innocent people alongside him, said

Ehab William, a surgeon at Cairos AngloAmerican Hospital. (Cairo Times, November 1999)
The Egyptian Civil Aviation Authoritys
(ECAA) 223-page report refuted the socalled deliberate act theory saying:
1. The relief first officer (RFO) did not deliberately dive the airplane into the ocean.
Nowhere in the 1,665 pages of the NTSBs
docket or in the 18 months of investigative
effort is there any evidence to support the
deliberate act theory. In fact, the record
contains specific evidence refuting such
a theory, including an expert evaluation
by Dr. Adel Fouad, a highly experienced
psychiatrist.
2. There is evidence pointing to a mechanical defect in the elevator control system
of the accident. The best evidence of
this is the shearing of certain rivets
in two of the right elevator bellcranks
and the shearing of an internal pin in a

power control actuator (PCA) that was
attached to the right elevator. Although
this evidence, combined with certain
data from the Flight Data Recorder (FDR),
points to a mechanical cause for the accident, reaching a definitive conclusion at
this point is not possible because of the
complexity of the elevator system, the
lack of reliable data from Boeing, and the
limitations of the simulation and ground
tests conducted after the accident.
3. Investigators cannot rule out the possibility that the RFO may have taken emergency action to avoid a collision with
an unknown object. Although plausible,
this theory cannot be tested because
the United States has refused to release
certain radar calibration and test data
that are necessary to evaluate various
unidentified radar returns in the vicinity
of Flight 990.
Survey to ensure safety and accuracy

Aircraft registration holders are being asked to confirm their aircrafts
registration details as part of a new CASA survey. The survey began in early
December and is targeting aircraft owners on their third anniversary of being
recorded as registration holder of their aircraft.
CASA is conducting the survey to make sure registration details are
accurate and up-to-date. This is vital so that airworthiness directives and
other safety-critical information can be sent to the right people.
CASA is mailing out survey forms asking registration holders to confirm the
details CASA holds are correct.
This includes checking information such as aircraft
ownership, manufacturer, model and serial
number as well as checking contact
details. Registration holders will have 28
days to tell CASA if the details are accurate
or need amending.
It is a regulatory requirement for registration
holders to reply to the survey and its quick
and easy to complete. Registration holders will
have the option of mailing, faxing or emailing their
completed survey forms.
More information on the survey can be found on
CASAs Aircraft Register website:
www.casa.gov.au/casadata/register/index.asp
SDRs to lodge or not to lodge?

CASAs Obaid Soomro
looks at Service
Difficulty Reports
ERVICE DIFFICULTY Reports,

or SDRs, cover all situations
where some potentially dangerous
anomaly or failure is noted in an aircraft,
on the ground or in the air.
Defects warranting prompt submission
of an SDR would usually be major defects
that caused or could cause:
primary structural failure
control system failure
engine structural failure
fire, or
an in-flight, uncommanded engine shutdown.
Defects discovered in the course of
complying with an Airworthiness Directive or other CASA directives should
also be notified through the SDR system.
Similarly, defects related to the components (installed or to be installed) which
might affect safety of the aircraft should
also be reported. Investigation findings of
the cause of the failure should also form
part of the report being submitted using
the SDR system.
Submission of the above types of defects
and investigation findings is mandatory
(Civil Aviation Regulations [CAR] 51 to
53).
Have you ever wondered what happens
after you submit the SDR to CASA?
Firstly, SDRs are entered into an electronic database and checked for missing
information. Once the missing blanks
are filled, reports are then codified: to
monitor trends, and to post on CASAs

website (www.casa.gov.au)
All SDRs are then allocated to CASA
technical specialists; e.g. an SDR on a
corroded wing spar will go to a CASA
airframe specialist, while a propeller
governor failure would be handled by a
systems specialist in the Systems & New
Technologies section.
Addressing safety-related matters is the
top priority for CASA, and accordingly,
any SDR referring to a failure with flight
safety implications is dealt with urgently,
and remedial action taken.
These actions may also imply contacting the product manufacturer or other
regulatory authorities, such as Americas

Federal Aviation Administration (FAA).
An SDR on a failure of the rudder gust
lock plunger assembly which locked the
Fairchild/Swearingen SA 227 Metroliners aircraft rudder while the aircraft
was in flight, prompted CASA to issue
Telex Airworthiness Directive AD/
SWSA226/93 Rudder Gust Lock.
As expected, not all SDRs result in the
issue of an airworthiness directive.
When we receive similar SDRs from
different submitters where an immediate
flight safety action is not warranted, we
issue advisory material. We communicate such advice through various means:

TELL IT TO ALL, BUT
MOST IMPORTANTLY,
TELL IT TO YOUR
MAINTAINER, THE
MANUFACTURER &
CASA.
advisory circulars, airworthiness bulletins and articles in Flight Safety Australia

magazine.
Airworthiness Bulletin AWB 85-001
Lycoming Engine Bearings and All

Operator Letter SA226 / SA 227Hydraulic System are examples of CASA advisory
material issued following such SDRs.
Service Difficulty Reports dealing more
with product durability than flight safety
are also assessed. Where appropriate, this
may involve informing the type certificate
holder or manufacturer. In the long term,
this can result in manufacturers issuing
modification service bulletins addressing
product reliability.
At times, CASA technical specialists
contact the submitter directly via email or
phone to confirm the SDRs receipt and to
obtain missing information, which is then
used in assessment of continued airwor-
thiness of that aircraft or engine type.

In summary, if you experience any
failure worth mentioning, tell it to all, but
most importantly, tell it to your maintainer, the manufacturer and CASA.
SDRs can easily be lodged online at
the click of a mouse: www.casa.gov.au/
airworth/sdr/index.htm
Dont forget to include your email
address if you would like an email from
CASA confirming receipt.
Remember safety is important for all
of us. If you dont tell us, who else will?
Obaid Soomro is a technical specialist in CASAs propulsion and mechanical
section.
AIRWORTHINESS BULLETIN
Cessna Fuel Stabilisation AWB 28-006 Issue : 1 Date : 31 October 2007
1. Applicability
Cessna 200 Series aeroplanes to which a CASA Airworthiness Directive Titled: Fuel Flow Stabilisation Placards and FAA
CESSNA AD 79-15-01 apply.
2. Purpose
Remind operators and maintainers of the applicable Cessna 200 Model aeroplanes to periodically ensure that all placards and
emergency instructions are in place as required by the documents referred to in applicable Airworthiness Directives.
3. Background
A feature of the Continental Avgas fuelled engines which employ the constant-flow, fuel injection system design, is a fuel vapor
purging system to ensure that solid fuel is delivered to the injectors. Under certain conditions, however, the fuel system can suffer
from accumulated vapor in the fuel lines and cause unstable fuel flow which may result in rough running, power surges and, if not
handled correctly, a complete loss of engine power, requiring an in-flight engine re-start. Full instructions for identifying various
types of unstable fuel flow events and the proper corrective actions, are contained in Cessna Service
Information Letter (SIL) SE79-25 (Supplement #1) which introduces two documents, a fixed placard and an expanded instruction
card which should be within reach of the pilot at all times. This requirement is mandated by AD/CESSNA 205/14, AD/CESSNA
206/29, AD/CESSNA 207/20 and AD/CESSNA 210/41, all of which make reference to CESSNA FAA AD 79-15-01. The affected
aeroplanes may not have a flight manual or Pilots Operating Handbook and therefore depend on a fixed placard and an expanded
instruction card to provide the emergency operating instructions for the engine fuel system. To ensure integrity of the approved
data, any system of maintenance for the aeroplane should include a periodic check to ensure that all required placards are in
place. For example, for any aeroplane maintained in accordance with CASA Schedule 5, note the following extract:
Section 4 - The Instruments
(1), Check internal and external required placards. NOTE: Reference should be made to the aircraft flight manual and airworthiness
directives for the required placards This means, for example, that compliance with CASA AD/CESSNA 206/29 Fuel Flow
Stabilisation Placard is to be checked
and certified for at each periodic inspection, even though there is no repetitive requirement in the AD. Adherence to the
manufacturers instructions will ensure that in the event of an unstable fuel flow condition being encountered, power for flight is
restored as quickly as possible.
4. Recommendation
CASA recommends that all operators and maintainers check that the required engine fuel operating instruction placards are
in place, including the expanded instruction cards as required by the requirements of the aircraft flight manual and applicable
Airworthiness Directives.
5. Enquiries
Enquiries with regard to the content of this Airworthiness Bulletins should be made via the direct link e-mail address:
AirworthinessBulletin@casa.gov.au. Or in writing, to: Airworthiness Engineering Branch GPO Box 2005, Canberra, ACT, 2601
30
SERVICE DIFFICULTY REPORTS AIRWORTHINESS PULL-OUT SECTION

SELECTED SERVICE DIFFICULTY REPORTS
NOVEMBER-DECEMBER 2007
confirmed using high frequency eddy current

inspection. (56 similar occurrences)
RH wing landing gear alternate extension motor

failed to operate. Investigation continuing.
AIRCRAFT ABOVE 5700 KG
Boeing 7377BX Passenger seat saddle cracked.

Ref 510005545
Boeing 747438 Pylon fuel shutoff valve wire damaged. Ref 510005496
Airbus A330202 Wing access panel missing.

Ref 510005428
RH flap track No1 fairing outboard access panel

(cap) 631CR missing. P/No: F57541302020.
(1 similar occurrence)
Airbus A330303 Cargo door cabin pressure switch
unserviceable. Ref 510005375
Aft cargo door cabin pressure switch 40mj

unserviceable. Investigation found the cabin
pressure sense port and the ambient pressure
sense line had been reversed preventing correct
operation. Investigation continuing.
P/No: 1266100.
Boeing 717200 Flight control wiring connector
burnt. Ref 510005542
Longitudinal trim flight control system connector

R5-6048 located on the aft pressure bulkhead
burnt and water contaminated.
P/No: AE74357W1405SN.
Boeing 737229 Landing gear retract/extension
system link cracked and corroded. Ref 510005518
RH main landing gear walking beam hangar link

and retraction actuation head end pivot point
corroded. Following dismantling of the hangar
link, the retraction actuator head end bearing
was found to contain four cracks. Suspect
cracking was caused by badly corroded pivot
bolt. P/No: 69-39464-4.
Boeing 737476 Horizontal stabiliser skin cracked.
Ref 510005535
RH horizontal stabiliser lower skin cracked at

Stn 97.5. (56 similar occurrences)
Boeing 737476 Hydraulic pump relay faulty.
Ref 510005408
Hydraulic B system electric hydraulic pump

relay R318 faulty. P/No: 106144524. (1 similar
occurrence)
Boeing 737476 IRU faulty. Ref 510005508
RH Inertial Reference Unit (IRU) faulty.

P/No: HG1050AD05. (10 similar occurrences)
Boeing 737476 Landing gear brake system pushrod broken. Ref 510005352
Park brake lever to bellcrank pushrod broken.

P/No: 691989.
Boeing 737476 Leading edge slat proximity sensor

faulty. Ref 510005481
No4 leading edge slat proximity sensor faulty.

P/No: 189929. (7 similar occurrences)
Boeing 737476 Leading edge slat up switch
Passenger seat saddle assemblies cracked.

Investigation found a total of thirteen defects.
Found during inspection iaw Webber Aircraft SIL
2806. P/No: 847367727. (14 similar occurrences)
Boeing 7377BX Rudder control system suspect
Uncommanded rudder/yaw damper input on

takeoff. Investigation continuing.
Boeing 737838 Aileron control pulley bearing collapsed. Ref 510005546
Aileron control pulley bearing collapsed. Pulley

is located on RH rear spar at RRS193.
P/No: BACP30F9. (1 similar occurrence)
Several reports of electrical burning smell coming

from rear toilet. Investigation continuing.
Boeing 7377BX Horizontal stabiliser skin cracked.
Ref 510005449
LH horizontal stabiliser lower inspar skin

cracked. Crack found by visual inspection and
Upper rudder power control module faulty.

Investigation continuing.
Boeing 747438 Tyre separated. Ref 510005366
Boeing 7474H6 Brake fire. Ref 510005486
Fumes in area of front galley. Investigation found

the lower forward coffee maker element blew
out. Investigation continuing. P/No: 3510004413.
(2 similar occurrences)
Boeing 737838 Galley station odour.
Ref 510005388
Electrical burning smell coming from rear galley

area. Smell lasted for about 45 seconds before
slowly dissipating. Ovens were turned off at
the time. Investigations could find no problems
with the electrical system and the smell did not
reccur.
Boeing 737838 Leading edge slat proximity sensor
No6 leading edge slat outboard proximity sensor

faulty. P/No: 189929. (7 similar occurrences)
Boeing 737838 Portable fire bottle extinguishers
incorrectly secured. Ref 510005488
Four BCF portable fire extinguishers replaced.

Three of the extinguishers were underweight and
one extinguisher had no expiry date recorded.
When inspected, three of the extinguishers had
the transportation pin still fitted and the trigger
lock lockwired during installation on the aircraft.
This would have prevented operation of the
extinguishers. Investigation continuing.
Boeing 737838 Standby power static inverter
Boeing 737838 Weather radar transceiver failed.

Ref 510005490
Boeing 7374L7 Electrical system odour from toilet

area. Ref 510005391
Boeing 747438 Rudder power control module

Boeing 737838 Galley coffee maker failed.

Ref 510005457
Boeing 737476 Pneumatic distribution system

bleed air odour. Ref 510005427
Stabiliser trim actuator failed. Investigation

continuing. P/No: AR7077M3. (11 similar
occurrences)
High frequency vibration through rudder. See

SDR510005550.
No11 tyre tread separated during takeoff.

Damage to wing/body fairing and a dent in the
pressure hull as well as damage to the landing
gear electrical harness and retaining clamps.
Loss of oil from APU. Suspect failed rear bearing

scavenge line. Smoke and fumes reported in
rear cabin area. Investigation continuing.
Standby power static inverter unserviceable.

Investigation continuing. P/No: 100201022062.
Boeing 737476 Stabiliser actuator failed.

Ref 510005509
Boeing 747438 Rudder control system vibrates.

Ref 510005564
Boeing 737838 APU oil system loss Ref 510005477
No3 leading edge slat up switch faulty.

Oil smell in cockpit. Investigation continuing.
No4 strut fuel shutoff valve wire W208-15416 had abrasion damage to the rigid conduit
resulting in a hole approximately 12.7mm long
by 3.175mm wide (0.5in by 0.125in). Investigation
continuing.
Weather radar transceiver failed.

Boeing 747400 Nacelle/pylon panel missing.
Ref 510005495
No3 engine start valve access panel missing.

Aircraft is foreign registered.
Boeing 747438 Hydraulic pump enable switch
connection leaking. Ref 510005553
No4 air driven hydraulic pump enable switch

connection leaking. Loss of hydraulic fluid.
Investigation continuing.
Boeing 747438 Landing gear electric motor failed.
Ref 510005552
LH front wing landing gear brake fire. Investigation

continuing. (6 similar occurrences)
Boeing 767338ER Air conditioning system odour in
cabin. Ref 510005455
Fuel odours experienced in cabin. Investigation

continuing. (5 similar occurrences)
Boeing 767338ER APU bleed air system duct
contaminated. Ref 510005531
Oil smell in aircraft. Extensive investigation

found minor oil contamination of the APU load
compressor ducting. Investigation continuing.
Boeing 767338ER BPCU faulty. Ref 510005357
Bus Power Control Unit (BPCU) PNo 734285C

and Generator Control Unit PNo 734284D faulty.
P/No: 734285C. TSN: 542,590 hours. TSO:
42,590 hours.
Boeing 767338ER Galley station odour.
Ref 510005454
Electrical burning smell from forward galley

area. Smell disappeared when galley equipment
was turned off. Initial investigation could find no
defect. Investigation continuing.
Boeing 767338ER Passenger oxygen system
disconnected. Ref 510005426
Oxygen module assemblies (30off) found with

oxygen mask tubes not connected to the oxygen
generator. Modules had not been fitted to
aircraft. P/No: 417T4200213.
Boeing 767338ER Trailing edge flap control system
end cap leaking. Ref 510005437
Flap/slat shutoff valve hydraulic module end cap

leaking. Loss of hydraulic fluid.
P/No: 73218718.
Bombardier DHC8202 Landing gear retract/extension system hose leaking. Ref 510005548
Nose landing gear drag brace actuator Down

flexible hose leaking. Loss of No2 hydraulic
system fluid. (1 similar occurrence)
Bombardier DHC8315 Cabin pressure outflow
valve venturi/filter blocked. Ref 510005532
Cabin pressurisation system outflow valve

venturi and filter cartridge PNo 147240-1 dirty/
blocked. TSN: 1,302 hours/1,367 cycles.
Bombardier DHC8315 Elevator tab control system
screwjack contam-water. Ref 510005528
LH and RH elevator trim screwjack assemblies

had water contaminated grease. Aircraft had
been subject to heavy rain while parked and it is

suspected that water entered the screwjack and
froze at altitude causing restricted elevator trim.
An access hole was also found to be incorrectly
sealed which may have contributed to water
entering the screwjack. TSN: 7,816 hours/7,366
cycles.
Bombardier DHC8402 Galley station connector
burnt. Ref 510005434 (photo below)
Galley urn electrical connector pin and socket

burnt and insulation melted. Investigation found
worn connector pins. (1 similar occurrence)
TSO: 251 hours/257 cycles.

Saab SF340B Engine tailpipe overheat detection
system wiring contam-water. Ref 510005445
RH engine tailpipe heat sensor wiring terminals

contaminated with moisture under the sealant.
Saab SF340B Landing gear brake cracked.
Ref 510005339
RH main landing gear brake assembly leaking

hydraulic fluid. Workshop investigation found a
crack in the fluid transfer ports. Brake unit had
been fitted before import from the USA.
P/No: 50125893.
Saab SF340B Landing gear steering linkage fractured. Ref 510005442 (photo below)
Nose landing gear steering linkage assembly

failed through lower attachment point (bearing
lug). Damage caused to steering input assembly
spigot which was bent. P/No: 3870172105
Cessna 310R Landing gear system poor condition.

Ref 510005397
Undercarriage incorrectly assembled and

misrigged following main/nose gear retraction
system tear-down and inspection.
TSN: 9,836 hours. TSO: 328 hours.
Cessna 310R Trailing edge flap actuator sprocket
broken. Ref 510005329 (photo below)
Embraer EMB120 Fuel boost pump worn.

Ref 510005370
LH flap actuator sprocket failed and broke into

two pieces from roll pin drive peg hole.
P/No: 086150071. TSN: 9,500 hours.
LH wing fuel pump wiring chafed. P/No: 1C717.

TSN: 29,497 hours/30,325 cycles. TSO: 29,497
hours/30,325 cycles.
Embraer EMB120 Wing spar cracked.
Ref 510005558
LH wing auxiliary lower spar cracked. Two cracks

in the skin located either side of the spar crack.
Cracks were located at Y-557 wing station.
Fokker F27MK50 Flight compartment window
cracked. Ref 510005512
Cockpit side window cracked.
Fokker F28MK0100 Airfoil anti-ice system sense

line split. Ref 510005438
Wing anti-icing modulating valve upstream

sense line split. Length of split approximately
10mm (0.393in). P/No: A80126431.
Fokker F28MK0100 APU shroud seal loose.
Ref 510005479
APU shroud seal loose in one area. APU fire

warning indication resulted in discharge of fire
bottle. Inspection found no evidence of fire.
Fokker F28MK0100 Galley station connector
contam-water. Ref 510005505
Galley hot water jug 115 volt AC connector

contaminated with water from spillage from
jug causing a partial short circuit. Investigation
found that the jug lid was not sealing correctly.
P/No: DLH141066.
Fokker F28MK0100 Portable fire extinguisher
bottle empty. Ref 510005485
LH lavatory bin fire extinguisher bottle empty.

Found during scheduled weight check.
Saab SF340A Fuel storage canister contaminated.
Ref 510005342
LH and RH wing fuel tank negative G canister

fuel pickup screens/strainers contaminated.
Contaminant appears to be unknown fibrous
material. P/No: 7228499503.
Saab SF340B Cabin cooling system heat exchanger failed. Ref 510005569
LH heat exchanger failed. Investigation found that

a welded side wall had completely separated.
32
AIRCRAFT BELOW 5700 KG

Beech 200 Fuselage frame cross tie cracked. Ref
510005468
Fuselage frame cross tie cracked. Cross tie is

located a FS226 RH. Found during inspection iaw
AD/B200/21. P/No: 50420013944. TSN: 10,559
hours/15,504 cycles/15,504 landings.
Beech 200 Landing gear retraction system faulty.
Ref 510005556
Landing gear would not retract. Gear jammed

during alternate extension. Landing gear was
eventually extended. Investigation continuing.
Beech 200 Wing attach fitting corroded. Ref
510005561
RH wing spar rear lower attachment fitting

corroded. RH forward upper attachment bolt P/
No: 81784-12-32 also corroded in threaded area.
P/No: 351150583. (1 similar occurrence)
Beech 58 Wing spar corroded. Ref 510005435
Cessna 404 Landing gear retract/extension system circuit breaker unserviceable. Ref 510005543.
LH wing spar contained a small spot of corrosion

located in area outboard of engine
Landing gear circuit breaker unserviceable.

P/No: 727425.
Beech 95B55 Power lever cable broken.

Ref 510005574
Cessna 441 Landing gear position and warning

system microswitch failed. Ref 510005510
LH engine throttle cable broken inside outer

sleeve at throttle body. P/No: 5038901215. TSN:
2,716 hours. (1 similar occurrence)
Britten Norman BN2B20 Horizontal stabiliser
structure hinge worn. Ref 510005573
Horizontal stabiliser centre elevator hinge and

bearing assembly excessively worn.
TSN: 11,201 hours/3,644 cycles.
Cessna 172M Wing spar sheared rivets.
Ref 510005387 (photo top right)
Rear wing carry through spar rivets sheared

due to corrosion. Found during inspection of RH
wing following birdstrike. P/No: 051212443. TSN:
9,541 hours. (1 similar occurrence)
LH main landing gear downlock microswitch

failed. (1 similar occurrence)
Cessna U206G Rudder control system bolt rusted.
Ref 510005473 (photo below)
Bolt attaching rudder torque tube to vertical tube

rusted. Vertical tube assembly holds the rudder
pedals. P/No: AN3011A.
De Havilland DH82A Wing structure unserviceable. Ref 510005493
LH top wing unserviceable. Details of damage:1. two aft ribs damaged by failed glue joint to
cap strip 2. two leading edge ribs damaged
by failed glue joint and cracks 3. forward spar
doubler damaged on lower aft face. 4. forward
spar doubler unapproved repair top aft face
5. wing lower fabric loose in area located just
outboard of strut attachment. All damage was
located around the wing strut attachment. P/No:
L1272MK2. TSN: 2,903 hours. TSO: 12 hours.
Diamond DA42 Main landing gear circlip
LH undercarriage pin circlip broken. P/No:

DIN471082P. TSN: 91 hours. TSO: 91 hours.
Gippsland GA8 Fuel wiring switch failed. Ref
510005361
Electric fuel pump switch failed.

W31X2MIG10. (1 similar occurrence)
P/No:
Gippsland GA8 Power distribution system

solenoid failed. Ref 510005359
Bus 2 solenoid failed in closed position.

brake torque tube failed and separated. New link

had been fitted during incorporation of SB-F40660 in June 2006. P/No: 086170046.
Swearingen SA227AC Passenger doors bolt
broken. Ref 510005555
Passenger door locking system faulty.

Investigation found the bolt connecting the
operating linkages broken through the split
pin hole allowing the three upper bayonets to
become disconnected.
Swearingen SA227DC Fuselage frame cracked.
Ref 510005560
Fuselage frame located at FS 88.060 LH side

cracked. P/No: 88060. (3 similar occurrences)
Tecnam P2002 Rudder pedal control arm broken.
Ref 510005484
Rudder pedal lower arm broken.

P/No: 215120001. TSN: 486 hours.
Main rotor blade pitch horn eye bolt assembly

nut incorrectly manufactured with the thread cut
at an angle. P/No: 330A31319407.
Gulfstream G73T Control column swivel cracked.

Ref 510005344
Eurocopter AS365N Tail rotor head spider

fractured. Ref 510005579
Piper PA31 Landing gear door retract spring

LH main landing gear flipper door uplock spring

broken. Flipper door opened in flight.
P/No: 762308.
Piper PA31350 Landing gear door actuator leaking. Ref 510005539
RH main landing gear door actuator travel out of

adjustment. Seal rolled allowing loss of hydraulic
fluid. P/No: 451825. (1 similar occurrence)
Tail rotor pitch change spider failed. Investigation

continuing. P/No: 360A33107003. TSN: 789
hours. (Local plus over-seas reports indicate
approx. 25 similar occurrences)
Kawasaki KH4BELL47G3B Main rotor gearbox
bearing failed. Ref 510005337
Main transmission lower bearing failed. Bearing

had come adrift and the lower bearing retention
nut severely damaged. Metal contamination of
transmission. Investigation continuing.
TSO: 287 hours. (1 similar occurrence)
Robinson R22 Beta Engine/transmission coupling
drive belt cracked. Ref 510005401
Engine to transmission forward drive belt

cracked on sides. Belts are from batch No 308
with date of manufacture Nov 2006.
P/No: A1902. TSN: 499 hours/5 months.
Robinson R44 Fuel system contaminated.
Ref 510005330
Aircraft fuel system and filter contaminated by

silicone. Investigation found that the fuel bowser
at the aircraft home base had been fitted with
new hoses and silicone had been used between
the hoses and fittings.
Piper PA34220T Hydraulic system, main pipe

Robinson R44 Main rotor indicating system horn

failed. Ref 510005469
Reims F406 Cockpit panel loose restricting

control column. Ref 510005385
Robinson R44 Engine/transmission coupling

clutch worn and damaged. Ref 510005436
(photo right)
Hydraulic power pack rigid line cracked in area

just below flare. Pipe was poorly aligned on
power pack. TSN: 793 hours.
Loose interior panel located adjacent to the
pilots feet contacted the mass balance attached
to the control column torque tube causing
restrictions in the control column.
Reims F406 Rudder control link failed. Ref
510005425
RH outboard link between rudder pedal and
Rescue hoist hook cracked on weld between

hook latch and hook body. Following inspection
of similar hooks another similar defect was
found. Hook is a D-LOK hook manufactured
by Lifesaving Systems. Hook is fitted to Royal
Australian Navy helicopters, but maybe installed
on civil rotorcraft. P/No: 411J. TSN: 164 hours/14
months
Main rotor head unserviceable due to corrosion,

rust, fretting and bearing roller brinelling/
spalling. TSN: 3,645 hours. TSO: 3,645 hours.
Nose wheel fork loose in housing. Investigation

found cracking at four bolt mountings.
LH main landing gearleg outboard support frame

bent by approximately 30mm (1.18in) at the rear
end of the saddle. Further inspection found
cracking in the lower tube and numerous bent and
damaged tubes with major cutting and rewelding
of the tubes at various locations. Indications
were that the condition had existed for some
time. Log book entry showed that major repairs
had been carried out to the LH main landing gear
in 1992 at approximately 10,166 airframe hours.
Airframe hours now 15,985. P/No: 6823065B1.
ROTORCRAFT COMPONENT: Lifesaving Systems

Rescue hoist hook cracked. Ref 510005348
(photo below)
Agusta A109C Main rotor head unserviceable.

Ref 510005336
Eurocopter AS332L Main rotor blade nut incorrectly made. Ref 510005570
Partenavia P68B Landing gear attach fittings

frame damaged. Ref 510005567
LH and RH upper honeycomb roof panels

delaminated. Area of delamination:- 1. RH panel
PNo: 76203-03004-054 685mm by 203.2mm
(27in by 8in) 2. LH panel PNo: 76203-03004-053
660.4mm by 190.5mm (26in by 7.5in).
P/No: 7620303004053. TSN: 17,268 hours.
ROTORCRAFT
Grob G115 Nose landing gear attach fork cracked.

Ref 510005506
Control column swivel cracked from lower

section to hole. P/No: 112702. TSN: 24,170 hours.
TSO: 800 hours.
Sikorsky S76A Fuselage skin panel delaminated.

Ref 510005581
PISTON ENGINES
Continental O200A Engine internal oil system
relief valve damaged. Ref 510005465
Engine oil pressure relief valve contained

chattering marks on the valve seat.
P/No: 21114. TSO: 1,578 hours.
Lycoming IO360L2A Engine servo & venturi contaminated. Ref 510005393
Fuel servo and venturi contaminated by oily

residue. P/No: 25765362. TSN: 177 hours.
Lycoming IO360L2A Engine starter drive gear
Engine starter motor drive gear cracked and

jammed engine ring gear. P/No: 2005001. TSN:
465 hours. (1 similar occurrence)
Lycoming IO540AB1A5 Engine fuel servo contaminated. Ref 510005526
Fuel servo contaminated by green fuel residue

on air side of diaphragm. P/No: RSA5AD1. TSO:
138 hours.
Rotor RPM warning system horn failed.

P/No: B3201. TSN: 464 hours.
Engine to transmission sprag clutch worn and

damaged internally. P/No: C0183. TSN: 1,069
hours/19 months. (2 similar occurrences)
Robinson R44 Main rotor transmission mount
collapsed. Ref 510005470
Main rotor gearbox forward mount collapsed.

P/No: A6531. TSN: 155 hours. (1 similar occurrence)

Lycoming IO540AB1A5 Engine starter motor
damaged. Ref 510005527
Starter motor drive gear teeth missing and

ring gear damaged TSN: 169 hours. (2 similar
occurrences)
Lycoming IO540E1B5 Engine fuel distribution
vapour separator blocked. Ref 510005467
Fuel vapour separator ejector contained a minor

blockage causing the manifold valve into the fuel
shutoff position.
P/No: 4630193507.
Lycoming IO540E1B5 FCU faulty. Ref 510005476
LH engine Fuel Control Unit (FCU) not responding

to mixture lever. Fuel flow does not change until
mixture lever is almost at idle cutoff when fuel
flow drastically drops. When mixture lever is then
moved in the direction of full rich, the fuel flow is
not restored until almost full rich position. The
mixture lever operates normally during ground
run. P/No: 3917874. (1 similar occurrence)
Lycoming LO360E1A6 Engine crankcase cracked.
Ref 510005389
RH engine running rough. Investigation found

the crankcase cracked in several areas, No4
cylinder connecting rod failed and No3 cylinder
almost separated from crankcase. Investigation
continuing. P/No: LO360E1A6D. TSN: 6672
hours. TSO: 253 hours/5 months. (2 similar
occurrences)
Lycoming O360A4M Engine starter drive gear
area just below the plastic coating. Damage to

compressor impeller. P/No: 6899396. TSO: 1,105
hours/1,405 cycles/28 months.
Garrett TPE33112UH Engine fire. Ref 510005441
RH engine fire. RH engine lost power during taxi.

Smell of burning and flames from engine. Fire
bottle discharged. Investigation continuing.
PWA PT6A34 Engine oil system o-ring deteriorated. Ref 510005453
LH engine accessory gearbox oil dipstick O

ring seal slightly perished with a flat spot on one
side. Loss of engine oil. P/No: MS9388222.
PWA PT6A42 Engine fuel line cracked.
Ref 510005343
RH engine primary fuel line located between the

rear fireseal and the FCU cracked longitudinally
at forward end. Crack is located in area where
the line diameter is reduced. P/No: 3026782.
PWA PT6A42 Engine fuel drain valve failed.
Ref 510005433
Engine firewall mounted fuel filter drain valve

failed allowing fuel leakage. Valve was a
replacement for valve which failed 1.6 hours
previously. See SDR510005431. Valve is
manufactured from plastic. P/No: 100014001.
TSN: 1 hours. (1 similar occurrence)
PWA PT6A42 Engine fuel pump failed.
Ref 510005461
Starter motor drive gear disintegrated during

engine cranking. P/No: EBB131A. TSN: 145
hours. (1 similar occurrence)
RH engine driven fuel pump failed. Suspect

sheared driveshaft. Fuel pressure switch also
found to be corroded. P/No: 91380003. TSO:
4,871 hours/7,750 cycles/7,750 landings/55
months. (1 similar occurrence)
Lycoming TIO540J2BD Magneto contact breaker

cam worn. Ref 510005498
PWA PT6A42 Engine inflight shutdown.

Ref 510005374
LH engine magneto contact breaker cam lobes

worn excessively.
P/No: M3611. TSN: 199 hours. (2 similar
occurrences)
Rotax 912 Engine fuel pump leaking. Ref 510005504
Engine driven fuel pump leaking oil around

crimped top. P/No: 892542. TSN: 28 hours.
TURBINE ENGINES
Allison 250C20B Engine compressor stator broken.
Ref 510005572
Compressor sixth stage stator broken off in
Engine inflight shutdown. Engine removed.

Investigation continuing. (3 similar occurrences)
PWA PW123B Engine oil cap incorrectly secured.
Ref 510005444
RH engine oil filler cap incorrectly secured. Loss

of engine oil. P/No: 3006084.
PWA PW125B Engine bearing faulty.
Ref 510005529
No15 bearing outer race moving in housing.

Found during boroscope inspection.
Rolls Royce RB211524D4 FFR faulty.
Ref 510005378
No4 engine flamed out during approach. Initial

investigation found a faulty Fuel Flow Regulator
(FFR). Investigation continuing.
Rolls Royce RB211524G Engine fuel manifold leaking. Ref 510005382
No1 engine pig tail fuel manifold leaking.

Investigation continuing. P/No: FK29501.
Rolls Royce RB211524H Engine smoke/fumes. Ref
510005456
Fumes in rear of cabin. Suspect fumes from No2

engine that had a compressor wash carried out
prior to flight. Investigation continuing.
Turbomeca ARRIEL1A Engine turbine section oring damaged. Ref 510005432
No1 engine leaking oil between module 4 and

module 5. Investigation found that the O ring
seal located between module 4 and module 5
was damaged during assembly due to a small
mark on the entry point of module 5.
P/No: 9681508502.
Turbomeca ARRIEL2B Engine fuel pipe cracked.
Ref 510005351
Engine starting system fuel pipe cracked and

leaking at lower end. P/No: 0292737300. TSN:
94 hours. (3 similar occurrences)
PROPELLERS
McCauley P7036368 Propeller blade bushing
disintegrated. Ref 510005562
Propeller blade bushings disintegrated.

TSN: 2,221 hours.
Rotol R352 Propeller feathering pump bobbin

worn. Ref 510005530
RH engine feathering pump bobbin worn. Oil

leaking from engine. Found during inspection
iaw AD/F50/88. P/No: 638005637. TSN: 19,227
hours.
Rotol R3904123F27 Propeller hub cracked. Ref
510005463
LH propeller hub cracked. Found during NDT

inspection iaw AD/PR/33 Amdt2.
P/No: 660714259. TSN: 18,778 hours. TSO: 6,901
hours. (6 similar occurrences)
Note: Occurrence figures based on data
received over the past 5 years.
SERVICE DIFFICULTY REPORTS
To report urgent defects

call 131757 fax 02 6217 1920
or contact your local CASA Airworthiness Inspector
(Freepost) Service Difficulty Reports, Reply Paid 2005, CASA, Canberra, ACT 2601
(Online) www.casa.gov.au/airworth/sdr
34
AIRWORTHINESS DIRECTIVES PULL-OUT SECTION

APPROVED AIRWORTHINESS
DIRECTIVES 20 DECEMBER 2007
Part 39-105 - Lighter Than Air
There are no amendments to Part 39-105
- Lighter than Air this issue.
Part 39-105 - Rotorcraft
Aircraft - General
AD/GENERAL/18 Amdt 1 - Automatic
Pilot Limitation Placard - Installation
- CANCELLED
AD/GENERAL/22 - Engine Oil Tank
- Modification - CANCELLED
AD/GENERAL/43 - Power Supply
Connections to Hourmeters - CANCELLED
AD/GENERAL/46 - Placarding of Fuel
Quantity Indicators - Modification
- CANCELLED
AD/GENERAL/51 - Electrical External
Power Connection - Inspection CANCELLED
AD/GENERAL/52 - Bonding - Modification
- CANCELLED
Agusta AB139 and AW139 Series
Helicopters
AD/AB139/2 - Engine Fire Extinguisher
Bottles
AD/AB139/3 - Fin Assembly
AD/AB139/4 - Fuselage Frame 5700 Middle
Section
Bell Helicopter Textron 205 Series
Helicopters
AD/BELL 205/70 Amdt 1 - Tail Rotor Blade
Fwd Tip Weight Retention Block and Aft
Tip Closure
Helicopters
Tip Closure
Helicopters
Tip Closure
AD/BELL 412/53 - Tail Rotor Blade Fwd
Tip Weight Retention Block and Aft Tip
Closure - 2
Helicopters
AD/BELL 427/7 - Tail Rotor Blades
AD/BELL 427/8 - Vertical Fin Attachment
Part 39-105 - Below 5700 kgs
Aircraft - General
- CANCELLED
- CANCELLED
- CANCELLED
Aerospatiale (Socata) TBM 700 Series
Aeroplanes
AD/TBM 700/41 Amdt 1 - Pilot Door
Locking Fittings
Airparts (NZ) Ltd. FU 24 Series Aeroplanes
AD/FU24/64 - Fin and Leading Edge
Beechcraft 18 Series Aeroplanes
AD/BEECH 18/8 - Undercarriage Limit
Switch - Inspection - CANCELLED
AD/BEECH 18/16 - Front Seat Restraint
Installations - Modification - CANCELLED
Beechcraft 19, 23 and 24 Series
Aeroplanes
AD/BEECH 23/2 - Rudder Leading Edge
- CANCELLED
AD/BEECH 23/6 - Rudder Pedal Position
Gear - CANCELLED
AD/BEECH 23/12 - Attachment of
ADF Noise Suppressor Capacitor
- CANCELLED
AD/BEECH 23/18 Amdt 1 - Front Seat
Restraint Installations - CANCELLED
AD/BEECH 23/31 - Pre-Certification
Requirements - CANCELLED
AD/BEECH 23/47 - Aircraft Repair
- CANCELLED
Beechcraft 33 and 35-33 (Debonair/

Bonanza) Series Aeroplanes
Installation - CANCELLED
AD/BEECH 33/22 - Internally Lighted
Altimeters - CANCELLED
Beechcraft 55, 58 and 95-55 (Baron)
Series Aeroplanes
AD/BEECH 55/96 - Structural Life Limit
for Airframe
Hawker Beechcraft (Raytheon) 390 Series
Aeroplanes
AD/PREMIER/3 - Hydraulic Pump Outlet
Tubes
Twin Commander (Gulfstream/Rockwell/
Aerocommander 500, 600 and 700) Series
Aeroplanes
AD/AC/101 - Fuel Filler Openings
Part 39-105 - Above 5700 kg
Aircraft - General
- CANCELLED
- CANCELLED
- CANCELLED
Airbus Industrie A319, A320 and A321
Series Aeroplanes
AD/A320/210 - 80VU Rack Attachments
Airbus Industrie A330 Series Aeroplanes
AD/A330/43 Amdt 2 - Cockpit Instrument
Panel
AMD Falcon 50 and 900 Series Aeroplanes
AD/AMD 50/43 - Rivets between Frames 9
and 10, and Stringer Reinforcements
Boeing 727 Series Aeroplanes
AD/B727/207 - Aft Pressure Bulkhead
Web
AD/B737/310 - Body Station 178 Bulkhead
Vertical Beam Webs
AD/B747/366 - Fuel Pump Housing to Wing
Structure Electrical Bonding
AD/B767/187 Amdt 1 - Aft Pressure
Bulkhead Insulation Blankets
AD/B767/232 - Fuel Pump Housing to Wing
Structure Electrical Bonding
Bombardier (Canadair) CL-600
(Challenger) Series Aeroplanes
AD/CL-600/90 - Fuel Line Couplings
Bombardier (Boeing Canada/De
Havilland) DHC-8 Series Aeroplanes
AD/DHC-8/103 Amdt 1 - Cockpit Door
Hinge Attachment
AD/DHC-8/133 Amdt 1 - Main Landing
Gear System
British Aerospace BAe 125 Series
Aeroplanes
AD/HS 125/181 - Panel DA Wiring
Aeroplanes
AD/BAe 146/16 Amdt 7 - Rear Spar Root
Joint Attach Fittings Wing Rib 2
AD/BAe 146/129 - Undercarriage Main
Beam Sidestay Bolts at Frame 29
Dassault Aviation Falcon 2000 Series
Aeroplanes
AD/F2000/28 - Rivets between Frames 9
and 10, and Stringer Reinforcements
Embraer ERJ-170 Series Aeroplanes
AD/ERJ-170/4 Amdt 2 - Flight Guidance
Control Unit
Fokker F50 (F27 Mk 50) Series Aeroplanes
AD/F50/85 Amdt 1 - Feathering Pump
Gasket - CANCELLED
AD/F50/88 Amdt 1 - Power Plant Feathering pump
SAAB SF340 Series Aeroplanes
AD/SF340/17 Amdt 3 - Airworthiness
Limitations - CANCELLED
Part 39-106 - Piston Engines

- Piston Engines this issue.
Part 39-106 - Turbine Engines
International Aero Engines AG V2500
Series
AD/V2500/4 - High Pressure Turbine
Stage 2 Air Seal
Part 39-107 - Equipment
Propellers - Variable Pitch - Dowty Rotol
AD/PR/37 Amdt 1 - Propeller Blades
- Metallic Leading Edge Guard
DIRECTIVES 17 JANUARY 2008
Aero Resources J2 Series Gyroplanes
AD/MCH/1 - Seat Restraint Installation
Eurocopter SA 360 and SA 365 (Dauphin)
Series Helicopters
AD/DAUPHIN/74 - Main Gear Box - Planet
Gear Carrier - CANCELLED
AD/DAUPHIN/77 - Main Gearbox (MGB)
Planet Gear Carrier - CANCELLED
AD/DAUPHIN/94 - Main Rotor Drive
McDonnell Douglas (Hughes) and
Kawasaki 369 Series Helicopters
AD/HU 369/119 - Tail Rotor Blade Root
Fitting - 2
Part 39-105 - Below 5700 kg
Aermacchi - Lockheed AL 60 Series
Aeroplanes
AD/AL 60/10 - Front Seat Restraint
Installation - Modification - CANCELLED
Aerospatiale Rallye Series Aeroplanes
AD/MSR/19 - Front Seat Restraint
Airparts (NZ) Ltd. FU 24 Series Aeroplanes
AD/FU24/41 - Pilot Restraint Installation
American Champion (Aeronca, Bellanca)
Series Aeroplanes
AD/CHA/10 Amdt 1 - Safety Restraint
Installations - CANCELLED
Auster/Beagle A.61 Series Aeroplanes
AD/AUS/20 - Front Seat Restraint
Avions Mudry Cap Series Aeroplanes
AD/CAP 10/5 Amdt 1 - Front Tank Support
Strap
Ayres Thrush (Snow) Commander Series
Aeroplanes
AD/AC-SNOW/10 - Safety Harness
- Installation - CANCELLED
Beagle A109 (Airedale) Series Aeroplanes
AD/BEA 109/3 - Front Seat Restraint
Beagle B121 (Pup) Series Aeroplanes
Beagle B206 Series Aeroplanes
Beechcraft 19, 23 and 24 Series
Aeroplanes
AD/BEECH 23/27 Amdt 1 - Engine Firewall
Aluminium Fittings - CANCELLED
AD/BEECH 23/32 - Engine Firewall
- CANCELLED
AD/BEECH 23/34 - Fuel Return Placard
- CANCELLED
Beechcraft 33 and 35-33 (Debonair/
Bonanza) Series Aeroplanes
AD/BEECH 33/3 - Insulation of Tachometer
Flexdrive - CANCELLED
Beechcraft 35 (Bonanza) Series
Aeroplanes
Beechcraft 50 (Twin Bonanza) Series
Aeroplanes
Beechcraft 55, 58 and 95-55 (Baron)
Series Aeroplanes
Beechcraft 56TC (Turbo Baron) Series
Aeroplanes
Beechcraft 60 (Duke) Series Aeroplanes
Beechcraft 65 and 70 (Queen Air) Series
Aeroplanes
AD/BEECH 65/28 Amdt 1 - Front Seat
Restraint Installations - CANCELLED
Beechcraft 90 and 65-90 (King Air) Series
Aeroplanes
Beechcraft 95 (Travelair) Series
Aeroplanes
Cessna 150, F150, 152 & F152 Series
Aeroplanes
AD/CESSNA 150/20 - Front Seat Restraint
AD/CESSNA 150/43 - Aircraft Repair
- CANCELLED
Cessna 170, 172, F172, FR172 and 175
Series Aeroplanes
- CANCELLED
Cessna 177 Series Aeroplanes
Cessna 180, 182 and Wren 460 Series
Aeroplanes
- CANCELLED
Cessna 188 (Agwagon) Series Aeroplanes
- CANCELLED
Cessna 190 and 195 Series Aeroplanes
Cessna 205 (210-5) Series Aeroplanes
- CANCELLED
- CANCELLED
Consolidated Aeronautics, Colonial and
LA-4 Series Aeroplanes
AD/LA-4/6 - Front Seat Restraint
De Havilland DH 60 (Moth) Series
Aeroplanes
AD/DH 60/2 - Seat Restraint Installations
DH 82 (Tiger Moth) Series Aeroplanes
DH 87 (Hornet Moth) Series Aeroplanes
AIRWORTHINESS DIRECTIVES PULL-OUT SECTION

DH 104 (Dove) Series Aeroplanes
AD/DH 104/30 - Front Seat Restraint
DHA-3 (Drover) Series Aeroplanes
AD/DHA-3/26 - Front Seat Restraint
DHC-3 (Otter) Series Aeroplanes
AD/DHC-3/27 - Front Seat Restraint
DHC-6 (Twin Otter) Series Aeroplanes
AD/DHC-6/34 - Pilot Seats Safety
Restraint Installations - Modification
- CANCELLED
Diamond DA42 Series Aeroplanes
AD/DA42/3 Amdt 2 - Engine Control Unit
Back-Up Batteries
Dornier DO-27 Series Aeroplanes
AD/DO-27/9 - Front Seat Restraint
Fairchild (Swearingen) SA226 and SA227
Series Aeroplanes
AD/SWSA226/8 - Front (Pilot) Seat
Restraint Installation - Modification
- CANCELLED
Fuji FA-200 Series Aeroplanes
AD/FA-200/16 - Front Seat Restraint
Gulfstream (Grumman American/
American Aviation) AA-1 Series
Aeroplanes
AD/AA-1/10 - Front Seat Restraint
Helio Courier Series Aeroplanes
AD/HELIO/2 - Front Seat Restraint
Meta Sokol L.40 Series Aeroplanes
AD/L.40/8 - Front Seat Restraint
Mitsubishi MU-2 Series Aeroplanes
AD/MU-2/7 - Front Seat Restraint
Mooney M20 Series Aeroplanes
AD/M20/16 - Front Seat Restraint
Navion Series Aeroplanes
AD/NAV/3 - Front Seat Restraint
Percival Vega Gull Series Aeroplanes
AD/GULL/3 - Front Seat Restraint
Percival Proctor Series Aeroplanes
AD/PROCTOR/10 (Re-Issue) - Front Seat
Restraint Installations - Modification
- CANCELLED
Piaggio P166 Series Aeroplanes
AD/P166/35 - Front Seat Restraint
Piper PA-11 (Cub) & J3 Series Aeroplanes
AD/PA-11/3 - Front Seat Restraint
Piper PA-18 and 19 (Super Cub) Series
Aeroplanes
Piper PA-20 (Pacer) Series Aeroplanes
Installations - Modifications CANCELLED
Piper PA-22 (Tri-Pacer and Colt) Series
Aeroplanes
Piper PA-23 (Apache and Aztec) Series
Aeroplanes
Piper PA-24 (Comanche) Series
Aeroplanes
Piper PA-25 (Pawnee) Series Aeroplanes
AD/PA-25/34 - Passenger Seat Restraint
Piper PA-28 Series Aeroplanes
AD/PA-28/89 - Aircraft Repair CANCELLED
Piper PA-30 & 39 (Twin Comanche) Series
Aeroplanes
36

Piper PA-31 Series Aeroplanes
Piper PA-32 (Cherokee Six) Series
Aeroplanes
Piper PA-36 (Pawnee Brave) Series
Aeroplanes
AD/PA-36/3 - Pilot Seat Restraint
Robin Aviation Series Aeroplanes
AD/ROBIN/4 Amdt 1 - Aileron/Flap
Support Brackets
AD/ROBIN/5 Amdt 2 - Engine Mountings
AD/ROBIN/9 - Rudder Bar Assembly
Welds - CANCELLED
AD/ROBIN/13 Amdt 1 - Vertical Stabiliser
Spar
AD/ROBIN/27 Amdt 2 - Rudder Pedal Bars
AD/ROBIN/39 - State of Design
Airworthiness Directives
AD/ROBIN/40 - Nose Landing Gear
Bracket - 2
Ryan ST Series Aeroplanes
AD/RYAN/2 - Seat Restraint Installations
- Modifications - CANCELLED
Short SC7 (Skyvan) Series Aeroplanes
AD/SC7/9 - Front (Pilot) Seats Restraint
Twin Commander (Gulfstream/Rockwell/
Aerocommander 500, 600 and 700) Series
Aeroplanes
AD/AC/47 - Front Seat Restraint
Victa and A.E.S.L. Airtourer Series
Aeroplanes
AD/VAT/38 - Front Seat Restraint
AD/A330/81 - Frame 53.3 Circumferential
Joint
AD/A330/82 - Longitudinal Doubler at
Vertical Tail Plane Attachment Cut-out
AD/B737/311 - Main Wheel Well Electrical
Connectors and Receptacles
AD/B747/343 Amdt 1 - Stretched Upper
Deck Frame and Tension Tie
Aeroplanes
AD/BAe 146/16 Amdt 8 - Rear Spar Root
Joint Attach Fittings at Wing Rib 2
Cessna 560 (Citation V) Series Aeroplanes
AD/CESSNA 560/9 - Minimum Airspeed
Placards
Fokker F100 (F28 Mk 100) Series
Aeroplanes
AD/F100/86 - Flight Controls - Horizontal
Stabilizer Control Unit
Pratt & Whitney Canada Turbine Engines
- PW300 Series
AD/PW300/1 - Engine High Pressure
Compressor Dru
Emergency Equipment
AD/EMY/34 Amdt 1 - Emergency
Evacuation Slide/Raft - Pressure Relief
Valves
Parachute Equipment
AD/PARA/15 Amdt 1 - VEGA 120 Type
Reserve Canopy
AD/PARA/17 Amdt 1 - Parachute Shop
Parachutes
DIRECTIVES 14 FEBRUARY 2008
Aircraft - General
AD/GENERAL/65 Amdt 5 - Hand Held

Portable Fire Extinguishers
Agusta A109 Series Helicopters
AD/A109/60 Amdt 1 - Pilot and Co-Pilot
Doors Emergency Release System
AD/A109/61 - Rotor - Main Rotor Blade
Tip Cap
Agusta A119 Series Helicopters
AD/A119/11 Amdt 1 - Pilot and Co-Pilot
Doors Emergency Release System
Helicopters
AD/BELL 205/15 - Tail Rotor Hub Assembly
- Inspection - CANCELLED
AD/BELL 205/23 Amdt 4 - Main Rotor
Blades - CANCELLED
AD/BELL 205/37 - Main Rotor Hub Fitting
Assemblies - Inspection - CANCELLED
Eurocopter AS 332 (Super Puma) Series
Helicopters
AD/S-PUMA/72 - Fuselage - TGB
Attachment Fittings
Eurocopter AS 350 (Ecureuil) Series
Helicopters
AD/ECUREUIL/129 - Seat Electrical
Bonding Modification
Eurocopter EC 120 Series Helicopters
AD/EC 120/17 - Seat Electrical Bonding
Modification
Eurocopter EC 135 Series Helicopters
AD/EC 135/15 - Rotor Flight Control - Tail
Rotor Control Rod and Ball Pivot
Kawasaki BK 117 Series Helicopters
AD/JBK 117/26 - Tail Rotor Transmission
Attachment Nuts
Part 39-105 - Below 5700 kg
Aircraft - General
Avions Mudry Cap Series Aeroplanes
AD/CAP 10/12 - Control Stick Base Cover
Mount
Cessna 150, F150, 152 & F152 Series
Aeroplanes
AD/CESSNA 150/3 - Map Case CANCELLED
AD/CESSNA 150/16 Amdt 1 - Control
Systems - CANCELLED
AD/CESSNA 150/19 - Seat Frame
- CANCELLED
AD/CESSNA 150/27 - Seat Frame
- CANCELLED
AD/CESSNA 150/29 Amdt 1 - Fuel Vent
Tube - CANCELLED
AD/CESSNA 150/35 - Flying Control
System Turnbuckles - CANCELLED
Cessna 170, 172, F172, FR172 and 175
Series Aeroplanes
AD/CESSNA 170/21 - Control Systems
- CANCELLED
AD/CESSNA 170/31 Amdt 1 - Fuel Vent
Tube - CANCELLED
- CANCELLED
Cessna 180, 182 and Wren 460 Series
Aeroplanes
- CANCELLED
AD/CESSNA 180/54 - Fuel Vent Tube
- CANCELLED
- CANCELLED
- CANCELLED
Cessna 188 (Agwagon) Series Aeroplanes
- CANCELLED
- CANCELLED
- CANCELLED
- CANCELLED
- CANCELLED
System Turnbuckles - Inspection
- CANCELLED
AD/CESSNA 525/6 - Electrical Power
- Relay Circuit Protection
Cirrus Design SR20 and SR22 Series
Aeroplanes
AD/CIRRUS/8 - Wingtip Drain Hole
Dornier 228 Series Aeroplanes
AD/DO 228/6 Amdt 1 - Horizontal
Stabiliser Leading Edge and Ribs
AD/DO 228/12 - De-bonding of Surface
Protection on Rudders and Elevators
AD/DO 228/13 - Cracks in Rudder Control
Cable Terminals
Pacific Aerospace 750XL Series
Aeroplanes
AD/750XL/3 Amdt 1 - Wiring Loom
Protective Sleeve
Pacific Aerospace Corporation Cresco
Series Aeroplanes
AD/CRESCO/12 - Fin Leading Edge
- Inspection
Aircraft - General
AD/A330/83 - Fuselage - Frame 12
Inspection/Repair
Beechcraft 400 Series Aeroplanes
AD/BEECH 400/29 - Galley Electrical
Power Circuit Wiring
AD/B737/250 Amdt 1 - Forward Entry Door
Forward and Aft Side Intercostals
AD/B737/311 Amdt 1 - Main Wheel Well
Electrical Connectors and Receptacles
AD/B737/312 - Aft Pressure Bulkhead
Inspection
AD/B737/313 - Circumferential Butt
Splices and Bonded Doublers
AD/B737/314 - Cracking Around Heads of
Fasteners
AD/B747/367 - Lower Cargo Compartment
Fire Extinguishing System - Time Delay
Relays
AD/B747/368 - Station 1241 Bulkhead
Fittings
AD/B747/369 - Passenger Oxygen Masks
AD/B767/226 Amdt 1 - Rudder and
Elevator Vibration
AD/B767/233 - Fuel Quantity Indicator
System Wire Harness
AD/B767/234 - Cargo Compartment Fire
Extinguishing System - Time Delay Relays
Aeroplanes
AD/BAe 146/120 Amdt 1 - Wing Top Skin
under Rib 0 Joint Strap
AD/BAe 146/130 - Fuselage - Airbrake
Upper Crossbeam
Rolls Royce Germany Turbine Engines
- BR700 Series
AD/BR700/11 - Reverse Wired
Independent Overspeed Protection Coils
- Equipment this issue
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Ever had a
CLOSE
CALL
Write to us about an
aviation incident or
accident that YOU were

involved in. If we publish
your story, youll receive
$ 500
Well be running MORE of your submissions, and seeking

readers involvement in discussing the incidents.
CLOSE CALL is the forum to have YOUR say in keeping
our skies safe!
Write about a real-life incident that youve been involved in, and send it to us via email: fsa@casa.gov.au. Clearly mark your
submission in the subject field as CLOSE CALL. Well publish a regular selection of your stories, with $500 for each published
submission. You must provide your full name, phone number and email contact, for your article be considered for publication.
Please provide any images you may have of the aircraft, terrain and/or mechanical parts involved in the incident you are
describing. You may also submit a photo of yourself to be included with the article, space permitting.
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Articles should be between 600 and 2,400 words. If preferred, your identity will be kept confidential. Please do not submit
articles regarding events that are the subject of a current official investigation. Submissions may be edited for clarity, length
and reader focus.
38
CLOSE CALL
Let it be somebody else!

BY MAX FENTON
t was a clear and cold July winter

morning as I ruefully surveyed the
Cessna 182K and noted the flying
surfaces coated with a thick covering of
rime ice from the heavy dew. There was
still 15 minutes before first light when I
was due to depart the paddock strip and
ferry the aircraft to a nearby large regional centre for a major airframe service and
engine overhaul.
With frozen hands and chattering
teeth the daily inspection, including ice
removal sans ladder, was completed and
after ensuring the livestock were out of
the way the engine was started, warmup
and checks performed, and a plan for
takeoff made.
With high voltage powerlines one end
and a forest of tall trees the other, my
friend the owner usually ran up to full
power, released, and then halfway down
the short strip dropped half flap. With
a grand total of 104 hours flying time
including 20 hours on type, I did not want
to be fumbling for the flap switch halfway
into this takeoff; so an oblique run was
made, at about 10 kt, onto the strip with
flaps set. Everything in the green, and all
knobs full rich.
On rotation with just me and half fuel,
we went up like an elevator well before
my cut-off point. Turning to heading
and reaching cruise B050, trimmed and
leaned the aircraft was as stable as a rock.
With the engine running at a smooth
purr, I contemplated the necessity of the
rules which required this relatively simple
machine to be disassembled and overhauled when in the prime of life.
But this thought was soon replaced.
With the sun just peeping over the horizon,
the Lilliputian panorama below was lit in
an ethereal glow, and the shadows from
trees in the wheatfields stretched for
miles. Fireplace smoke being held down

by the inversion rose only a few feet from
the well-spread toy-like farmhouses and
then, in turn, spread out in line with the
shadows. Nothing else moved.
It was one of those rare occasions when
the world seemed at peace. A moment
in time well remembered, but one that
cannot readily be explained, except
perhaps to another pilot.
Six weeks later I was dropped off at
the regional airlines large maintenance
centre to pick up the aircraft. It was late
in the afternoon, but only a 30 minute
flight back to base. The aircraft was sitting
outside the large hangar, allowing me to
do a walkaround check without anyone
else about.
After this, I found someone in charge
and asked for a hinge pin for the pilots
door, as one is not enough, and if anyone
knew where the fuselage/wingstrut fairing
boot was for the passenger side?
Having fixed the first, located the
latter and put it in the aircraft, I loaded
myself and started up what a racket! A
chaff-cutter would sound better.
Closing down, I again located someone
and off came the cowls. Another start,
still a little rough in my view but magdrop, although full, is within margin.
One mag was not timed right, I was
informed on with cowls.
Taxiing out, I requested clearances
from the tower Sorry, not available,
came the reply. A new rule had just come
in all flights over 50 nm now required a
flightplan.
My destination was 51 nm, so I changed

it to my home strip which was 49 nm. All
checked and cleared, controls full and free,
and with just a bit of rudder trim to counteract the P-factor swing, I commenced
takeoff.
No problems ... until lift-off, when the
nose swung violently, and without realising it, I had a boot-full of rudder on to stay
straight. A quick change of plan is relayed
to the tower who approve my circuit
which, after trimming out the rudder
forces, is uneventful.
Again back to the hangar, I am not in
a good mood and last light is now a real
concern. But a quick changeover of the
back to front rudder trim wires via the
inspection hatches fixes the problem.
A normal takeoff, a departure from
over the top, and a somewhat unusual, if
effective, short-field landing back in my
friends paddock at last light completes
the days lesson.
The lesson is this: flying, like anything
else, comprises good and bad. Enjoy the
one and beware the other but dont be
put off !
Following these incidents, my flying
career went on for another 30 years and
overall my experiences with LAMEs was
very good.
But from those early days I always
remember the answer one person gave
to the question: What is the best accessory you can have on a new aircraft? The
reply: On a new aircraft, or one just out of
major maintenance, 20 hours flying BY
SOMEBODY ELSE!
CLOSE CALL
Prop drop
BY JOCK ANDERSON
he aircraft is a home-built
Zenith Tri-Z (CH300). It is an
all aluminium, three seat, singleengine low-wing cantilever-style light
aircraft, resembling a Grumman Tiger.
The power plant is a Lycoming O-360
180 HP normally-aspirated engine.
Originally, I had a Sensenich twobladed fixed-pitch prop, but this gave me
weight and balance problems so I decided
to switch to a wooden prop. The propeller
I wanted was a fixed-pitch commercially
manufactured two-bladed type, and much
lighter than the Sensenich.
In 1984, it was unusual to have a wooden
prop on a Lycoming 180 HP engine
although there were some flying about.
The department at the time therefore
allowed me to use the prop on an approval
basis. I was to fly it and try it, and record
the performance so that it could be generally approved for others. I was happy to do
this, so I ordered the prop.
When the prop arrived, it looked fine.
But to our great disappointment, it didnt
fit when we tried to bolt it on to the
engine. Careful examination of the bolt
holes showed that on the forward side
they were exactly as they should be, but
on the reverse side some of them were
slightly out. The degree that they were out
40
increased slightly the further away from

the first bolt hole they were.
I am quite sure that the prop had not
been correctly secured when the bolt
holes were being drilled, and swarf was
gathering under it so that it was progressively being lifted as each hole was being
drilled. The bolt holes, therefore, were not
parallel.
I contacted the manufacturer, confidently expecting that I would be offered
an apology and another prop not so.
I was told that he would move the bolt
holes! I was amazed at this concept and
asked how one could move holes in a
wooden prop.
No problem, I was told. Use a roundbodied file. I asked how this could possibly secure a prop to an engine, as I thought
it would wobble. No, I was assured. The
prop is secured by compression, not
torsion. So the manufacturer moved the
bolt holes with a round-bodied file and
the propeller was secured to my engine by
a LAME.
I started to fly the aircraft (without a
spinner) and all seemed well for about
three hours. Then a friend asked if he
could come for a ride, as he was considering getting a pilots licence. We went for
a fly out of Bankstown, with my friend in
the right seat. We landed at Wedderburn
for a break and all seemed well.
We departed Wedderburn and turned
to make a scenic flight around Camden
and then north to Warragamba and back
to Bankstown over Prospect Reservoir.
Around Camden I invited my friend to
take the control stick (it was dual control)
to get a feel for the aircraft.
Around The Oaks I felt something

uncomfortable or unfamiliar for a
moment, but put it down to my imagination. I settled quickly and I directed my
friend to steer for Prospect Reservoir.
I made my inbound call and just then I
felt a distinct shudder and knew there was
a problem. Just what was wrong I did not
know, but I took over control and reduced
power and the shudder disappeared, so I
maintained altitude and flew close to the
circuit in case I had to turn for the aerodrome.
I made minimal changes in power
settings and we made a normal landing
on 29R and I gingerly taxied over to the
hangar. I shut the engine down, and my
passenger jumped out declaring he would
open the hangar door so we could push
back as he had seen me do before. As he
walked around the aircraft he called out
to me, There is a bolt on the tarmac.
Now I knew there was something really
wrong. I got out of the cockpit and found
that there was only one bolt left holding
the prop in place, and that had only half
an inch of thread left in the backing plate.
All the safety wire had gone and the bolt
on the ground was fractured at the shank,
with the thread still in the backing plate.
I took the weight of the prop in one
hand and unscrewed the remaining bolt
with the fingers of the other hand. Just
then the resident LAME walked by and
said, Hi, are you changing the prop? I
replied, No, its changing itself.
The incident was duly and properly
reported to the department and all of the
remaining prop bolts and the prop itself
were sent to Canberra for analysis. The
result of that enquiry was never made
available to me, but I am perfectly confident that the problem was due to a faulty
propeller.
The point of this story is that, if an accident had occurred, it would have been
reported as another of those dangerous
homebuilts! I know though, that the
engine was not homebuilt, nor was the
propeller, and the prop was put on by a
LAME. None of it was my doing.
By the way the friend never went for
his pilots licence.
CLOSE CALL
Fuel cap mishap
BY DAN ENDE
Dont forget your fuel caps

The Cessna 185 immediately after the incident.
n October 1998, I was working as a

casual pilot for a Perth/Jandakotbased, aerial survey and photography
company. I had about 700 hours flying
time, so I was relatively inexperienced in
comparison to the companys flight crews;
however, I had more tail wheel hours than
nose wheel, and felt extremely privileged
when I was invited to captain the companys first aircraft: a Cessna 185, VH-KPA.
She was bought new in 1963 and virtually kept due to sentimentality by the
company owner. She was the early model
with a 260 HP IO-470, rather than the 300
HP IO-520 that most of 185s have, and she
had been ground looped on several occasions, so she flew a little sideways. But
after each event she was lovingly rebuilt
and returned to service.
When I got to know her, she was a
beautiful 35-year-old, resplendent in the
companys red, gold and white colours,
and I cared for her as if she was mine.
I had been engaged to fly a dog-baiting
contract commencing in Madura on the

Nullarbor. We had done a couple of days;
however, we were going to be operating in
increasingly remote areas, so following
the days flying, I was to ferry her alone to
Kalgoorlie for the fitting of an HF unit for
our SAR ops. I landed at Madura in the
late afternoon.
I organised the refuelling from drum
stock. I filled the left tank, and the hose
was passed to one of the crew to fill the
right. She was not NVFR, so the rush was
on to get airborne and to Kalgoorlie before
dark. As they completed the refuelling I
went to my tent to gather my bag.
As I approached her from behind, I
noted both tank caps were in place; I had
fitted the left, the crew member had fitted
the right, but in the need for haste I did
not get up and check the right.
First and second factors

I ran through my pre-flight checks and got
airborne, streaking away from the sun.
The right-hand cap had been fitted incorrectly, and at some point early in the flight
was removed by the low pressure, laying
back silently on its chain in the airflow.
As it was the tank furthest from me, I
did not see the escaping fuel; and as she
was an early model, she did not have a
fuel selector, just an on/off, pull-out knob,
with both tanks feeding simultaneously
into the fuel bowl. She was fitted with two
150-litre bladder tanks connected by a
balance tube.
The low pressure siphoned the contents
of the right tank overboard, then pulled
the bladder up, holding the fuel indicator
float up, which gave me a half-tank indication. The low pressure set about siphoning the left-hand contents through the
balance tube.
Third factor
She had a tendency to burn part of one
tank, then would balance as the flight
progressed, so I noted nothing out of the
CLOSE CALL
ordinary. Nearly at Kalgoorlie, I could

see the aerodrome 6 nm away, and had
commenced my descent, passing through
about 3000 ft.
The engine stopped.
I went through the checks: the righttank gauge suggested it was half full; the
left less so, but still indicating. I gave a
radio call expressing the occurrence, and
then commenced an approach on a wide,
straight road. At about 500 ft I saw a truck
whose day was about to get a lot more
exciting, and the engine restarted.
In retrospect, it was the extreme deck
angle bringing the last of the fuel to the
line; however, the fuel gauge indicated
half tank, and I had no reason to disbelieve it. I set climb, rushed out a radio call,
and prepared for a straight-in approach
on Kalgoorlies main runway.
At 1000 ft the engine stopped again.
I rushed out another radio call, and
prepared an approach on a mine site road.
I recall the deck angle; even though the
plane was fitted with STOL droop wing
tips, the glide was steep. At 100 ft I noted,
to my dismay, a low chain-link fence and
gate about 10 metres beyond my proposed
touch-down point. I selected half flap and
aimed for a point just beyond the gate.

She staggered over the gate in the
three-point attitude, and with her last
remaining energy, arrived on the gravel. I
alighted from the cockpit, got on the step
and gazed at the wing. The right-hand
cap was lying on the wing on its chain. I
went to the other side, replaced the cap,
and rang the company. I stepped out the
distance from touch-down to stop: a mere
100 paces.
On further inspection I noted a fleck
of paint about the size of a twenty-cent
piece missing from the left lower inboard
STOL tip that hadnt been missing at the
start of the day. I looked back up my glide
path and noted that, had I not evaded the
fence, I would had put the left wing into a
tailings pile not evident from above, with
an ensuing messy semi-airborne ground
loop, probably destroying the aircraft.
I climbed the tailings pile and noted
a shallow groove running across its top,
in line with my glide path. I pondered
the circumstances, and ran my hand
down her engine cowling, thanking her;
Id taken care of her and she had looked
after me. The first mine site vehicle with
surprised-looking occupants arrived.
The company sent an engineer, and

overnight, we cleaned the fuel strainer,
put some fuel in her, and flew her out the
following morning on an adjacent longer
road.
The HF was fitted, and the operation continued the following day. I have
considered since that a landing on the road
with some power may have been a better
decision; however, I had no reason not to
believe my fuel gauge indication, and the
semi-trailer I was head-to-head with was
a significant obstacle, the drivers reaction
difficult to predict.
The factors of pressure with time and
darkness, failure to physically check the
fuel cap, reliance on visual inspection, the
nature of the fuel system, the erroneous
fuel indication, and my own inexperience
all conbined to cause this incident.
All things considered, the outcome was
as good as I could have hoped for despite
some questionable command decisions. I
can only hope this account serves to help
others to avoid my evident mistakes.
Theres ALWAYS time to check fuel cap
security, and doubly so when non-flight
crew are involved.
Safe and happy landings!
SHE STAGGERED OVER

THE GATE AND WITH
HER LAST REMAINING
ENERGY, ARRIVED ON
THE GRAVEL.
42
CLOSE CALL
Close Call follow-up:

The safety seminar that saved me
Our research shows that the Close Call section of this
magazine is one of the most widely read. We are pleased to
have submissions from pilots who put their hand up and admit
their failings so that others may learn.
A readers letter
(name & address provided):
Your journal (Flight Safety Australia Sept-Oct) has just been passed
to me by a friend, and I feel I must
comment regarding the article The
safety seminar that saved me.
No pilot should ever be allowed
to undertake a cross country flight
without some rudimentary knowledge of instrument flying; one does
not need an autopilot to keep the
wings level.
This pilot was prepared to descend
through cloud without reference to
safety height. Not too far from Mt
Gambier the Grampians rise to over
3,000 ft, yet this pilot was happy to
break cloud at 3,800 feet. Too many
pilots in Australia fly into mountains
in bad weather. He/she should have
descended over the ocean and then
returned visually to the target airfield;
then again he/she should never have
embarked on this flight.
I was trained in the 1950s as a
night/all-weather jet fighter pilot.
We didnt have auto pilots or fancy
navigation aids but flew in atrocious
weather, right down to the deck. We
were taught by probably the worlds
best, the Royal Air Force, to think
about what we were doing.
Its a pity that the article did not
list all the mistakes referred to. No
wonder the name was withheld.
CASAs Southern Region Aviation Safety Advisor, Tim Penney, responds

1. This pilot was the first to admit that he
should have planned the flight better and
not allowed himself to get caught VFR on
top of cloud in the first place. We stress in
our Evening Safety Seminars that one of
the key defences to avoid becoming a VFR
pilot going onto IMC is proper pre-flight
preparation and planning on the ground.
The best way to avoid becoming a statis-
tic is by not allowing yourself to go VFR

into IMC in the first place. This pilot was
very clear to make the point that with a bit
more planning and forethought, he would
not have got himself into this predicament.
2. The pilot was also the first to put his
hand up and acknowledge that he should
have turned back before the overcast over
CLOSE CALL
THE FACT THAT HE

ATTENDED AN EVENING
SAFETY SEMINAR AND
MANAGED TO COME
AWAY WITH JUST ONE
PIECE OF INFORMATION
SPEAKS VOLUMES
which he was flying thickened to the point
that he could no longer guarantee a visual
arrival to below the cloud base.
Again, he acknowledges the less-thanideal in-flight decision making he demonstrated when he had prior opportunity to
divert or plan an alternative.
3. This pilot also makes mention of the fact
that he should have done what the Evening
Safety Seminar tells all pilots to do if they
find themselves in such a situation. That
is to hit the transmit button and seek
assistance from Air Traffic Services.
Controllers on the Area Frequency can
do a number of things, such as to seek
the assistance of other aircraft for guidance to areas where there may be breaks
in the cloud, or to report the height of the
cloud base. They can steer a pilot away
from regions of high terrain or seek the
assistance of ground-based personnel
at various locations to provide actual
weather reports at alternative airfields.

A calming voice in the headset can be
enough to settle the pilots nerves and put
them in a better frame of mind for decision making.
4. The correspondent was critical of the
fact that the pilot did not consider the
high terrain of the Grampians as he began
his let down in cloud. Bear in mind that
he let down near Mt Gambier, which was
some considerable distance to the SW of
the high terrain and not in his immediate vicinity. In fact, the terrain around
Mt Gambier aerodrome has a relatively
uniform elevation of about 300 ft AMSL.
5. The correspondent is also highly critical of the pilot for not flying out to sea and
letting down over the water, then breaking cloud and flying back to Mt Gambier
airport. Such a procedure could have cost
the pilot an additional 30-40 minutes or
thereabouts in nil wind conditions.
We dont know whether he considered
this procedure; however, the extra time
and fuel required may have precluded
such an action.
6. The point of the story remains. That is,
by attending a CASA-sponsored Evening
Safety Seminar, this pilot managed at least
to pick up one vital piece of information
(among many tips and suggestions which
we provide), which according to him,
probably saved his life.
That is, if penetration into cloud is
inevitable, make use of every aid you
have available to you, including the auto-
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44
pilot. In this case, the pilot remembered

from the seminar that use of the autopilot would at least allow him to keep the
aircrafts wings level, which would help
guard against a pilot-induced spiral dive.
History has shown such dives are
highly likely to occur to VFR-rated pilots
in IMC as they contend with the conflicting information coming from the flight
instruments, their inner ear balance
mechanisms and the seat of their pants.
So yes, the pilot did make numerous
errors of judgement and omission both
during the flight and during the flight
planning stages, which he fully admits to.
That is beyond doubt.
However, the fact that he attended an
Evening Safety Seminar and managed to
come away with just one piece of information speaks volumes for the efforts of
the Aviation Safety Advisors and Safety
Promotion to make a real impact on air
safety in the field.
Hopefully this pilots story will encourage those who do not attend these seminars (and it is the pilots who dont attend
that most need to hear our message) to
participate and learn something which
one day might just save their lives.
Safety seminars 2008, coming to a town
near you. Go to:
www.casa.gov.au/seminars/safety.htm
for more details on the FebruaryJune
2008 seminar program.
AVMED
Prostate cancer and

aeromedical certification
BY DR DAVID FITZGERALD
ach year in Australia, 18,700 men will

be diagnosed with prostate cancer.
Thirty thousand will die from the
disease. The five-year relative survival
experienced by men diagnosed with prostate cancer in 19992003 in NSW was
88 per cent. Prostate cancer is the most
common cancer in Australian men, and is
the second most common cause of cancer
deaths in men.
Early, curable prostate cancer may not
have symptoms. One in nine men over
the age of 50 will be diagnosed with it.
At autopsy, studies show that up to 40
per cent of men have prostate cancer that
they were unaware of, which means many
men die with prostate cancer rather than
from it.
This means that prostate cancer too
frequently presents itself as an identified
issue at the DAMEs surgery. (This should
not be the case, as licence holders should
report it at the time of diagnosis, as it is
a safety-relevant condition under CASR
67.265). Not reporting it causes unnecessary delays in certification, while information is sought from treating specialists.
Luckily, for most medical certificate
holders, it is discovered at a very early
stage. This may well be a result of more
frequent medical checkups for those
holding a licence.
Treatment for prostate cancer may
involve radical prostatectomy (surgical
removal of the prostate), radiotherapy
(direct beam or brachytherapy) and/or
hormone therapy. The type of treatment
advised will depend on a number of
factors: the stage of spread of the cancer;
the grade or behaviour of the cancer; the
level of prostate-specific antigen (PSA) in

the bloodstream; age and general health;
potential side effects of the treatment.
Although screening for prostate cancer
is not a requirement for aeromedical certification, given that it is such a common
condition its recommended that male
patients discuss screening for the disease
with their DAME. If it is picked up in
the early stages, before it has spread, the
chances of cure are very good notwithstanding the 12 per cent mortality rate as
noted above.
That prostate cancer is picked up at
an early stage in pilots is reflected by the
statistics held by the Aviation Medicine
Section, notably:
Of the 221 pilots with prostate cancer
since 1991, all but three have been returned
to flying in some capacity, mostly with no
restrictions on their certificate apart from
annual specialist review and PSA blood
testing at the next annual medical.
In some aggressive cases where there
is evidence that the cancer has spread or
has recurred locally, CASA places restrictions like as or with co-pilot to ensure
flight safety was not at risk from sudden
or subtle incapacitation. These are the
exception rather than the norm.
The only other requirement CASA
commonly applies is that licence holders
must have a period of grounding during
acute treatment such as surgery or radiotherapy. In addition, treatment with some
hormone therapies produces significant
side effects in 1020 per cent of cases,
particularly lethargy, and less typically a
chronic confusional state.
Before return to duties, an applicant
receiving hormone therapy may require
an operational check or documentation
from the treating specialist that side effects
have been looked for and discounted.
In other words, CASA returns 98 per

cent of pilots diagnosed with prostate
cancer to flying, with the most common
requirement placed on them is that they
see their treating doctor once a year and
have a blood test to ensure that cancer has
not returned or spread to other parts of
the body.
This annual review is no more than is
recommended by urologists for anybody
who has had this disease. To monitor
stability, CASA generally asks that the
pilots provide a copy of their review to
accompany their next medical as we do for
pilots with dozens of other conditions.
CASA had a joint avmedindustry
workshop on this topic last year to review
the evidence, and that meeting included
oncologists and industry representatives. The meeting reaffirmed that CASAs
liberal approach to recertification of pilots
with prostate cancer was appropriate,
given the fairly benign prognosis in many
cases and the presence of a reliable marker
for follow up in the PSA.
The message for pilots regarding prostate cancer is: talk to your DAME about
screening early detection my save your
life!
Dr David Fitzgerald is a medical officer
with CASA.
AVMED
A not-so-innocent bump on the head

BY DR DAVID FITZGERALD
etting a bump on the head is not

an uncommon occurrence for
pilots. Wing struts, propellers,
pitot tubes, hangar doors etc, are culprits
which seem to jump out at you when you
are not looking. Luckily enough, apart
from causing an outburst of certain fourletter words and some localised pain on
the noggin, most bumps on the head go
without significant disability.
However, this is not always the case.
More severe head injuries can result
in significant ongoing health risks and
impairment. Of particular concern for
flying is the potential for significant
cognitive impairment, and the high risk
of post-traumatic epilepsy.
There is strong evidence that the risk
of post-traumatic epilepsy (PTE) after
head injury is significant, and the risk
lasts up to even 20 years post injury . Post
traumatic seizures are thought to be due
to damage to the brain, generated both
from the physical damage itself, as well
as iron deposition from blood following
injury. Unfortunately, blood released into
the brain substance after head injury can
remain there and cause problems for a
long time.
The good news is that while the risk may
be prolonged, it drops approximately
80 per cent of individuals with PTE will
have their first seizure within the first 12
months post injury, and more than 90 per
cent by the end of the second year. It is
CASA practice that aircrew have a period
of grounding of at least two to five years
after significant head injury.
The bad news is that 1520 per cent
of patients may still be at risk of having
their first seizure after two years post
injury. The incidence of seizures increases
significantly for penetrating brain injuries; for injuries leading to blood in the
brain substance (e.g. brain contusions
46
and subdural haematomas); for prolonged

amnesia post injury; for injuries requiring surgical intervention; and in cases of
depressed skull fracture. Injuries with
these findings are likely to be associated
with a longer period of medical certificate
suspension.
A review of CASAs aviation medicine
database reveals a total of 120 head injuries. Of these, 61 were minor, or some time
in the past, and were given a pass assessment. Twenty-six individuals were failed.
Thirty-three required a delay in their
certification, until the risk of seizure
had reduced; and of these, 23 eventually
returned to flying. Some did not return
for recertification.
Head injury remains a significant cause
for failing or cancellation of a medical
certificate, particularly in young, otherwise healthy, pilots.
Statistics show that the incidence of

PTE is highest among young adults,
as they are more prone to head injury.
Alcohol-related falls, assaults and motor
vehicle accidents are common causes in
this group, and the results can be devastating for a career in aviation.
For any head injury which is more than
a simple uncomplicated bump on the
head, CASA requires certificate holders
to cease exercising the privileges of their
licence and be reviewed by their DAME,
particularly if:
any hospital observation is required
there is any associated amnesia
there is more than momentary loss of
consciousness
there are any abnormalities shown on
CT or MRI scans
there are any ongoing symptoms, such
as headache or confusion.
CASA uses a case-by-case approach.
However, for more severe injuries a
minimum grounding of two to five years
would be the norm.
Head injury is a common preventable
cause for loss of licence, particularly in
young certificate holders. Prevention is
the best way to avoid losing your licence.
Head injury is related to:
motor vehicle accidents buckle up!
And wear your helmet on your motorcycle. Leave travelling at 200 kt for the air!
assaults and falls, particularly those
related to alcohol. Moderate your alcohol
intake when out and about, and leave the
car at home if youre drinking.
sports dont go in head first!
work hazards observe occupational
health and safety practices; stop and
think!
If you use your brain first, youll
continue to be able to use it to fly!
Dr David Fitzgerald is a medical officer
with CASA.
AVMED
Brain injury case studies

Case study 1
A 33-year-old private pilot was struck
by a car. At the scene, he was found to
be poorly responsive to the ambulance
officers, and had multiple orthopaedic
injuries.
In hospital he was found to have brain
contusions in his right temporal lobe,
left frontal and parietal lobes and
cerebellum; an extradural haematoma,
and an extensive skull fracture.
He underwent neurosurgery and
extensive rehabilitation, during which
he demonstrated ongoing periods of
confusion and delusions.
He also became depressed and
was started on antidepressants.
Neuropsychological testing revealed
severe cognitive deficits.
Four years later he went to his DAME

for his aviation medical. He still had
difficulties with speed of psychomotor
performance, poor visual attention and
tracking, poor mental flexibility and
significant impairment in his memory
and problem-solving abilities. Given his
severe head injuries, his neurologist
noted the risk of a post-traumatic
seizure was still very high, even though
he had been seizure-free for four years.
Given his cognitive problems, a lot of
which would impair him significantly in
flying, and his seizure risk, CASA denied
his application for a medical certificate.
Case study 2
A 21-year-old, Class 1 certificate holder
was assaulted on his way home. He
was kicked in the head and fell to the
ground. His eyes rolled back and he
suffered urinary incontinence. He was

taken to hospital, but elected not to
wait in the emergency department.
For the next three days he had a slight
headache and felt unsteady. He saw his
GP who ordered a CT (computerised
axial tomography) scan, which showed a
haemorrhage in his right frontal lobe.
He saw his DAME some six months later.
An MRI (magnetic resonance imaging)
scan one year post-incident continued
to show areas of blood from the injury.
On the basis of the retained blood on
the scan, his neurologist assessed his
ongoing risk of post-traumatic seizure
as high, and advised him not to continue
to pursue his aviation training. CASA
subsequently cancelled his medical
certificates.
For bookings, call 131 757 limited advertising space available.

AVMED
Alcohol and other drug testing

C
BY BRENDA CATTLE
ASA is about to introduce regulations for a drug and alcohol testing

program. The random testing
program aims to raise awareness in the
aviation sector of the potential safety
impact of alcohol and other drug use.
Evidence shows that there are substances
which may affect people in performing
their duties and cause risk to themselves,
or the general public.
The random testing program is basically the auditing/assessment part of a
much broader program covering safetysensitive activities within aviation. CASA
and industry are working together on the
broad program, which includes education
and awareness; employee assistance; and
rehabilitation and return to work.
Random testing - FAQs

What substances will be tested?
The active component of cannabis:
delta-9-tetrahydrocannabinol (THC)
Amphetamines and amphetamine type
stimulates, including methylamphetamine, also known as goey, speed, ice and
crystal meth and methylenedioxymethylamphetamine (MDMA), commonly
known as ecstasy
Benzoylecgonie, the major metabolite
of cocaine.
Opiates, which can be found in heroin,
morphine and codeine. Over-the-counter
cold and flu medication/cough mixture
and pain relief medication both over-thecounter and prescription.
Alcohol
What are the permitted levels?
The testable drugs will be measured
against the target concentrations specified
in the Australian Standard 4760-2006.
For alcohol a concentration below 0.02
gms of alcohol in 100 mls of blood (BAC
0.02%)
On who, when and where will testing be
conducted?
Any person present in any area, airside
48
or landside where safety sensitive aviation

activities are undertaken can be asked
to undergo a drug and/or alcohol test in
accordance with the regulations.
Testing will be conducted 365 days a
year, 24/7.
Testing will not be limited to metropol-
itan and major regional centres.

How will the testing work?
An independent authorised collector can
ask for an oral fluid sample for drug testing
and/or a breath sample for alcohol testing.
Brenda Cattle is manager of CASAs AOD
testing program.
Alcohol Testing
Other Drug Testing
All testing will be conducted with

privacy a primary consideration.
All testing will be conducted with

privacy a primary consideration.
The donor will be asked to provide a

measured breath sample.
The donor will be asked to collect a

measured sample of oral fluid onto the
device provided.
A positive or negative result will be

known almost immediately.
If the test is negative you will able to
continue on with your duties.
If the test is positive you will be
required to wait with the authorised
collector for 20 minutes before providing a second confirmatory sample.
If the confirmatory test is negative, a
negative test result is recorded and
you can continue on with your duties.
On a positive result being confirmed
you will asked to cease safety sensitive work until you are authorised to
return to it.
The screening for the presence of

any of the target drugs takes approximately five minutes.
If the test is negative, you will able to
continue on with your duties.
If the test is positive, you will be
required to be observed while the
sample is split and the specimens
then sealed for security. Both these
samples will be sent to a laboratory
for confirmatory analysis.
You will then be asked to cease safety
sensitive work until you are authorised
to return to it.
When the confirmed results are
known, one of CASAs Medical Review
Officers will contact the donor immediately to confirm the nature of the
positive result.
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ELTs (certified portable ELTs are suitable
for most aircraft). This would be consistent with the ICAO standards, and the
rules of most leading aviation countries.
CASA has initiated a project to develop
the proposed technical amendments.
Aircraft operators and flight crew should
be aware of the imminent changes and
prepare for the 406 MHz switchover.
More information is available on the
Australian Maritime Safety Authority
website at: http://beacons.amsa.gov.au/
Distress beacon changes

CASA WILL SOON amend regulations
governing emergency locator transmitters (ELTs). These devices are among the
most critical items a pilot can have in the
event of an accident.
When activated, they transmit a distress
signal which is detected by satellites (the
Cospas-Sarsat search and rescue system)
and other aircraft. The ELT can then be
located quickly, and accurately, to aid
in the search and rescue of a distressed
aircraft, especially in remote locations
and/or inhospitable terrain.
At present, ELTs in Australia must be
capable of transmitting on the frequencies 243 MHz and 121.5 MHz. However,
beginning 1 February 2009, these beacons
will not be detected by the Cospas-Sarsat
satellite system. Instead, only ELTs that
transmit on the frequency 406 MHz will
be detected by these satellites.
These 406 MHz ELTs have been available for well over a decade. Recently their
availability and more competitive pricing
have significantly increased their accessibility to aviators.
Instrument rating renewals
From February 2009, it is an International Civil Aviation Organization (ICAO)

requirement that all aircraft are to carry
a 406 MHz beacon. CASA is of the view
that the advantages of 406 MHz ELTs,
and the impending satellite tracking and
processing restrictions from February
2009, means that it is desirable Australian
registered aircraft be fitted with 406 MHz
CASA HAS RECENTLY amended rules

relating to instrument rating renewals.
Australian pilots can now renew their
instrument rating through an overseas
flight simulator training provider, subject
to certain conditions being met.
The rule changes were driven by the
recognised safety advantages of sophisticated flight simulators, and their advanced
training and checking capabilities. Most
of the simulators are overseas, and some
operators use them for proficiency checks
and refresher training. The training and
NEW VFR FLIGHT GUIDE - OUT NOW!

The fully revised and updated 2007 edition
450 pages of essential visual flight rules information.
Produced by CASA.
Contact Airservices Australia to place your order:
http://airservicesaustralia.com/store
visual flight ru
les guide
24-hour phone service 1300 306 630

fax 02 6268 5111
email publications.unit@airservicesaustralia.com
50
VERSION
2 J U LY 2 0
07
checking conducted through these facilities will now be recognised for counting
towards an instrument rating renewal.
The requirements for this method of
instrument rating renewal are contained
in Civil Aviation Order (CAO) 40.2.1 and
are supported by Civil Aviation Advisory
Publication (CAAP) 5.14-1(0). Both can
be found in notice of final rule making
(NFRM) 0710OS on the CASA website:
www.casa.gov.au/newrules/ops/f ltsim/
nfrm0710os.htm.
English language proficiency

IN LINE WITH ICAO standards and
recommended practices, CASA is introducing English language proficiency
requirements for flight crew. A Notice
of Proposed Rule Making (NPRM) was
published in November 2007 to attract
responses from industry on the proposed
rules. Comments to this NPRM closed in
11 January
The proposed rules would require
flight crew of aircraft to be assessed for
their competency in speaking English.
However, pilots who hold licences prior
to 5 March 2008 will not be affected by
the new ICAO Standard if they are only
involved in domestic operations.
International pilots, and pilots who
apply for a pilot licence after 5 March
2008, will be required to be assessed on
their ability to speak English.
To find out more about the new rules, visit
the CASA website at: www.casa.gov.au/fcl/
language/index.htm
Fatigue risk management

systems (FRMS)
CASA will soon introduce rules which
permit operators to control their own
fatigue risk management system (FRMS).
This will give relief from the prescriptive
requirements contained in CAO 48.
It is proposed to withdraw all exemptions to CAO 48, and amend the existing
CAO 48 to limit the potential for fatiguerelated performance impairment arising
from hours of service.
The preferred method of fatigue
risk management is an organisationalmanaged FRMS. However, operators
will have the option of a revised CAO 48
prescriptive duty time rule set.
CASA appreciates that many operators already have in place comprehensive
procedures to ensure their employees
are effectively rested to combat fatigue
sustained in the workplace and in their
personal lives.
As a minimum, an FRMS must consider
the impact of:
sleep opportunity provided by rosters;
sleep obtained by personnel to indicate
fitness for duty
hours of wakefulness sustained by
personnel
circadian influences
sleep disorders
operational demographics (e.g. type of
task, environment, aircraft, personnel, etc).
It is intended that, in the future, the
concept of FRMS be integrated into other
fields of the aviation industry including

air traffic control, maintenance organisations, cabin crew, etc.
To stay up-to-date with the projects progress, visit the CASA website at: www.casa.
gov.au/newrules/ops/OS0203.asp
Multi-crew pilot licence

A proposal to introduce a multi-crew
pilot licence (MPL) into the Australian
flight crew licensing system will soon be
published to invite industry comment. The
notice of proposed rule making (NPRM)
will detail the background and objectives
of the proposed licence.
It is proposed that the holder of an MPL
will be entitled to act as co-pilot of a multicrew certificated aeroplane for which he or
she holds a type rating. All other requirements that apply to flight crew apply to
MPL holders, such as having an appropriate medical certificate, instrument rating
and meeting recent experience and recurrent training requirements.
ICAO has established the MPL in Annex
1 of the International Convention on Civil
Aviation. The reason for the proposed
change to Australias safety regulations is
to provide a simple set of rules that establish the MPL in Australian legislation.
Once the MPL is established in legislation, training organisations will be able to
conduct training for the MPL and airlines
will be able to employ MPL pilots. Further
information on the proposed MPL is
available here:
www.casa.gov.au/fcl/multicrew/index.htm
GET BRIEFED BY CASA

Theres an easy, new way to get the inside story
on aviation safety regulation in Australia.
Its called the CASA Briefing.
The CASA Briefing is a monthly email newsletter that gives you uptodate information
on key regulatory issues, plus the latest in news from CASA.
If youre a pilot, engineer, aviation business manager
or active in aviation in any way you need the CASA Briefing.
Its quick to read, simple to get and its free.
For more information email:

peter.gibson@casa.gov.au
To subscribe just go to: http://www.casa.gov.au/corporat/casabriefing/subscribe.htm

AV-QUIZ
TEST YOUR AVIATION KNOWLEDGE
FLYING OPS
(d) 1.5% down
1. A single engine aircraft has

two wing tanks fuelled to
approximately a quarter
capacity in each tank. The
tank outlets are at the rear
inboard corner of each tank.
In a turning type takeoff
involving a left turn on to
the runway, there is a risk
of engine failure due to:
(a) fuel starvation if
the right hand tank was
selected
(b) fuel starvation if the left
hand tank was selected
(c) fuel starvation if
the engine has a float
carburettor
(d) a fuel pump running dry
if mounted on the left side of
the engine
4. You are intending to track

275(M) in an area where the
magnetic variation is 12E. If
the forecast wind (from the
area forecast) was 280/25
you would be expecting:
(a) left drift
(b) right drift
(c) no drift
(d) no drift and a headwind
2. According to ERSA the

threshold height of runway
29 is 3115 and that of
runway 11 is 3107. If the
runway is 1676 metres long
the average slope on 29 is
nearest to:
(a) 0.15% up
(b) 0.15% down
(c) 1.5% up
5. The area forecast

indicates that the cloud
above an aerodrome with
an elevation of 1500 FT
consists of SCT ST at
2000FT and BKN SC at
3000FT. The ceiling would
therefore be:
(a) 2000 FT
(b) 500 FT
52
3. Selecting carburettor heat

on a piston engine:
(a) makes the mixture richer
(b) makes the mixture leaner
(c) does not change the
mixture ratio
(d) makes the mixture leaner
only until the ice has melted
(c) 3000 FT
(d) 1500 FT
6. The QNH at a particular
aerodrome is 1010 HPA
and the elevation is 300 FT.
Before starting the fuel
injected piston engine on
your aircraft you notice
that the manifold pressure
gauge reads 29 In Hg. In the
circumstances the gauge
is:
(a) over reading which could
result in the engine being
over-boosted
(b) over reading which could
result in the engine being
under-boosted
(c) under reading which
could result in the engine
being over-boosted
(d) under reading which
could result in the engine
being under-boosted
7. Human balance is provided
by organs in the:
(a) middle ear
(b) inner ear
(c) eustachian tube
(d) outer ear
8. To equalise the pressure

across the ear drum during
a descent, air flows, via the
eustachian tube:
(a) into the middle ear
(b) from the middle ear
(c) into the inner ear
(d) from the inner ear
9. In instrument flying, the
leans is induced:
(a) turning at more than rate
one
(b) banking too quickly
(c) correcting a banked
situation that was
previously sensed but
temporarily ignored
(d) correcting a banked
situation which was
previously not sensed
10. An illusion where, on a dark
night without background
lighting, a point source of
light appears to be moving
is termed:
(a) somatogravic illusion
(b) hypsometric tinting
(c) autokinesis
(d) tunnel vision
MAINTENANCE
1. When changing a battery
installation from lead
acid to NiCd the voltage
regulator setting:
(a) will require changing
(b) is usually sufficiently
within tolerance
(c) is the same for both
types
(d) will require reducing to
14.7VDC
2. Lead acid batteries, other
than dry charged, should be
stored:
(a) without electrolyte and
fully discharged
(b) without electrolyte and
fully charged
(c) fully discharged
(d) fully charged and with
the correct electrolyte level
3. When a failure within an
Aexhaust heat exchanger
allows exhaust gases to
enter the cockpit, loss of
consciousness by the pilot
and passengers can occur
because the fumes entering
the cabin contain:
(a) carbon dioxide which
reduces the ability of the
blood to carry oxygen
(b) carbon dioxide which
induces hyperventilation
(c) carbon monoxide which
reduces the ability of the
blood to carry oxygen
(d) carbon monoxide which
induces hyperventilation
4. Ethylene dibromide is a
compound that is added:
(a) to hydraulic oil to inhibit
corrosion
(b) to engine oil to minimise
frothing
(c) to fuel to raise the
octane rating
(d) to fuel to convert lead
deposits to a form that may
be scavenged more easily
5. The type of piston engine
fuel injection system that
employs an engine-driven
constant displacement
pump:
(a) uses airflow variables to
meter the fuel
(b) provides an output
pressure which is
independent of the fuel inlet
pressure
(c) provides an output
pressure which is
proportional to engine
speed
(d) must always be set to
idle cut-off for starting.

6. Fuel nozzles used with
turbocharged piston
engines have shrouds
around the air screen which
are connected to the:
(a) turbocharger side of
the throttle valve to ensure
that the air pressure on
the outside of the screen
is always higher than the
manifold pressure
(b) turbocharger side
of the throttle valve to
compensate for altitude
(c) induction manifold to
prevent fuel being forced
through the air screens
(d) induction manifold to
compensate for altitude
7. A thermocouple type
cylinder head temperature
gauge:
(a) does not rely on the
aircraft electrical system
(b) requires a DC supply
(c) requires an AC supply
(d) can use either a DC or
AC supply
8. A wooden spar shaped as
an I beam is routed out in
the centre to:
(a) distribute the bending

moment of the spar
(b) reduce the weight
(c) reduce the compression
of the top fibres when the
spar is in upward bending
(in flight)
(d) reduce the tension on
the bottom fibres when
the spar is in downward
bending (on the ground)
9. Flux is used during welding:
(a) as a catalyst to the
melting process
(b) to remove oxides or
prevent oxides from forming
(c) to reduce the carbon
content in the weld zone to
reduce brittleness
(d) to reduce hydrogen
embrittlement
10. If the air pre-charge
pressure on a hydraulic
accumulator was 1000
PSIG, the pressure on the
air side of the accumulator
when the system was
charged to 3000 PSIG would
be:
(a) 1000 psig.
(b) 2000 psig
(c) 3000 psig.
(d) 4000 psig.
AV-QUIZ
I F R OPER ATIONS
CAIRNS RWY 33 LLZ
APPROACH (PLATES DATED
24 NOV 05 AND 16 MAR 06)
You are inbound to Cairns
(YBCS) on the 187 radial
tracking via Totty,
currently maintaining 9000
in cloud. Your aircraft type
is a Cessna 310 (category
B aircraft). Part of the CS
ATIS reads:
4. Which of the following is

correct concerning the
distance reference for this
approach?
(a) CS DME 113.0, CS LLZ
109.5 or TSOd GPS
(b) CS DME 113.0, TSOd
GPS only
(c) CS DME 113.0, CS LLZ
109.5 only
(d) CS DME 109.5 only
RWY 33 wet, wind 360/20

visibility 6000, cloud BKN
1000
You are advised by CS ATC
to expect the RWY 33 LLZ
approach and to track via
the 24 DME ARC, descend to
6500 when established on
the ARC. You acknowledge
this and brief the approach.
The following questions
relate to this approach.
1. What is the title of the
correct approach plate to
use?
(a) RWY 15 ILS or LLZ with a
circling approach to land
(b) RWY 33 LLZ-Y
(c) RWY 33 LLZ-Z
(d) RWY 33 LLZ
Once established on the 24

DME ARC you descend to
6500. Your NAV 1 is tuned
and identified on CS LLZ
109.5, NAV 2 on CS VOR
113.0 and ADF (fixed card)
on CS NDB 364. At the lead
in to intercept the LLZ your
HDG is now 065M.
5. Which of the following are
the correct indications on
the navigation equipment at
the lead in?
(a) NAV 1 half scale CDI
right; NAV 2 CDI centred
TO with 334 selected on
OBS; ADF 334R
(b) NAV 1 CDI full scale
2. What is the title of the

correct approach plate
if you were operating a
Hawker 800 (category C
corporate jet)?
(a) RWY 15 ILS or LLZ
(b) RWY 33 LLZ-Y
(c) RWY 33 LLZ-Z
(d) RWY 33 LLZ (one plate
for all categories)
You consider a lead in
distance to establish the
24 DME ARC and the initial
heading (assuming nil
wind) to turn onto.
3. What would be this initial
heading and what is the
tolerance in maintaining the
ARC?
(a) 277M 1nm
(b) 097M 1nm
(c) 097M 2nm
(d) 207M 2nm
54
FLIGHT SAFETY AUSTRALIA NOVDEC 2007

OBS; ADF 089R
(c) NAV 1 CDI half scale
FROM with 154 selected;
ADF 269 R
(d) NAV 1 CDI full scale
OBS; ADF 269R
6. The approach profile is
slightly steeper at 3.1
than the normal glidepath
profile:
(a) True
(b) False
7. In order to maintain a
stabilised descent path, at
what distance would you
commence descent and
what would be your rate of
descent for a groundspeed
of 110 kt?
(a) 24nm and 600fpm
(b) 22nm and 550fpm
(c) 22.4nm and 550fpm.
(d) 22.4 nm and 600 fpm
8. Where is the FAF. and what
is the nominal crossing

height at this fix?
(a) No FAF. since there is no
O.M. thus no crossing height
(b) 8 DME 1825 ft
(c) 5.4 DME 1800 ft
(d) 11 DME 2800 ft
9. What is the minima for this
approach?
(a) MDA 730 VIS 4.1 km
(b) MDA 730 VIS 5.0 km
(c) MDA 780 including 50 ft
P.E.C. VIS 4.1 km
(d) MDA 780 including 50 ft
P.E.C. VIS 5.0 km
10. Where is the MAPt
and what is the missed
approach track?
(a) 2.1 DME tracking the CS
VOR 040 radial
(b) At the MDA, tracking the
CS VOR 020 radial
(c) At 4.6 DME, tracking 020
for an intercept of the CS
VOR 040 radial
(d) At the MM, tracking 020
for an intercept of the CS
VOR 040 radial
ANSWERS
FLYING OPS
9. (d)
8. (b)
and LLZ scaling is per dot
1. (a) In the LH turn, fuel flows

to the outboard of the tank
away from the tank outlet.
10. (c)
9. (b)
6. (a) Typical glidepath is 3
10. (c)
7. (d) You need slightly more

than the usual 5 x groundspeed = RoD rule of thumb.
2. (b)
3. (a)
4. (b) track 275(m); forecast
wind is in degrees true so wind
is 268 (m) so right drift.
5. (d) ceiling is height above the
aerodrome of more that 4 OKTAS.
6. (c) QFE is 1000HPA and at this
pressure it should read 29.52 InsHg.
MAINTENANCE
IFR
1. (a) NiCd batteries generally

require a higher charging voltage.
All answers are obtained from

the relevant approach plate.
2. (d) recharging should occur
1. (b)
periodically to compensate for
2. (c)
discharge during storage.
3. (c)
3. (c)
4. (a) A separate DME can

be received when the LLZ
frequency is selected not
too common in Australia
4. (d)
5. (c)
7. (b)
6. (a)
8. (a)
7. (a)
5. (d) LLZ CDI will be hard

scale since the lead in is 5
8. (b) FAF. is correct, not FAP. since

LLZ is non-precision approach
9. (a) RWY 33 does not have HIAL
so visibility for landing takes this
into account i.e. no need for 900m
increase. Also no PEC. since not a
full ILS. AIP ENR 1.5-31 para 5.4.1
and AIP ENR 1.5-12 para 1.18.2
10. (c) 2.1nm is distance from
RWY 33 threshold, not the DME
a critical one to be aware of.
Imagine if there was no AOPA
Australian GA needs AOPA

and AOPA needs your support
Join or rejoin us now

www!aopa!com!au
Ph! "# $%$& $"$$
NOVDEC 2007 FLIGHT SAFETY AUSTRALIA 55
The Australian
Executive Director's Message
The ATSBs
international
engagement with
Indonesia
Most readers will know
that on 7 March last year, a
Garuda Boeing 737 overran
the runway at Yogyakarta
Airport at high speed and the
impact and subsequent fire
claimed 21 lives including
five Australians.
Within hours of the accident the
he Indonesian Government
requested ATSB assistance. Three senior aviation safety
investigators, led by an ATSB Deputy Director, departed
that evening to join Indonesian investigators to work
collaboratively on unravelling the events that contributed
to the accident. We also worked on the FDR and CVR in
Canberra.
The tragedy of the Yogyakarta accident set in train a
package of measures to assist Indonesia improve transport
safety. In the May 2007 Budget, the former Government
announced funding of up to $24 million over several years,
for various Australian agencies to provide assistance to
our Indonesian counterparts. The ATSB is playing a key
role in this program, and building on a long history of
engagement with Indonesias investigation agency, the
National Transportation Safety Committee (NTSC).
So far the ATSB has worked closely with the NTSC on both
the Garuda and AdamAir investigations supporting the
development of the NTSCs accident reports, and giving
technical assistance through the download and analysis
of flight data and cockpit voice recorders. The Bureau
has also commenced a series of long term placements
for Indonesian investigators to spend up to 12 months
completing specialist training and working with ATSB
investigators. That program will be extended to also
provide training in recorder analysis to support the NTSCs
aim of establishing its own recorder laboratory.
In December 2007 the ATSB hosted the first of a series of
human factors training courses in Jakarta. Human factors
are an integral part of modern transport safety investigations, and the ATSB has established a world-class
reputation in this field. Around 60 participants attended the
inaugural course in Jakarta, including NTSC investigators,
staff from Indonesias civil aviation regulator, and other
professionals involved in marine, road and rail transport.
Future activities will include a new course covering human
factors in the maintenance engineering environment and in
basic investigation techniques.
The Indonesian assistance package will help the ATSB
foster an even closer relationship with our colleagues in the
NTSC, and over time, will deliver real safety benefits for our
neighbour and travellers in the region.
Kym Bills, Executive Director
CFIT: Australia in context

1996 to 2005
ontrolled flight into terrain (CFIT) has

been identified as one of aviations
historic killers, claiming the lives
of more than 35,000 people since the
emergence of civil aviation in the 1920s.
Given the catastrophic nature of CFIT,
the international aviation community has
invested a considerable amount of time and
resources to prevent CFIT, particularly in
the commercial sector of the industry. Most
notable are the efforts made by the Flight Safety
Foundation through CFIT awareness and education,
and the introduction of terrain awareness technologies
such as the Ground Proximity Warning System and Terrain Awareness and
Warning System. Even though these measures have, directly or indirectly,
contributed to a reduction in the number of CFIT accidents involving
commercial jet aircraft since 1998, CFIT accidents remain a challenge.
An ATSB report published in late 2007 provided an overview of CFIT
from an international perspective, explored the initiatives introduced in an
effort to reduce CFIT, and examined CFIT in the Australian context.
A search of the Australian Transport Safety Bureaus (ATSB) aviation
safety database identified 25 CFIT accidents and two CFIT incidents in
the period 1996 to 2005. Of the 25 CFIT accidents, 15 were fatal accidents
resulting in 47 fatalities. General aviation accounted for the greatest
proportion of CFIT accidents, fatal accidents and fatalities. Only one CFIT
occurrence over the reporting period involved regular public transport
operations (VH-TFU, Lockhart River, Queensland, 7 May 2005), but
this accident accounted for nearly one-third of all CFIT fatalities. This
highlights the seriousness of CFIT accidents and the reason they remain
high on the agenda of aviation safety organisations worldwide.
In line with international experience, nearly two-thirds of CFIT accidents
and incidents in Australia occurred in the approach phase of flight, with
half of these during an instrument approach. Of the CFIT instrument
approach occurrences, 67 per cent involved a satellite-based instrument
approach. The prevalence of satellite-based approaches may reflect the
growing popularity of these types of approaches and a shift away from
the traditional terrestrial-based navigation aids. The data suggest that
there is scope to reduce CFIT further by implementing approaches with
vertical guidance (APV), which provide vertical guidance on approaches
much like precision approaches. This capability can assist pilots with
maintaining vertical and lateral situational awareness and hence, reduce
the risk of CFIT. Australian aviation authorities are currently investigating
options to provide APV.
Overall, when compared with the total number of accidents recorded
in the ATSBs database for the 10-year period, CFIT in Australia is a rare
event. However, should a CFIT occur, there is a high risk that it will result
in fatal injuries to the aircraft occupants. A continued focus on developing
preventative strategies is therefore warranted in an effort to reduce the risk
of CFIT further. !
56
!"#$%$&'()**+++,-.,,
Aviation Safety Investigator
he ATSBs final investigation report

into a Piper Chieftain accident near
Condobolin, NSW on 2 December
2005, resulting in four deceased persons,
confirms that the aircraft broke up during
flight when its structural limits were
exceeded in the vicinity of thunderstorms.
The Australian Transport Safety Bureau
report states that there was no indication,
either by way of emergency radio
transmission from the pilot, or in a change
in the altitude, track and speed of
the aircraft as recorded by radar,
that the flight was not proceeding
normally. Some minutes after the
pilot reported diverting left of track
to avoid weather, communications
with the aircraft were lost.
The absence of an on-board
recording device on the aircraft
prevented a full analysis of the
circumstances of the breakup.
However, while post-impact fire
damage limited the extent to which
some of the aircrafts systems,
including the fuel and electrical
systems, could be examined, wreckage
examination did not reveal any pre-existing fault or condition that could have
weakened the aircraft structure and caused
it to break up at a load within the design
load limit.
A line of severe thunderstorms crossed
the aircrafts planned track and were
the subject of a SIGMET (significant
weather advice) issued by the Bureau of
Meteorology. As the SIGMET information
did not meet the criteria for direct notification, it was not advised directly to the
pilot of the aircraft. The investigation
was unable to determine if the pilot had
obtained the SIGMET from any of the
range of pre and in-flight weather briefing
services available to the pilot.
Analysis of the prevailing weather

indicated that, immediately before the
accident, the aircraft was likely to have been
surrounded to the east, west, and south by
a large complex of thunderstorms. That
situation may have limited the options
available to the pilot to avoid any possible
hazardous phenomena associated with the
storms.
Although, as a result of a review of
Flight Information Service initiated in
contains recommendations to Airservices

Australia and the Civil Aviation Safety
Authority to review Australian procedures
with a view to minimising those
inconsistencies.
The circumstances of the accident are a
salient reminder to pilots of their responsibilities to request weather and other
information necessary to make safe and
timely operational decisions, and of the
importance of avoiding thunderstorms by
large margins.
Resulting from this investigation,
the ATSB made the following
recommendations to CASA and
Airservices Australia:
ATSB safety recommendation

R20070025
November 2004, Airservices Australia had

identified inconsistencies and ambiguities
in the provision of Flight Information
Service, including Hazard Alert procedures,
they were not assessed by the investigation
to be contributing factors to the accident. As
a result of its review, Airservices Australia
initiated changes to the Flight Information
Service and Hazard Alerts sections of the
Manual of Air Traffic Services and the
Aeronautical Information Publication to
improve future safety.
While not contributory to the accident,
the report identifies a number of inconsistencies between Australian SIGMET dissemination procedures and those contained in
International Civil Aviation Organization
(ICAO) documentation. The report
The Australian Transport Safety

Bureau recommends that the
Civil Aviation Safety Authority,
in consultation with Airservices
Australia, review the requirements
for the dissemination of SIGMET
information with a view to
minimising differences between air traffic
control procedures contained in the
Aeronautical Information Publication and
those contained in ICAO Doc.4444 and
ICAO Doc.7030.
ATSB safety recommendation

R20070026
Australian Transport Safety Bureau
Final ATSB investigation report on

Condobolin in-flight breakup 4-fatality accident
The Australian Transport Safety Bureau

recommends that Airservices Australia, in
consultation with the Civil Aviation Safety
Authority, review the requirements for the
dissemination of SIGMET information
with a view to minimising differences
between air traffic control procedures
contained in the Aeronautical Information
Publication and those contained in ICAO
Doc.4444 and ICAO Doc.7030. !
JANUARYFEBRUARY 2008 FLIGHT SAFETY AUSTRALIA 55

/01/1$&+++//2$/2,%+#3
Investigation
!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!
Loss of control
Loss of control
!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!"!
briefs
Occurrence 200600851
At about 1922 EDST on 16 February 2006,

the pilot of a turbine PZL-Warszawa-Ockie
M-18A, Dromader, registered VH-FVF, was
fatally injured when the aircraft impacted
terrain during fire-bombing operations
approximately 20 km south-south-west of
Cootamundra, NSW.
The aircraft was one of two fixed-wing
fire-bombing aircraft that were despatched
from Wagga Wagga to drop retardant on an
active fire area east of Mount Ulandra. At
about 1921, volunteer firemen working to
the west of the fire area saw the Dromader
and although they could not recall the
sound of the aircraft, they reported that
there was no unusual noise or change to
the noise level to attract their attention. The
pilot was an experienced agricultural pilot
with previous fire-bombing experience.
Although he had considerable flying
experience on radial-engine Dromader
aircraft, and in other turbine agricultural
aircraft, his total flying experience in the
modified turbine Dromader was 4.7 hours.
Prior to commencing fire-bombing duties
two days before the accident, the pilot had
not recorded any fire-bombing flights in
the previous 3 years. The pilots limited
familiarity with the handling characteristics
of the modified and heavily-loaded aircraft
might not have allowed him adequate
recognition of an impending stall. The pilot
had not jettisoned the load of retardant
when the aircraft stalled. The ensuing loss
of control occurred at a height that did not
permit recovery before the aircraft collided
with the ground. The possibility that the
pilot was distracted by a problem with the
operation of the fire doors or some other
activity could not be determined.
Subsequently, the state fire authority
reviewed its minimum pilot experience
levels for aerial fire suppression. The
minimum aircraft type experience for
fire-bombing pilots was made more specific
to the type of aircraft. It also introduced
a recency requirement for fire-bombing
operations. !
On 1 September 2006, at approximately 1100 WST, the pilot of a Cessna

C172L aircraft, registered VH-RIL, was
conducting a private, visual flight rules
(VFR) flight, and together with four
passengers (two adults, one child and an
infant), departed from Bronco, a cattle
mustering area on Mt Vernon station, WA.
The pilot was to fly to the homestead on
the property, a flight of approximately
10 minutes duration.
At the same time, members of the pilots
family and station staff left Bronco in
motor vehicles to drive the approximately
30 km journey back to the homestead. Upon
their arrival, it was noted that the aircraft
had failed to arrive at the homestead. After
attempts to contact the pilot by radio
failed, a search was conducted, during
which the pilot and child passenger were
found walking towards the homestead. The
pilot, who was disorientated and injured,
reported that the aircraft had crashed
in bushland adjacent to the homestead
airstrip. The child had minor injuries.
After obtaining general directions to
the aircraft, the search party were able to
locate the aircraft wreckage. On arrival,
searchers found a female adult passenger
semi-conscious with extensive injuries.
The male adult passenger and the infant
had been fatally injured.
The pilot and female passenger reported
that the aircraft had entered severe
turbulence during the descent to land,
which resulted in a near-vertical nose
down attitude of the aircraft approximately 300 to 350 feet above the terrain.
The investigation determined that the
pilot had most likely flown through a strong
willy-willy and was unable to recover from
the in-flight upset. The investigation also
found that it was likely that inadequate
restraint of some occupants increased the
severity of injuries sustained. !
56 FLIGHT SAFETY AUSTRALIA JANUARYFEBRUARY 2008

58 FLIGHT SAFETY AUSTRALIA JANFEB 2008
!"#$%$&'()**+++,-.,/
Reporting trends in airline

operations
The reporting of aviation safety

occurrences enables the ATSB to
investigate accidents and incidents, and
monitor safety. On 1 July 2003, reporting
obligations changed with the introduction
of the Transport Safety Investigation Act
2003 (TSI Act). For the first time, the
types of occurrences that need to be
reported to the ATSB were prescribed.
These occurrence types are defined as
either immediately reportable or routine
reportable matters (IRMs and RRMs,
respectively). A research report released by
the ATSB in December examined trends in
IRMs involving regular public transport
(RPT) operations.
The study examined the period from
mid 2001 before the introduction of the
TSI Act to mid 2006. The results indicate
that despite an increase in RPT activity,
the number of IRM occurrences remained
stable or declined. When measured in
relation to airline activity, the trend rate
was generally downwards.
Violations of controlled airspace
reduced over the period while occurrences
involving a fire, explosion or fumes
and crew injuries or incapacitation also
decreased, but only marginally. Other
IRM categories such as contained engine
failures and fuel exhaustion were rare, or
absent. The exception was breakdowns of
separation (BOS) and airprox events, where
occurrence numbers went up. However,
when measured in terms of rate, BOS
and airprox events were relatively stable,
suggesting that the increase was largely
linked to increased activity. Accidents
were extremely rare. Only one accident
involved fatalities, with the loss of all 15
people on board a regional airliner near
Lockhart River. All other accidents were
limited to damage to the aircraft, or injury
to crew or passengers.
This study highlighted the value of a
strong reporting culture and provided
encouraging data concerning safety trends
in Australian airline operations. !
Collision with terrain
Crew incapacitation
On 8 August 2006 at 1115 EST, a Cessna

Aircraft Company model 182P aircraft,
registered V
VH-WNR, departed Archerfield
Aerodrome
Aerodrome, Qld, on a private flight to
Goondiwin
Goondiwindi, Qld. The pilot was the only
person on board. A few minutes after
takeoff, an internal mechanical failure
caused a su
substantial loss of engine power.
At 1121, th
the pilot transmitted a distress
message to air traffic control that he was
attempting an emergency landing and that
th
i
f engine had failed. At that
the aircraft
time, the aircraft was approximately 5 km
west of Archerfield Aerodrome at about
1,000 ft above ground level. He attempted
to position the aircraft for a landing in
the only area he could see that appeared
suitable for an emergency landing. Ground
witnesses saw a thick stream of white
smoke emanating from the right side of
the engine.
On 21 February 2006, a Robinson

Helicopter Company R44 Astro helicopter,
registered VH-HBS, was being operated
on a series of aerial survey flights approximately 100 km to the north of Mt Isa
Airport, Qld. The helicopter was operating
from Gunpowder airstrip and had
completed three flights by 1254 EST. The
pilot refuelled the helicopter and at 1341
departed for a survey flight with three
passengers on board. When the helicopter
did not arrive at a pre-arranged rendezvous
point, a search was initiated. Searchers
found the burnt wreckage of the helicopter
the next day. The four occupants were
fatally injured.
The helicopter had impacted the ground
with significant force in a nose-down,
fuselage-level attitude. The main rotor
displayed evidence of low rotational
energy and coning. Other than impact
and fire damage, there were no identified
mechanical defects or abnormalities.
There was evidence that the engine was
rotating at impact, but the amount of
engine power being developed was not
able to be established.
The previous aerial survey flights were
reported to have included low speed flight
and occasional hovering. At the estimated
helicopter weight and the prevailing
air density, the helicopter did not have
the performance to hover at the survey
altitude, which was estimated to be about
1,000 ft above ground level. The investigation considered that the helicopter
probably descended contrary to the
pilots intentions, possibly influenced by
a partial engine power loss or downdraft,
and induced the pilot to apply collective,
which developed into overpitching and
ultimately main rotor stall.
The investigation found that the
helicopter was being operated at gross
weights that exceeded the specified
maximum take-off weight. The investigation also found that the operators
procedures did not provide a high level of
assurance that a relatively low time pilot
could conduct aerial survey operations
safely. !
A Boeing Company 767-300 aircraft,

registered VH-OGP, was being operated
on an overnight international passenger
flight from Nagoya, Japan to Cairns, Qld.
On board the aircraft were a pilot in
command (PIC), a copilot, seven cabin
crew and 162 passengers. The copilot was
the pilot flying for the sector and had just
completed a period of crew rest. The PIC
handed back the control of the aircraft to
the copilot at about 1600 UTC and got up
to go to the toilet. The copilot heard a bang
and turned to see the PIC had collapsed on
the cockpit floor. There was no response
from the PIC to the copilots questioning.
The copilot switched on the cockpit lights
and saw that the PIC appeared to be staring
into space and remained unresponsive.
The copilot then alerted the cabin service
manager to come to the flight deck.
At approximately 1650 UTC, the PIC
had recovered sufficiently to return to
the cockpit, where he remained for the
duration of the flight. A PAN call was
transmitted when the aircraft entered the
Australian Flight Information Region and
emergency services were placed on standby
for the aircrafts arrival and landing at
Cairns.
The aircraft subsequently collided with

powerlines before impacting the roof of
a house. It traversed the roof and came to
rest inverted a short distance from the rear
of the house. A fire began when leaking
fuel ignited. The pilot received serious
burns to his upper body. The aircraft was
destroyed by impact forces and fire. The
house sustained major structural damage
to its roof and two of the three occupants
received minor injuries.
Subsequent engine disassembly and
examination revealed catastrophic damage
to the engine related to the failure of
the number-5 cylinder connecting rod
assembly. Reduced connecting rod
pre-load, due either to insufficient
assembly torque, or excessive torque
producing permanent bolt stretch, was
considered the most likely reason for the
failure of the connecting rod assembly.
However, because of the consequential
damage caused by continued engine
operation, there was inadequate evidence
to directly support either failure mode. !
Engine failure
The PIC was subsequently examined

and cleared to return to flight duties by
a Designated Aviation Medical Examiner
(DAME). The DAME determined that
the PIC probably had been affected by a
gastro-intestinal illness that had previously
been experienced by members of the PICs
family. A Norovirus gastro-intestinal
disorder was prevalent in the Queensland
region at the time. !
JANUARYFEBRUARY 2008 FLIGHT SAFETY AUSTRALIA 57

0/101$&+++002$%203+#4
Repcon briefs
!"!"!"!"!"!"!
Australias voluntary confi

nfidential
denttial aviation
a
reporting scheme
REPCON is a voluntary confidential
reporting scheme for aviation. REPCON
allows any person who has an aviation
safety concern to report it to the ATSB
confidentially while protecting the reporters
identity. REPCON can issue a For Your
Information notice or an Alert Bulletin
to the relevant organisations that can
take action to address the safety concerns
outlined in the de-identified report. This
can also include providing the de-identified
report to the investigator in charge (IIC)
of a current ATSB investigation. From the
commencement of the REPCON scheme,
three REPCON reports have been provided
to the ATSB to investigate or help with an
ongoing investigation. One such report has
been included in this article (R200700072).
REPCON is keen to hear from you if you
have experienced a close call and think that
others may benefit from the lessons that
you have learnt.
Back tracking
R200700096
Report narrative:
Concerns have been expressed about
the safety of aircraft operated at Hoxton
Park Aerodrome during road works on
the airfield. Aircraft have been reported
backtracking along the main runway.
REPCON comment:
The aerodrome operator informed
REPCON that they believed the report
concerned taxiway works that had been
completed earlier in the month. Due to
the nature of the works, back tracking
was unavoidable. The works had been
carried out following planning and consultation with tenants on the airport and stake
holders. A consultation plan was developed
in accordance with the then Department of
Transport and Regional Services guidelines.
Also, a Method of Works Plan was developed
although not required by CASA. CASA
reviewed the plan and it was distributed to
all tenants. A NOTAM was issued notifying
of the works. The aerodrome operator also
allocated a works safety officer for the work
site. !
If you wish to obtain advice or further information on
REPCON, please visit the ATSB website at www.atsb.gov.au
or call REPCON on 1800 020 505.
60
Wing skin corro

corrosion
osion
ETOPS operations
R200700062
R200700072
Report narrative:
Wing skin corrosion was discovered on
two Learjet 45s operated by [operator].
The aircraft are about seven years old.
CASA was informed through the Service
Difficulty Report (SDR) system. The
SDR report stated: During scheduled
maintenance inspections of the wings, areas
of apparent surface corrosion were noted
on the external surfaces of the lower left
and right wings. Further investigation and
assessment of the affected areas indicated
that the corrosion removal process would
exceed the Structural Repair Manual limits.
Advice was sought from Bombardier Learjet
Engineering. Following extensive investigation and assessment by Bombardier, an
FAA-approved repair drawing detailing
corrosion removal and treatment, airworthiness limitations and supplemental
maintenance inspections, was issued. The
lower wing skins have been repaired in
accordance with the approved data, and the
aircraft returned to service.
REPCON comment:
The airframe manufacturer informed
REPCON that they were conducting their
own investigation to determine if there was
a fleet concern. The preliminary investigation indicates that this event is unique to
those two aircraft, which are not utilized in
the same way as the rest of the fleet. Prior
to operating in Australia, the aircraft were
operated by the same organisation overseas.
To date, REPCON has not received the
manufacturers final investigation report.
CASA provided further information that
the SDR system had only received the two
reported cases of wing skin corrosion in
this aircraft type; the two cases relate to
the Learjet 45s referred to in this REPCON
report. Both the aircraft involved had low
airframe hours and were operated in an
environment that was prone to corrosion.
CASA issued AWB 57-4 issue 1 on 13 July
2007 to notify operators of Lear 45 aircraft
to check for wing skin corrosion. CASA
assessed the SDR as requiring no further
action and the SDR was closed. !
Report narrative:
There have been multiple instances of the
Airbus aircraft being certified as ETOPS
capable while its APU was inoperative under
the Minimum Equipment List (MEL).
The Airbus Defect Deferral Guide
(DDG) which covers the MEL manual
and Configuration Deviation List, does
not mention the issue regarding ETOPS
capability when the APU is inoperative.
However, the company's ETOPS Manual
explicitly states that an inoperative APU
renders the aircraft non-ETPOS capable.
The reporter claims that the [operator]
has repeatedly put forward the interpretation 'if it is not specified in the DDG, it is
ETPOS capable' contrary to the company's
ETOPS Manual. These and other instances
of ETOPS Manual misinterpretation have
been discussed between LAMEs and the
operators safety department staff.
REPCON comment:
On the reporters request, REPCON
provided the de-identified information to
the IIC of a relevant ATSB aviation safety
investigation (No. 200704612). The investigation is continuing. The safety investigation Preliminary report is available on
the ATSB website. !
REPCON reports received
Total (29 Jan* to 31 Dec 2007)
117
Last quarter (1 Oct to 31 Dec 2007
28
What happens to my report?

For Your Information notices issued
Total (29 Jan* to 31 Dec 2007)
58
Last quarter (1 Oct to 31 Dec 2007)
15
Alert Bulletins issued

Total (29 Jan to 31 Dec 2007)
Last quarter (1 Oct to 31 Dec 2007)
Who is reporting to REPCON?#

Aircraft maintenance personnel
23.9%
Air Traffic controller
2.6%
Cabin crew
1.7%
Facilities maintenance personnel/ground crew
0%
Flight crew
23.9%
Passengers
Others+
6.0%
41.9%
* REPCON commenced on 29 January 2007.

# 29 Jan to 31 Dec 2007.
+ examples include residents, property owners, general

public.
58 FLIGHT SAFETY AUSTRALIA JANUARYFEBRUARY 2008

!"#$%$&'()*+)+,-*++.../&
%0121$&...03243%0.56
HUMAN FACTORS
New factor for CASAs Human Factors

CASAs new Manager,
Human Factors & Safety
Analysis, Ben Cook,
introduces himself, having
been in the position for four
months.
ike many of us who are passionate

about aviation, I grew up with a
keen interest in everything associated with it. In the early days, it was strapping into anything I could afford (gliders,
hang gliders and Cessna 152s) which led
to a career mainly involving instructional
and safety roles in both military and civilian operating environments. I succumbed
to the human factors (HF) bug in the early
90s, and have been fortunate to work
closely in recent years with both engineers and air traffic controllers (ATCs) in
formal human factors roles.
The International Civil Aviation Organization (ICAO) continues to identify
human error as the single most serious
threat to aviation safety. And if you are
reading this as a pilot and you think youve
got a difficult job, try spending some
extended time in maintenance and/or air
traffic control! Working closely with engineers and ATCs has provided me with a
very healthy respect for the challenges
they face.
According to James Reason and Alan
Hobbs (world renowned experts in error
management), If an evil genius was set the
task of designing an area of activity most
likely to generate human error, it would
be closely aligned with those activities
associated with maintenance. (2000)
As a pilot, Ive often thought my job
was being made more difficult if there
was confusion with ATC which affected
my crew and aircraft. Looking back at my
time with ATC, one error from a single
aircraft (and often the ATCs strategic
picture involves many aircraft) can create

the need to modify their entire plan of
attack, causing increased workload and
requiring communications with multiple
aircraft to provide separation assurance.
And whilst you or I might fumble with a
simple data entry task and make corrections (e.g. updating a global positioning
system (GPS)), a similar type of error
from ATC can result in an immediate
stand down until the safety department
has reviewed the incident.
As it stands, the aviation industry in

most developed countries, including
Australia, has a fantastic safety record.
But the next few years remains a big challenge for all of us, particularly given the
unprecedented growth in the industry
and shortages of experienced personnel
(pilots, engineers and ATCs).
This is likely to place greater demands
on training systems to increase training
throughput (hopefully without detrimentally affecting standards), and for
HUMAN FACTORS
EXPECT TO SEE
US IN THE FIELD
ON A REGULAR
BASIS, PROVIDING
PRACTICAL SUPPORT
TO INDUSTRY, AND I
LOOK FORWARD TO
MEETING AS MANY
OF YOU AS POSSIBLE.
ground and the aircraft was shut down.

This individual is one of the most proficient and meticulous operators I know,
with exceptional levels of discipline and
strongly ingrained habit patterns. Unfortunately, the human factors associated
with the operational environment of the
time caught him out.
He had a number of other duties to
perform aside from the instructing, and his
workload was very high. On this particular
day, this meant he was running late for the
training exercise and his mind was still on
other things as he conducted his pre- flight
inspection. Additionally, the walk around
was interrupted through a further distraction that broke his normal habit pattern.
Whilst there was much embarrassment
at the time, the majority of us knew that
if this could happen to him, then it could
happen to any of us. On a positive note, the
factors contributing to the incident were
broadly disseminated providing safety
lessons to other personnel. I believe we will
see more incidents of this type due to the
increased pressures within our industry
and I believe in some cases organisations
and/or individuals will have to learn to say
NO when they do not have the resources
to perform their tasks safely.

So back to the human factors role
at CASA. The immediate priority of
our human factors team is to build and
strengthen internal and external working
relationships to ensure we stay in touch
with those issues confronting the industry.
As CASAs new Manager, Human
Factors & Safety Analysis, I believe our
team brings a strong operational focus
(soundly balanced through research and
academia) which sees us keen to translate
the academic aspects of human factors
into practical and tangible outcomes for
the benefit of the industry as a whole.
Lets face it: all of us, individuals, operators and CASA, have a common goal a
viable and safe Australian aviation industry.
And I did appreciate the advice I received
from CASA senior management when I
started: I dont want the CASA human
factors section to be a bunch of boffins
locked behind closed doors! So expect
to see us in the field on a regular basis,
providing practical support to industry,
and I look forward to meeting as many of
you as possible.
organisations to start doing more with

less. Some areas of concern from a human
factors perspective include the potential
for increased short cuts and operational
pressures to get the job done and higher
workloads/distractions and fatigue, all of
which will need to be monitored closely.
A number of organisations have also
recognised that the basic training schools
underpinning industry are critical in
providing support for this growth.
Not so long ago a friend
of mine, a very experienced
instructor (4000+ total hours)
walked around an aircraft (as
he had done hundreds of times
before) and forgot to remove
a wing tie-down strap. Other
ground personnel also missed
it. As the aircraft commenced
the taxi roll, he conducted a
check of the brakes as a normal
part of procedure.
Because the tie-down strap
was still connected to the
aircraft wing, just as he did this
check the aircraft nose yawed
to the right. This experienced
pilot, immediately believing there was a problem with
the brakes, made one further
check. More revs and further
yaw to the right. At this point
Out and about
the ground personnel realised
Meeting the locals in PNG when conducting an HF review of mountainous operations for 38SQN.
the wing was still tied to the
62
New Availa
prod ble no
w
uct
from
CAS
A
Global navigation satellite systems (GNSS)

Satellites have been guiding Australian pilots for more
than 15 years. Now technology has entered a new phase,
with CASA giving the go-ahead to receivers
that will revolutionise satellite navigation.
THIS PILOT PACK FROM CASA INCLUDES:
DVD GNSS overview video covering GNSS
technology, GNSS system architecture: errors
and limitations; augmentation systems; human
factors.
Booklet The science behind the technology,
human factors, GNSS IFR navigation approvals,
GNSS operation and requirements, warnings
and messages.
Global
Navigation
Satellite
Systems
Glo
Sat bal N
elli avig
te S ati
CIV
yst on
IL
AV
I AT
Ove ems
IO
The information in this package is for educational purposes only. It does not replace
ERSA, AIP, regulatory documents, manufacturers advice or NOTAMs, Operational
information presented should only be used in conjunction with current operational
documents. Pilots should refer to the relevant pilot operating handbook or flight manual,
as well as current operational documents.
SA
FE
TY
AU
Copyright CASA August 2006

www.casa.gov.au
Phone 131 757
Civ
rvie
w
TH
OR
ITY
DVD
il A
v
iat
ion
Sa
fet
y A
u
tho
rit
Sa
fet
y P
r
om
ot
ion
ORDER YOUR COPY FROM THE CASA ONLINE STORE: www.casa.gov.au
WHEN ENOUGHs
ENOUGH
If you believe the safety of an operation

is being compromised ...
CALL THE
CASA HOTLINE
1800 074 737

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Airmanship and safety tips from
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QBE asks some of Australias most experienced pilots to share their knowledge in the interests of safer flying.
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ISSUE NO. 60, JANFEB 2008

EDITOR, FLIGHT SAFETY AUSTRALIA

LET IT BE ... SOMEBODY ELSE!

You wouldnt wish this on anyone...

NEW FACTOR FOR CASA

Changed your address?

Ben Cook, CASAs new Manager Human Factors &

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SDRs ... TO LODGE OR NOT TO LODGE?

SELECTED SERVICE DIFFICULTY REPORTS

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expressed in this publication are those of the authors, and

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Copyright 2008, Civil Aviation Safety Authority,

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