CASA Flight Safety Mar-Apr2012

85
MarchApril 2012
The learning curve | Training for the future Change in the air | ADS-B and airspace reform
HOW TO BUILD THE IDEAL AVIATION PROFESSIONAL
Last year, the series targeted those in rural and regional areas the 2012 series will feature six metropolitan venues across Australia. CASA supports the continued operation of ageing aircraft, as long as it can be done safely. Come and hear the experts, who will be appearing at the following seminars: Date 17 March
10am-1pm
City Perth Sydney Darwin Melbourne Brisbane Adelaide
28 April
10am-1pm
12 May
10am-1pm
26 May
10am-1pm
2 June
10am-1pm
16 June
10am-1pm
Venue Convention & Exhibition Centre 21 Mounts Bay Road Waterview Bicentennial Park Australia Ave, Sydney Olympic Park Crowne Plaza 32 Mitchell St Convention & Exhibition Centre 1 Convention Centre Place South Wharf Convention & Exhibition Centre Cnr Merivale & Glenelg Streets South Bank Hilton Adelaide 233 Victoria Square
Venue space is limited, so bookings are essential and strictly on a first-in, best-dressed, basis. To secure your place, please go to www.casa.gov.au/ageingaircraft and complete your booking online. Please bring your booking reference to the seminar.
Issue 85 | MarchApril 2012
CONTENTS
08
40 FEATURES
08 The learning curve
Aviation training issues and trends
58 REGULARS
02 Air mail Flight bytes
Aviation safety news
20 New SMS kit on its way

CASAs new safety management systems resource kit
16 ATC Notes
News from Airservices Australia
22
22 New thinking on old aircraft

Ageing Aircraft Management Plan update
18 Accident reports
18 International accidents 19 Australian accidents
24 Change in the air

ADS-B and airspace reforms
31 Airworthiness section
34 SDRs 39 Directives
28 New year, new look

AvSafety seminars for 2012
46 Close calls
46 Scud running 48 Born to fly 50 Not very happy returns
30 Lift-off
The dynamics of flight: how the media took flight with an old story
52 ATSB supplement
News from the Australian Transport Safety Bureau
31 The trouble with cables

The importance of cable maintenance
66 Av Quiz
Flying ops | Maintenance IFR operations
40 Fishing for chips

New data recovery methods from modern electronic devices
70 Calendar
Upcoming events for March-July
44 Sharing the skies

A new occasional series begins with a look at ballooning
71 Quiz answers 72 Coming next issue Product review

OnTrack
58 An unnecessary tragedy
Colgan Air Flight 3407
62 The cabin connection

Training cabin crew members
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AIR MAIL / FLIGHT BYTES Aviation safety news
AIR MAIL
The Jan-Feb issue of Flight Safety Australia featured an article on fuel management and various pitfalls. I have a problem, but one with a twist. In 1979 I was flying our homebuilt Pitts S1 VH-SIE when training at Murray Bridge prior to the Australian Aerobatic Championships. None of the Pitts owners had starters fitted; they had been removed to lighten the aircraft. I checked my fuel with my dipstick. There was a quarter of a tank ample I thought for a 15-minute aerobatic flight. One of the first manoeuvres was a vertical climb followed by a stall turn, but I was not as far as the stall turn when the engine quit. I got the nose down immediately, hoping that my speed would turn the engine over, but I was too low to gain sufficient speed to turn over the engine and I had to plan an emergency landing. I had been practising over the cross strip so I did a steep approach, turned onto finals and side-slipped down to a rather bumpy landing. I left my aircraft there and went into the clubhouse for a cup of coffee. After the coffee I returned to my Pitts with another AAC member and strapped myself in. The other member gave one pull and my engine fired. I took off and did one circuit to steady my nerves. This was a valuable lesson for other Pitts owners and for me. A quarter tank of fuel was unusable when vertical. I later fitted a header tank that only had about three litres of unusable fuel when vertical, but this was OK since it held about 12 litres in total. Hilton Selvey
Director of Aviation Safety, CASA | John F McCormick Manager Safety Promotion | Gail Sambidge-Mitchell Editor, Flight Safety Australia | Margo Marchbank Writer, Flight Safety Australia | Robert Wilson Sub-editor, Flight Safety Australia | Joanna Pagan Designer, Flight Safety Australia | Fiona Scheidel ADVERTISING SALES Phone 131 757 | Email fsa@casa.gov.au Advertising appearing in Flight Safety Australia does not imply endorsement by the Civil Aviation Safety Authority. CORRESPONDENCE Flight Safety Australia GPO Box 2005 Canberra ACT 2601 Phone 131 757 | Fax 02 6217 1950 | Email fsa@casa.gov.au Web www.casa.gov.au CHANGE OF ADDRESS To change your address online, go to www.casa.gov.au/change For address change enquiries, call CASA on 1300 737 032. DISTRIBUTION
Bi-monthly to 89,730* aviation licence holders, cabin crew and industry personnel in Australia and internationally.
CONTRIBUTIONS Stories and photos are welcome. Please discuss your ideas with editorial staff before submission. Note that CASA cannot accept responsibility for unsolicited material. All efforts are made to ensure that the correct copyright notice accompanies each published photograph. If you believe any to be in error, please notify us at fsa@casa.gov.au NOTICE ON ADVERTISING The views expressed in this publication are those of the authors, and do not necessarily represent the views of the Civil Aviation Safety Authority. Warning: This educational publication does not replace ERSA, AIP airworthiness regulatory documents, manufacturers advice, , or NOTAMs. Operational information in Flight Safety Australia should only be used in conjunction with current operational documents. Information contained herein is subject to change. Copyright for the ATSB and ATC supplements rests with the Australian Transport Safety Bureau and Airservices Australia respectively these supplements are written, edited and designed independently of CASA. All requests for permission to reproduce any articles should be directed to FSA editorial.
Copyright 2012, Civil Aviation Safety Authority Australia.
FLIGHT BYTES Phone payments ceasing for medicals

In order for the Permissions Application Centre to have consistency across applications coming into CASA, phone payments for medicals will cease as of close of business, 16 March 2012. From Monday 19 March, all medicals will need to have the payment slip completed and attached to the medical received from the DAME.
RegisteredPrint Post: 381667-00644. Printed by IPMG (Independent Print Media Group) ISSN 1325-5002.
*latest Australian Circulation Audit Bureau figures Sept 2011
This magazine is printed on paper from sustainably managed forests and controlled sources Recognised in Australia through the Australian Forestry Standard
Flight SaFety auStralia Issue 85 March-April 2012
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2011 a safer year in the skies

The Aviation Safety Network (ASN) has described 2011 as a very safe year for civil aviation: the second safest year by number of fatalities and the third safest year by number of accidents. The year also marked the longest period without a fatal airliner accident in modern aviation history. In 2011, the ASN recorded a total of 28 fatal airliner accidents, resulting in 507 fatalities and 14 on-ground fatalities. This number of fatalities is lower than the ten-year average of 764. The worst accident happened on 9 January 2011, when an Iran Air Boeing 727 crashed on approach to Orumiyeh, Iran, killing 77 people. The number of accidents involving passenger flights was relatively high, with 19 accidents as compared to the ten-year average of 16 accidents. Seven of 28 accident aircraft were operated by airlines on the European Union black list, as opposed to six of 29 in 2010. The E.U. added a total of nine airlines to the black list and removed three airlines, after they achieved improved safety records. In 2011, Africa showed a continuing decline in accidents: 14 per cent of all fatal airliner accidents happened there. However, the continent only accounts for about three per cent of all world aircraft departures. Russia suffered a very bad year, with six fatal accidents. The approval covers a Class 1 EFB running Type A and Type B software applications for electronic manuals and charts. The FAA requires crew members to secure or stow Class 1 EFBs not attached or mounted to the aircraft during critical flight phases. Those with Type B software, including dynamic, interactive applications, may be used, but must be secured and viewable during critical phases of flight and must not interfere with flight control movement. American Airlines pilots secure the iPad to the forward chart holder with an FAA-approved securing mechanism. American has carried out 777 flight evaluations using digital manuals, gathering thousands of hours and test points in the process. American Airlines is not the only commercial carrier to use iPads as EFBs, a practice that has proliferated in business aviation. Last spring, Alaska Airlines started issuing iPads to 1,400 pilots to replace paper manuals, largely as a weight and fuel-saving measure. British Airways is also distributing iPads to 2,000 senior cabin crew for customer service applications. In Australia, Qantas is in a staged trial of EFB. CASA has also convened an EFB industry working group with representation from the major players. A draft CAAP will be released shortly for public comment.
Electronic flight bag approval

American Airlines is the first carrier to allow pilots to use iPad tablet computers for digital charts and manuals in all phases of flight. The airline will use the iPad on its Boeing 777s as a Class 1 electronic flight bag (EFB), described by the FAA as a portable, commercial, off-the-shelf computing device that is not attached or mounted to the aircraft.
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FLIGHT BYTES Aviation safety news
Safety award presentation

At a recent ceremony, the 2011 Australasian Aviation Ground Safety Council (AAGSC) Safety Award was presented to Queensland Airports. They won the gong for producing a DVD for airside and landside manual handlers, showing ground handling operations from the perspective of both ramp and passenger services. The DVD also shows ground staff performing their roles, highlights ways in which they can improve their manual handling techniques, and explains the risks staff expose themselves to by not following good manual handling techniques. The DVD will be shown during the induction process for all new Queensland Airports staff, as well as helping to educate current staff about improved work practices and correct manual handling techniques.
Join the RAAF Association

Very few people engaged in general aviation are aware that they are eligible to join the RAAF Association. All you need is a keen interest in aviation. Here at the northwestern Tasmania branch, for example, we hold monthly meetings for general business; several commemorative dinners are held yearly, as well as BBQs and bus tours. There is also the pleasure of socialising with people of similar interests, writes Derek Padgett, northwestern branch committee member. Associate membership allows partners to join, making it family friendly. And your area of aviation expertise may also be valuable for volunteer work with such groups as the air cadets. For further details see http://www.raafa.org.au
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05
New ATM role for EASA

Patrick Goudou, executive director, European Aviation Safety Agency (EASA) speaking to Air Transport News in January, discussed the Agencys new role in overseeing air traffic management safety, previously the responsibility of Eurocontrol. We have the role of everything regarding safety, and its important to know that, because previously it was also Eurocontrol, which was taking care of safety, of ATM. Now this task has been transferred to EASA we now have under our umbrella all domains of aviation regarding safety. Goudou went on to explain that the time frame for implementing EASAs air traffic management responsibilities, would be the end of 2012, at which stage the agency will start working on real issues, because by then we will have all the regulatory framework in place.
Contemporary Air Safety Investigation

The 2012 Australian & New Zealand Societies of Air Safety Investigators (A/NZSASI) seminar will be held in Sydney at the Mercure Hotel, George Street, from 13 June. The seminar will include wide-ranging presentations and papers covering contemporary air safety investigation and air safety issues. This years seminar promises to be A/NZSASIs biggest and best, so save the date. There is still a limited number of positions available for papers and presenters, so if you would like to present a paper addressing contemporary air safety investigation and air safety issues, please submit an abstract and short bio to Paul Mayes by 14 March 2012, at ropadofelix@hotmail.com To register, go to http://asasi.org/seminar/rego_main.htm where you can download a registration form. You can make seminar hotel reservations directly with the Mercure, Sydney, George Street by email at H2073-RE05@ accor.com, or phone on 02 9217 6612. The hotel is offering a special rate of A$170 per night, but you need to book before 1 May to receive this rate. Quote the A/NZSASI seminar block code of ASA080611. For further information, go to http://asasi.org/anzsasi.htm
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FLIGHT BYTES Aviation safety news
RCAs now NCNs

CASAs regulatory oversight processes are changing, with a greater emphasis being given to effectiveness and clear guidelines for industry and CASA inspectors alike. One of these changes involves what were formerly known as Requests for Corrective Action, or RCAs. From 16 April 2012, RCAs will become Non-Compliance Notices (NCNs). While neither the substance nor the status of the notice has changed, the name change to NCN tells it like it is. It clearly shows recipients that CASA believes they have breached the regulations and are expected to take appropriate action to bring themselves back into compliance. Non-Compliance Notices also advise recipients to examine the underlying reasons why the identified breach occurred, and to take appropriate steps to rectify those underlying deficiencies.For more information, visit the CASA website at www.casa.gov.au/surveillance
US Senate Passes FAA Bill

A bill to speed the switch from radar to an air traffic control system based on GPS technology, and to open US skies to unmanned aircraft flights within four years, received final congressional approval on Monday. The bill authorises $63.4 billion for the Federal Aviation Administration (FAA) over four years, including about $11 billion toward the air traffic system and its modernisation. The system is central to the FAAs plans for accommodating a forecast 50 per cent growth in air traffic over the next decade. Most other nations already have adopted satellite-based technology for guiding planes, or are heading in that direction, but the FAA has moved cautiously. The United States accounts for 35 per cent of global commercial air traffic and has the worlds most complicated airspace, with a greater volume and more varied private aviation than other countries. Within nine months of the bills passage, the FAA must also submit their plan as to how they will provide military, commercial and privately-owned unmanned/remotely piloted aircraft (RPA) safe access to airspace currently reserved for manned aircraft, to fly in the same airspace as airliners, cargo planes, business jets and private aircraft.
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The FAA must then provide these RPA with expanded access to US airspace currently reserved for manned aircraft by 30 September 2015. Currently, the FAA restricts UAS/RPA use primarily to segregated blocks of military airspace, border patrols and about 300 public agencies and their private partners. Those public agencies are mainly restricted to flying small, unmanned aircraft at low altitudes away from airports and urban centres. Washington Post 6 February 2012
the aircraft flight manual, or approved flight manual supplement, or an approved placard in the aircraft, or the aircrafts type certificate, or type certificate data sheet. If you wish to take advantage of the exemption, not only must you comply with the above, but you must also ensure that: you operate your aircraft in accordance with the manufacturers or supplemental type certificate holders published operational limits and maintenance instructions where applicable, you correctly calculate and record weight related, time-in-service In some applicable aircraft types, if they are operated at MTOW above the baseline used to establish the service life of the aircraft, the increase in take-off weight results in increased fatigue effects and a consequent reduction in service life. you forward relevant information about the exemption to anyone involved in operating or maintaining your aircraft. If you have any queries about the exemption, please contact the manager of your nearest CASA regional office, at GPO Box 2005, Canberra ACT 2601, or phone 131 757.
New MTOW exemption

Previous maximum take-off weight (MTOW) requirements for aircraft operated in a restricted category, or used in aerial application operations, are now found in one exemption Exemption CASA EX01/12designed to clarify and simplify the MTOW requirements for applicable aircraft. If your aircraft is eligible under the exemption, and you wish to take advantage of it, then you must comply with the conditions stated in schedule 3 of the exemption, that is: There is no provision in the exemption to exceed whichever is the highest applicable MTOW specified in
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FEATURE Aviation training
ThE LEARNiNG CURvE

Training (and how best to do it) is one of aviations big questions. Flight Safety Australia examines some of the issues and trends involved
For aviation, the good times are back in sight. The GFC held it at bay; continuing economic uncertainty in parts of Europe and the United States is still having an impact, but the pundits agree forecast aviation growth will mean a shortage of trained personnel in the next decades. The International Civil Aviation Organization (ICAO), in its publication Global and Regional 20-Year Forecasts: Pilots. Maintenance Personnel. Air Traffic Controllers. (Doc 9956 Feb 2011), says the shortage will be especially critical in the Asia-Pacific region. No one learns to fly without some form of training. Its the law that no one can perform more than minor maintenance on a VH-registered aircraft without being specifically trained for it. And, with the exception of the children of a certain US controller, amateurs are banned from control towers. In aviation, as in society at large, the trend is towards spending more time in formal education and training. In Australia in the 1930s, for example, only seven per cent of 16-17 year olds were at school. In 2010, the Year 12 retention rate was 79 per cent. During World War I trainee pilots frequently flew solo after as little as three hours, and could be instructing new pilots after 20 hours. In World War II, about six hours to solo was not uncommon. Today, any solo in a general aviation aircraft before about 10 hours raises questions about whether all the necessary skills have been taught. Fifteen hours is now considered an appropriate time before first student solo. Cabin crew, who began in the 1920s with a role combining advertising, reassurance and food service, are now part of an airlines safety system and undergo intensive training in this
Pilot attrition comparison: 2010 - 2030

60 000 40 000 20 000 0 -20 000 Africa Asia/ Pacific Europe Latin Middle America East North America Training capacities Training needs Surplus Shortage
Graph adapted from ICAO report
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area. Engineers must now meet the challenges of rapidly evolving technology in materials, avionics and propulsion. Several common themes emerged as Flight Safety Australia spoke to pilots, engineers, academics, air traffic controllers and cabin crew about aviation training in its broadest sense. They were: the impact of supply and demand on training and safety standards, resilience, competency and experience, practical learning and theoretical or simulated learning, and the importance of continual learning.
While supply and demand is not the regulators bailiwick, the challenge for us as a regulator is that if a shortage occurs that theres no potential for any reduction in standards. We will need to be vigilant to ensure that does not occur. Weekss analysis is that, overall, pilot supply is squeezed by both boom and bust. During the GFC, flying schools closed down; for example, in the Sydney basin three or four closed, and our figures show a 38 per cent reduction in the number of instructors being trained. This level of infrastructure is not going to meet the increased training demand. I think what well see is two strong pathways in Australia, the traditional pathway of CPL, building your hours and approaching the airlines. Then theres the new cadet model, with Rex establishing an academy in 2008 and Jetstar recently establishing a program. We wont see the end of the standard direct entry model, but I believe we will see increased use of cadets, Weeks says, adding that cadet programs are not new, having been used by both Qantas and Ansett in the past and in widespread use internationally.
Supply and demand

The big issue is that were going to be facing another global pilot shortage, says Roger Weeks, CASA manager, flying standards branch. ICAOs global and regional forecast for pilots, maintenance engineers and air traffic controllers predicts the aviation growth rate is going to exceed four per cent per annum for each decade until 2030. It shows the Asia Pacific region will have the highest growth rate, with that regions fleet projected to grow by 9.1 per cent annually. By 2030, that region will equal North America in size. The most likely scenario, ICAO says, is a training deficit worldwide of about 8000 pilots, 18,000 maintenance personnel and 2000 air traffic controllers every year a grand total of 560,000 personnel over the next two decades. Couple that with the age demographics 30 per cent of pilots worldwide are aged over 50 in 15 years theyll be in their retirement phase. Were certainly going to see a major issue, which we got a taste of in 2007-08 before the GFC, when the industry at all levels was under significant pressure. Schedules were being curtailed and aeroplanes were being parked because there were not enough crews to fly them.
Resilience
The mystery of what makes the perfect pilot, engineer, controller or executive is summed up in one of aviations most celebrated clichs the right stuff. And, as with all clichs, it contains a grain of truth there appear to be attributes that define the best in each of these areas. But research suggests that the actual right stuff is different from the popular perception. In a study published in 2001, US Air Force psychologist Raymond E. King, and academics Paul D. Retzlaff and Daniel R. Orme compared pilot psychological profiles to safety outcomes.
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Their method was to examine the psychological assessments of air force pilots who had had accidents or incidents. They found: Pilots who had received high scores on subscales related to self-assurance and devotion to duty were 3.75 and 2.39 times, respectively, more likely to have pilot-error mishaps/incidents. No relationship was found between mishaps/incidents and orderliness, achievement striving, self-discipline, and deliberation.
And, you have to combine that lateral thinking with technical creativity to come up with an innovative solution to the problem, he adds. Rodd Sciortino, Airservices Australia ATC academy training manager, describes resilience in the ATC context as the ability to make solid decisions under intense time pressures. It also involves continual assessment of those decisions and a willingness to adapt or abandon them if necessary. Former air traffic controller, Peter Cromarty, is now CASAs executive manager of airspace and aerodrome regulation. He says humility is part of resilience. You need to be decisive, with the self-confidence to stand by your own judgement. But youve also got to be flexible enough not to die in a ditch to make a plan work. Youve got to be humble enough to change a plan if its not working, Cromarty says. Engineer Stuart Hughes, Australian managing director of human factors and safety management consultants, Baines Simmons, says confidence is essential. You need be able to say, Im not happy with the condition of this aircraft. This is not right. James Reasons analysis of resilience in The Human Contribution uncovers more paradoxes. Some of the examples he quotes, such as the crash of United Airlines Flight 232, or the Air Canada Gimli Glider, involve improvisation, while others involve disciplined application of basic principles, such as the by-the-book sang-froid of captain Eric Moody and the crew of British Airways Flight 9 when volcanic ash stopped all four engines over Java.
How then do you train for this flexibility and resilience?
While counter-intuitive, it may be that these traits represent a lack of flexibility of the pilots such that they are less able to meet novel demands in crisis situations, the authors wrote. They added a note of caution: alternatively, those with higher feelings of competence, particularly in this relatively inexperienced sample, may have over-stretched their ability. Or, perhaps pilots with these traits are more likely to report significant incidents that fall short of a mishap. These interpretations are preliminary; more cases need to be collected and analyzed. Their findings correspond with a 1991 study by Charles L. Lardent, who found that pilots who had been involved in a crash were more conscientious, on average, than those who had not been involved in a crash. Lardent mentioned unrealistically high standards and reluctance to quit, even in the face of adversity, as potential dangers of excessive conscientiousness. The flexibility mentioned in King and Lardents studies is similar to what Professor James Reason in his most recent book, The Human Contribution, calls resilience. It is the factor that allows pilots, engineers and controllers to recognise, reduce and recover from the mistakes that are an unavoidable part of being human. Former airline executive engineering manager, Mark Sinclair, is now CASAs executive manager of safety education and promotion. He says resilience is related to the ability to think laterally under stress. Its the capacity to join the dots and get to the real technical issue to understand that the problem is not necessarily what it appears to be.
Teamwork
How then do you train for this flexibility and resilience? Anthony Petteford, managing director of Oxford Aviation Academy, based at Moorabbin, says there is one factor that much pilot traditional training does not address: the ability to work as part of a team. This is essential for airline pilots, he says.
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An airline pilots is a highly sophisticated role. Its a specialist job thats not just about flying skills any more, he says. Its a team management activity involving high degrees of automation in a hostile, dense environment. An airline pilot has to be trained for the profession from the outset, and that training must be ongoing. You wouldnt train a doctor, dentist or lawyer to gain a basic qualification, and then go out into the world and work it out as they went along. Crew resource management is (or should be!) a well-known concept to commercial pilots, but Hughes says something similar is essential in the maintenance hangar. There needs to be communication between management and maintenance people, asking, how can we do this together? Too often there is a disconnect between the maintenance function and planning, leading to unrealistic deadlines, which compromise safety, he says. Dr Peter Bruce teaches aviation and aviation management subjects at Swinburne University in Melbourne. He argues that while pilots comprise probably 10 per cent of the aviation industry, the
concepts of CRM, safety management systems and human factors are essential knowledge for anyone working in aviation, whether they be baggage handler or chief executive. Swinburne aviation students, whether in the pilot or management streams, all study many common subjects including basic aeronautical knowledge and human factors in their first year, because we see it as an important part of the industry. Rodd Sciortino says close cooperation is central to the ATC system of aircraft being handed on from one sector to the next. One thing thats not negotiable is teamwork. Every controller looks after the aircraft in their airspace and they need to ensure they progress safely through that volume on to the next volume, he says. But Petteford says embracing the team approach raises further questions about potential gaps in training. Heres something that has really raised a flag; theres so much emphasis on the pilot flying. But do we really train pilots in the monitoring mode? What do we mean by that? he says. The question is as basic as where the pilot monitoring should be looking, Petteford says. Everyone understands youll be doing the radio, monitoring systems, navigation logs and so on; stuff that supports the pilot flying. But during the final phases of approach should you be placing greater emphasis on monitoring the primary flight display, on looking out, or on the engines? Where should your eyes be and what should you be doing? This is such a primary question that the UK Civil Aviation Authority has commissioned a research study into the matter. There are no answers yet, but I think theres an awareness that we may have followed a standard model for too long.
Oxford Aviation Academy - students in the briefing room
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Competency and experience

Well-publicised incidents involving Australian carriers and media interest have put pilot training in the spotlight. Some reporting has made much of the comparative lack of hours that some newly qualified airline pilots have when they first sit in the cockpit. Multi-crew licensing, which trains ab-initio candidates to take the first officers seat in an airliner, is now throughout Europe and Asia, but is not yet offered in Australia. In this country, airline cadets are trained from having little or no aviation experience to a direct first officer role. Some schemes, such as the Jetstar cadet program administered by Oxford Aviation Academy, offer an additional module of multi-crew cooperation (MCC) in their training. Petteford is aware that some in Australia, with its stronger GA sector than Europe, see Oxfords model as controversial. (Oxfords model has operated in Europe since 1964.) What were not saying, and what weve never said, is that you should completely rubbish other means of training, he stresses, provided that when pilots are trained for their licence qualification that the training they undergo is structured, good quality and that, ideally, they do not enter into it without being pre-assessed. Some people go in with predetermined ideas that were not teaching people to fly, but both our ab-initio ATPL and (overseas) MPL courses have a mandatory upset avoidance and recovery component. The primary emphasis is avoidance, not just recovery. Were trying to develop an intuitive thinking that they should constantly be evaluating threats and errors to avoid being upset in the first place. Flying instructor Steve Pearce, a holder of the Royal Federation of Aero Clubs Australia Master Instructor award, is among the voices that say nothing replaces time in command of an aircraft of any size. My personal view is that I want someone in the right-hand seat whos done the hours, the hard yards, and has the experience to draw on.
A thousand hours of flying may involve 1000 different flights or the same flight 1000 times the competency that results can be very different
Oxford Aviation Academy - King Air used for training
The concept of someone whos got the experience in the simulator, but not in the real world, is hard for me to get my head around. However, Petteford argues that structured ab-initio training can respond to safety trends in a way that individual pilots working their way through the informal progression system of night freight, charter and low-capacity regular public transport operations cannot do easily. During our second Flybe MPL course, the airline has asked us to increase the amount of handflying on instruments power plus attitude partly as a result of the Air France accident, he says, as an example. CASAs Roger Weeks says both experience and competency are necessary, but there is some exclusivity to the two. Experience doesnt necessarily guarantee competence and competency-trained low hours pilots are by definition inexperienced.
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Experience does count, but competency also counts, Weeks says. A thousand hours of flying may involve 1000 different flights or the same flight 1000 times the competency that results can be very different. However, Pearce firmly believes there is no substitute for command hours, regardless of type. Its in the subconscious, for you to draw on.
What is not as widely appreciated is how simulation is being applied to fields other than pilot training. Swinburnes aviation and aviation management students continue to encounter safety in the second and third years. The bachelor of aviation and bachelor of aviation management courses use an airline business simulation to teach airline management to senior students. They buy aircraft, set up route structures, schedules, and make decisions about fares, advertising, staffing, catering and seat configurations, Bruce explains. Swinburne aviation senior lecturer, Dr David Newman, says simulation teaches the relationship between safety and organisational culture in a way that classroom lectures cannot. The same things happen in simulation as in the real world. We get fare wars, mergers and alliances, requests for bailouts, he says. The simulation reinforces that safety underpins profit, he adds. Safety is an emphasis throughout the whole course and students are well aware of how the brand is affected by safety. If they dont do maintenance properly, the aircraft become unreliable and may crash. Then people wont travel with their airline, no matter how much they discount. Bruce continues: Through subjects like SMS, the course tries to prepare students to be aware of the safety systems and culture in aviation, not only in airlines but in airports, and the system overall. Newman adds, If you have a safety issue in a retail business, you might get a fine from the occupational health and safety authorities. But in the airline, a safety issue can threaten the viability of the business, not to mention people dying. Its a commodity-based business, selling seats; but its also volatile, dynamic, safety critical and very much in the public eye. Airservices Australia and its predecessors have used simulators for many years in ATC training, but Sciortino says they are now of a standard that can deliver highly sophisticated scenarios in high fidelity.
Practical vs simulation
The competency vs experience debate sometimes merges into a discussion of the merits of simulator vs real-world training. (Flight Safety Australia looked at this topic in When to Sim? November-December 2010.)
Top to bottom: Swinburne Universitys fixed-wing simulator; inside Swinburnes helicopter sim: Hong Kong at night; and on approach to Bankstown
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There are still the core competencies and things we need to instruct. Our tower visual simulator is a 360-degree simulator that can be loaded with any scenery in Australia, he says. Airservices also has a radar simulator and Eurocat en-route simulator.
Were in a learning environment for the whole of our careers. Part of lifelong learning is mentoring, which Pearce finds valuable because it often allows two-way learning: the teacher learning from the student as well. Im only ever a phone call away, he tells his former students. CASA director, John McCormick, emphasises the importance of contextual knowledge. If you say, Im going to be a pilot, that doesnt mean you never read anything again about general business or management. Youve got to have an understanding of how your occupation fits into the grand scheme of that, he said. Petteford says pilot training should not just be ongoing and set against regulatory minimum requirements; it should be tailored to a training needs profile (pilot and airline). One should take training records and evaluate the strengths and the potential threats/errors and use them as a means to tailor ongoing training design. Weeks says the key thing is to look at the big picture. Where are the accidents happening and what is being done to address these issues in training? Training for the big three killers: loss of control, runway in/excursions, and controlled flight into terrain should not just be the domain of airlines and air forces. This philosophy extends into the hangar, the office and the tower. Sciortino says the cycle of assessment and training in ATC is, in effect, continuous learning. I tell our students, Get used to being under scrutiny, whether it be with an instructor behind you every day for the next 15 months or, once you get your licence, having a check controller behind you every six months. Hughes says Good engineers ask themselves what can I learn next? You never stop learning.
Good engineers ask what can I learn next? You never stop learning.
[Simulators] were more rudimentary in the old days. In the 80s, the tower simulator was watching a slide show. The dot above the Mt Macedon range was meant to be an F-27 on final. Now we can press a button and create rain, low cloud, night or fog. We can thoroughly test the controller. Sciortino says the simulators allow an integration of theory and practice that was much more difficult in the days of classroom-only instruction. ATC trainees study in a sandwich structure beginning with theory, simulation, further theory, a second round of simulations and, finally on-thejob training under supervision. CASAs director of aviation safety, and former Cathay Pacific flying training manager, John McCormick, says simulators are good predictors of successful pilots. Piloting is first and foremost a psychomotor skill. If you cannot think and fly the aircraft at the same time you are in the wrong occupation, he says. When I look at my logbook of the pilots I checked in simulators, there is an absolute 100 per cent correlation between people who could fly the simulator well and those who went on to senior positions in the company.
Lifelong learning
Although there are some sharp differences of opinion about training there is one common point of agreement: it should never stop. All the experts interviewed stressed the importance of lifelong learning for anyone making aviation their career, or hobby. An American writer, Richard S. Drury, said were all student pilots until we retire, I think that sums it up perfectly, says Pearce.
15
CASA Training Centre

CASA is setting up a new training centre at its Brisbane offices, due to open in the second half of this year. The Centre, CASA executive manager education and safety promotion, Mark Sinclair, explains, is not teaching the basics of how to be a pilot or an engineer. Rather, its focus is squarely on helping to build a baseline of regulatory skills, so that CASA delegates, or key personnel in an aviation organisation, understand the core regulatory competencies associated with that function and know what we expect of them. At the Centre, people in key positions, such as accountable managers, safety managers, delegates, responsible managers, approval personnel (and those aspiring to be), will develop an understanding of their regulatory obligations, and the expectations CASA has of such roles. As we progress to the outcome-based style of legislation, organisations will have the ability to better self-manage, Sinclair explains. But at the same time, with that flexibility comes responsibility, and a certain required level of maturity. The Centre is about assisting key individuals in these organisations to develop that level of maturity.
NGAP
CASA flying training and education managers are contributing to ICAOs global effort to address the forecast shortage of aviation personnel, and build training capacity. ICAO is holding a series of regional conferences and global symposiums focusing on the issue, under the title of the Next Generation of Aviation Professionals (NGAP). The first NGAP symposium was held in Montreal in early 2011, followed by a round of regional conferences. The second symposium will be held in Montreal in April of this year (2012).
Online Human Factors training

Practical, cost effective and flexible Human Factors training for flight operations, engineering, cabin crew and ground handling.
For more information, visit www.hfts.com.au email info@hfts.com.au or phone 0412 542 859.
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18
date
ACCIdENT REPORTS International accidents | Australian accidents
International accidents/incidents 17 december 2011 26 January 2012

Aircraft Location
Mesquite Airport, Nevada, USA YogyarkartaAdisutjipto Airport, Indonesia Osh Airport, Kyrgyzstan, Kyrgyz Republic
Fatalities
0 0
damage
Substantial Substantial
description
Skydiving plane landed, skidded off the runway, crossed a road and slid down a slope into a golf course, stopping on its belly at the 17th hole. The pilot and passenger only suffered minor injuries. Passenger jet (first flight 1996), with 131 occupants, damaged in a runway excursion. The aircraft landed in strong rain, failed to stop, and veered onto the grass, where the RH main gear and nose gear collapsed. Several passengers were injured in the evacuation. The IJOG localiser for ILS approaches to the runway was NOTAMed out of use. Passenger jet (first flight 1979) landed hard in dense fog and rolled over, causing the right wing to separate. A fire erupted but was quickly contained. All six crew members and 19 of the 82 passengers were taken to hospital for medical treatment. Ultralight crashed killing the pilot and his son, who were observing the Dakar Rally. Helicopter came down in a field near a business park. Witnesses said they heard a bang and saw the helicopter plummeting to the ground from about 500ft, landing upside down and breaking into pieces. Pilot killed on impact. Balloon on a scenic flight clipped HT powerlines, caught fire and crashed, killing everyone on board. Madiba Bay School of Flight aircraft crashed, killing both occupants. Experimental aircraft crashed shortly after take-off when the engine failed while performing test take-offs and landings. Pilot killed. Aircraft crashed shortly after take-off, killing the 22-year-old pilot and his 13-year-old passenger. Aircraft crashed and caught fire on approach, 500 yards from North Spirit Lake Airport in a blinding snowstorm. Five people were on board. Helicopter used for herding deer was reported missing. Pilot and passenger found dead at the scene. Emergency crews began searching for the aircraft after the pilot reported smoke in the cabin and then lost contact with ATC. Helicopter clipped high-voltage cables and crashed near a highway, killing both occupants. Aircraft crash landed with no wheels. Helicopter crashed in rough weather in mountainous terrain, killing all five people aboard. Helicopter crashed into Wax Lake, killing the pilot and passenger. According to witnesses the pilot was performing aerobatic manoeuvres before the aircraft made a strange noise and crashed. During instruction in the landing phase, the pilot apparently performed a bad landing procedure and broke the National Police aircrafts tail cone. The vintage American-built fighter plane crashed after what was described as a technical malfunction, killing the pilot and co-pilot.
17 dec Cessna 208 Caravan 1 20 dec Boeing 737-36M
28 dec Tupolev 134A-3 1 Jan 6 Jan 7 Jan 7 Jan 8 Jan 8 Jan 10 Jan 11 Jan 15 Jan 15 Jan 16 Jan 18 Jan 19 Jan 23 Jan 24 Jan 26 Jan Ultralight Robinson R22 Beta Cameron-A210
Written off
Orense, Buenos Aires 2 Province, Argentina Witchford, near Ely, 1 Cambridgeshire, UK 11 2 1 2 4 2 2 2 0 5 2 2 0 2
Written off Written off Written off Written off Written off Written off Written off Written off Written off Written off Unknown Written off Written off Written off Minor Written off
Clareville, near Carterton, Wairarapa, NZ Cessna 150L Fyfergat Farm, near Uitenhage, Kruisrivier, South Africa Bowers Fly Jackson County Baby 1A Airport, Georgia, USA Cessna 152 Near EnghienMoisselles Airfield, France Piper PA-31-350 North Spirit Lake Navajo Chieftain Reserve, Ontario, Canada Robinson R44 Mosjen, Nordland, Raven II Norway Piper PA-24-180 St Landings Beach, Comanche near Brewster, Massachusetts, USA Robinson R22 San Liberato, Italy Mustang Whitianga Airfield, NZ Bell 206L-4 Long Auyantepui Mountain, Ranger IV Canaima National Park, Venezuela Robinson Wax Lake, Louisiana, R44 Raven II USA Yakovlev Timona Park, near Yak-52TW Feilding, NZ Robinson Villa Hayes, Chaco, R44 Raven Paraguay Grumman near Bushehr, Iran F-14A Tomcat
International accidents
Compiled from information supplied by the Aviation Safety Network (see www.aviation-safety.net/database/) and reproduced with permission. While every effort is made to ensure accuracy, neither the Aviation Safety Network nor Flight Safety Australia make any representations about its accuracy, as information is based on preliminary reports only. For further information refer to final reports of the relevant official aircraft accident investigation organisation. Information on injuries is not always available.
Australian accidents
compiled from the Australian Transport Safety Bureau (ATSB). Disclaimer information on accidents is the result of a cooperative effort between the ATSB and the Australian aviation industry. Data quality and consistency depend on the efforts of industry where no follow-up action is undertaken by the ATSB. The ATSB accepts no liability for any loss or damage suffered by any person or corporation resulting from the use of these data. Please note that descriptions are based on preliminary reports, and should not be interpreted as findings by the ATSB. The data do not include sports aviation accidents. *indicates investigation continuing
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Australian accidents/incidents 03 december 2011 29 January 2012

date
03 dec 03 dec 04 dec 05 dec 05 dec 06 dec 07 dec 11 dec 15 dec 20 dec 23 dec 24 dec 25 dec 28 dec 29 dec 30 dec 30 dec
Aircraft
Piper PA-28-161 Warrior PZL-Bielsko 48-3 Jantar STD 3 Cessna 182E Skylane
Location
Injuries
damage description
Serious Serious Serious Serious Serious Serious Serious Serious (a/c tail) Destroyed Serious Substantial Nil Substantial Substantial Substantial During landing, the aircraft landed hard on its nose landing gear before bouncing a number of times. During the turn onto final, at low level, the wing struck the ground and the glider crashed. During landing roll on the short strip, the aircraft did not decelerate as expected. The pilot attempted to turn onto the crossing strip, resulting in the aircraft sliding off the runway. During landing roll, the aircraft encountered a willy willy before leaving the runway, colliding with a fence and coming to rest upside down.* During flying training, the helicopter rolled over and hit the ground. The two occupants were uninjured.* During take-off, the aircraft hit a gusting crosswind and was pushed off the runway, hitting a bank and stopping among trees.* The aircraft crashed, killing the pilot.* While aerial spraying, the aircraft struck a power line and made a precautionary landing at Moree. During take-off roll, the aircraft hit an obstacle and came to rest inverted.* During the take-off run, the aircraft ran off the end of the airstrip and hit a mound of dirt.* During the hover, the left skid hit the ground, resulting in a dynamic rollover.* A helicopter crewman was killed while attempting to retrieve an injured bushwalker by winch.* During final approach, the pilot received a stall warning and applied full power, but the aircraft continued to descend, landing on the soft wet surface before the runway. The landing gear dug into the wet grass.* During the landing, the nose landing gear collapsed. The engineers could not find any faults with the system. During the landing, the aircraft groundlooped.
West Sale Aerodrome, Vic Nil Bathurst Aerodrome, 270 Nil M 13km, NSW Lower Light (ALA), SA Nil Nil Minor Nil Fatal Nil Minor Serious Nil Fatal Nil Nil Nil Nil Nil
Taylorcraft BC12-D near Gunnedah Aerodrome, NSW Schweizer 269C-1 Moorabbin Aerodrome, Vic Rockwell 114 Meekatharra Aerodrome, Commander WA Cessna 210M Roma Aerodrome, Qld Air Tractor Moree Aerodrome, NSW AT-502B Auster J5F Aiglet near Tyabb (ALA), Vic Cessna A188B/A1 St George Aerodrome, Agtruck Qld Robinson R22 Beta Caloundra (ALA), Qld Agusta AW139 Nowra Aerodrome, 012 T 36km, NSW Cirrus SR22 Warnervale (ALA), NSW Piper PA-31-350 Chieftain Cessna A188B/A1 Agtruck Cessna 172R Skyhawk PZL WarzawaOkecie M-18A Dromader Cessna A188B/A1 Agtruck Robinson R22 Beta Scone Aerodrome, NSW Gunnedah Aerodrome, NSW Cambridge Aerodrome, Tas Dirranbandi Aerodrome, 225 M 36km, Qld
Substantial After starting the engine, the instructor left the aircraft to replace the headset. The aircraft taxied forward and struck a hangar. Substantial During agricultural operations, the engine failed and the pilot made a forced landing in a paddock. Destroyed The aircraft crashed during aerial agricultural operations.*
01 Jan 03 Jan 04 Jan 04 Jan 05 Jan 05 Jan 07 Jan
Forbes Aerodrome, NSW Minor Richmond (Qld) Aerodrome, 067 M 45km, Qld Happy Valley (ALA), Qld Minor Minor Nil Nil Nil Nil
Substantial After take-off, the helicopter lost power and the pilot made a forced landing. The helicopter rolled onto its side and was destroyed in a post-impact fire.* Substantial During initial climb, the aircraft lost power and crashed.* Substantial During an aerial agricultural spray run, the aircraft struck a powerline and the pilot made a precautionary landing in a nearby field. Substantial During the take-off run, the aircraft did not accelerate normally. The pilot attempted to dump the load but the left wing stalled and the aircraft veered left and crashed. Substantial During approach, the pilot forgot to lower the landing gear, resulting in a wheels-up landing. Substantial During approach, the nose landing gear did not extend. The crew did a non-normal checklist, but this did not rectify the problem. They retracted the landing gear and landed wheels up. Engineering inspection did not reveal any faults, but it was suspected that the nose landing gear-up lock had jammed. Substantial During landing, a strong wind gust lifted the aircraft, blowing it to the side of the runway. The pilot applied power to go around, but due to the proximity of the fence rejected the take-off. The landing gear collapsed when it struck the soft ground at the side of the strip. Substantial During landing, the aircraft ballooned and landed hard on its nose landing gear, which collapsed. The passenger suffered minor injuries. Investigation continuing. Substantial During cruise, the engine failed and the pilot made a forced landing in scrub. The main landing gear hit a tree stump, causing the aircraft to cartwheel. The pilot escaped the aircraft uninjured before it was destroyed by fire. Substantial During approach, the glider lost lift. The pilot attempted to land in a paddock, but collided with a fence. Substantial During initial climb, the aircraft lost power and the pilot made a forced landing in a field. Destroyed During return from crop spraying operations, the engine lost power, resulting in a forced landing.* Destroyed It was reported that the aircraft had crashed.* Substantial During initial climb, the engine failed and the pilot made a forced landing. Substantial It was reported that the aircraft had crashed, killing the pilot.
Cessna 172N Skyhawk Schweizer G-164B Goondiwindi Aerodrome, Ag-Cat NSW Air Tractor AT-502 near Collarenebri (ALA), NSW Aero Commander Warrnambool Aerodrome, 500-S Shrike Vic Nanchang CJ-6A near Parafield Aerodrome, SA Eagle X-TS 150 Yarrawonga Aerodrome, Vic Mildura Aerodrome, Vic
09 Jan
Nil
12 Jan 14 Jan 15 Jan 21 Jan 25 Jan 27 Jan 29 Jan 29 Jan
Beech 23 Musketeer Amateur-built Renegade Spirit ICA Brasov IS-28B2 Ayres S2R-R1820 Turbo Thrush Schweizer 269C de Havilland DH82A Tiger Moth de Havilland DHC-1 MK 22 Chipmunk Amateur-built Pitts S2-ZZ
Minor
near Whyalla Aerodrome, Nil SA near Benalla Aerodrome, Vic Condobolin Aerodrome, W M 41km, NSW Long Hill (ALA), Tas Serious Nil Nil
Maryborough Aerodrome, Fatal Vic Goulburn Aerodrome, Nil NW M 2km, NSW near Murray Bridge (ALA), SA Fatal
20
FEATURE Safety management systems
NEw SMS kiT ON iTS wAy

Just obey the rules and nothing bad will happen. If only. For aviation safety to continue to improve, aviation organisations not only have to comply with the rules, but then move beyond that basic (and fundamental) compliance to a new level. At this next level, every person in an aviation organisation strives for safety by identifying hazards, evaluating risks, communicating them and taking steps to mitigate them. But what are the hazards? A safety management system is an approach to safety that shares its logic with former US Secretary of Defense, Donald Rumsfelds, sometimes derided unknown unknowns phrase of 2002. Rumsfeld said: There are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns there are things we do not know we dont know. Similarly, in aviation there are hazards that we dont know about and we dont even realise that we dont know them: a flight management system inundating a crew with more than fifty error messages, for example. There are no rulebooks and checklists to guard against these so-called black swan hazards (from Talebs 2007 book, The Black Swan, where he talks about black swan events as being undirected and unpredicted). Only a safety management system based on constant alertness, reporting, analysis and mitigation can hope to discover and address them. Hazards may be latent in new aircraft types, buried in new or time-honoured procedures, or inherent in certain destinations.
As a regulator CASA deals with the common and known areas of potential hazardtraining standards; airworthiness controls; certification and entry control; operational issues such as loads and balances and fuel management, for example. As the regulator for the Australian aviation industry as a whole, it is appropriate that CASA does this. But CASA cannot regulate against the unique and unknown unknowns hazards that may reside with individual operators. They must observe, analyse and improve their own safety. Thats where safety management systems (SMS) come in. New regulations in place and underway, mean that organisations will need to have SMS in place. CASA is working on a resource kit, SMS for Aviationa Practical Guide, to assist organisations with SMS, whether they are updating and improving an existing system, or developing and implementing a new one from scratch. It is practical, written in plain English, and takes a jargon-busting approach. The set of six booklets outlines the structure of an SMS, following the global ICAO framework. The kit includes: 1. An introductory booklet: Safety Management System Basics why have an SMS? Whats in it for me? What is the difference between an SMS and a quality management system? Safety Management System Basics also includes jargon busters: a list of useful definitions and abbreviations/acronyms. 2. Four booklets (nos. 25) covering each of the four main parts of the global ICAO safety management system framework. Each of these contains useful checklists and templates, which organisations can adapt to suit their individual needs.
SMS FOR SAFETY AVIATIONA PRA BASICS MANAGEMENT CTICAL GUIDE SYSTEM
SMS FOR SAFETY AVIATIONA PRA PLANN POLICY, OBJEC CTICAL GUIDE ING TIVES AN D
SMS FOR SAFETY AVIATIONA PRA RISK MA CTICAL GUIDE NAGEM ENT
SMS FOR SAFETY AVIATIONA PRA ASSUR ANCE CTICAL GUIDE
SMS FOR SAFETY AVIATIONA PRA TRAININ CTICAL GUI G AND PROMO DE TION
SMS FOR HUMAN AVIATIONA PRA FACTOR CTICAL GUIDE S
Safety Mana
gement
Systems
Safety Mana I
gement
Systems
Safety Mana I
gement
Systems
Safety Mana 1
gement
Systems
Safety Mana 1
gement
Systems
Safety Mana 1
gement
Systems
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SMS for Aviationa Practical Guide. Safety policy, objectives and planning Good safety management is not about having an SMS manual on your shelf, outlining each of the elements you have in place. Safety policy, objectives and planning looks at the vital role of management in having an effective SMS, setting up roles and expectations, clear policy guidelines, and making sure everybody in the organisation, whether its big or small, knows about and supports the SMS. SMS for Aviationa Practical Guide. Safety risk management With policies and people in place, the next step in an SMS is to identify the hazards in your organisation, and to make sure you have controls to manage risk. This booklet looks at managing risk, the idea of reducing risk to be ALARP (as low as reasonably practicable) and ALoS (acceptable level of safety) and provides templates and checklists such as a sample risk register and hazard ID. SMS for Aviationa Practical Guide. Safety assurance Safety assurance is the way you show that your SMS works, so this booklet looks at ways to monitor and record your safety performance. It includes investigation, reporting and auditing; as well as important things to consider in managing change.
SMS for Aviationa Practical Guide. Safety training and promotion Good communication is vital for an effective SMS. If the boss keeps everyone in the loop on safety issues, and in turn, listens to what employees have to say, the SMS will be much more effective. Equally, part of an effective SMS is ensuring employees have the skills and knowledge they need. This booklet therefore focuses on the safety training and promotion part of an effective SMS. 3. Booklet 6 in the SMS for Aviationa Practical Guide kit is Human Factors, dedicated to promoting an understanding of humansour behaviour and performance. Then, from an operational perspective, we apply that human factors knowledge to get the best fit between people and the systems in which they work, to improve safety and performance. 4. A DVD containing all the checklists and templates is included so that organisations can adapt these to suit their individual needs.
The kit is due for release by mid-2012, and will be widely publicised.
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22
FEATURE Ageing aircraft management plan
Flight Safety Australia reviews the state of play in the Ageing Aircraft Management Plan with project manager, Pieter van dijk
The first stage of CASAs Ageing Aircraft Management Plan is complete and the true scale of the issue discovered. The Stage 1 report reached three main conclusions: CASA fully supports the continued operation of ageing aircraft in Australia providing it can continue to be done safely. Aircraft owners may not be able to continue operating the existing fleet of ageing aircraft indefinitely, with only a minimal amount of the existing type of maintenance, and expect the inherent risks to remain at an acceptable level. Identified ageing issues are affecting the continuing airworthiness of aircraft. Stage 1+ took place in 2011 and involved providing feedback to industry on the findings of Stage 1 and delivering an aircraft owner awareness program on the science of aircraft ageing. This was done via the CASA website and through a series of seminars around the country in metropolitan and regional venues. Stage 2 includes further seminars this year following the successful 2011 round. These seminars will be fewer in number but larger in scale than those that took place across the country last year. Well go for larger venues, van Dijk says. Stage 2 also involves preparing a discussion paper and developing ageing aircraft training programs, both of which are scheduled for release in mid 2012.
A prototype online matrix tool is also under development to allow aircraft owners to assess the degree to which the many factors in aircraft ageing affect their aircraft. We want to have this facility available for industry to trial so owners can run some what-if scenarios on the airworthiness status of their aircraft, says van Dijk. The online tool leads the person through a series of questions about their aircraft, based on engineering and scientific factsnothing subjective. At the end, the answers to each question will produce a likelihood index number, which will give an indication of the likelihood that their aircraft is affected by ageing issues. The questions include a range of objective data fields including the type of aircraft, its certification basis, whether it has ever been damaged, how it has been repaired, how it has been operated and where it is usually kept (in a hangar, on grass, or near the coast). You can enter your individual aircrafts details and get some idea of whether you should be making some fundamental changes to it, or its maintenance system. Later this year CASA intends to publish a notice of proposed rule making, after the responses to the ageing aircraft discussion paper have been assessed. A notice of final rule making should follow in mid to late 2013. All interested industry parties are invited to comment on CASAs proposed initiatives to manage ageing aircraft. One trend that has emerged in the Stage 1 investigation is that ageing aircraft are primarily a general aviation problem.
FLIGHT SAFETY AUSTRALIA Issue 85 March-April 2012
23
Aircraft in the airline transport sector are more heavily used than most GA aircraft, but they also tend to be both newer and more comprehensively maintained. Were less worried about airline transport aircraft, van Dijk says. They are very intensively used, but thats fine, as their systems of maintenance are continuously monitored and improved. Thats a different situation to GA, where the systems of maintenance havent necessarily been adapted over the years to include ageing-related issues. Stage 1 was somewhat reassuring in that it confirmed what we know about the issue of metal fatigue as part of ageing. Corrosion has turned out to be a more significant issue than fatigue, van Dijk says. It seems weve managed fatigue reasonably well over the years, but corrosion is a lot more prevalent than we anticipated. If you have a hard-to-get-to bit of the aircraft, chances are its not been looked at for decades, and chances are also that it will have corrosion damage. Thats significant because corrosion damage compromises the structural strength of the aircraft. Wiring emerged as another significant factor in ageing. Some GA aircraft more than 40 years old were seen by the ageing aircraft team to be still flying with their original circuit breakers and wiring. Original wiring in a 40-year-old aircraft is not going to be reliable, van Dijk says. To fly in IMC with ageing wiring is to put your life in the hands of some cracked-up, ageing wiring insulation that could easily be your undoing. The schedule of maintenance, known as CASA Maintenance Schedule 5, calls for aircraft wiring to be inspected, but does not provide any guidelines for its replacement. Therefore wiring often goes unreplaced for decades. Schedule 5 was never intended as a catch-all for large fleets of aircraft that are twice as old in age and hours as manufacturers originally expected them to be, van Dijk says. It was initially designed several decades ago as a schedule of maintenance for a few orphan aircraft that did not have adequate maintenance data available from their manufacturers. The concept of a minimum maintenance standard is obviously valid, but there is a strong case that its current content needs to be updated into some sort of enhanced Schedule 5. All these concepts will be discussed in full in CASAs upcoming discussion paper and notice of proposed rule making on the topic.
For details of the 2012 seminars,see the full-page ad on the inside front cover of this issue.
www.casa.gov.au/ageingaircraft
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FEATURE Air traffic management reforms
Change in the air

After a long period of consultation and development, which began in 2010 with an initial discussion paper, CASA is close to finalising important air traffic management (ATM) reforms. ... for ongoing safety and efficiency, CASA is proposing a number of changes to avionics equipment
Broadly, the proposed changes involve requiring operators of certain aircraft to fit avionics equipment to enable safe and efficient utilisation of new technologies supporting future ATM and satellite navigation. The proposed changes come at a time of increasing global harmonisation of ATM and satellite navigation standards. Historically, these changes have been developed in a co-operation with ASTRA* members as an acceptable compromise between the various industry sectors. The changes mainly affect IFR and do not affect Class G airspace below 10,000 feet. (*ASTRA, the Australian Strategic Air Traffic Management Group, is an aviation industry body dedicated to developing an optimum air traffic management system for Australia. ASTRA members include the airlines, CASA, Airservices, the Aircraft Owners and Pilots Association, the Regional Aviation Association of Australia, the Australian Sport Aviation Confederation, the Australian & International Pilots Association and others.) In Australia, too, there are powerful drivers for change. Australia is at a watershed in its ATM, with many legacy ground-based navaids, such as non-directional beacons (NDB) and VHF omni-range (VOR) equipment, approaching the end of their useful life. The intention is to complete the transition to satellite navigation, which commenced in 1995, by early 2016, while retaining selected navaids to back up and mitigate any problems with GPS. Airservices is also providing new Mode S radars, multilateration at major city airports, wide area multilateration (WAM), and more ADS-B ground stations are being commissioned to provide improved services, coverage and increased safety.
Another factor is increased air traffic: Western Australias growing mining activity, for example can mean that aircraft are unable to enter or leave Perth controlled airspace when they request. The fact that en-route ATM outside radar is presently handled by procedural methods, with a 50nm procedural limitation, affects the amount of traffic in the airspace around Perth. Consequently, for ongoing safety and efficiency, CASA is proposing a number of changes to avionics equipment. These changes apply especially to satellite-based IFR navigation; fitting of Mode S/ADS-B (automatic dependent surveillance broadcast) transponders; and fitting of the updated version of the traffic collision avoidance systemTCAS II version 7.1.
25
Comments of the Notice of Proposed Rule Making 1105AS, circulated in January 2012, close on 13 March. No rule changes will be undertaken until feedback received by this date has been considered. Broadly, the proposed changes are: Mandatory avionics equipmentGNSS navigation/ IFR aircraft New* RPT and charter aircraft must be equipped for GNSS navigation under instrument flight rules (IFR) 6 February 2014 (*placed on the Australian register on/after 6 February 2014) Existing* RPT and charter aircraft must be equipped for GNSS navigation under instrument flight rules (IFR) 4 February 2016 (*placed on the Australian register before 6 February 2014) New* private and air work category aircraft undertaking IFR flight, must be equipped for GNSS navigation 6 February 2014 (*placed on the Australian register on/after 6 February 2014) Existing* private and air work category aircraft undertaking IFR flight, must be equipped for GNSS navigation 4 February 2016 (*placed on the Australian register before 6 February 2014) Mandatory Mode S ADS-B transponders (with ADS-B out capability*) (*transponder must be ADS-B capable, but the aircraft does not necessarily need to have GPS to support ADS-B)
For aircraft operating in controlled airspaceA, B, C and E, and above 10,000ft in class Gmandatory for new transponder installations and new aircraft placed on the Australian register on/after 6 February 2014 All aircraft operating at Brisbane, Melbourne, Perth and Sydney airports must be Mode S transponder-equipped by 4 February 2016. Mandatory ADS-B out capability New* aircraft flying IFR must be equipped to transmit ADS-B 6 February 2014 (*placed on the Australian register on/after 6 February 2014) Existing* aircraft flying IFR must be equipped to transmit ADS-B 2 February 2017 (*placed on the Australian register before 6 February 2014) Any aircraft flying IFR in classes A, C or E airspace in the area bounded by a 500 nautical mile arc north and east of Perth Airport must be equipped to transmit ADS-B by 6 February 2016 Mandatory fitting of TCAS II v7.1 avionics equipment Before turbine-powered aeroplanes used in public transport, with maximum certified take-off weight over 5700kg, and certified to carry more than 19 passengers, and first placed on the Australian register on/after 1 January 2014 (ICAO-determined compliance date) can fly, they must be fitted with a serviceable, approved TCAS II v7.1
Another AdS-B mandate is even closerin fact its happening next year
By 12 December 2013, operators of aircraft flying at and above 29,000ft (FL290) must have ADS-B equipment installed and operating correctly. CASA mandated this mandatory fitting of ADS-B in 2009. We are now seeing over 70 per cent of all international flights in our flight information region getting the ADS-B service, said Airservices senior engineering specialist and ADS-B program manager, Greg Dunstone, in December last year. A small number of airlines and business jet operators appear not to have made the move to have ADS-B installed. They need to get a move on, because the effective date is fast approaching, Dunstone added. CASA is not expecting to issue exemptions. After 12 December, 2013, non-ADS-B equipped aircraft will have to operate below FL290, with the corresponding disadvantage of less operational flexibility and potential delays because of procedural separation standards applied outside radar airspace.
26
FEATURE Air traffic management reforms
What is AdS-B?
Simply, automatic dependent surveillance - broadcast, or ADS-B, is aircraft automatically sending flight information to air traffic control and to each other. ADS-B broadcasts information about an aircraft, including its: identification position altitude (barometric and/or geometric) speed direction The system also broadcasts technical information, such as position integrity/accuracy. This data is automatically sent about every half-second. The system takes its information from other aircraft systems: a barometric encoder for altitude, and global navigation satellite system (GNSS) equipment for speed position and direction data. The initials ADS- B describe the main characteristics of the system: Automaticthe system requires no human input. No radar is needed to interrogate it. dependentthe system relies on information from aircraft systems. Surveillancethe system allows ATC, and individual aircraft with cockpit displays of traffic information (CDTI), to see a picture of air traffic in an area. Broadcastthe system is a broadcast to all listeners, rather than directly to a known receiver. Airservices Australia completed the installation and commissioning of its nationwide automatic dependent surveillance-broadcast network in December 2009, with Australia becoming the first in the world to provide nationwide ADS-B coverage. ADS-B is available to suitably-equipped aircraft at all flight levels within coverage of ground stations at 29 sites throughout the country, providing radar-like coverage over continental Australia for the first time. ADS-B data is also received by wide area multilateration (WAM) systems in Tasmania and at Sydney. The accuracy of the information displayed on air traffic controllers screens allows separation standards to be reduced from 30nm to 5nm.
Using AdS-B
ADS-B systems typically broadcast two means of identifying the transmitting aircraft. The first is a technical means called the aircraft address (also known as the 24-bit code) and the second is the flight identification (FLTID)the visual equivalent of a call signused to identify targets on a display and link them to their flight plans.
Level off! Level off!

TCAS stands for traffic collision avoidance system, which has evolved through several versions since first introduced in 1990. TCAS II V7.1 is an enhancement that verifies pilot response to a resolution advisory (RA) and may generate a TCAS resolution reversal, and changes the verbal advisories from adjust vertical speed, adjust to level off, level off. This enhancement came in response to the Uberlingen mid-air collision of 2002. In that accident, 71 people were killed when a Boeing 757 and a Tupolev 154 collided over southern Germany. The Tupolev crew had followed conflicting directions from the controller instead of obeying TCAS alerts. ICAO is mandating TCAS II V7.1 on/after 1 January 2014. All public transport, turbinepowered aircraft above 5700kg certified to carry more than 19 passengers, first placed on the Australian register on/after 1 January 2014, must have TCAS II V7.1 before they can fly.
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Aircraft identification
The aircraft identification (sometimes called the flight identification) is the equivalent of the aircraft call sign and is used in both ADS-B and Mode S-SSR technology. It is up to seven characters long, and is usually set by the flight crew using a cockpit interface. It enables air traffic controllers to identify an aircraft on a display and to correlate a radar or ADS-B track with the flight plan data. Aircraft identification is critical information, so enter it carefully. Punching in the wrong characters could lead to ATC confusing your aircraft with another. It is important that the identification exactly matches the aircraft identification (ACID) entered in the flight notification. Intuitive correlation between an aircrafts identification and radio callsign enhances situational awareness and communication. Airline aircraft should use the three-letter ICAO airline code used in flight plans, not the two-letter IATA codes. For aircraft using registration, the code should exactly match the flight plan. For Australian domestic flights the preceding VH should not be included.
Aircraft address
Each aircraft has a unique aircraft address, which consists of a 24-bit code allocated by CASA. This code is usually entered into the unit by a LAME at installation. The code is on the aircraft registration letter sent to aircraft owners by CASA. If your aircraft is not registered by CASA, you can get a code from the aircraft registry.
S for safety
ADS-B broadcasts are made using Mode S, the same standard as used on Mode S transponders, which are replacing the Mode A/C transponders used in radar surveillance. ADS-B enables automatic safety alerting within the ATC system including short term conflict alert and cleared level adherence monitoring. This is already active across the whole continent for equipped aircraft. Mode S has less signal garbling, less erroneous data, and allows aircraft call signs to be displayed on the ATC radar screen. Mode S transmits a unique 24-bit aircraft address to greatly reduce the probability of identification errors.
28
FEATURE AvSafety seminars
SEMiNARS 2012 NEw yEAR, NEw LOOk

CASAs successful AvSafety seminar series returns in 2012 with two new topics added to the line-up. And you can now register online to attend the next seminar in your area. AvSafety seminars are aimed at everyone in the aviation community, and are held in regional centres, as well as in capital cities. In 2011, more than 5000 people attended 120 AvSafety seminars run by CASA across the nation. The 2012 seminar program continues with a new focus on two key issues: aviation safety resources on the internet and human factors in aviation. There is a wealth of official and unofficial information on aviation to be found on the internet, but the key is understanding where to find the official information you need. The aviation resources on the internet seminar will guide attendees on how to find information on the official websites most people in aviation need to use: CASA (www.casa.gov. au), Airservices Australia (www.airservicesaustralia.com), the Bureau of Meteorology (www.bom.gov.au) and the Australian Transport Safety Bureau (www.atsb.gov.au). The seminar will demonstrate how to find training materials, general information, advice and regulations, as well as how to lodge reports (such as SDRsservice difficulty reports) and access self-learning resource centres. The aim of the seminar is not to explain each of the websites in detail, but to give attendees an understanding of the sort of information they contain and to encourage attendees to explore them on their own.
The human factors seminar looks at how an understanding of human performance is important to the safety of all aspects of aviation operations. The seminar uses the kit, Safety BehavioursHuman Factors for Pilots*, produced by CASA, as its major resource. There will be a focus on the major elements that make up the study of aviation human factors and a demonstration of how they can be applied in a practical way to everyday operations. People attending this seminar will be provided with resources so they can research in greater detail the aspects of human factors relevant to their operations. This topic is vital as human factors is fast becoming a major safety focus for both CASA and the International Civil Aviation Organization (ICAO), and a required part of new aviation regulations. (*A new companion kit, Safety BehavioursHuman Factors for Engineers, is in production, due for release in June 2012. To ensure consistency of the two kits, the Safety Behaviours Human Factors for Pilots is being reprinted. It is therefore not available from the CASA online store until late April; however, until then, it can be downloaded from the resources section of the Skybrary website www.skybrary.aero) Both topics are applicable to all members of the wider aviation community. The safety seminar program also covers a wide range of other topics, from airmanship to glass cockpits, and maintenance to fuel management. Go online to the Seminars and Workshops section of the CASA website (which you can find via the Education dropdown menu on the top navigation bar) to request a seminar in your area. All seminars are sponsored by CASA, and are free to attend.
B OOK E ARLY ,
LIMITED AVAILABILITY !
29
3 4 2
Alternatively, you can follow this link: www.casa.gov.au/avsafety to see the 2012 schedule for a seminar in your area. This year, if you wish to attend an AvSafety seminar, you register online. Simply follow the link above, click on the Register option and follow the instructions. You do not need a user name or password to register for seminars, and there is no cost involved. Once you register, you will receive a booking reference, which you should print out and bring to the seminar.
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30
FEATURE The dynamics of flight
LiFT-OFF: hOw ThE MEdiA TOOk FLiGhT wiTh AN OLd STORy
To those who know aerodynamics intimately its not exactly news, but a viral video on YouTube has revived the public discussion on how a wing creates lift.
Cambridge scientist debunks flying myth proclaimed the London Daily Telegraph of 24 January. Engineer debunks theory of flight, trumpeted The Sydney Morning Herald on 26 January. Er, not quitethe truth has been available for years. But any chance to revisit the fundamentals of lift is worth taking Professor Holger Babinsky, of Cambridge University has been mildly annoyed at the persistence of the equal transit time fallacy for many years. This is the sentence that persists in popular explanations, including some aviation theory textbooks (Babinsky found one at his daughters school). It says that when the airflow separates to go over and under a wing, Bernoullis principle dictates that the upper and lower streams will meet at the same time at the trailing edge. So when Cambridge University proposed he contribute to a series of Science in a Minute videos he had a ready topic. The university wanted to accompany this by a press release and it all took off from there, he told Flight Safety Australia. In the university statement we have been very careful to avoid giving the impression that this is new. His video, posted on YouTube, (and at http://preview.tinyurl. com/6wyfea6) uses interrupted smoke streams to show that the top stream arrives at the wings trailing edge much sooner than the lower stream. A 2003 paper by Professor Babinsky in Physics Education (at http://preview.tinyurl.com/72bnyeq) explains what is happening. Air moving over a wing can be thought of as layers of streamlinesand smoke streams in a wind tunnel can illustrate these. Babinsky says the wings airfoil shape causes curved streamlines, centripetal force acting on the air, and a progressive drop in pressure towards the centre of curvature of the streamlines. This accounts for the lower pressure on the upper surface of a wing. There is a also a downwards flow of air as it leaves the wing (as any student pilot who has tried to land a low-wing aeroplane can attest).
Photos: Screen captures from Cambridge Universitys video
Under this explanation there is no prediction that air from above and below the wing must rejoin at the same time at the trailing edge. There is no need even to introduce Bernoullis equation, Babinsky concludes. CASA engineer, Neville Probert, does not believe Bernoullis principle should be thrown out. But he agrees that equal transit time is a demonstrable fallacy. It is important that pilots accept the practicalities of lift and have a sound understanding of the implications for drag, stalling and spinning, he says. There are a number of suitable explanations to choose from. Pilots should choose the explanation of lift that they find most satisfactory and that matches their background knowledge. Babinsky is philosophical too. Clearly Wednesday (25 January) was not a big day for news but the response has been overwhelmingly positive.
31
ThE TROUbLE wiTh CAbLES

Aircraft owners have had a timely reminder of the importance of flight control cable maintenance. The basics of cable maintenance are as important as ever, particularly given the ageing of some of the Australian general aviation fleet
Flight Safety Australias January 2012 story about a control cable failure turned out to be only the first chapter in CASAs response to the issue. Between printing and distribution of the magazine more cases of control cable wear or failure in some Beechcraft aeroplanes were discovered, prompting a series of airworthiness directives for mandatory inspections of the cables on Beechcraft Debonair, Bonanza and Baron models. Seven cases of frayed or broken cables have been found so far in response to the directives. But no aircraft owner can afford to be smug. Cables are critical maintenance items on any aircraft that uses them because of their obvious importance to flight control. Regardless of age, cables require close attention. They are a maintenance sensitive item. There are five major points about cable maintenance aircraft owners and maintainers should revisit, particularly at this time.
1. Wear
Under normal use cables wear, unavoidably, in two ways. External wear comes from the abrasion of the cables individual wires, coming into contact with pulleys, guides, rubbing strips or, sometimes with poorly installed wiring or other fittings. A recent service difficulty report describes an egregious piece of mis-rigging. The elevator trim cables on a single engine aircraft had been replaced, but mis-routed, which brought them into contact with an electrical wiring loom. Someone who should have known better wrapped the electrical cables in tape in an effort to prevent the cables from cutting through the electrical wiring. An unusual feature of external wear is that it seems to affect cables that make small direction changes at pulleys more so than cables that make sharper direction changes. Lightly loaded pulleys, for example, may revolve slowly during flight in response to engine vibration, wearing the cables.
Cable wear patterns Source: Figure 7-17, Advisory Circular 43.13-1B
Internal wear is much more difficult to detect, and comes from wires and strands in the cable rubbing against each other at the point where the cable changes direction over a pulley. Internal wear is greatest at the point where the cable changes direction, and is related to the radius of the direction change. A small radius produces more internal wear, as the cable has to bend more sharply.
32
AIRWORTHINESS The trouble with cables
2. Fatigue
Related to wear is fatigue, which can take the form of work hardening and brittleness of individual wires, or strands of wires, in a cable. Fatigue is an inevitable consequence of a cable doing its job over several years, but can be accelerated when aircraft are parked in the open with their flight controls locked in the cabin and the control surface still free to move. The movements caused by wind on the ground take a toll on the cables that may be the equivalent of hundreds of hours extra flying time. However, the effects of fatigue can be minimised, or at least brought to acceptable levels, by correct maintenance of cables. To combat the effects of corrosion on coated carbon steel cables, some manufacturers have introduced stainless steel cables. While this seemed a good idea at the time - stainless steel is a very effective material in marine use - they have been found to wear far more rapidly than plain old, plated carbon steel. An FAA special airworthiness inspection bulletin (SAIB: CE-12-01) says manufacturers are now moving away from stainless steel. This is backed up by CASAs considerable case log of wear-related failures in stainless steel cables. The FAA now recommends that stainless steel cables only be used in marine environments where corrosion is a major problem.
3. Corrosion
Corrosion is another enemy of cables. The extent and rate of corrosion is affected by where the aircraft is flown and stored. Cables that run near batteries, toilets and galleys, or that are exposed in wheel wells, or other open areas, are particularly susceptible to corrosion. Corrosion pitting on the cable acts as a stress raiser and significantly reduces the fatigue life of a cable. Another characteristic of cable corrosion is that it can be insidious. Cables can be riddled with it while appearing sound from the outside. There is at least one well-documented anecdote of an apparently serviceable looking cable with a very sound coating of anti-corrosive compound which snapped when an engineer accidentally leaned on it. The commuter aircrafts flight control cable was riddled with corrosion beneath its covering of anti-corrosive compound. The compound had served to retain moisture: as well as keeping water out, it also kept water in.
4. Tension
The literature on cable wear and maintenance dates well beyond 1957, but in that year, an airworthiness directive was brought out for Auster A61 aeroplanes following a series of rudder cable failures. The AD required that the cables be removed and inspected every 100 hours. The cables had failed mostly due to fatigue, it seems, after vibrating in response to frequency generated by the aircrafts engine, propeller or airframe. If cables were improperly tensioned, in effect, they behaved like guitar strings becoming more sensitive than they should be to the vibrations from the engine and propeller. As a general rule, under-tensioned cables are subject to lowfrequency vibrations, and over-tensioned cables are subject to high-frequency vibrations. This is in addition to the problems of loose control feel that result from under-tensioned cables and tight control feel, sometimes coupled with restricted range of motion, that accompanied over-tensioning. The solution is tensioning the cable to manufacturer specifications, using an accurate and calibrated tensiometer and thermometer.
DIAMETER 3x7 DIAMETER DIAMETER 7x7 7 x 19 DIAMETER 7x7 7x7

Internal end view of cable wear Source: Figure 7-19, Advisory Circular 43.13-1B
DIAMETER DIAMETER DIAMETER 3x7 7x7 3x7 DIAMETER
DI
DIAMETER DIAMETER DIAMETER DIAMETER 7 x 19 6 x 19 7 x 19

Flexible cable cross section Source: Figure 7-8, Advisory Circular 43.13-1B
DIAMETER 6 x 19 6 x 19
33
Pulley wear patterns Source: Figure 7-20, Advisory Circular 43.13-1B
5. Temperature
The cable tension is frequently specified by the manufacturer for a certain temperature range. This is because an aluminuim fuselage expands and contracts at a different rate to the steel cables. If cables are not correctly tensioned it can result in the cables going slack in cold weather or at high altitude. It can also result in cables becoming too tight during hot weather.
The need to check

It is to be expected that there will be more cable changes done this year in response to CASAs series of airworthiness directives. When cables are changed, duplicate inspections for correct run and correct response to control surface are critical. But cable replacement has its own hazards. It has been known for aircraft to have passed through these inspections, and still have their controls rigged incorrectly - even backwards. As in so many areas of aviation you, the pilot, are your own last line of defence. One thing you can tilt in your favour is your daily/pre-flight inspection. Take advantage of the quiet,
Cable inspection technique Source: Figure 7-16, Advisory Circular 43.13-1B
before the engine starts and gyros start running up, to really listen when you move the controls. Is there any unusual noise or binding when you move the control column or surfaces? Later, at the threshold, check again, and not just a cursory glance. Do the controls really move in the right direction? Do they really feel free? A few moments of sensitive observation before you commit to the sky could save you from being the victim of a cable catastrophe.
34
AIRWORTHINESS Pull-out section
SELECTEd SERvICE dIFFICULTY REPORTS 19 Nov 2011 6 Feb 2012

Note: Similar occurrence figures not included in this edition Boeing 737476 Aircraft fuel crossfeed valve failed. SdR 510014213 Fuel crossfeed valve failed to close. Investigation found crossfeed valve actuator and gate unserviceable. P/No: 737M28500011. TSN: 57,802 Hours. TSO: 14,522 Hours. Boeing 737476 Air distribution fan recirculation fan failed. SdR 510014002 Electrical smell in area of rear galley. Investigation found LH recirculation fan extremely hot. P/No: 6454051. TSN: 64,478 Hours. TSO: 64,478 Hours. Boeing 737476 Passenger station equipment system seat separated. SdR 510014114 Passenger seat 14ABC separated from seat track. Investigation found the forward RH fitting had migrated out of the frame. Investigation continuing. Boeing 7377Bk Pneumatic distribution system bleed air contaminated. SdR 510014174 Bleed air system system contaminated with oil smell. Suspect caused by overnight engine wash. Boeing 7377FE Cabin cooling system actuator failed. SdR 510014235 Warning light during flight ram door full open. No change in air conditioning when tried cooling and warming. Defect confirmed, MEL applied. P/No: 5416744. TSN: 22,526 Hours/12,776 Cycles. Boeing 7377FE Hydraulic pump, (electric/ engine) unserviceable. SdR 510014038 RH engine driven hydraulic pump seized and drive sheared. Metal debris completely blocked case drain filter. P/No: 66087. TSN: 22,026 Hours/12,530 Cycles. Boeing 7377Q8 Fuselage main, structure window frame cracked. SdR 510014205 RH No1 cockpit window frame cracked on C-D post. Crack confirmed using FPI inspection. Boeing 73782R Brake unserviceable. SdR 510014170 No2 main landing gear brake assembly damaged and partially disintegrated. Damage also to wheel hub and heat shield. P/No: 26123121. TSN: 20,674 Hours/10,842 Cycles. TSO: 7,447 Hours/4,326 Cycles. Boeing 73782R Galley station equipment system galley odour. SdR 510013912 Burning smell in aft galley. Investigation found a smouldering cleaning cloth on the G4 coffee maker hotplate at location 407. Boeing 737838 drag control actuator ratio changer unserviceable. SdR 510014109 No8 and No9 spoilers floating. Investigation found a faulty spoiler ration changer. Spoiler mixer P/No:251A1741-5 also changed. P/No: 654637026. Boeing 737838 Navigation system navigation sys failed. SdR 510014011 No1 and No2 VHF nav panels failed. Loss of navigational capability. Circuit breakers reset. Half hourlater No1 VHF nav panel failed again. Aircraft diverted to another airport. Investigation continuing. Boeing 737838 pitot line disconnected. SdR 510014149 Auto throttle disconnected during take-off. Investigation found the piton connection to Captains Air Data Module not properly connected. Investigation continuing. Boeing 7378Bk Fuselage main, structure window frame cracked. SdR 510014218 RH No1 cockpit window frame cracked in upper outboard corner. High Frequency Eddy Current (HFEC) inspection confirmed cracking. P/No: 141A8800Y54. Boeing 7378FE Brake pad separated. SdR 510014016 LH main landing gear brake pads separated from rotors causing wheel to jam. TSN: 20,627 Hours/11,632 Cycles. TSO: 9,740 Hours/5,861 Cycles. Boeing 7378FE Elevator tab control system spring sheared. SdR 510013924 RH horizontal stabiliser elevator tab control mechanism spring (1off4) sheared and displaced. Suspect manufacturing fault. Boeing 7378FE Flight compartment lighting reminder unit contaminated. SdR 510013964 Captains control wheel reminder aid unit smoking. Investigation found electrical contacts contaminated with fluff causing smoking and burning smell. P/No: 3103. Boeing 7378FE Fuselage main, bulkhead skin cracked and corroded. SdR 510014238 Cracking and corrosion found in fuselage skin (section 47, pressurized non-crown) in the location of rear pressure bulkhead. Crack is approx 0.40 long through entire skin thickness and corrosion is intergranular. Swelling has caused the skin to lift and crack. Temporary repair carried out under CAR 35.Aircraft ferried unpressurized for further assessment and permanent repair. Boeing 747438 Ac power distribution system cable worn. SdR 510014061 No2 and No3 engine Integrated Drive Generator feeder cables rubbing on cable support brackets. Investigation continuing. Boeing 747438 Hydraulic pump, (electric/ engine), main pump cracked and leaking. SdR 510014261 No2 engine driven hydraulic pump cracked and leaking. Boeing 747438 Passenger compartment lighting. SdR 510013990 Upper deck LH rearmost mood light located above seat 18AC sparking. Investigation found one wire pulled from pin1 on the light connector DL9874 and shorting against pin2. Investigation continuing. P/No: 0203521001. Boeing 747438 tyre failed. SdR 510013962 Main landing gear No14 tyre failed on takeoff causing damage to RH wing landing gear fixed door. Investigation continuing. Boeing 747438 Waste disposal system waste water leaking. SdR 510013987 Water leaking into Main Equipment Centre. Initial investigation found major water leakage from galleys. Investigation continuing. Boeing 747438 Windshield de-ice short circuit. SdR 510014107 Window 2L heating switch short-circuiting between connector and airframe causing sparking and smoke. Suspect caused by chafing of heat shrink. P/No: 9750002002. Boeing 767336 Wing, longeron/stringer stringer cracked. SdR 510014180 During inspection in R/H dry bay stringer found to have 2.25 inch crack. Boeing 767338ER Adf system receiver failed. SdR 510014044 No1 ADF receiver internal failure. Unable to reset circuit breaker. LH ADF receiver and control panel replaced. Investigation continuing. P/No: 6225222102. TSO: 63,840 Hours.
AIRCRAFT ABOvE 5700kG

Airbus A320212 Elevator, spar/rib rib corroded. SdR 510014117 LH elevator No10 rib corroded and cracked at aft end. P/No: D55281546200. Airbus A320232 Escape slide cable frayed. SdR 510014160 LH aft door slideraft assembly deployment wire cable frayed. Found during slideraft removal. Airbus A320232 Hydraulic system, main hose ruptured. SdR 510014195 RH main landing gear inboard lock stay hydraulic hose ruptured. Loss of green system hydraulic fluid. P/No: 201655146. TSN: 9,723 Hours/5,846 Cycles. Airbus A320232 Landing gear retract/extension system hose sheared. SdR 510014184 Upon selection for gear up after take-off the landing gear did not retract with various ECAM messages. Green hydraulic system failure. Upon landing and inspection the R/H main landing gear lockstay actuator hose was found to have sheared from its attachment. P/No: 201655147. TSN: 9,719 Hours/5,844 Cycles. Airbus A321231 Public address and entertainment system battery overheated. SdR 510014137 IPad external battery overheated with electrical smell. Investigation continuing. Airbus A330202 Wing, miscellaneous structure cover missing. SdR 510014047 LH outboard flap cover missing on the fairing for No3 flap track. Suspect that the panel detached during flight. The panel was sighted (fitted) prior to flight. P/No: F5757416100000. Airbus A330301 Landing gear brake system hose ruptured. SdR 510014228 Aircraft returned to gate due to green hydraulic system failure.L/H main landing gear green hydraulic system brake supply line found to be ruptured. P/No: AE2463936G0265. ATR 72212A Fire detection system fire warning system suspect faulty. SdR 510014146 No1 engine fire warning. Investigation could find no evidence of fire. Further investigation found that the engine fire warning system is susceptible to tail winds when engine is feathered. Bae 146300 pitot tube fod. SdR 510013906 Rejected takeoff due to ASI failure. Investigation found Captains pitot tube blocked by a bug. Bae JETSTM4101 Cargo/baggage doors roller separated. SdR 510013957 Aft cargo door upper forward roller separated from door rails. Incident occurred while door was open during loading. P/No: 1415206091. TSN: 23,107 Hours/27,605 Cycles. TSO: 23,107 Hours/27,605 Cycles. Beech 1900d Elevator, spar/rib fitting cracked. SdR 510014040 RH elevator torque tube adapter/fitting contained circumferential cracking between two of six rivet holes in the fitting flange. P/No: 1016100171. Boeing 737376 Fuselage main, longeron/stringer stringer cracked. SdR 510013911 Stringer splices located at BS 907 stringer 4L and 4R cracked over butt strap splice.
35
SELECTEd SERvICE dIFFICULTY REPORTS ... CONT.

Boeing 767338ER Apu doors door separated. SdR 510014108 APU inlet door separated in flight. Investigation continuing. TSN: 79,793 Hours. TSO: 26,003 Hours. Boeing 767338ER Fuselage main, plates/skin bracket failed. SdR 510014029 Hydraulic Motor Generator (HMG) power panel P65 support attachment brackets failed. Initial investigation found lightning strike burn marks on the brackets. Investigation continuing. Boeing 7773ZGER Escape slide reservoir failed test. SdR 510014093 Door 1 LH slideraft reservoir assembly failed hydrostatic test. Found during inspection iaw AD/ Gas/1. Investigation found damage to the reservoir assembly at the threaded area of the O ring sealing surface. P/No: 660421. TSN: 13,134 Hours/1,133 Cycles. Boeing 7773ZGER Tyre separated. SdR 510014162 (photo below) RH main landing gear No8 tyre tread separated. Damage caused to RH engine stator case acoustic liner. P/No: APR07700R2. TSN: 1,749 Hours/129 Cycles. TSO: 1,749 Hours/129 Cycles. Bombardier dHC8402 APU engine compressor blade failed. SdR 510014112 APU impeller blade separated due to bending forces. Investigation also found engine mount P/No:40012651-1 cracked. Exhaust silencer also cracked. Investigation continuing. TSN: 11,422 Hours/13,254 Cycles. Bombardier dHC8402 Engine oil pressure transducer failed. SdR 510014230 Main engine oil pressure transducer failed causing oil pressure fluctuations. Following replacement of the transducer, the oil pressures were indicating high and were adjusted. P/No: CPW312244801. TSN: 758 Hours/734 Cycles. Bombardier dHC8402 Engine oil temperature regulator bypass valve failed. SdR 510014214 LH engine oil cooler bypass valve failed. TSN: 1,966 Hours/2,163 Cycles. Bombardier dHC8402 Wheel nut loose. SdR 510013945 LH main landing gear outboard wheel had 9 loose nuts (finger tight). Investigation also found one bolt sheared. P/No: 42FLW720. TSN: 7,009 Hours/7,731 Cycles. TSO: 28 Hours/40 Cycles. British aerospace BAE1251000 aircraft structures aircraft lightning strike. SdR 510013954 Aircraft sustained two possible lightning strikes during descent. Lightning strike inspection found the following: LH aileron burnt, secondary burn to the top tail cap, various rivets down the fuselage burnt. doug dC3CR1830 Engine oil cooler oil cooler leaking. SdR 510014018 LH engine indicated low oil pressure and was shut-down in flight. Upon landing oil was found on LH nacelle and oil level in tank was low. LH engine oil cooler replaced. Suspect oil cooler bench tested for leaks and found to be leaking from centre core. Possible centre core damage from last landing when LH main wheel was off sealed runway. P/No: V16011. Embraer ERJ170100 Pneumatic distribution system gasket unserviceable. SdR 510014068 No1 bleed air system leaking. Investigation found an unserviceable interface gasket at the LH wing precooler. P/No: 17016603001. Embraer ERJ190100 Aircraft structures fuselage lightning strike. SdR 510014186 Lightning entered the nose of aircraft travelled along the lower side of fuselage and the wing to body fairing. Lightning exited at rudder tip cap and ejected the upper most static wick. Caused dual HF comms system failure.57 maintenance defect entries raised in relation to this lightning strike. Embraer ERJ190100 Escape slide support cracked. SdR 510014268 LH aft entry door escape slide support board centre attachment bracket cracked. P/No: 4A402047. Embraer ERJ190100 Flight compartment windows windshield lightning strike. SdR 510014204 RH windshield damaged by lightning strike. Further investigation found multiple entry points on the forward and centre fuselage and the exit point on the LH stabiliser trailing edge. P/No: NP18730116. Embraer ERJ190100 Fuselage floor panel panel corroded. SdR 510013978 Aft cabin floor structure RH shear panel PNo 17091919-001 corroded along forward edge upper surface. Corrosion depth was beyond repair limits. Aft cabin floor structure centre shear panel P/No 170-65928-001 also corroded. Depth of corrosion approximately 0.203mm (0.008in). Embraer ERJ190100 Hydraulic pump, (electric/ engine) unserviceable. SdR 510014073 No3 hydraulic system electric hydraulic pump failed. P/No: 5116603. TSN: 7,244 Hours/6,663 Cycles. TSO: 6,301 Hours/5,646 Cycles. Fokker F28Mk0100 Apu core engine aux power unit surged. SdR 510014273 APU surging with intermittent low bleed pressure. Boroscope inspection found evidence of black goo and oil coming from the front of the compressor. APU replaced. Investigation continuing. TSN: 28,913 Hours. Fokker F28Mk0100 Auto throttle system servo unserviceable. SdR 510013928 No1 engine thrust lever stuck. Thrust lever became free when the auto throttle was disengaged. Investigation found No1 autothrottle servo unserviceable. Fokker F28Mk0100 Brake brake disc cracked. SdR 510014173 RH inboard brake assembly carbon discs contained numerous hairline cracks. Crack lengths less than 25.4mm (1in). TSN: 1,796 Hours/9,922 Cycles. Fokker F28Mk0100 Flight compartment windows windshield cracked. SdR 510014001 Pilots windshield contained extensive cracking. Caused by moisture hitting an electrical heating element in the windshield. Suspect faulty seal allowing moisture ingress. Fokker F28Mk0100 Main landing gear attach section pintle incorrect fit. SdR 510014183 During scheduled maintenance of MLG change the pintle pins P/N D12031-001 and D12030-001 were found to be installed incorrectly between fore & aft. It was noticed that these pins are able to be locked/ secured in their wrong positions even though there is 4mm difference in length. Fokker F28Mk0100 Pitot/static system pitot head contaminated. SdR 510014155 System 1 pitot probe contaminated by wasp nest. Fokker F28Mk070 Landing gear actuator actuator cracked. SdR 510014266 Main landing gear retraction actuator eye end cracked in threaded area. Found during Magnetic Particle Inspection (MPI). Suspect eye end incorrectly fitted with the grease nipple pointing down.
Bombardier dHC8102 drag control actuator unserviceable. SdR 510014092 (photo below) LH outboard spoiler actuator unserviceable. Investigation found actuator cracked and leaking. P/No: A44700009.
Bombardier dHC8102 Power lever friction brake faulty. SdR 510014065 Power lever friction brake leave assembly interfering with flight idle gate allowing power levers to be pulled through the gate without stopping. Bombardier dHC8106 Hydraulic pressure sensor pressure switch failed. SdR 510013936 Engine driven standby hydraulic pump pressure switch failed allowing standby pressure to turn the propeller. P/No: 7G733. TSN: 14,982 Hours/13,856 Cycles. TSO: 2,958 Hours/1,937 Cycles. Bombardier dHC8202 Fuel transfer valve check valve incorrect fit. SdR 510013963 Fuel transfer check valve incorrectly fitted 180 degrees out with the check valve hinge in the lower position. Bombardier dHC8315 Engine oil pressure indicator faulty. SdR 510014142 LH engine oil pressure fell below 50psi limit. Investigation found No1 engine oil pressure indicator faulty.
AIRCRAFT BELOW 5700kG

Beech 200BEECH Power lever arm migrated. SdR 510014015 FCU input arm found to have moved on shaft. Unable to reduce engine power below 80% Ng. Arm repositioned and secured. P/No: 509440763. Beech 200BEECH Trailing edge flap track broken. SdR 510014060 RH outer flap inboard track broken away from the rear spar structure. Further investigation found failure of the lower attachment clips P/Nos 35-115393-1, 35-115393-3. Track to spar attachment angles also pulled out of rear spar. Rear spar and adjacent wing internal structure also damaged. Beech 35C33 Elevator control system cable unserviceable. SdR 510014154 Elevator down cable frayed with broken strands in area located behind instrument panel. P/No: 3352400061.
36

Beech 36BEECH Elevator control system cable frayed. SdR 510013966 Elevator down cable frayed and ready to fail at pulley PNo 18754-6. Cable is located forward of the instrument panel. Found following discovery of a failed cable on a similar type aircraft (Beech E33) with the same part number (PNo 33-524000-23). P/No: 3652400023. Beech 58 Mixture control cable failed. SdR 510014236 LH engine mixture control cable failed at flexible to solid joint. P/No: 5038901229. Beech A36 Elevator control system cable frayed. SdR 510014203 Front elevator cable frayed in area around pulley located behind instrument panel. Found during inspection iaw AD/Beech36/54. P/No: 3657400023. Beech A36 Rudder control system cable frayed. SdR 510014269 Rudder forward RH cable frayed. Cable is located in the same area mentioned in AD/Beech35/74. P/No: NAS304351696. Cessna 172R Aileron control system aileron system incorrect rigged. SdR 510014179 Ailerons found to be incorrectly rigged with 17 degrees up travel but should be 20 degrees +/- 1 degree. Aircraft has been recently imported to Australia with 24.8 hrs total time. Cessna 172S Main landing gear strut/axle/truck axle corroded. SdR 510014226 (photo below) During tyre change severe pitted corrosion found at wheel axle underside and also on axle nut threads. P/No: 0541191. TSN: 3,021 Hours. Cessna 210L Landing gear position and warning system wire broken. SdR 510013955 Main power wire for landing gear indicator lights broken at first terminal board in nose wheel well. Cessna 310R Landing gear system drive rod sheared. SdR 510013902 Nose landing gear drive rod attachment fork failed and sheared approximately halfway down the shank where it attaches to the drive collar. P/No: 52435182. Cessna 402C Antenna corroded. SdR 510014051 Marker beacon antenna contained heavy exfoliation corrosion. Minor corrosion also found found on fuselage skin. P/No: CI102. Cessna 404CESSNA Wing spar spar web cracked. SdR 510013939 RH wing main spar web cracked. Found following removal of RH main landing gear actuator bracket PNo 5841141-2 for cracking. TSN: 11,473 Hours. Cessna R182 Horizontal stabilizer structure hinge corroded. SdR 510014189 RH horizontal stabiliser hinge assembly corroded. P/No: 12324002. TSN: 4,353 Hours. TSO: 4,353 Hours. Cessna R182 Landing gear door actuator pin migrated. SdR 510014166 Nose landing gear actuator downlock pin migrated approximately 2mm (0.0078in) inboard to rest on the nose landing gear actuator pushrod, preventing full retraction. Pin is held in place by a small split pin which had broken. Aircraft landed with nose gear not fully extended and nose gear collapsed on landing. P/No: 12802091. TSN: 2,611 Hours/372 Months. Cessna U206G Wing, control surface attach fittings bracket cracked. SdR 510013959 (photo below) LH and RH aileron brackets PNo 1220052-17 and PNo 1220052-18 cracked. P/No: 122005217. TSN: 5,723 Hours. Gulfstream 500S Fuel wiring wiring burnt. SdR 510014224 L/H fuel Boost pump wiring found Burnt and exposed at connector during troubleshooting of a separate fault. Defect entered on maintenance release. Gulfstream 500S Trailing edge flap control system cable failed. SdR 510013922 Trailing edge flap cable failed. Investigation continuing. Gulfstream 500S Trailing edge flap control system cable frayed. SdR 510014219 Flap control cable when removed found to be frayed through 30% of cable strands. Cable failure would lead to assymetric flap condition. Defective cable was found as result of company directive to replace all primary flight control cables on AC50 fleet. This is 2nd cable failure of same type. It is believed that the flap cable is failing in an area that is not readily accessible for visual inspection. P/No: 50000439. TSN: 7,032 Hours/145 Months. Jabiru SP470 Nose/tail landing gear strut/axle suspension rubber deteriorated. SdR 510014120 (photo below) Nose landing gear suspension rubbers deteriorated and collapsed causing propeller to contact the ground. Aircraft is registered with Recreational Aviation Australia. TSN: 212 Hours.
Pac CT4B Ac alternator unserviceable. SdR 510013994 Alternator rotor driveshaft sheared. P/No: ER28C. TSN: 50 Hours. Parten P68B Aircraft fuel system filter contaminated. SdR 510014222 L/H engine reported to be intermittently running rough. Upon investigation severe corrosion and water contamination found in fuel system at inlet fuel filter (FCU) and airframe fuel filters both L/H and R/H. Piper PA23250 Elevator tab control system cable incorrect routed. SdR 510014249 (photo below) Trim cable incorrectly routed. Adjacent wire bundle had been shielded with electrical tape to prevent damage. P/No: 151310.
Cessna 182Q Horizontal stabilizer, plates/ skin skin incorrect repair. SdR 510014239 (photo below) Repair patch on horizontal stabilizer skin is found not to comply with Cessna 182 structural repair manual. P/No: 123260032. TSN: 4,403 Hours.
Giplnd GA8 Horizontal stabilizer, spar/rib rib cracked. SdR 510014006 Horizontal stabiliser rib flange cracked in area near RH inside attachment bolt hole. Found during inspection iawSB-GA8-2002-02 issue 6. P/No: GA855102123. Giplnd GA8 Horizontal stabilizer, rib cracked. SdR 510014138 Horizontal stabiliser RH rib cracked in rear lower area. Further cracking found in area of attachment bolt and spar doubler. Attachment bolt also found to be loose. P/No: GA85510111. TSN: 2,952 Hours/84 Months. Grob G115C2 Engine air intake system frame cracked. SdR 510014212 Induction air filter cage aft lower frame cracked and separated. Piece of frame entered the carburettor and partially restricted butterfly valve movement. P/No: 115C6601.
Cessna 208B Aileron tab structure hinge seized. SdR 510014052 Aileron trim tab hinge seized. TSN: 7,947 Hours/8,734 Cycles. Cessna 208B Engine air intake system lever cracked. SdR 510014190 Inertial separator lever cracked at middle attachment point. P/No: 265805713.
Piper PA31350 Navigation system navigation sys failed. SdR 510013914 KNS81 navigation system failed with smoke coming from component. Investigation found a blown capacitor. P/No: 066401000.
37

Reims F406 Brake brake failed. SdR 510013900 RH brake failed during taxi. Brake pedal hit the floor. Investigation continuing. Reims F406 Non standard equipment system inverter faulty. SdR 510013981 Electrical fumes in cockpit. Investigation found faulty mission system radar inverter. P/No: 1B10001G. Seabrd SB7L360A2 Ailerons doubler cracked. SdR 510014049 Aileron hinge doubler cracked in area of mass balance attachment. Investigation found similar cracking on another aircraft. Swrngn SA227AC Aileron control system cable unserviceable. SdR 510014041 Pilot reported autopilot would not hold heading or make commanded turns. P/No: 9923166001. Swrngn SA227dC Cargo/baggage doors handle incorrectly stowed. SdR 510013898 Cargo door warning activated. Investigation found door handle not correctly stowed in recess. Investigation continuing. Swrngn SA227dC Control column section bearing cap unserviceable. SdR 510014037 Pilot reported aileron controls felt stiff and binding. Engineering investigation confirmed the fault. P/No: KP16B. Swrngn SA227dC dc power distribution system switch unserviceable. SdR 510014252 Bus tie switch intermittent in operation. Switch had been fitted iaw Fairchild SB CC7-24-12. P/No: 8781K11. TSN: 628 Hours/486 Cycles/8 Months. Swrngn SA227dC Pitch Trim actuator actuator faulty. SdR 510014216 Stabiliser trim actuator slow in operation followed by increasing requirement for forward control pressure. Investigation continuing. P/No: DL5040M8. TSN: 4,653 Hours. TSO: 4,653 Hours. Swrngn SA227dC Trailing edge flap actuator actuator cracked and leaking. SdR 510014099 RH flap actuator casing cracked and leaking. P/No: 2736053001. TSN: 19,486 Hours/24,379 Cycles. Jabiru JABIRU2200B Reciprocating engine internal oil system dipstick incorrect length. SdR 510014122 Oil dipstick approximately 38.1mm (1.5in) too short. Engine had just been overhauled. Aircraft is registered with Recreational Aviation Australia. Lycoming IO360L2A Reciprocating engine cylinder section exhaust valve stuck. SdR 510013935 No4 cylinder exhaust valve stuck open. P/No: LW19001. TSN: 3,202 Hours. Lycoming IO540k1A5 Engine fuel pump pump damaged. SdR 510014089 Engine driven fuel pump failed. Spline failed. Lycoming IO540k1A5 Engine fuel pump failed. SdR 510014014 Engine driven fuel pump internal failure. Investigation continuing. P/No: 201F5003R. TSO: 434 Hours/8 Months. Lycoming LTIO540J2Bd Reciprocating engine power section crankcase cracked. SdR 510014147 RH engine Rh crankcase half cracked from No3 cylinder base. Crack length approximately 100mm (4in). P/No: 11F20022D3. TSO: 1,045 Hours. Lycoming O360J2A Fuel control/reciprocating engines arm broken. SdR 510014208 Carburettor mixture control arm broken at cable attachment bolt hole. TSN: 427 Hours/10 Months. TSO: 427 Hours/10 Months. Lycoming O540F1B5 Reciprocating engine cylinder section plug failed. SdR 510014248 (photo below) Piston pin plug failed causing major damage to piston. P/No: 72198. TSN: 1,008 Hours. Agusta Westland AW139 Hydraulic system, main hose failed. SdR 510013961 (photo below) No1 Pressure Control Module (PCM) hydraulic pressure hose ruptured. Loss of hydraulic fluid. Hydraulic pump replaced due to suspected dry running. P/No: A494AE3E00E0580X. TSN: 1,434 Hours/3,812 Landings/35 Months. Agusta Westland AW139 Ac power distribution system relay unserviceable. SdR 510013940 Main battery relay (K3) failed. Investigation found evidence of heat damage on the external surfaces of the relay. P/No: 11526203. TSN: 1,620 Hours/4,442 Cycles/4,442 Landings/48 Months. Agusta Westland AW139 Fuselage main, plates/skin cowling cracked. SdR 510013998 (photo below) Top forward cowl cracked on internal surface at Stn 6445 located above the No1 engine air intake. P/No: 3G7106P08431. TSN: 464 Hours/834 Landings/12 Months.
PISTON ENGINES
Continental IO520C Reciprocating engine internal oil system contam-metal. SdR 510013923 Engine oil system contaminated with metal. Low compression also found in No6 cylinder. Engine returned to manufacturer under warranty. Continental IO520L Reciprocating engine power section nut split. SdR 510014135 (photo below) Engine No4 cylinder through bolt nut cracked/split. TSN: 686 Hours. Lycoming TIO540A2B Reciprocating engine power section crankshaft broken. SdR 510014101 RH engine crankshaft broken through No6 connecting rod journal/counterweight cheek. P/No: 13F17776. TSO: 486 Hours/64 Months. Lycoming TIO540J2Bd Reciprocating engine power section stud sheared. SdR 510013952 No5 cylinder bottom rear holddown stud sheared flush with cylinder base. P/No: 5015. TSO: 520 Hours. PWA R985AN14B Reciprocating engine cylinder section engine cylinder separated. SdR 510014042 No2 cylinder head separated from barrel. Cylinder stamped UT10 (ultrasonic inspection 2010). P/No: 126742. TSO: 183 Hours. Continental TSIO520vB Reciprocating engine low oil pressure. SdR 510014072 RH engine oil pressure low. Investigation found oil filter and pressure relief valve contaminated with a large amount of carbon pieces as well as scoring of the oil pressure relief valve seating surface. Agusta Westland AW139 Hydraulic system, main hose leaking. SdR 510013970 No2 main servo system hydraulic hose fire shielding ruptured and hose leaking from the edge of the swaged fitting. P/No: A494AD2C00C0496X. TSN: 1,634 Hours/4,477 Cycles/4,477 Landings/48 Months. Eurocopter EC135T2 Engine egt/tit indicating system probe broken. SdR 510014090 (photo below) No2 engine thermocouple probe broken. Probe is located at the 4 oclock position. P/No: TC26801. TSN: 458 Hours/537 Cycles/1,338 Landings.
ROTORCRAFT
Agusta-Bell A109E Exterior lighting wire worn. SdR 510014034 Position light wire insulation worn through and short circuiting where unsupported wire passes through internal lightening holes in the stabilator.
38

Eurocopter EC225LP Aircraft fuel distribution system jet pump blocked. SdR 510013905 Forward fuel tank jet pump blocked preventing fuel transfer. P/No: 332A5211610001. TSN: 2,824 Hours. Sikorsky S76C Main rotor gearbox gearbox corroded. SdR 510014260 Main rotor gearbox No2 hydraulic pump mount bore corroded. P/No: 7635109600044. TSN: 8,383 Hours/15,002 Cycles. TSO: 2,575 Hours. Sikorsky S76C Rotorcraft servo system servo unserviceable. SdR 510014258 Aft main rotor servo feedback linkage drive pin displaced by approximately 40mm (1.57in). P/No: 7825001. TSN: 9,561 Hours/52,774 Cycles. Sikorsky S92A Tail rotor gearbox gearbox damaged. SdR 510014088 Tail rotor gearbox damaged by screw holding two hydraulic hose clamps together. Damage approximately 4.76mm (0.185in) diameter by 3.175mm (0.062in) deep. Investigation found clearance when static but vibration can cause the screw to contact the gearbox. P/No: 9235806100043. TSN: 2,860 Hours/2,372 Cycles/2,372 Landings/48 Months. TSO: 2,860 Hours/2,372 Cycles/2,372 Landings/48 Months. GE CFM567B Fuel controlling system HMU suspect faulty. SdR 510014237 Aircraft returned from taxi due No#2 ENG CONTROL light illuminated. No#2 engine hydro mechanical unit replaced. P/No: 5416744. TSN: 7,098 Hours/4,236 Cycles. GE CFM567B Turbine engine compressor section fan blade bird strike. SdR 510013984 No2 engine birdstrike. Investigation found significant damage to No 10 and No 11 fan blades. P/No: 3400010260. Lycoming LTS101750B1 Fuel control/ turbine engines fcu faulty. SdR 510013941 (photo below) No2 engine N1, N2 and torque decreasing to zero. Investigation found a faulty Fuel control Unit (FCU). FCU removed. P/No: 430128308. TSO: 444 Hours. PWA PW150A Fuel control/turbine engines fadec failed. SdR 510014063 LH engine Full Authority Digital Engine Control (FADEC) failed. Investigation continuing. P/No: 8193007008. TSN: 6,574 Hours/7,534 Cycles. PWA PW150A Turbine engine accessory drive drive failed. SdR 510014004 No1 engine failed. Preliminary boroscope inspection found the drive between the core engine and the accessory drive gearbox failed causing loss of fuel supply. Investigation continuing. Rolls Royce BR700710A220 Turbine engine accessory drive bearing suspect faulty. SdR 510014167 (photo below) Engine chip detector contaminated with a large amount of metal filings. Suspect caused by failure of the generator drive shaft bearings. Generator also failed.
TURBINE ENGINES
Allison 250B17C Fuel control/turbine engines fcu faulty. SdR 510013907 LH engine Fuel control Unit (FCU) faulty. FCU had been returned from overhaul but caused hot starts during engine ground runs following SDRit. P/No: 23065107. TSO: 861 Hours. Allison 501d13 Turbine engine oil system pump cracked and leaking. SdR 510014250 LH engine oil quantity diminishing. Investigation found the rear turbine scavenge pump cracked. P/No: 6821270. Garrett TPE33111U611 Engine (turbine/ turboprop) turbine engine inflight shutdown. SdR 510014031 Aircraft suffered an uncommanded yaw to the left. This was accompanied by an oil pressure warning light, sudden change in engine noise and a loss of airspeed. Left engine failure. Initial investigation by engineer found a quantity of metallic particles on the LH engine magnetic chip detector and some unusual noises from the LH engine gearbox when the propeller was rotated by hand. Last oil filter and SOAP sample 02Dec2011 with no unusual remarks. Further investigation and details to follow. Garrett TPE33112UH Engine (turbine/turboprop) turbine engine contam-metal. SdR 510014256 LH engine chip detector illuminated. Initial investigation found metal contamination. Engine removed for further investigation. GE CF680E1 Turbine engine turbine section sleeve incorrect part. SdR 510013972 Engine High Pressure Turbine (HPT) damper sleeve incorrect part for this model engine. Damper sleeve PNo 1327M75P02 should be fitted instead of PNo 1327M75P01. P/No: 1327M75P01. TSN: 28,464 Hours/5,040 Cycles. TSO: 28,464 Hours/5,040 Cycles. GE CFM567B Engine fuel pump leaking. SdR 510013985 No2 engine fuel pump leaking from 50.8mm (2in) blanking plug located on the top of the pump resulting in pump replacement. P/No: 8283005. TSN: 28,162 Hours/14,517 Cycles. TSO: 8,948 Hours/4,650 Cycles. Lycoming LTS101750B1 Fuel control/turbine engines fcu seized. SdR 510014100 No2 engine Fuel Control Unit (FCU) drive seized. FCU to fuel pump coupling internal splines stripped. Investigation continuing. P/No: 430128308. TSO: 2,050 Hours. PWA PT6A112 Fuel control/turbine engines fcu suspect faulty. SdR 510014077 During taxi after landing, No1 engine low oil pressure and generator warning. Engine shutdown. Smoke/fumes smelt so No2 engine shutdown and aircraft evacuated with fire services called. Investigation found No1 engine had flamed out due to a faulty Fuel Control Unit (FCU). P/No: 32447454. TSO: 270 Hours/131 Cycles/3 Months. PWA PT6A114A Fuel control/turbine engines fcu suspect faulty. SdR 510014078 Engine parameters all rose beyond take-off limits during cruise. Nil response to power lever and engine eventually cut at 11,000 feet with aircraft gliding to a successful landing. Suspect faulty Fuel Control Unit. Engine had only 2.2 hours operation since overhaul. Investigation continuing. PWA PT6A42 Turbine engine reduction gear damaged. SdR 510014053 Engine chip detector indication. Investigation found substantial sun gear, planetary gear and bearing damage in the reduction gearbox. PWA PW120A Fuel control/turbine engines plug dirty. SdR 510014175 No1 engine suffered a momentary power loss for approximately 2 seconds. No1 engine ECU plug cleaned. Slight fuel flow fluctuations during ground run but cleared when fuel flow transmitters were transposed. PWA PW150A Engine fuel distribution o ring deteriorated. SdR 510013956 LH engine leaking fuel from fuel heater transfer tubes. Investigation found deteriorated O ring seals PNo M83461-1-116 and PNo AS3209-126. P/No: M834611116.
Rolls Royce TAY65015 Fuel control/turbine engines FFR failed. SdR 510014030 LH engine failed to accelerate. Investigation found Fuel Flow Regulator (FFR) unserviceable. Investigation continuing. P/No: CASC509. TSN: 10,810 Hours/9,364 Cycles. TMECA ARRIUS2k Engine fuel distribution pipe worn and damaged. SdR 510014209 Main engine fuel supply line between HMU and fuel valve worn halfway through on 90 degree bend in area where the line passed through the fire shield. P/No: 0319739500. TMECA MAkILA1A Fuel control/turbine engines ecu unserviceable. SdR 510014069 No1 engine N1 rpm deteriorated accompanied by a large bang and yawing. Engine eventually stabilised. Investigation found a faulty Electronic Control Unit (ECU). P/No: 0177698350.
COMPONENTS
Fuel pump TRW Hartzell propeller inc 201F5003R Pump damaged. SdR 510014089 Engine driven fuel pump failed. Spline failed. Load frame cracked. SdR 510013969 Balloon burner load frame cracked in two places. P/No: KLF201088CBS. TSN: 199 Hours/228 Cycles. Sleeve incorrect part. SdR 510013972 Engine High Pressure Turbine (HPT) damper sleeve incorrect part for this model engine. Damper sleeve P/No 1327M75P02 should be fitted instead of P/No 1327M75P01. P/No: 1327M75P01. TSN: 28,464 Hours/5,040 Cycles. TSO: 28,464 Hours/5,040 Cycles.
39
APPROvEd AIRWORTHINESS dIRECTIvES 2 - 15 december 2011

ROTORCRAFT
Agusta A109 series helicopters 2011-0236 Main landing gear (MLG) actuator bracket attachment bolts - replacement/inspection Agusta AB139 and AW139 series helicopters 2011-0226-E Flight control collective control system inspection/installation Bell Helicopter Textron Canada (BHTC) 206 and Agusta Bell 206 series helicopters CF-2011-19R1 Incorrect assembly of hydraulic servo actuators Eurocopter AS 350 (Ecureuil) series helicopters 2011-0237 Engine controls - twist grip assembly adjustment/functional check/replacement Fokker F100 (F28 Mk 100) series aeroplanes 2011-0227 Wing and integral centre wing tanks modification (fuel tank safety) 2011-0233 Fuel - wing and integral centre wing tanks - inspection/modification Eurocopter AS 355 (Twin Ecureuil) series helicopters 2011-0244-E Lights - position strobe light inspection/deactivation
PISTON ENGINES
Teledyne Continental Motors piston engines 2011-25-51 Replacing CMI starter adapters due to fractures in shaft gears
ABOvE 5700kG
Airbus Industrie A330 series aeroplanes 2011-0242 Windows - fixed windows/windshield heating connectors - inspection/replacement Airbus Industrie A380 series aeroplanes 2011-0248 Fuel - feed tank 1 and/or 4 main and standby pump fault light flickering operational procedure AMd Falcon 50 and 900 series aeroplanes 2011-0246 Time limits and maintenance checks - airworthiness limitations - amendment/ implementation Boeing 737 series aeroplanes AD/B737/297 Amendment 2 - de-icing fluids and main wheel well electrical connectors Boeing 767 series aeroplanes AD/B767/243 Engine indication and crew alerting system - CANCELLED Boeing 777 series aeroplanes 2011-26-03 Prevention of electrical arcing on the fuel tank boundary structure or inside the main and centre fuel tanks Bombardier (Canadair) CL-600 (Challenger) series aeroplanes CF-2011-45 Horizontal stabiliser trim actuator attachment pins and trunnions not serialised Bombardier (Boeing Canada/de Havilland) dHC-8 series aeroplanes CF-2011-46 Burnt alternating current wire bundle under floor - cockpit door area Embraer ERJ-170 series aeroplanes 2011-12-01 Escape slide deployment failures Embraer ERJ-190 series aeroplanes 2011-12-02 Escape slide deployment failures Learjet 45 series aeroplanes 2011-25-03 Main landing gear actuator end cap fatigue cracking
TURBINE ENGINES
International Aero Engines AG v2500 series 2011-25-08 High-pressure turbine (HPT) Pratt and Whitney turbine engines - JT9d series 2011-25-10 High-pressure compressor Pratt and Whitney turbine engines PW4000 series 2011-25-09c High-pressure turbine stage air seal Rolls Royce Germany turbine engines BR700 series 2011-0232 Engine - low-pressure (LP) compressor booster rotor - inspection/rework
BELOW 5700kG
Aerospatiale (Socata) TBM 700 series aeroplanes 2011-0235-E Nose landing gear (NLG)/actuator axle attaching bolt - check/replacement
ABOvE 5700kG
Airbus Industrie A319, A320 and A321 series aeroplanes 2011-0229 Forward fuselage frame (FR) 24 - inspection/repair 2011-0231 Fuselage - windshield central lower node continuity fittings - inspection/repair Boeing 737 series aeroplanes 2011-24-12 Fuselage skin at stringers S1 and S2 right, between STA 827 and STA 847 Boeing 767 series aeroplanes 2011-25-11 Operating program software for engine indication and crew alerting system Fokker F27 series aeroplanes 2011-0228 Wing main tanks - modification (fuel tank safety) 2011-0234 Fuel - main wing tank - inspection/ modification Fokker F28 series aeroplanes 2011-0227 Wing and integral centre wing tanks modification (fuel tank safety) 2011-0233 Fuel - wing and integral centre wing tanks - inspection/modification Fokker F50 (F27 Mk 50) series aeroplanes 2011-0228 Wing main tanks - modification (fuel tank safety) 2011-0234 Fuel - main wing tank - inspection/ modification
EQUIPMENT
Emergency equipment 2011-25-01 Apical Industries emergency float kits
15 - 31 december 2011
ROTORCRAFT
Bell Helicopter Textron Canada (BHTC) 206 and Agusta Bell 206 series helicopters AD/BELL 206/130 Amendment 3 Main landing gear cross tubes - CANCELLED CF-1995-17R1 Main landing gear cross tubes Bell Helicopter Textron Canada (BHTC) 407 series helicopters CF-2011-17R1 Incorrect assembly of hydraulic servo actuators Bell Helicopter Textron 427 series helicopters CF-2011-17R1 Incorrect assembly of hydraulic servo actuators Bell Helicopter Textron 412 series helicopters 2011-0247 Main Rotor - collective lever - inspection/ replacement Eurocopter AS 350 (Ecureuil) series helicopters 2011-0244-E Lights - position strobe light inspection/deactivation
PISTON ENGINES
Engines - general 2011-26-07 Champion Aerospace (formerly Unison Industries) (slick) magneto SMA piston engines AD/SMA/4 Air inlet manifold hose clamps CANCELLED 2008-0078R1 Engine air - air inlet manifold hose clamps - inspection
continued on page 42
TO REPORT URGENT DEFECTS
CALL: 131
757
FAX:
02 6217 1920
or contact your local CASA Airworthiness Inspector [freepost] Service Difculty Reports, Reply Paid 2005, CASA, Canberra, ACT 2601 Online: www.casa.gov.au/airworth/sdr/
40
AIRWORTHINESS Data recovery
FiShiNG FOR ChipS
Modern electronic devices are giving accident investigators a new way of investigating aircraft crashes
Flight data recording is no longer the exclusive preserve of airline transport operations. It is entering general and sport aviation almost by stealth, as accident investigators exploit the data-recording potential built into modern consumer electronics. Theres some digital data in almost every crash now, says Alex Talberg, technical investigator with the Australian Transport Safety Bureau (ATSB). Most electronics these days uses flash memory, whether its for processing data or for storage of dates or last known information. Flash memory can withstand huge impact loads and fairly high temperatures. Ive seen research that says that data is only completely lost at 450 degrees Celsius. Its generally a stable and robust recording medium. Recreational Aviation Australia (RA-Aus) operations manager, Zane Tully, says some modern GPS units automatically record and store a history of height and track data of the aircrafts most recent travels. In older versions this function may need to be enabled, he notes. In many cases a GPS units memory was downloadable and when analysed, provided valuable information about the fateful flight. The ATSB generously assists RA-Aus (and the police for that matter) with data recovery from all types of devices like: GPS, EFIS, iPad and even engine management systems that have inbuilt data recording software and memory, Tully says.
41
Among the devices that cross Talbergs desk after a crash are smartphones GPS receivers, (we see a lot of them, often damaged), fuel computers, engine monitoring units and engine management systems. Engine electronics contain flash memory for data logging, or to store the maps of engine fuel, ignition and spark configurations. We get on average now two or three devices to work on from any aviation accident. Well often get a portable GPS or a phone. There was one accident where there were four people on the aircraft and three smartphones were recovered, Talberg says. We had another accident where we had a GPS and an iPad. The GPS recorded up to five minutes before the accident because of buffering, which is where it records to volatile memory and then transfers that on to its non-volatile memory. Because of that buffer we lost the last five minutes of data on the GPS, but the iPad we analysed had exactly the same track, but continued all the way to impact. The electronic devices that end up on Talbergs desk fall into two categories: undamaged units, from which information is relatively easily downloaded; and damaged units, which require one of three techniques to extract their secrets. First, we try to fix the device, says Talberg.If that doesnt work, we transfer the memory on to a golden chassis unit and download from it that way, substituting a working unit for the damaged one. The third alternative is to download raw binary data from the flash memory itself. You get binary data of zeroes and ones that has to be interpreted. We then either work with the device manufacturer to decode it, or reverse engineer the information by downloading known data on an identical device. The ATSB undertakes about three investigations annually involving this level of in-depth data recovery from damaged electronic devices. Talberg says a global community of investigators is developing, based around sharing information on how to extract data from electronic devices. One of the first things well do is ask several international agencies if they have had any experience with similar units, he says. A complicating factor is the rapid evolution of consumer electronics, which means that different models of the same device may use different components behind a similar interface. Talberg says the increasing presence of flash memory devices can have a positive effect on safety, provided they are set to record data. He encourages pilots who carry and use handheld or built-in flash memory equipment to set it up to record flight data. No-one sets out to have a crash, but if the worst does happen, this is a way to help investigators find out what happened - and contribute in a small way to aviation safety, he says. Tully says; It goes without saying that ATSBs assistance is a valuable and integral affiliation that RA-Aus is thankful for. This type of information is invaluable to RA-Aus investigators as it can add a major piece to the accident puzzle.
Clues to a Spitfire mystery

On 22 October 2010, a replica Supermarine Spitfire MK26 recreational/light sport aircraft crashed near Gympie authorised landing area, in Queensland, killing the pilot, Barry Uscinski, 75. A former defence scientist and academic, Uscinski was also a highlyregarded, aerobatic-rated GA pilot. Recreational Aviation Australia (RA-Aus) assisted the Queensland Police in their investigation of the crash. Although it had no flight recorder, the Spitfire replica had an automotive engine with a Motec M600 engine management system. RA-Aus asked the Australian Transport Safety Bureau (ATSB) for technical assistance to recover data from the M600s flash memory. ATSB technical investigators removed conformal coating from the circuit board and removed the flash memory from the circuit board using a hot-air rework station. The investigators practised on a sample circuit board provided by the manufacturer before attempting the operation. On 2 May 2011, they successfully recovered binary data from the flash memory. The data allowed conclusions to be drawn about engine rpm, manifold pressure and throttle position during the Spitfires final flight, which it logged at 16 minutes and 44 seconds. This information has been sent to the Queensland state coroner.
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APPROvEd AIRWORTHINESS dIRECTIvES ... CONT

continued from page 39
Teledyne Continental Motors piston engines 2011-26-07 - Champion Aerospace (formerly Unison Industries) (slick) magneto
TURBINE ENGINES
Engines - general 2011-26-07 Champion Aerospace (formerly Unison Industries) (slick) magneto AlliedSignal (Garrett/AiResearch) turbine engines - TFE731 series AD/TFE 731/33 Amendment 1 - LPT stage 1 nozzle and disks Rolls Royce turbine engines - RB211 series 2011-0243 Engine - low pressure (LP) fuel tubes and clips - inspection Turbomeca turbine engines - Arriel series 2011-0249 Engine fuel and control - digital engine control unit (DECU) - identification/replacement
Bombardier (Boeing Canada/de Havilland) dHC-8 series aeroplanes CF-2012-01 Beta warning horn system failure CF-2012-02 Rudder control system - seizure of the rudder feel trim unit CF-2012-03 Electrical power - wire chafing within the alternating current contactor box British Aerospace BAe 146 series aeroplanes 2012-0003 Ice and rain protection - wing leading edge anti-icing piccolo tube end cap - inspection Embraer ERJ-190 series aeroplanes 2012-01-01 Main landing gear (MLG) side stay Fokker F28 series aeroplanes 2011-0227R1 Wing and integral centre wing tanks modification (fuel tank safety) Fokker F100 (F28 Mk 100) series aeroplanes AD/F100/34 Amendment 2 - nose landing gear main fitting - CANCELLED 2011-0227R1 Wing and integral centre wing tanks modification (fuel tank safety) 2012-0002 Landing gear - nose landing gear main fitting - inspection/modification/replacement
Beechcraft 50 (Twin Bonanza) series aeroplanes AD/BEECH 50/34 Beechcraft forward elevator cable - replacement Beechcraft 55, 58 and 95-55 (Baron) series aeroplanes AD/BEECH 55/98 Beechcraft forward elevator cable - replacement Beechcraft 56TC (Turbo Baron) series aeroplanes AD/BEECH 56/36 Beechcraft forward elevator cable - replacement Fairchild (Swearingen) SA226 and SA227 series aeroplanes AD/SWSA226/43 Amendment 7 - supplemental inspection program and life limited items
ABOvE 5700kG
Airbus Industrie A319, A320 and A321 series aeroplanes AD/A320/147 Amendment 2 - life limited and monitored parts - CANCELLED 2012-0008 Time limits and maintenance checks safe life airworthiness limitation items - ALS Part 1 - Amendment 2012-0012 Flight controls - flap interconnecting strut - identification/modification/ replacement Airbus Industrie A330 series aeroplanes 2012-0009 Flight controls - spoiler servo controls (SSC) - Identification/operational test Airbus Industrie A380 series aeroplanes 2012-0010 Indicating and recording systems - flight data recording system (FDRS) - software installation 2012-0011 Auxiliary power unit (APU) air intake duct access cover cut-out - inspection/repair 2012-0013 Wings - wing rib foot - inspection Airbus Industrie A330 series aeroplanes 2012-0015 Flight controls - flap interconnecting strut - identification/modification/ replacement Boeing 767 series aeroplanes 2011-25-05 Main fuel tank boost pumps and centre auxiliary tank override and jettison pumps Bombardier (Boeing Canada/de Havilland) dHC-8 series aeroplanes CF-2012-04 Hydraulic accumulators - screw cap/ end cap failure CF-2012-05 Chafing of the wire harness at the wing leading edge British Aerospace BAe 146 series aeroplanes 2012-0004 Time limits/maintenance checks - airworthiness limitations - amendment/ implementation
EQUIPMENT
Radio communication and navigation equipment 2011-0239 Navigation - radio altimeter indicator- modification
PISTON ENGINES
Lycoming piston engines AD/LYC/90 Amendment 2 - fuel injection supply lines Teledyne Continental Motors piston engines AD/CON/60 Amendment 3 - fuel injection supply lines AD/CON/81 Amendment 1 - Unison Industries (slick) magnetos - CANCELLED
1 - 12 January 2012
ROTORCRAFT
Bell Helicopter Textron 212 series helicopters 2012-0001 Main rotor - main rotor blades inspection/replacement Enstrom F-28 series helicopters 2011-26-10 Modification of the lateral and longitudinal trim actuator assembly Eurocopter SA 360 and SA 365 (dauphin) series helicopters AD/DAUPHIN/94 - main rotor drive - CANCELLED 2007-0288R1 Main rotor drive - main gearbox (MGB) planet gear carrier - inspection/replacement kawasaki Bk 117 series helicopters TCD-7805A-2011 Flight manual temporary revision - generator failure
TURBINE ENGINES
General Electric turbine engines - GE90 series 2009-25-14 Stage 6 LPT blades 2011-26-11 Inspection of stages 1-2 seal teeth of the HPC stages 2-5 spool Rolls Royce Germany turbine engines BR700 series AD/BR700/10 Amendment 1 high-pressure turbine (HPT) time limits - CANCELLED 2007-0152-CN engine high-pressure turbine (HPT) disc assembly - reduction of the time limits manual maximum approved
BELOW 5700kG
Beechcraft 55, 58 and 95-55 (Baron) series aeroplanes 2011-27-04 Airspeed indicator - STC SA1762SO Beechcraft 200 (Super king Air) series aeroplanes AD/BEECH 200/67 Amendment 6 - fuselage rear pressure bulkhead
13 - 26 January 2012
ROTORCRAFT
Agusta A109 series helicopters 2011-0236 (correction) Main landing gear (MLG) actuator bracket attachment bolts - inspection/ replacement
ABOvE 5700kG
Airbus Industrie A330 series aeroplanes 2012-0005 Fuselage - belly fairing rods - inspection Beechcraft 1900 series aeroplanes 2011-27-51 Elevator bob weight (stabiliser weight) Boeing 737 series aeroplanes AD/B737/297 Amendment 3 - de-icing fluids and main wheel well electrical connectors 2011-26-09 Replacement of the thumbnail fairing edge seals 2011-27-03 Horizontal stabiliser trim actuator (HSTA) - inspections/lubrication/overhaul/ modification
BELOW 5700kG
Beechcraft 33 and 35-33 (debonair/Bonanza) series aeroplanes AD/BEECH 33/48 Beechcraft forward elevator cable - replacement Beechcraft 35 (Bonanza) series aeroplanes AD/BEECH 35/74 Beechcraft forward elevator cable - replacement Beechcraft 36 (Bonanza) series aeroplanes AD/BEECH 36/54 Beechcraft forward elevator cable - replacement
PISTON ENGINES
Teledyne Continental Motors piston engines AD/CON/60 Amendment 4 - fuel injection supply lines
TURBINE ENGINES
General Electric turbine engines - CF34 series 2012-01-10 CVD support assembly removal from service and determination of fan drive shaft serviceability
43
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44
FEATURE Sharing the sky
ShARiNG ThE Sky ... bALLOONS

Aerostation (the art of ballooning) in Australia began in 1964, more than 200 years after the first manned balloon flight in the skies above Paris. There are currently over 400 registered (but not necessarily active) hot air balloons in Australia, mostly flying along the east coast, with a few in Western Australia and South Australia. These balloons operate under two distinct Australian organisations: the sport balloonists (represented by the Australian Ballooning Federation [ABF]); and commercial balloonists, (represented by the Professional Ballooning Association of Australia [PBAA]). About 230 of Australias 400-plus balloons belong to the ABFs 290-or-so members, who fly over 1100 hours annually. There are about 30 commercial operators in Australia, most of whom belong to the PBAA. Together these commercial operators fly for about 10,000 hours and carry 150200,000 fare-paying passengers annually. The larger commercial balloons can carry up to 24 passengers in ideal conditions. Balloons in Australia range in size from 19,000 to 450,000 cubic feet, and can be up to 130 feet tall. Generally, sport balloons are smaller and less expensive than those operated commercially. Sport balloons are not permitted to carry farepaying passengers. Australia has a significant record in international competition and achievement, per capita and size, in comparison to the rest of the ballooning world.
Balloons tend to fly in the early morning to take advantage of decoupled catabatic or drainage winds, temperature inversions and stable atmospheric conditions. Experienced balloon pilots have an impressive knowledge and understanding of micrometeorology and regularly navigate their aircraft to exact predetermined points. Balloons travel with the wind, and vertical control is extremely precise. Nine fare-paying passenger balloons recently flew from Bundoora in Victoria to Moorabbin aerodrome and landed, as pre-arranged, between the runways.
Equipment carried
Altimeter, variometer, envelope temperature indicator, timepiece, compass, fire extinguisher, ground handling drop line, GPS, UHF air-to-ground radio, VHF radio, and transponder where required. There is no air speed indicator because there is no airspeed in a balloon.
Licensing
Recreational or sport ballooning refers to pilots who hold a private balloon certificate issued by the Australian Ballooning Federation and who do not carry fare-paying passengers. The ABF is responsible for the day-to-day administration of recreational ballooning in Australia, and under arrangements with CASA, carries out safety and surveillance duties. These include: Safety issues Landowner relations Production of operations manual Training and issuing certificates for pilots, instructors and examiners The Professional Balloon Association of Australia has three classes of membership: AOC holders, commercial pilots and associates (manufacturers, maintainers, legal and insurance advisors etc.) Some commercial operators run training courses for aspiring commercial pilots. For a private licence from a zero hours starting point, you need about two weeks, during which you would have a minimum of 16 hours flight instruction and, provided your progress is satisfactory, a flight test. An Australian commercial licence requires a minimum of
Where do they fly?

Recreational balloons cannot operate in controlled airspace (unless authorised by CASA), but can access registered aerodromes, as long as they carry and use radios and transponders, as appropriate. They usually fly below 3,000 feet, but the current Australian (hot air) altitude record is 37,839 feet (11,533 metres), and the world (gas) altitude record 113,740 feet (34,668 metres). When flying over populated areas balloons currently must be at or above 1,000 feet above ground level, but this is about to change to 500 feet.
Photos 1-5, 7-8: courtesy of Andrew Chapman, photo 6, courtesy of Paul Gibbs
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75 hours flying experience plus eight hours of advanced training. Australian licences are much respected (and sought after) in commercial operations internationally. This may partly be due to ballooning being taken up by people who are already involved in other forms of aviation, but also because licensing here is taken more seriously by operators and the regulator than in many other nations around the world.
Safety and balloons

Australias last hot air ballooning fatalities were in 1989. In October of that year, four people were killed in two separate accidents (both involving wirestrike), and earlier in 1989, 13 people died near Alice Springs in a mid-air involving two balloons. The chief pilot and flying instructor at Brisbane Hot Air Ballooning, Steve Griffin, was quoted in The Sydney Morning Herald in January 2012 as saying most power line incidents occurred in good weather, when people were relaxed and the flight was going beautifully. Its very important that when conditions are very benign you dont let your guard down, because thats when these types of incidents tend to happen and they happen to pilots of all levels of experience. CASA has developed draft guidelines requiring commercial balloon operations to implement a safety management system that includes low-flying procedures. The new rules will be released for public comment later in 2012. CASA has also advised the ABF on developing a coordinated training package Cost of ballooning for instructors. A complete type-certified Damian Croc, chief executive sport balloon for private of Professional Ballooning operators, with two to Association, quoted in four people on board January 2012 in a WA regional (POB),costs $5070,000 newspaper, said Australia had new, or around $20,000 an exemplary ballooning safety for a good second-hand record. Australian commercial aircraft. An average hot air balloon companies charter balloon with operate under strict regulations eight to 11 POB costs [with] extensive operations from $160,000 new. The manuals subject [to] regular envelope (specialised audit by CASA. Commercial nylon/Nomex fabric) lasts balloon pilots here are also 400 to 600 hours and the subject to regular supervised basket (wicker/stainless flight reviews to ensure safety, steel) lasts at least 1500 Croc concluded. hours. LPG/propane fuel is 65c per litre (60 to Further reading 150 litres used per hour). One or two people with a CAAP 157-1(0) Balloon 4WD and trailer follow the flight over populous areas balloon as retrieval crew. CAO 95.54
Sharing the skies with balloons

Balloons are very visible and move very slowly. If an aircraft comes out of cloud and sees them, it will be easier for it to avoid them than vice versa. Balloon envelopes are made in contrasting colours, to help others to see them even better. Below 500 feet, balloonists exercise extreme caution, care and vigilance. They always do downwind landings. They do not do circuits on landing. They carry and use radios and transponders, as required. Please keep in touch. Balloons are registered and subject to regular airworthiness checks and maintenance. Optical illusions can make balloons look closer and higher than they actually are. Balloons have been reported to be in one location, but tracked on radar somewhere quite different. They are courteous and polite to land occupiers and respectful of landowners rights, and make reasonable efforts to obtain permission prior to entering private property. They leave launch and landing areas in the same condition as they found them, with gates, fences and locks as they were. They fly in a manner that does not unduly disturb residents or animals. They always ascertain the location and dimensions of, and any restrictions associated with, sensitive zones prior to flying. They avoid known sensitive zones, and communicate information about new or changed sensitive zones to all other pilots and operators.
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CLOSE CALLS Scud running
In the late 80s I was working at a flying school in Parafield, as a junior grade 3 instructor the lowliest of the staff building my hours and experience in the way everybody seems to have to. It was my first job since obtaining my rating, and at first I was grateful - there were plenty of aircraft and students, and the weather was generally excellent. What more could I want? Well pay, for one thing. Sadly, this was in short supply as I was only paid for flight time no retainer, and no briefing and was expected to be available seven days a week and 24 hours a day (how I ran my logbook was my business I was told!). I did what I was told, when I was told, and accepted the instructions of my boss. This was almost my downfall one day, when I was tasked with a two-hour navex with a student in one of the Cessna 172s we had on line. It was to be part of a multi-aircraft exercise, where three students would fly the same basic route, leaving at 10-minute intervals, with the middle aircraft (mine) doing the route in reverse. Normally, this would have been fine, and it wasnt the first time Id done this, but the weather was deteriorating, and the forecast was for low cloud and rain, just when I would be trying to come back in over the Adelaide hills via the lane of entry. As it was, much of the route would need to be flown at low level, as the pre-frontal
cloud was already down to 2-3000 feet. The aircraft departing before and after me were planned to fly initially out to the east, and then track northwards, eventually completing a huge loop almost up to Port Pirie and returning to Parafield via the coastal training areas. This would have them potentially scud running along the coast, but that was much more acceptable than trying to come in over the ranges with the same cloud base the path I was assigned. I was concerned about this and approached the chief flying instructor suggesting that I too should take the anti-clockwise route. It wouldnt have been any problem to replan, and the student was already working on that anyway. He wouldnt give me a reason, just a firm no. This was not what Id anticipated, but I was just the junior, so my student and I dutifully boarded our trusty steed and departed. The navex went quite well for the first forty minutes or so, as we flew along the coast past Dublin and Long Plains, and then across to Clare and Burra before turning southwards for the lane of entry and then Parafield. All the way, I was monitoring the developing weather, and eventually decided that I needed to cut the navex short, so had my student divert as early as possible and track around the Edinburgh control zone and training areas so that we could arrive at South Para reservoir
Scud running
A junior instructor does as he is told and lives to regret his ber obedience
Name withheld by request
47
in a timely fashion. In spite of this, we found that the low cloud and rain had beaten us there and we were now as predicted stuck on the wrong side of the ranges. Since there was clearly no way we could get through the lane of entry, we continued southbound in the forlorn hope that the weather might improve sufficiently to allow a VFR transit of Adelaides control zone and back to Parafield that way. We got all the way to Murray Bridge without a single opportunity to cross the ranges. Eventually, we turned northwards again and found ourselves about 35 miles northeast of South Para, with nowhere else to go. Our options were now limited, and for a while it looked as if we might have to divert to Waikerie or Renmark to land, leaving us without transport, or funds, in a remote airfield on a Friday afternoon! Not a particularly inviting prospect, but one we had to consider. The other option was to call Adelaide Approach and ask for a low-level transit of Edinburghs control zone to arrive into Parafield from the north. We did this, and after a little dodging around low cloud, managed to weave our way overhead Edinburgh. I had also dialled up the NDB as additional navigational assistance, but insisted that my student maintain visual contact with the ground, even if we got a little low. Otherwise, we would turn around and head back for Waikerie.
Just north of Edinburgh, we encountered a very low band of cloud around 300 feet but it was only narrow. The visibility below it was good enough to see Parafield, so we continued, calling visual with the airfield and being transferred to the tower frequency. We flew a normal, low-level circuit, followed by a very welcome landing. Home at last. Needless to say, the other two aircraft were already parked and everybody had gone home for the weekend. Even the CFI had departed even though I still required direct supervision as a junior. Thanks a lot boss! My student and I put the aeroplane to bed, and I sent him home after a thorough debrief. Once alone, I took out an incident report form, and documented everything for the (then) DoT examiner who was likely to require some answers. I placed the completed form on the bosss desk and went home. Next morning, I got a very irate phone call from him, telling me that it was none of the DoTs business, and that he would not be submitting the report as he didnt need the interference that would result. It was interesting to see his attitude, as I had been told when I joined the company that we do things the right way no exceptions! I phoned the local inspector to talk over the situation anyway. He was concerned about the attitude of my boss, but together we worked out that I had acted appropriately in the end, even though I should never have departed Parafield in the first place. I had learned several very valuable lessons that day: 1. Even though you may be junior in experience, you must use that experience and your judgement to keep you out of situations that could ultimately be dangerous or difficult to recover from. Always leave yourself an escape route, or plan for an early termination of the flight even if it means you have to wait it out a long way from home. 2. Never be frightened to stand up for what you believe to be the right course of action. If it doesnt feel right, it probably isnt right! Dont be bullied by superiors or peers into doing something you know to be foolhardy, wrong or illegal. (See rule number 1) 3. Having found yourself in a difficult situation, never give up. Work carefully and find the best solution, and dont be afraid to ask for help from the air traffic controllers. They dont want you in trouble any more than you do, so they will work with you. 4. Dont be afraid to own up to the authorities if you feel the safety of the flight was in doubt, or you broke some rules. Generally, you will find a willing listener, and sage advice. You may still be punished or cautioned, but it will be worse if they have to come looking for you! 5. Embarrassment contrary to popular belief is not fatal. Foolhardiness however, can be.
Born toFl y
48
CLOSE CALLS Born to fly
Experience and recency: fuelling the debate
The gentle hum of the large turbo jet engines nursed me to sleep on my way back to Hong Kong. I was one month old in my first log book entry and my father, a Cathay Pacific captain, was proudly bringing me home on my first flight from Brussels, Belgium, arriving in Kai Tak at precisely 0115 on 27 Oct 1984. I know that he was already hoping I would become a pilot like him some day. Twenty-three years later I found myself working towards my private pilot licence. I was sitting in the left seat of a Cessna 172, a bit nervous, but very excited about my first flight in this new type after graduating from the Cessna 152. I began to go through the checklists and asked my instructor if the fuel switch was in the on position. After a quick glance and an OK from him, we completed the rest of our checks and taxied down the runway for the pre-flight take-off checks. I took another quick glance at the fuel valve and all was looking good to go for my first flight as pilot in a C172. It had been six months since my last flight, and I caught myself trying to remember all the important safety steps. My head was full of V speeds for this first C172 flight. At that early point in my career I also knew I wasnt familiar enough with the sound of the engine, or how the aircraft was handling to diagnose any problems. We finished our pre-flight take-off checks and began to line up for the take-off. I started to give the aircraft more power as we rolled down the runway. So many things were running through my head, Ts Ps green, airspeed live, no fire. Everything was looking good as we lifted off the ground, but, without any warning, the engine started to sputter and cough. Before I knew what was happening my instructor cut in and said I have control. I replied You have control and he began to turn us around in preparation for an immediate landing. The tension was clear, and I could tell by the sound of his voice that we were not safe, as he alerted the tower to our return for a low-level circuit for immediate landing. That fear in his voice was nothing compared to the sound our engine was making as we began our descent, and prepared for our emergency landing.
After a few precious and very nerve-wracking seconds we managed to land smoothly and safely before we taxied off the active runway. We came to a complete stop, breathed a sigh of relief and my instructor began to examine the cockpit. After a few moments he stopped and stared, his head looking down at the fuel valve and his eyes wide open. The fuel valve is off!
Analysis
The dangers of flying a new type of aircraft are found in unexpected places. Thanks to standardisation of instrument cluster layouts and engine control levers, some of the traps and confusions are gradually being eliminated. In this case the fuel valve on a C172 is quite different to that on a C152. The rotary type of valve on the C172 can be selected to left, right, off, or both tanks, with no separate off switch in earlier models. The C152 fuel switch is much simpler, with just an option for on or off. The run-up checks say that the fuel valve should to be set to both tanks. The valve is similar looking to a pool pump valve lever, which I had used only a few days earlier while doing routine pool maintenance at our house. Perhaps my familiarity with this system had affected my judgement as to where the lever should be positioned for the selection desired. I have since learned that a C172 is nothing like a pool pump, even though it had me swimming in my own juices. I set the C172s valve to what I thought was both tanks. I had my doubts and because I had never operated this system before I asked my instructor whether I had indeed switched the valve to the on position. He glanced down and nodded in acknowledgement. He might have misheard my question and probably didnt imagine that anybody could make a mistake with such a simple system. He might have also not realised how confusing a fuel valve could be to someone who had just graduated from the C172s little brother, which was almost identical in operation. Further research has shown that I am only one of many who have fallen into this trap.
49
After a few moments he stopped and stared, his head looking down at the fuel valve and his eyes wide open. The fuel valve is off!
Instructor-student trust is important so that the student can gain confidence and autonomy in their flying. Too much trust can cause dangerous situations, as we both found out. Also, trusting your instructor to know everything about you and your level of knowledge can create potential crises. My lack of knowledge of the fuel system could have been our downfall, as I had spent all my study time learning the C172s limitations, speeds and procedures. My questions should not have been is the fuel on? but rather, - how do I operate the fuel system? which would have necessitated a full answer with undivided attention rather than a quick nod.
In run-up and pre-take-off checks we both glanced down and saw what we thought was a fuel gauge set to both tanks. We had checked this valve three times and seen off without realising it. If our subconscious had a voice it would have been screaming Look! Its off! The aircraft took off and climbed to about 300ft before it protested that it was starving. How could we have done all our checks, taxied all the way across the airport and taken off without any fuel being fed to the engine? People have told me since that this is an impossible situation, but the aircraft had just been fully fuelled and must have had enough fuel in her lines to take us up and very quickly back down again. If the fuel had been exhausted just seconds later we would have been over factories and houses with very limited landing options, if any. It is lucky in a way that the active runway was so far from our starting point, and that our engine starting quitting when it did. My instructor was very quick to recognise the problem and immediately acknowledged the need to land as quickly as possible. My flying instincts had become dormant in the months preceding the flight and I was not able to recognise the problem as rapidly as he did a wake-up call about the importance of experience and recency to safe flying.
Recommendations
OTH LAN FF B EO HT 33 GAL ATT DING K ITU TA FLIG DE S LL A

LEFT
Ask for an elaborated answer to questions relating to important systems and procedures. Instructors should look out for student mistakes in even the simplest tasks. Checklists should be vigilantly checked by all, especially the ones that are carried out so routinely that we sometimes forget to actually verify the item being checked.
19 gal LEVEL FLIGHT ONLY
FUE
ELEC LS
RIGHT
19 gal LEVEL FLIGHT ONLY
R TO
OFF
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CLOSE CALLS Not very happy returns
NOT vERy hAppy RETURNS

... In that split second he had suffered deep cuts to four fingers on his right hand.
I was 18-years-old, and each day I drove past the airport heading to work. From the road you can see the hangars and the aircraft parked on the apron, with at least two or three aircraft flying circuits above. Sometimes I counted up to six aircraft, sometimes more. My birthday was a few months away. What better present to give myself than flying lessons? The following weekend I went to the airport, where in those days every second building housed a flying school. For no particular reason I chose a school that used Beechcraft Sundownersfour-seat, low-wing, fixed undercarriage, with a Lycoming 0-360 engine. The staff were friendly, and after a brief chat, we scheduled a trial instructional flight for the next day. Less than 24 hours later, I was back at the school meeting the instructor who would take me for the flight, and just minutes after I was airborne and heading towards the local training area. Yes, I thought, this is definitely for me.
In the next few weeks I attended the necessary aviation medical, filled in forms, bought text books and booked my first lesson. Then the morning arrived. The weather was calm, blue sky, and a mild temperature for that time of the year. It looked like a great day for flying. I was scheduled for the first lesson of the day and it was the first time that day the aircraft would be used. I met my instructor and we had a pre-flight briefing. Then it was out to the aircraft, where I was shown how to perform the preflight inspection and check the fuel for water. My anticipation and excitement were growing with every passing minute. Finally we climbed into the aircraft and I sat in the left seat. We made ourselves comfortable, adjusting seats and seatbelts. My instructor then commenced the start-up procedure, while talking me through it. I sat as an interested observer taking in as much as I could.
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Everything was going to plan. My instructor flicked the master switch on and turned the key. I expected the dials to come alive, lights flash and the engine burst into life, but nothing happened. Everything was quiet and the dials were still. No response from the aircraft at all silence. Dead battery, said the instructor. My anticipation and excitement evaporated in an instant. Just as he spoke, another aircraft from the school was taxiing into a parking position close to our aircraft. Its pilot was a student who was about to obtain his PPL. My instructor then said, I will show you how to hand start an aircraft, and called the other student pilot over. He explained the dead battery situation and his intentions to hand start the aircraft and asked for help to start our disabled aircraft. I was now an interested spectator with absolutely no idea of what was about to occur. The student pilot sat in the aircraft and instructor gave him instructions about the start-up procedure. The instructor stood directly in front of the aircraft, grabbed hold of the propeller blade on his left-hand side and proceeded to turn the propeller several revolutions opposite to its normal direction. He gave more instructions to the student pilot in the aircraft and then, with his right hand, pulled down forcefully on the right propeller blade in the normal direction. The propeller turned and the engine coughed briefly but did not start. More instructions to the student pilot, and the process was repeated. The instructor performed his previous procedure of turning the propeller in the opposite direction, then grabbing the right-hand blade of the propeller with his right hand and forcefully pulling down on it. What happened next took place in a split second at high speed. When the propeller blade was at about four oclock, the engine spluttered then backfired, and the propeller blade went in the opposite direction to the instructors forceful pull.
The suddenness and speed of this change of direction caught him completely by surprise and he was still hanging onto the leading edge of the propeller. His arm extended upwards and he only managed to release his hand when he appeared to be at full stretch. He was still able to stand, but was pale and slumped over, grabbing at his bleeding right hand with his left one and grimacing in intense pain. In that split second he had suffered deep cuts to four fingers on his right hand. His right arm was hanging limp and he said he thought that his arm was broken, indicating an area close to the shoulder. Blood was dripping through his fingers onto the tarmac and his pain level appeared to increase. He did remain conscious and was able to make his way to the office some 25 metres away with the assistance of the student pilot. The staff gave him first aid help and an ambulance was called. I stayed with the aircraft until another instructor came over to lock it up. Needless to say, my lesson and the instructors other lessons for that day were cancelled. This incident certainly did not put me off learning to fly, or off that flying school. My first lesson was rescheduled for the following week with another instructor, who turned out to be the CFI. I never saw the injured instructor again and the incident wasnt discussed with me or ever spoken about again. I have often wondered why the instructor decided to show a brand-new student a complicated, high-risk, dangerous procedure that had claimed many victims. Why didnt he just ask the LAMEs who shared the schools hangar to investigate the flat battery? Fast forward to the present day: had this accident occurred now, I imagine I would have been debriefed, required to fill in incident reports and offered access to counsellors. How times have changed.
CLOSE CALL?
Write to us about an aviation incident or accident that youve been involved in. If we publish your story, you will receive
ever had a
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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.
Articles should be between 450 and 1,400 words. If preferred, your identity will be kept confidential. Please do not submit articles regarding events that are the subject of a current official investigation. Submissions may be edited for clarity, length and reader focus.
The Australian
If in doubt, notify the ATSB
Most people know the ATSB as Australias national transport investigatorthe agency that investigates aviation and other transport accidents to nd the cause and prevent them from happening again. To help us do our safety job in aviation, we are also the notication point for all aviation safety occurrences in Australia. This means that whenever theres an aviation incident or accidentno matter how seemingly minoryou should notify us. We use this information in two ways: to decide whether to investigate an occurrence; and to make real practical improvements to aviation safety. The data we get from notications helps us analyse trends, nd patterns in aviation safety and alert the relevant people to any ongoing problem or risk. But to do this effectively, we need to be told about these occurrences. This is where we rely on the people at the fore of the aviation industry: the operators, pilots, engineers, and safety managers. Besides being a legal requirement, your notication to the ATSB is invaluable to helping prevent another accident. Ultimately your notication could save a life. If youre not sure if an incident or accident is notiable, the best rule of thumb is to report it to the ATSB anyway. That includes recreational and sports aviation as well. We know that people are generally pretty good at reporting already. But it could be even better. One example: well soon be publishing a safety investigation report that reveals that at least 40 per cent of aviation wirestrikes are not reported to the ATSB. This is a startling nd and we strongly encourage everyone involved in a wirestrike to tell us about it. Were currently nalising some changes to the rules for notication to make them clearer and simpler. In the meantime, you can nd more information on the notications process by calling 1800 011 034 or by clicking the Submit a mandatory accident or incident notication icon on the ATSB website www.atsb.gov.au.
Rare software glitch causes sudden pitch down
sudden pitch down of a Qantas A330
Perth in October 2008, according to the ATSB report into the incident. At least 110 of the 303 passengers and nine of the 12 crew members were injured. Of these, 51 received hospital medical treatment. was a unique event and extremely unlikely to suddenly pitched down, due to a combination of problems involving two air data inertial reference units (ADIRUs).
incorrect angle of attack data from one of the ADIRUs. ATSB Chief Commissioner, Mr Martin Dolan, said that Airbus had taken prompt action to reduce the likelihood of another similar accident.
Dolan said.
happen again. An extensive investigation into what triggered the ADIRU failure mode concluded that it was very unlikely to have been caused by electromagnetic interference from the Harold E. Holt Naval Communications station at Exmouth or from a personal electronic device such as a laptop or mobile phone. A range of other possible mechanisms were also discounted. Mr Dolan stated that the ATSB investigation covered a range of complicated issues, including some that had rarely been considered in depth by previous accident investigations.
systems, Mr Dolan said.

Martin Dolan Chief Commissioner
www.atsb.gov.au
Aviation Safety Investigator

Buckle up Potentially catastrophic data error
assengers on board a Sydneybound Qantas A380 Airbus were reminded of the importance of
resulted in a near catastrophe for an Emirates A380 Airbus at Melbourne Airport on 20 March 2009. While taking
been a number of other accidents and incidents that involved similar errors in
9 January 2012. About three hours from Singapore, the Captain switched on the seat belt lights to keep clear of thunderstorms. Ninety two very short, but severe sets of turbulence. Despite the severity of the turbulence, only seven passengers were injured in the incident. None of these passengers were wearing seat beltsmost of the injured were believed to be walking through the cabin when the turbulence struck. likely because the vast majority of passengers were seated with their seat belts fastened before the turbulence hit. In fact, media coverage of the incident quotes several passengers who noted how fortunate they were for having their seat belts fastened during the event. accident where a Qantas Airbus A330 en route from Singapore to Perth that due to a rare technical problem in the who were seated without their seat belts fastened, were injured. Although some of those wearing a seat belt were also injured, most of the injuries occurred when unrestrained much greater for those who were not wearing a seat belt.
three times. It then overran the runway before hitting infrastructure more than 170 metres away. serious safety consequences, said ATSB Chief Commissioner, Mr Martin Dolan.
All of those events had two basic elements in common: the error in entering the was not detected until well into the take-
Mr Dolan noted that, currently, the only checks in place to prevent these types of safety action that is occurring as a accidents are procedural and vulnerable result of the ATSBs to human error. But investigation. The aviation industry as a whole a lot of work is being Mr Dolan was realises the seriousness of these done to minimise the speaking about the risk of similar events in issues and is working towards release of the ATSBs future, he said. a solution. EK407, with 18 crew and 257 passengers, sustained a tailstrike on departure from Melbourne Airport, Victoria. result of the crew using incorrect takeerror was likely due to mistyping, when a weight of 262.9 tonnes, instead of the intended 362.9 tonnes, was entered into developing technological aids to assist
aviation industry as a whole realises the seriousness of these issues and is working towards a solution. To stress that further action is still needed with technological aids, the ATSB has issued a safety recommendation to the United States Federal Aviation Administration. It has also issued safety advisory notices to a number of international aviation organisations. the meantime of managing the problem pilots face in deciding whether the parameters calculated for a particular A full copy of the investigation report AO-2009-012 is available on the ATSB website www.atsb.gov.au
subsequent checks without detection. a number of systemic safety issues investigation was supported by an ATSB research report titled performance calculation and entry errors: A global perspective. We now understand what caused the error and why it wasnt picked up, Mr Dolan said. We also know there have
Poor fuel management remains a safety risk

Is there enough left in the tank?
An avoidable tragedy
A fatal helicopter accident in the Northern Territory has highlighted the importance of pilots and operators using consistent, reliable procedures to independently verify the fuel quantity in their aircrafts tanks. On 4 October 2010, the pilot of a Robinson Helicopter R22 Beta was mustering cattle on a station property about 170 km east of Katherine, NT. When the station owner was unable to make radio contact with the pilot he immediately conducted an aerial search. The search found that the helicopter had crashed heavily into the ground and the pilot did not survive the impact. The ATSBs investigation found that the helicopters engine had stopped while operating at low altitude. The cause of the engine stoppage was most likely due to fuel exhaustion, which happens when there is insufficient useable fuel to supply the engine. To maximise the performance of the R22 during mustering, the stations pilots generally minimised the helicopters weight by only uplifting enough fuel for the expected duration of the flight. If the pilot took off with less than a full tank of fuel he may have thought that there was more fuel on board the helicopter than was actually the case.
Accident site of VH-THI
On the day of the accident, neither the fuel uplifted and consumed, nor the flight time was formally recorded by the station pilots.
Preventing fuel exhaustion and starvation

Poor fuel management in some aircraft operations continues to pose a serious risk to aviation safety.
Safe flight depends on reliable power

Fuel exhaustion and fuel starvation are the two main reasons for the interruption of fuel supply. Fuel exhaustion and starvation incidents and accidents have led to forced landings, diversions to other aerodromes and, in the worst cases, fatal crashes. And its not just single pilot operations that are at riskall pilots, including those flying with multiple crew, are vulnerable to human error and its consequences. The ATSB urges all pilots and operators to review their fuel management practices and procedures to ensure they are effective, consistent and reliable. The ATSBs latest Avoidable Accident report, Starved and exhausted: Fuel management aviation accidents, helps pilots and operators better understand and manage the risk of fuel exhaustion and starvation. You can download the report free of charge from the Safety Awareness section at www.atsb.gov.au or request printed copies by emailing ATSBinfo@atsb.gov.au
Fuel exhaustion
Many accidents involving fuel exhaustion and starvation are avoidable through good fuel management practices and procedures. Pilots and operators can reduce the chance of fuel exhaustion by: using more than one source of information to obtain consistent results about the fuel on board before flight implementing a consistent procedure, and checking it regularly, to establish and monitor the exact rate of fuel consumption monitoring the flight to ensure that sufficient fuel will remain on board in the event of unplanned delays.
Fuel starvation
Fuel starvation usually happens when the selected tank is run dry. The chance of fuel starvation can be reduced by following procedures and by: ensuring the pilot is familiar with the operation of their aircrafts fuel system during normal and abnormal operations adhering to pre-flight procedures and checks to ensure the correct tank is selected before takeoff and landing using a fuel log during flight to provide a record of the fuel usage from each tank selecting the appropriate tank before descending and ensuring it has adequate fuel for landing.
Your notification improves safety, saves lives

f you were involved in a serious car accident, one of the first things youd do is alert the authorities (if you were able to do so). After all, that important phone call could save a life and prevent injuries.
notifications, we can make tangible improvements to safety through safety advisory notices, recommendations and further safety investigations.
and prevent an accident from happening again. The best rule of thumb is to report any accident or incident to the ATSB. We much prefer over reporting to under reporting. You can find more information on accident and incident notifications including when, what and how to notify on the ATSB website or by calling the ATSB notifications number on 1800 011 034.
In 2011, for instance, the ATSB began a safety issue investigation into the In the same way, by notifying the ATSB of Robinson Helicopter R22 drive belt system aviation accidents and incidents you could following several notifications of accidents make a real difference to the safety of your and incidents involving the R22 V-belt. fellow pilots. While the investigation is still ongoing, the ATSB has already found key factors As the national transport safety that can affect the reliability of the drive investigator, the ATSB is the Australian belt system and directly Government The best rule of thumb is to report any alerted R22 pilots and agency you operators on how to accident or incident to the ATSB. should notify manage the issue. We much prefer over reporting for all aviation accidents and Besides the obvious safety to under reporting. incidents. While benefits of reporting we use your notification to determine an occurrence, there are also legal whether to investigate an occurrence, requirements to report certain accidents looked at as a whole, notifications also and incidents to the ATSB. Even if there give us a bigger picture of aviation safety are no injuries or there is minimal aircraft trends and patterns. damage, you should still let the ATSB know. Like a jigsaw piece in a bigger puzzle, certain notifications can often be joined together to reveal a broader, systemic safety problem. Once weve identified an accident or incident trend from your Also, when considering whether to report or not, remember that the ATSB does not investigate to lay blame or apportion liability. We investigate to improve safety
Notify the ATSB of an accident or incident

You can report an accident or serious incident (an Immediately Reportable Matter IRM) to the ATSB 24 hours a day, seven days a week. call 1800 011 034 (you can also use this number if you need advice or clarification on reporting matters) submit written reports by any meansbut online notifications are preferred by the ATSB if possible. Simply click the Submit a Mandatory Notification button on the homepage of the ATSB website www.atsb.gov.au
ATSB encourages installation of audible cabin pressure warning systems

The Australian Transport Safety Bureau has reinforced its call for operators of singlepilot, turbine-powered, pressurised aircraft to consider installing an aural cabin altitude pressure warning system that operates separately from their aircrafts visual warning system. Unrecognised hypoxia in an unpressurised cabin continues to pose a serious safety threat. In many cases, pilots have either not noticed existing visual warning systems, or those systems failed to operate correctly. Audible warning systems provide a voice prompt warning through the aircrafts cockpit speakers and the pilots headset. Considering the potential outcome if an aircrafts existing visual depressurisation warning is missed, or fails to operate, an additional and independent warning system could prove invaluable. In response to Safety Advisory Notice AO-2009-044-SAN-068 (Flight Safety Australia Issue 84) the ATSB has had a number of requests from operators to help locate vendors of alarm systems. While not endorsing any particular product, the ATSB is aware of the following suppliers: Electric Force Measurement P: 03 9859 8356 W: www.electricforcemeasurement.com.au Anders Sundstrm P: +46 703 180 712 E: anders.sundstrom@lnctv.com The ATSBs investigation report AO-2009-044 and Safety Advisory Notice can be found on the ATSB website www.atsb.gov.au
Typical King Air C90 cabin pressurisation controller with adjacent three-position cabin pressure control switch indicated by arrow
Investigation briefs
Importance of pre-flight planning
Investigation AO-2011-051
Recording service life in overweight operations

PT6A-67 series engine bolt failure

A fatal helicopter accident on the NSW south coast has again highlighted the importance of thorough pre-flight planning and informed in-flight decisionmaking. On 24 April 2011, the owner-pilot of a Robinson R44 helicopter departed Nerrigundah, with one passenger on board, for a private flight to a property near Berry, NSW. Takeoff was delayed and by the time the flight departed, there was not enough daylight left for the pilot to complete the flight under the day visual flight rules. During the flight, the pilot observed cloud, moderate rain and low visibility along the planned track and decided to divert to a private helicopter landing site to maintain visual meteorological conditions. The pilot reduced airspeed and descended over water to what he believed to be 100 feet. Now flying in darkness, the pilot lost visual reference and the helicopter collided with the sea in Lilli Pilli Bay. The pilot survived and the passenger was fatally injured. The safety lessons from this accident have relevance to every flight: pre-flight preparation and planning is vital always check the weather forecast and other operational details before takeoff and in-flight have a backup plan and be prepared to use it make decisions earlyif theres any doubt, turn about. The booklet Accidents involving Visual Flight Rules pilots in Instrument Meteorological Conditions and investigation report AO-2011-051 are available on the ATSB website at www.atsb.gov.au
On 29 December 2008 the pilot of a PZL-M18A Dromader aircraft was conducting agricultural spraying near Nyngan NSW. Witnesses reported seeing something detach from the aircraft before it rolled and crashed into the ground. The pilot was killed in the accident. The ATSBs investigation found that during the flight a 1.8 metre section of the aircrafts right wing had detached from the aircraft.
Bolts that had not been cold rolled during manufacture and overhaul on PT6A-67 series engines caused total power loss for the pilot of a medical evacuation flight in WA. On 29 January 2010, during a flight in a single-engine Pilatus PC-12/45 aircraft with four people on board, the pilot felt a shudder and heard a loud noise as the aircraft passed through flight level 180. Subsequently, the engine CHIP light illuminated indicating the detection of metal chips in the engine oil. The pilot continued the climb and immediately turned back towards Derby. The engine lost oil pressure, engine torque decreased and the inter-turbine temperature increased. The aircrafts rate of climb began to reduce and the pilot established into level flight before further reducing engine power. The pilot shut down the engine when the OIL QTY warning light came on. The ATSBs investigation found that the engine propeller reduction gearbox had seized when four of the six reduction gear assembly carrier bolts failed due to fatigue. The engine manufacturer determined that a quantity of assembly carrier bolts had not undergone the necessary cold rolling during manufacture. Service bulletins were issued that identified affected gearboxes and provided recommended compliance times for the removal from service of suspect carrier bolts. The investigation also found that the Society of Automotive Engineers specification AS7477D was ambiguous in relation to the need to cold roll the headto-shank fillet radius of MS9490-34 carrier bolts. The Society published a revised specification in October 2011, clarifying the need for cold rolling of those bolts. The final report is available on the ATSB website at www.atsb.gov.au
While not directly related to the inflight breakup the ATSB also identified that a number of operators of PZL-M18 Dromader aircraft were not calculating the correct flying hours when the take-off weight was over 4,700 kilograms. That resulted in the overestimation of those aircrafts remaining service life and meant that it could not be assured that they were being operated within their safe service life. The investigation has prompted the following safety actions: the operator examined its fleet and retrospectively applied the correct service life factors and adjusted their processes to apply correct service life factors to all future flights CASA contacted operators of M18 Dromader aircraft to ensure that procedures are in place to record aircraft time-in-service for overweight operations and that overweight flight time is factored into the calculation of Dromader airframe service life. The final report is available on the ATSB website at www.atsb.gov.au
REPCON briefs
Australias voluntary confidential aviation reporting scheme
REPCON allows any person who has an aviation safety concern to report it to the ATSB confidentially. All personal information regarding any individual (either the reporter or any person referred to in the report) remains strictly confidential, unless permission is given by the subject of the information. The goals of the scheme are to increase awareness of safety issues and to encourage safety action by those best placed to respond to safety concerns. REPCON would like to hear from you if you have experienced a close call and think others may benefit from the lessons you have learnt. These reports can serve as a powerful reminder that, despite the best of intentions, well-trained people are still capable of making mistakes. The stories arising from these reports may serve to reinforce the message that we must remain vigilant to ensure the ongoing safety of ourselves and others. My findings are as follows: The average 14 day duty cycle for the High Capacity crews are ranging from 60 85 hours well within the 100 hour limit. It is very rare for a crew member to have cumulative duty in excess of 90 hours on this fleet. The average 14 day duty cycle on the Low Capacity is approximately 75 hours. We do fly seven days per week although there is only one scheduled flight on Saturdays and one scheduled flight on Sundays. Crews very rarely do a weekend flight on subsequent weekends. The Flight and Duty exemption restrictions are adhered to at all times. I have reinforced to crews that fatigue management is both the pilots and the companys responsibility and if a flight crew member is not adequately rested and in a physically and mentally fit state to fly, then they must inform their fleet manager or myself who will remove them from the roster. Operations do not expect pilots to automatically accept duty extensions. It is, and always has been, the decision of the pilot to extend a duty in accordance with the fatigue management system. I do not believe the author is correct in his observations.
New company procedure

Report narrative: The reporter expressed safety concerns over a new procedure being trialled at Sydney Airport which involves taxiing the aircraft to the arrival gate without starting the auxiliary power unit (APU). The new procedure requires flight crew to listen to both company radio frequency as well as the ground frequency after landing, to monitor the status of ground power serviceability. Both these frequencies are reported to get very busy at this airport. The reporter is concerned that there is an increased risk of a runway incident with this increase in monitoring workload. Response/s received: REPCON supplied the operator with the de-identified report. The following is a version of their response: A limited trial associated with APU management is being conducted. The purpose of the trial is to quantify the benefits and identify any issues associated with the APU management procedure. Based on feedback from flight crew and review during the trial period, the requirement to monitor the company radio frequency for this procedure has since been removed. ATSB comment: Two days after the de-identified report was sent to the operator, the reporter advised REPCON that the requirement to monitor both company and ground frequencies was removed from the new procedure.
The operator also advised that since their previous response, the procedure to taxi to the arrival gate without starting the APU was cancelled after four weeks of trials. Now the APU is kept running to the gate and there is no need for monitoring of additional frequencies for this purpose.
Flight crew and cabin crew fatigue

Report narrative: The reporter expressed a safety concern regarding the increase in fatigue levels in both flight and cabin crew members. The reporter stated that it is common for crew members to be rostered on for the maximum duty time, but in reality this means that the crews will have to extend due to normal delays. It is expected that crews will be happy to extend their duty to complete the flight. The reporter also stated that the work load is increasing constantly with a trend for 6-day weeks, multiple sector days, long duties and extensions appearing. The operator is currently using the dispensation to Civil Aviation Order (CAO) 48 to the maximum extent, with the result being an increase in crew fatigue levels. Response/s received: REPCON supplied the operator with the de-identified report. The following is a version of their response:
I have carried out a random audit of our fatigue management system and Flight and Duty times recorded and rostered.
REPCON supplied CASA with the de-identified report and a version of the operators response. The following is a version of the response that CASA provided:
This matter has been reviewed by CASA with the operators Chief Pilot. CASA is satisfied with the operators response and its internal investigation.
How can I report to REPCON?

Online: www.atsb.gov.au/voluntary.aspx Telephone: 1800 020 505 Email: repcon@atsb.gov.au Facsimile: 02 6274 6461 Mail: Freepost 600 PO Box 600, Civic Square ACT 2608
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FEATURE Colgan Air crash Flight 3407
AN UNNECESSARy TRAGEdy
It was a cold and icy night, but the crash of Colgan Air Flight 3407 was due more to mishandling, a poor training system and ignoring procedures than the weather, as Macarthur Job writes
On a night ILS approach to Buffalo Niagara International Airport and in icing conditions, a Bombardier Dash Eight stalled and crashed into a house. The 50 occupants in the aircraft, and one person in the house, were killed. Although light snow was falling, night VFR conditions prevailed at the time.The twelfth day of February 2009 was a rotten day for flying in the northwest United States. A 74-seat, Bombardier Q400, owned by Colgan Air of Newark, New Jersey, was operating a daily commuter flight to Buffalo in New York State, under contract to Continental Airlines but the crews first two scheduled flights for the day had been cancelled because of high winds. Their planned departure for Buffalo was now 7.10pm, with an estimated flight time of 53 minutes, cruising at 16,000 feet.
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But, as often happens after a long day of dirty weather in crowded airspace, taxi clearance was delayed. The 50 people on board had to wait in the aircraft until 8.30pm. The first officer was not feeling well. Suffering from a cold and sneezing, she remarked to the captain as they were taxiing, Im ready to be in the hotel room well see how it feels flying. The tower cleared the aircraft for take off at 9.18pm, the captain indicating he would fly the leg himself. During the climb to cruising level, with the weather typical of winter, the crew turned on the propeller and airframe de-icing equipment. They also engaged the autopilot. The cruise was uneventful, and although the crew engaged almost continuously in conversation, they did not at this stage contravene the sterile cockpit rule. At 9.50pm, the first officer reported the wind at Buffalo was from 250 at 15 knots, gusting to 23 knots, and the captain said they would use runway 23. The first officer briefed the airspeeds for landing, with flaps 15 as 118 knots for their reference landing speed, and 114 knots for go-around speed. The first officer said it might be easier on her ears if we start going down sooner, and the captain told her to get discretion to 12,000 feet. Cleveland ATC cleared them to descend to 11,000 feet, and instructed them to contact Buffalo approach control. The captain began the approach briefing, but was interrupted by the controller clearing them to descend and maintain 6000 feet. Resuming, the captain repeated the airspeeds the first officer announced for a flaps 15 landing. The aircraft descended through 10,000 feet; from that point, the crew was required to observe the sterile cockpit rule. After approach control cleared the aircraft to descend and maintain 4000 feet, the captain asked the first officer how her ears were. She said they were stuffy and popping and asked him if ice was accumulating on his side of the windscreen. He replied that it was. She told him her side had, lots of ice, and the captain said, Thats the most ice Ive seen on the leading edges in a long time. The first officer commented she had accumulated more flight time in icing conditions in her first days of experience with Colgan Air than she had before she joined the company. She also remarked that she wouldnt mind going through a winter in the north-east before becoming a captain. Before she joined the company, she explained, she had never seen icing conditions never de-iced never experienced any of that.
At 10.12pm, the controller cleared them to descend and maintain 2300 feet but, as they followed ATCs instructions, they continued their conversation. Less than three miles from the outer marker, the captain reduced engine power to minimum thrust to slow the aircraft for final approach, and the controller instructed them to call the tower. The first officers acknowledgement was the last transmission from the aircraft. The crew extended the undercarriage, and advanced the propeller levers to maximum rpm. The autopilot applied noseup pitch trim, and the airspeed decreased to 145 knots. As the autopilot applied more nose-up pitch trim, an ice detected message appeared on the cockpit engine display. At almost the same time, the captain called for flaps 15 and for the prelanding checklist. The first officer selected the flaps to 10, and the airspeed fell to 135 knots, but suddenly the stick shaker activated and the autopilot disconnect horn began sounding. Caught completely by surprise, the captain began wrestling with the control column, at the same time advancing the engine power levers to about 70 per cent. With the airspeed at 131 knots when the autopilot disengaged, the aircraft pitched up sharply as the engine power responded, rolled left 45, and then rolled right. As it did so, the stick pusher attempted to lower the nose, but the captain fought its action. On her own initiative, the first officer selected flaps up. The airspeed fell to about 100 knots, and the right roll reached 105 before the aircraft began rolling back to the left. The stick pusher activated a second time but, now grunting with exertion, the captain continued to fight the nose-down force. From about 25 nose down and banked 100 to the right, the aircraft finally entered a steep descent, and as the flaps became fully retracted, the stick pusher activated a third time. The captain called out, Were down! and a moment later the CVR recorded the noise of impact as the aircraft crashed into the house.
Investigation
Fourteen investigators from the National Transportation Safety Board were assigned to examine the circumstances of the accident. The aircraft had sheared off the tops of two trees before striking the southern side of the house near ground level, and exploding into flames. Only its empennage remained intact. The captain, aged 47, received his command on the Q400 four months before the accident and three years after joining the company. His total flying experience was around 3400 hours, of which 111 hours were on the Q400. He also had experience on Beech 1900 and Saab 340 aircraft.
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FEATURE Colgan Air crash Flight 3407
Federal Aviation Administration records indicated he had failed flight tests on four occasions during his training. The first officer, 24, had been with the company for a little over a year and had accumulated 2244 hours flying time, including 774 hours on turbine aircraft. She was considered above average for her level of experience. When the crew turned on the de-icing equipment, the captain would also have turned the reference speeds switch on the ice protection panel to the increase (icing conditions) position. This would have lowered the angle of attack reference, increasing the speed for activation of the stick shaker by about 15 knots. Although the aircraft did encounter snow and light-to-moderate icing during its approach, and some ice had accumulated on its surfaces, flight recorder data showed it was responding normally and the ice was not affecting the crews ability to control the aircraft. But because the reference speeds switch was selected, the aircraft was not close to stalling at the time, and because stick shakers provide a 5-to-7-knot warning of an impending stall, the crew actually had a 20-to-22-knot warning. When the autopilot disconnected as the stick shaker activated, the captains response was a heavy pull on the control column. At the same time he added substantial power, causing the aircraft to nose-up sharply. This did produce an aerodynamic stall, with a roll to the left that reached 45, despite the captains opposing control inputs. This was followed by several roll oscillations, during which the captain repeatedly fought the stick pushers attempts to lower the nose by pulling back on the control column with forces of up to 160 pounds.
FAA ILS/LOC approach plate to runway 23 at Buffalo Niagara International Airport (KBUF). The crash site occurred about five nautical miles from the threshold of Rwy 23. Source: Wikimedia
Analysis
When the controller informed the crew they were three miles from the outer marker and cleared them for the ILS approach, their airspeed of 184 knots was too fast for their position. The captain had to slow the aircraft quickly, probably because, distracted by his conversation, he had lost positional awareness. He did so by extending flaps to 5, reducing power to near idle, lowering the undercarriage, and moving the condition levers to maximum rpm. Because autopilot altitude hold mode was engaged, the autopilot continued to add nose-up trim to maintain altitude after the aircraft levelled off at 2300 feet. But neither pilot remarked on the increasing pitch, even though it should have indicated that the airspeed was continuing to slow.
In addition to other instrument indications, the numbers on the IAS display changed from white to red as the aircraft reached the higher stick shaker activation speed. The captain had the primary responsibility for monitoring the instruments, with the first officer responsible for providing backup. The investigation believed that explicit cues that the aircrafts attitude was becoming excessively nose-up and that the onset of the stick shaker was impending, should have been evident in adequate time to take corrective action. But neither pilot responded. Furthermore, the crew failed to consider the position of the reference speeds switch when the stick shaker activated. After the accident, another Colgan crew had a similar experience when the stick shaker activated during a night VMC approach to Buffalo. Again they had forgotten that the reference speeds switch, set to increase, had raised the stick shaker activation speed, and failed to realise the stall warning was impending.
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It was evident that Colgans approach procedures for setting airspeed bugs did not adequately remind crews of the reference speeds switch position, creating an opportunity for confusion. When the stick shaker activated, the aircraft was not in an aerodynamic stall, and there was sufficient airspeed to correct the situation, but the captain inexplicably pulled back on the column rather than pushing it forward to reduce the aircrafts angle of attack. As a result, its airspeed decreased further, and it stalled, and because the airspeed remained low after the stall, the stick shaker remained active. Even though the captain added power in response to the stall warning, he did not add full power as required. The first officer also did not tell him it had not increased to the rating detent, or advance the power to the detent when the captain failed to do so. The captain did not call for the flaps to be retracted, yet about seven seconds after the stick shaker activated, the first officer raised the flaps, only telling the captain afterwards. The investigation was concerned that the captain pulled against the stick pusher three times, and that his control inputs repeatedly fought the stall protection systems attempts to reduce the severity of the situation. His actions were entirely inconsistent with any procedure or basic requirement for recovering from a stall. Had the captain not overridden the stick pusher, it would have forced the nose of the aircraft down. If the captain had responded correctly to this nose-down input, the aircraft might have recovered flying speed in time to avoid the impact. But the first officers raising of the flaps reduced the lift produced by the wings and increased the stalling speed when the aircraft was already stalled. The captains response to the stick shaker should have been automatic, but rather than responding from well-learned habit, his reaction was one of surprise and startled confusion, and his control inputs were totally inconsistent with basic flying training. He did not recognise the stick pushers action to decrease the aircrafts angle of attack and his efforts to override it only exacerbated the situation. Although the stall recoveries he had practised did not involve an autopilot disconnect, or an element of surprise, his experience should have allowed him to react correctly. His history of failure during training showed weaknesses throughout his career with instrument flying, with heavy reliance on autopilots, and this could have contributed to his deficient performance. Research has shown it can be difficult for pilots to recognise and recover from quite unexpected unusual attitudes, and the
poor night visibility at the time precluded any reliable visual reference. Also, the aircrafts G loadings and its proximity to the ground would have increased the stress of the moment. Fatigue might also have been a contributing factor. Both pilots lived a long distance from Newark and regularly commuted by airline from their homes for their tours of duty. Both had been at Newark Airport overnight and all day before their 9.18pm departure, without adequate rest facilities.
Reasons for incorrect recovery procedures

Did the captain respond incorrectly to the stick shaker because he was applying techniques appropriate to a tailplane stall? Both the captain and the first officer had watched a NASA video on icing that explained that tailplane stalls were most likely with regional and corporate turbo-prop aircraft with ice on the tailplane. The recommended tailplane stall recovery procedure entailed pulling back on the control column and reducing flaps, which the crew did. However, the video also said that typical tailplane icing symptoms were a lightening of control forces, pitch excursions, difficulty in pitch trim, control buffeting, and sudden nose-down pitch, none of which occurred in this case. Furthermore, the stick shaker activation was a clear warning of an impending conventional stall, not a tailplane stall, and the change in the IAS numbers to red was a conspicuous signal inconsistent with a tailplane stall.
Flight management
Although the captain was responsible for managing the flight, he and the first officer engaged in irrelevant conversation throughout much of it. During cruise this did not conflict with regulations or company policy, but probably contributed to delays in performing checklists. Once the aircraft had descended through 10,000 feet, sterile cockpit procedures should have been observed. They were not, and the crew squandered time that should have been spent monitoring, maintaining situational awareness and preventing errors.
Cause
The National Transportation Safety Board attributed the accident to the captains inappropriate response to the activation of the stick shaker, producing an aerodynamic stall from which the aircraft did not recover. Contributing factors were the crews failure to monitor airspeed and adhere to sterile cockpit procedures, the captains failure to manage the flight effectively, and Colgan Airs inadequate procedures for selecting airspeeds during approaches in icing conditions.
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FEATURE Cabin crew training
ThE CAbiN CONNECTiON

Cabin crew members are the eyes and ears of the flight crew. Training them well is vital.
Aviation is an information-rich industry and training programs may be the first exposure that aspiring cabin crew members (and their fellow aviation professionals) have to all the safetycritical information that will potentially save their, and others, lives. Cabin crew members are the eyes and ears of the flight crew. The best available training and regular recurrence, in facilities that allow for realistic simulation of all the emergency situations that might arise (including the occasional dirty nappy scenario) are important in developing competency. The U.S. Federal Aviation Administration (FAA) has encouraged airlines to implement an advanced qualification program (AQP) for flight attendants as an alternative method for developing training and testing materials for flight attendants based on instructional systems design, advanced simulation equipment and comprehensive data analysis to continuously validate curriculums. Jargon aside, the FAA expects this standardisation to require flight attendants to complete hands-on performance drills every 12 months, using emergency equipment and procedures, with trained and qualified flight attendant ground instructors and evaluators. Bringing cabin and flight crew together in training, assists in ironing out inconsistencies which have arisen in cockpit-cabin communication and coordination, especially in these times of locked flight deck doors. Crew resource management training, and pre-flight briefings that include both pilots and cabin crew, allow the entire team to work together more effectively and safely.
What qualities make for the best cabin crew members?

Having a cool head under pressure, diplomacy, flexibility, resilience, common sense, the ability to think on your feet, efficiency and time management, good problem-solving abilities, friendly, sociable, able to make conversation easily and caring. You need to care about your guests, care about your teammates, care about improvement and care about safety! Domestic cabin crewmember and cabin safety officer
Exceptional face-to-face customer service, attention to detail, punctuality, sense of humour, real communicator, procedure based, team player, ability to be a quick thinker and follow directions. Team leader, cabin crew training
Australia has a mandate for annual recurrent testing. Further, all cabin crew instructors must be CASAapproved.
A genuine team player, a skilled follower as well as leader, a clear communicator, considerable patience and understanding of others, strong assertive skills, high emotional and social intelligence, strong time management skills, able to cope with shift work. Safety systems inspector
The ideal CCM has that balance of service and safety that allows both elements to be implemented at all times. Cultural issues can crop up from time to time. For example, the cultural backgrounds of some passengers may clash with the background of the CCM. As a stereotype and with my tongue firmly in my cheek, Id say that the ideal CCM is a waiter in a Michelin-starred restaurant, a clothes hanger in a fashion show, a sheepdog when its time to round the passengers up and an old-fashioned drill sergeant in an emergency. Quality and safety manager
Photos courtesy of Sue Rice and Emirates Aviation College
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What did you learn/wish you had learned in your training?

I had mixed emotions about my training. I was very excited and my expectations were high, as it was my first flying job and I was with a large airline. Unfortunately I found that from day one we were treated like children. We were lectured by the trainers, who basically read from the manual word for word. It was death by PowerPoint, and the usual teaching techniques role plays, group activities and multiple choice exams were used and overused. Surely there is room for more creative techniques and individuality? It was a six-and-a-half-week course which covered aviation first aid and CPR, fire training, security training, dangerous goods, manual lifting, emergency procedures, standard operating procedures and service. The security training was basic and although Id love to tell you more, if I did Id have to kill you. Disappointedly we hardly touched on service, which set no expectations for those new to the company. But after all was said and done, I walked away from my training with a warm feeling of camaraderie and an endorsement on an RPT aircraft. Having said all that I feel lucky that my training was paid for and I was paid during my training. Ive heard much worse stories. Domestic cabin crew and cabin safety officer
I wish that I had been given more practical negotiation tools and strategies to deal with working under pressure within tight timeframes; with different personality types and within the tight commercial pressures versus safety environment. Safety systems inspector
Crowd control, aviation language and acronyms, how to remain calm under pressure, follow procedures to the letter and open aircraft doors, non-verbal communication skills. Cabin crew trainer
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FEATURE Cabin crew training
What skills do cabin crew need to learn?

Emergency procedures / fighting fires Emergency drills / evacuations / ditching Equipment location on various aircraft Safety briefings Aircraft systems and components Customer service essentials / service sequences / responsible service of alcohol Company knowledge Human factors / crew resource management Leadership / assertiveness Time management Handling difficult passengers SMS including reporting systems Security / threat and error management / dangerous goods Occupational health and safety First aid / aviation medicine / CPR British Airways also trains its crew to deliver babies Airport codes Over 2,600 China Eastern Airlines flight attendants are being trained in kung fu. All Hong Kong Airlines staff have also been invited to undergo training in wing chun a form of kung fu used in close combat with compulsory training for cabin crew, as a means of dealing with unruly passengers and even terrorists.
The basis of what trainees need to know will always be the SOPs, emergency procedures and crowd control. Their technical knowledge can be quite limited, as long as the basics are addressed e.g. snow and ice contamination on the wing (my airline is in northern Europe). The ability not to show fear and thereby create panic in unusual/emergency situations is important. Equally, pretending that as a CCM you know it all is a bad thing. Years ago, travelling as a passenger, I pointed out to a CCM that the engines magnetic chip detector panel door was open and the chip detector was possibly not in (risking total oil loss from that engine). I did this during pushback and just prior to engine start. Her (it was a female CCM) reaction was that it was normal and if the panel was open the flight crew wanted it that way. Her view was that no passenger knew more about the aeroplane than she did. I did eventually convince her - by showing my crew card - to inform the flight deck. Immediate action was taken to put the plug back and shut the panel. In short, she needed to know that if you dont understand the situation go and ask! Quality and safety manager
iStock Photo
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Emirates Aviation College

Emirates opened a state-of-the art, multi-million dollar training centre in 2007 to provide training for its cabin crew members. The centre houses two full-motion emergency evacuation cabin simulators a B777 and an A330/340 and an A380 full-height static simulator; a ditching platform into a freezing pool; and a purpose-built firefighting facility all for safety and emergency procedures training. A further 14 cabin service simulators, replicating every cabin in the Emirates fleet, form part of the service training equipment, with specialised classrooms for image and uniform, medical and security training, and a Majilis in which students explore and experience the all-important Arabic culture of hospitality. In 2010 the airline carried 31.4 million passengers. Emirates has more than 14,000 cabin crew and will almost double its crew numbers within the next decade. Cabin crew members come from over 130 nationalities and speak over 50 languages, with some individuals speaking three, four and even seven languages fluently! Only five per cent of applicants are selected to commence training. Every Wednesday, up to 120 aspiring cabin crew members arrive in Dubai to begin their ab-initio course. Students complete seven and a half weeks of intensive training and assessment, including induction, safety and emergency procedures, service, image and uniform, aviation medicine, security and CRM, culminating in a simulated flight with unexpected challenges.
How do our Gen Y students like to learn? Research states they are socially aware, tolerant, tech savvy, team oriented and good at multi-tasking. Our training reflects a brain-friendly learning approach that is multi-sensory, facilitative, honours our multicultural students unique qualities, and keeps it real, ensuring they are competent and confident when they leave. We do not hose them with information, but instead allow them to explore through a mix of visual, auditory and other kinaesthetic learning, while emphasising the context in which they are operating. Integrating our safety and service training ensures that our cabin crew have safety at the heart of everything they do, whilst delivering an exceptional customer experience. Catherine Baird, Emirates senior vice president cabin crew training
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AV QUIZ Flying ops | Maintenance | IFR operations
FLyiNG OpS
1. With respect to a jet engine, core lock refers to a situation where, after a flameout, the rotating portion of the engine seizes due to: (a) reduced internal clearances aggravated by a high airspeed (b) reduced internal clearances aggravated by a low airspeed (c) increased internal clearances aggravated by a high airspeed (d) increased internal clearances aggravated by a low airspeed. 2. In a TAF, the term FU vv030 means: (a) smoke and a visibility of 3000m (b) smoke and a vertical visibility of 3000ft (c) fumes and a visibility of 3000m (d) fumes and a vertical visibility of 3000ft. 3. The appropriate care procedure for lead-acid batteries if there is a long time interval between flights is to: (a) let the battery go completely flat (b) empty out the electrolyte (c) give the battery a fast charge just before use (d) charge the battery at least every 30 days to replace the energy lost due to self discharge. 4. For vFR flights, an alternate must be provided for flights where the distance from the point of departure will be more than: (a) 10nm (b) 50nm (c) 50nm when the forecast conditions are below the VFR alternate minima of 1500ft ceiling and 8km visibility (d) 50nm when the forecast conditions are below the VFR minima of 1000ft ceiling and 3NM visibility. 5. Airframe icing is: (a) possible below 0C because, in some circumstances, water can remain liquid below that temperature (b) not possible below 0C (c) most likely around 13C if the humidity is high (d) most likely around 4C. 6. The indicated airspeed at which a given aircraft stalls: (a) for a given weight, increases with altitude (b) for a given weight, is the same at all altitudes, but the corresponding true airspeed increases with altitude (c) increases with weight and reduces with altitude (d) increases with weight and altitude. 7. If a tailwheel aircraft bounces on the main wheels during landing, the subsequent rebound will be: (a) assisted by the increased lift resulting from the increased angle of attack due to the position of the main wheels ahead of the centre of gravity (b) assisted by the increased lift resulting from the increased angle of attack due to the position of the main wheels behind the centre of gravity (c) opposed by the reduced lift resulting from the reduced angle of attack due to the position of the main wheels ahead of the centre of gravity (d) opposed by the reduced lift resulting from the reduced angle of attack due to the position of the main wheels behind the centre of gravity. 8. The vFR alternate minima for a helicopter are: (a) 1500ft ceiling and visibility of 8km (b) 1500ft ceiling and visibility of 8nm (c) 1000ft ceiling and visibility of 3000m (d) 1000ft ceiling and visibility of 5000m.
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9. In approaching, on the runway extended centre line, for a landing in a left crosswind using the crab and kick method (no side slip on the approach), the aircraft is: (a) drifting right and the balance ball will be centred (b) drifting left and the balance ball will be centred (c) not drifting and the balance ball will be offset right of centre (d) drifting right and the balance ball will be right of centre. 10. On aircraft with vacuum-driven gyro instruments, the need to replace or clean the inlet filter to the instruments will be indicated by: (a) a low vacuum gauge reading (b) a high vacuum gauge reading (c) erratic instrument performance and a low vacuum gauge reading (d) erratic instrument performance and a normal vacuum gauge reading.
MAiNTENANCE
1. An aircraft mode S skin code or mode S address is: (a) allocated and unique to a particular aircraft (b) allocated by ATC and set by the pilot (c) only used by ADSB-in systems (d) only used by ADSB-out systems. 2. The skin code is verified: (a) when ATC requests it (b) when an aircraft is issued with a C of A and also on each occasion when AD/RAD/47 is carried out (c) during the transponder self-test at start-up (d) during the transponder self-test at shutdown. 3. Algae in jet fuel: (a) cannot live long enough to present a problem (b) are, in most cases, not an issue because of the filters in the boost pumps (c) require water for multiplication and as well as blocking filters can cause electrolytic corrosion of fuel system components (d) will multiply in proportion to temperature in jet fuel, regardless of the presence or absence of water. 4. Chromate passivation during the plating process of a metal is used to: (a) provide further protection to a plated finish (b) prepare the base metal for an improved adhesion of the subsequent plating (c) enhance subsequent paint adhesion (d) place the metal surface under slight compression in order to reduce the likelihood of fatigue cracking. 5. With reference to steel, martensite is: (a) a carbon-rich compound formed when steel is cooled rapidly, such as when normalising (b) a carbon-rich compound formed when steel is cooled rapidly, such as when quenching (c) alternate zones of ferrite and pure carbon (d) where carbon is precipitated out as a heavy deposit around the grain boundaries. 6. When an AC supply is half-wave rectified, the resulting waveform is: (a) at the same frequency as the supply (b) at twice the frequency as the supply (c) at half the frequency of the supply (d) DC with a slight ripple.
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AV QUIZ Flying ops | Maintenance | IFR operations
7. A wild frequency engine-driven AC generator produces power at a: (a) frequency that follows the engine RPM (b) frequency that remains constant because of the integrated drive (c) voltage that always increases with engine RPM (d) voltage that always decreases with engine RPM. 8. A P lead is the: (a) magneto control wire. Grounding this lead switches the magneto off. (b) magneto control wire. Grounding this wire switches the magneto on. (c) high voltage wire from the magneto to the spark plug. (d) high voltage wire from the magneto to the cockpit switches. 9. The main function of a coalescer in an air-conditioning pack is: (a) to filter dust particles from the incoming bleed air (b) to filter dust particles from the incoming cabin air (c) to filter water vapour from the air leaving the air cycle machine (d) to increase the size of the water droplets in the air leaving the air cycle machine so that they can be inertially separated.
10. MIL-W-5086 refers to: (a) 50-ohm coaxial cable (b) a 75-ohm coaxial cable (c) an unshielded, insulated copper airframe wire (d) a shielded, stranded copper airframe wire.
iFR OpERATiONS
The circling approach
1. You are inbound on the final approach of the Bendigo (YBdG) runway 17 NdB. You are at the minimum descent altitude (MDA) for your category B aircraft with 0.5nm to run to the beacon when you become visual, with the aerodrome in sight. The AWIS wind is 030/20kt. Which of the following would be the correct circling manoeuvre to conduct? (a) A slight sidestep to the left to join upwind for runway 17, left-hand circuit (b) Break left to join a right downwind for runway 35 (c) A slight sidestep to the right to join a left downwind for runway 35 (d) Break right to join an oblique downwind to base for runway 05. 2. You are inbound on the final approach of the Lismore (YLIS) NdB-A. You are at the MDA for your category B aircraft with 2nm to run to the beacon when you become visual with the aerodrome in sight. The AWIS wind favours a landing on runway 15. Which of the following is correct concerning your circling area? (a) You must remain within the circling arcs of 1.68NM from the thresholds of runway 15/33 joined by tangents (b) You must remain within the circling arcs of 2.66NM from the thresholds of runway 15/33 joined by tangents (c) You are restricted to a 1.5nm arc area to the west of the aerodrome due to terrain restrictions (d) You are restricted to a 1.5nm arc circling area joined by tangents for the whole circling area due to terrain restrictions.
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3. Refer to the Georgetown (YGTN) Queensland NdB What is the size of the circling area for this approach plate? (a) 3nm radius centred on the aerodrome reference point (A.R.P) (b) 3nm arcs from the thresholds of the runway 06/24 joined by tangents (c) 1.68nm arcs (category A) and 2.66NM arcs (category B) from the thresholds of runway 06/24 joined by tangents (d) 1.68nm radius (category A) and 2.66NM radius (category B) centred on the A.R.P . 4. You are on final approach of the Griffith (YGTH) NdB-A approach You are at the MDA for your category B aircraft with 0.5nm to run to the beacon when you break visual. Where do you expect to see the aerodrome as you establish cloud break? (a) Directly in front of the aircraft (b) In front and to the right of the aircrafts nose (c) Off the right wingtip (d) Off and behind the left wingtip. 5. Which of the following is a true statement concerning the minimum obstacle clearance during a circling manoeuvre on a new-style chart. (a) 300ft for category A and 400ft for category B (b) 300ft for categories A and B (c) 400ft for categories A and B (d) 400ft for category A and 300ft for category B. 6. Which of the following is a true statement concerning the minimum obstacle clearance during a circling manoeuvre on an old-style chart. (a) 300ft for category A and 400ft for category B (b) 300ft for categories A and B (c) 400ft for categories A and B (d) 400ft for category A and 300ft for category B. 7. You have established cloud break at the MdA on the Moorabbin (YMMB) NdB-A approach. It is night and you have received the AWIS (outside tower hours). The AWIS wind is 180/25kt. Since the cloud break was close to the beacon, you elect to overfly and position for a left circuit to runway 17. What is the cloud ceiling at your MDA and when would you commence descent from this height for the approach to land?
(a) 670ft and descent on base (b) 720ft and descent on base (c) 570ft and descent turning base (d) 570ft and descent late base to final. 8. You are inbound on final approach of the Albury (YMAY) NdB-A approach at night. You are at the MdA for your category B aircraft with 1nm to run to the beacon when you establish cloud break with the runway lights in sight. The wind favours a landing on runway 07. due to lower scattered cloud north of the aerodrome you elect to overfly for a right circuit to runway 07. When can you descend from the MDA to set up the approach to land? (a) Continual visual descent during the overfly and on downwind to achieve normal profile turning base at circuit height (b) Continual visual descent ensuring the minimum obstacle clearance of 300ft until turning final (c) Only when established on the base leg for runway 07 (d) Only when established on final approach for runway 07. 9. Refer to the Nhill (YNHL) victoria NdB-A approach. You are established clear of cloud and with the threshold of runway 27 in sight at the MDA for your category B aircraft. On the left downwind leg for runway 27 you re-enter cloud. What actions must you now take? (a) Descend to re-establish visual reference, being aware of the obstacle clearance requirement of 300ft until turning final (b) Execute a missed approach, turning left to the NDB and then tracking 050 while climbing to 2400ft (c) Execute a missed approach, manoeuvring to immediately intercept a track outbound of 050 while climbing to 2400ft (d) Maintain the M.D.A. whilst turning left to the NDB then execute the missed approach, tracking 050 and climbing to 2400ft. 10. If the weather conditions are such that you establish visual reference at the MdA and with the specified circling visibility, there is no minimum number of legs of a circuit to fly, or any requirement to fly the specified circuit direction. True or false? (a) True (b) False.
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CALENdAR March-July 2012
UpCOMiNG EvENTS
NORTHERN TERRITORY
May 12 Ageing Aircraft Seminar Darwin www.casa.gov.au/ageingaircraft
vICTORIA
March 1 AvSafety Seminar Latrobe Valley www.casa.gov.au/avsafety March 14 AvSafety Seminar Point Cook www.casa.gov.au/avsafety March 21 AvSafety Seminar Ballarat www.casa.gov.au/avsafety April 18 AvSafety Seminar Warrnambool www.casa.gov.au/avsafety April 18-19 Certification Flight Testing Seminar Melbourne www.casa.gov.au May 26 Ageing Aircraft Seminar Melbourne www.casa.gov.au/ageingaircraft
QUEENSLANd
March 7 AvSafety Seminar Goondiwindi www.casa.gov.au/avsafety March 14 AvSafety Seminar Coolangatta www.casa.gov.au/avsafety March 28-29 ATO Professional Development Program Cairns www.casa.gov.au April 14 AvSafety Seminar Heckfield www.casa.gov.au/avsafety June 2 Ageing Aircraft Seminar Brisbane www.casa.gov.au/ageingaircraft July 24-26 Aircraft Airworthiness and Sustainment Conference Brisbane www.ageingaircraft.com.au/aasc.html
24-26 JULY
Aircraft Airworthiness and Sustainment Conference, Brisbane QLd www.ageingaircraft.com.au/aasc.html
ACT/NEW SOUTH WALES

March 8 AvSafety Seminar Moree www.casa.gov.au/avsafety March 13 AvSafety Seminar Nowra www.casa.gov.au/avsafety March 15 AvSafety Seminar Ballina www.casa.gov.au/avsafety March 21 AvSafety Seminar Coffs Harbour www.casa.gov.au/avsafety April 6-7 Natfly 2012: The sky is no limit Temora http://www.natfly.com.au/ April 11 AvSafety Seminar Moruya www.casa.gov.au/avsafety April 12 AvSafety Seminar Merimbula www.casa.gov.au/avsafety April 15 Wings, wheels, wine and wool Mudgee http://mudgeeaeroclub.hwy.com.au/ April 18-19 ATO Professional Development Program Bankstown www.casa.gov.au April 18 AvSafety Seminar Broken Hill www.casa.gov.au/avsafety April 28 Ageing Aircraft Seminar Sydney www.casa.gov.au/ageingaircraft May 6 Wings over Illawarra family air show Albion Park www.woi.org.au
WESTERN AUSTRALIA
March 7 AvSafety Seminar Kalgoorlie www.casa.gov.au/avsafety March 17 Ageing Aircraft Seminar Perth www.casa.gov.au/ageingaircraft April 11 AvSafety Seminar Narrogin www.casa.gov.au/avsafety April 20 Australian Women Pilots Association Education Seminar (open to public) Bunbury Organiser and more info: Susan Ward susan_ward1@yahoo.com.au
SOUTH AUSTRALIA
March 21 ATO Professional Development Program Adelaide www.casa.gov.au March 25 Parafield Airshow Parafield www.parafieldairshow.com.au June 16 Ageing Aircraft Seminar Adelaide www.casa.gov.au/ageingaircraft
INTERNATIONAL
April 2-5 Aircraft Airworthiness and Sustainment Conference Baltimore, Maryland, USA www.airworthiness2012.com/ April 17-19 World Airline Training Conference and Tradeshow, Orlando, Florida, USA www.halldale.com/wats-2012 May 7-8 Safety in Aviation Asia Conference Singapore www.flightglobalevents.com/safety2012
To have your event listed here, email the details to fsa@casa.gov.au Copy is subject to editing.
Please note that some CASA seminar dates may be subject to change. Please check the Education and Avsafety sections of the CASA website for final details and booking arrangements. CASA events Other organisations events
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AOPA National Airfield Directory 2012
Coming Soon!
The 2012 AOPA National Airfield Directory is coming soon.
First published over 20 years ago the National Airfield Directory is the only comprehensive collation of places to land an aircraft across Australia, be it your Beechcraft or your Boeing. It gives vital information to aid safe, efficient flight planning by aviators traversing the continent.
RRP $65 Aircraft Owners Associa and Pilot tion of Australia s
Contact the AOPA office to pre order your copy today
Ph: 02 9791 9099 Email: mail@aopa.com.au Web: www.aopa.com.au
QUiZ ANSwERS
Flying ops
1. (b) a minimum airspeed is required to maintain rotation and therefore a cooling airflow through the core 2. (b) AIP GEN 3.5 12.12.8 3. (d) lead acid batteries slowly discharge in service and, if left in place but partially discharged, any unused capacity will be lost due to sulphation 4. (c) AIP ENR 69.2 5. (a) 6. (b) 7. (a) (d) applies to nose-wheel aircraft 8. (c) VFRG page 358 9. (a) 10. (d) the instrument reading will be regulated to normal values even if there is no flow at all through the instruments
IFR operations
1. (b) 2. (c) YBDG NDB approach plate. Note the no circling west of 17/35 centreline. This also precludes the use of runway 05. YLIS-A approach plate. Answer B is ordinarily correct for category B aircraft, but at Lismore there is a further 1.5nm restriction to the west. Remember also that these circling area distances are the maximum surveyed area for the category of aircraft. On poor-visibility days or nights you will be tucked in closer to the field to maintain the flight visibility required, while (and this is vitally important!) keeping the approach end of the runway in sight. DAP EAST.DAP 1-3 i.e. old chart. Note that answer B is correct if the runway is longer than 1800m. YGTH-A approach plate. This is vital to be aware of, pre-flight, so that you can smoothly transition from instruments to the visual manoeuvre at the cloud break. DAP East or West DAP 1-3 DAP East or West DAP 1-3 YMMB-A Approach plate. AIP-ENR 1.5-33 para 5.3.2 AIP-ENR 1.5-3 para 1.7.6 This descent from a position on the normal profile is vital to achieve obstacle clearance and is strongly recommended, both day and night, even though daytime regulations might allow a clearance of 300ft (new) or 400ft (old) until on final. The question is above what? You might not have this information available, so maintaining the MDA to that position for a descent from normal circuit height will ensure clearance. YMAY NDB-A approach plate AIP-ENR 1.5-8 Figure 1 YNHL NDB-A approach plate. AIP-ENR 1.5-9 para 1.10.1 e para 1.10.3 A good point to note here is that the NHL NDB is a significant distance (1.3nm) north of the aerodrome. AIP-ENR 1.5-4 para 1.7.6 note 1 Ideally, left hand is better while conducting the visual circling manoeuvre, since this will give the (single) pilot in the left seat the best view. Once cloud break occurs, it is vital to place the heading bug on the runway heading to help maintain orientation, particularly in conditions of low visibility and at night.
3. (a) 4. (d) 5. (b) 6. (c) 7. (d)
Maintenance
1. 2. 3. 4. 5. 6. 7. 8. 9. (a) (b) (c) (a) (b) (a) (a) (a) (d) AWB 34-015 and AD/RAD/47 8. (a) 9. (b)
10. (a) There is no CSD The wire to the cockpit switches It is more effective to inertially separate larger water droplets
10. (c)
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NEXT ISSUE / PROdUCT REvIEW Essential aviation reading
COMiNG NEXT iSSUE

MAY-JUNE 2012
Helicopter safety The Heathrow Trident crash Sharing the skies ... trikes ... and more close calls
pROdUCT REviEw
ONTRACk
Sunshine Coast Airport is the latest addition to OnTrack, CASAs interactive guide to operating in and around Australias controlled airspace. OnTrack now covers 10 Class D aerodromes. OnTrack includes explanations of Class D procedures, demonstrations on how to avoid airspace infringements and multimedia on how to fly the aerodromes inbound/ outbound tracks. Visit OnTrack: www.casa.gov.au/ontrack
NO ONE IS MORE QUALIFIED TO KEEP YOU QUALIFIED.

We have an unrivalled 40-year reputation, having trained 100s of pilots With SAs widest range of aircraft for training, your employment chances are greatly improved We are SAs leading Multi-Engine Instrument Rating training provider We have ATOs on staff, authorised for all licences and ratings Training done from our newly refurbished facilities at Adelaide Airport, with the controlled airspace procedures of an international airport
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Our costs are always keen and competitive

Quite simply - there is no ight training service in South Australia better equipped than Air South.
For more information and a full price list, contact Air South on (08) 8234 3244 or visit www.airsouth.com.au
2012 CPL and ATPL Examinations Scholarship

Applications are invited for the 2012 CPL and ATPL Examinations Scholarships. Two scholarships will be awarded. One will cover the CASA/ASL examination fees for the complete set of CPL Examinations. The second will cover the CASA/ASL examination fees for the complete set of ATPL examinations. For further details and application form visit www.gapan.org.au or email scholarship@gapan.org.au
The Guild of Air Pilots & Air Navigators (GAPAN) Assessment Services Limited (ASL)
Applications close 26 March 2012
Mia Angus and Chris Lee were the successful GAPAN/ASL applicants in 2011. Mia has successfully completed 4 of her ATPL examinations with an 80% average, a very creditable result for given that she is working full time and self studying.
Making career choices?

Know someone who is?
get your copy today

www.casa.gov.au/onlinestore
* please note that a postage and handling fee of $15 applies to each order
There has never been a better time
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Contact details for you and your broker: Melbourne Ph: (03) 8602 9900 Sydney Ph: (02) 9375 4445 Brisbane Ph: (07) 3031 8588 Adelaide Ph: (08) 8202 2200

CASA Flight Safety Mar-Apr2012

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85

HOW TO BUILD THE IDEAL AVIATION PROFESSIONAL

City Perth Sydney Darwin Melbourne Brisbane Adelaide

Issue 85 | MarchApril 2012

20 New SMS kit on its way

22 New thinking on old aircraft

24 Change in the air

28 New year, new look

31 The trouble with cables

40 Fishing for chips

44 Sharing the skies

71 Quiz answers 72 Coming next issue Product review

62 The cabin connection

AIR MAIL / FLIGHT BYTES Aviation safety news

FLIGHT BYTES Phone payments ceasing for medicals

Flight SaFety auStralia Issue 85 March-April 2012

2011 a safer year in the skies

Electronic flight bag approval

Now available in Australia!

Ph: 02 9708 6666 Web: www.guimbal.com.au

FLIGHT BYTES Aviation safety news

Safety award presentation

Join the RAAF Association

BAK & PPL

Also available online:

All CPL Subjects plus IREX

Check out our website at www.bobtait.com.au or email bobtait@bobtait.com.au

Home study and full-time courses available

Flight SaFety auStralia Issue 85 March-April 2012

New ATM role for EASA

Contemporary Air Safety Investigation

FLIGHT BYTES Aviation safety news

RCAs now NCNs

US Senate Passes FAA Bill

Flight SaFety auStralia Issue 85 March-April 2012

New MTOW exemption

To find out more call 1-800-461-776 or go to www.spidertracks.com #STL 0112

FEATURE Aviation training

ThE LEARNiNG CURvE

Pilot attrition comparison: 2010 - 2030

Graph adapted from ICAO report

Flight SaFety auStralia Issue 85 March-April 2012

Supply and demand

FEATURE Aviation training

How then do you train for this flexibility and resilience?

Flight SaFety auStralia Issue 85 March-April 2012

Oxford Aviation Academy - students in the briefing room

FEATURE Aviation training

Competency and experience

Oxford Aviation Academy - King Air used for training

Flight SaFety auStralia Issue 85 March-April 2012

FEATURE Aviation training

Flight SaFety auStralia Issue 85 March-April 2012

CASA Training Centre

Online Human Factors training

The smarter way

ACCIdENT REPORTS International accidents | Australian accidents

International accidents/incidents 17 december 2011 26 January 2012

17 dec Cessna 208 Caravan 1 20 dec Boeing 737-36M

Orense, Buenos Aires 2 Province, Argentina Witchford, near Ely, 1 Cambridgeshire, UK 11 2 1 2 4 2 2 2 0 5 2 2 0 2

Flight SaFety auStralia Issue 85 March-April 2012

Australian accidents/incidents 03 december 2011 29 January 2012

01 Jan 03 Jan 04 Jan 04 Jan 05 Jan 05 Jan 07 Jan