jul-aug05 - Civil Aviation Safety Authority
Transcription
jul-aug05 - Civil Aviation Safety Authority
FLIGHT SAFETY AUSTRALIA Vol 9 No 4 WIN $1000 FOR YOUR STORY p. 26 J U LY- A U G U S T 2005 “JAL 123, JAL 123 UNCONTROLLABLE “ • GPS FOR DUMMIES • EVACUATION CHALLENGE • LIGHTNING STRIKES Work with Australia’s leading experts as t Canberra 22 October 05 National Convention Centre D Melbourne 12 November 05 University of Melbourne Sydney 29 April 06 Bankstown Sports Club Limited seating, bookings essential, visit www.casa.gov.au/seminars to download r David Newman Dr David Newman Flight Medicine Systems. David is an aviation medicine specialist and consultant to ATSB and CASA. Mike Watson AustraliaTransport Safety Bureau. Mike is part of ATSB’s research team. He’s also a transport safety investigator and former charter pilot. Geoff Klouth Australia Transport Safety Bureau. Geoff is an ATSB safety investigator and former Ansett and Qantas airline pilot. Other presenters include senior CAS they unravel the causes of a fatal accident CSI CRASH scene investigation An in-depth pilot safety workshop for commercial and private pilots that will increase your chances of survival. Learning outcomes 1. Understand the early warning signs of disorientation 2. Learn how visual and sensory illusions can work against you 3. Improve your weather interpretation skills 4. Sharpen your in-flight decision making abilities 5. Know how to maximise your chances of survival and rescue if you are involved in an accident Adelaide 20 May 06 Glenelg Stamford Grand Perth 24 June 06 Rendezvous Observation City All sessions 10.00 am – 4.00 pm a registration form or telephoneToni Crompton 131 757. Wal Slaven AustraliaTransport Safety Bureau. Wal is a senior transport safety investigator. Wal is a former GA instructor and airline pilot for Skywest and Aero Mongolia. SA and Airservices Australia Specialists. David McBrien Australian Search and Rescue. David is an aviation adviser to Search and Rescue. Oliver Lemmel Bureau of Meteorology. Oliver is a meteorologist who specialises in aviation weather services. WWW.SAFESKIESAUSTRALIA.ORG PAST LESSONS FUTURE SAFETY S A F E S K I E S A U S T R A L I A C O N F E R E N C E S I N C O R P O R AT E D SAFESKIES 2005 SAFESKIES 2005 OVERSEAS AND DOMESTIC SPEAKERS Australian Government Cabinet Minister. Mr Bruce Byron AM Director of Aviation Safety and Chief Executive Officer, Civil Aviation Safety Authority, Australia. Mr Ken Smart CBE, CEng, FRAeS Formerly Chief Inspector of Accidents, Air Accidents Investigation Branch, United Kingdom. Chief Executive Officer /or Nominee Air Services Australia The Honourable Justice Peter R Graham, Sydney, Australia An acknowledged legal expert on the ‘Duty of Care’. Mr David Behrens, Regional Director, Safety, Operations and Infrastructure Asia Pacific Region, IATA, Singapore. Dr Kwok Chan, Safety Manager, Dragonair, (Hong Kong). Mr David Lattimore, Chairman, ASASI Asia Pacific Cabin Safety Working Group, New Zealand. Mr Don Bateman, Chief Engineer, Flight Safety Systems, Honeywell International , USA. Mr George Morgan. Co-founding Director, Gippsland Aeronautics, Australia Dr Rob Lee, FRAeS. Aviation Safety Consultant & GPCAPT RAAFSR, Australia. A presentation of “A Tri-Service Approach to Air Safety Management” To be presented by: The Chief of Air Force; Head of Navy Aviation; & Head of Army Aviation, Australia. Mr Kym Bills Executive Director, Australian Transport Safety Bureau, Australia. Mr John Borghetti Executive General Manager, Qantas Airways, Australia. Capt David Carbaugh, Chief Pilot-Flight Operations Safety, The Boeing Commercial Airplane Group, USA. Captain Trevor Jensen, MAP Head of Technical Operations, Jetstar Airways Ltd, Australia. Mr Yannick Malinge, Vice President - Flight Safety, Airbus Industrie, France. Capt Stephen Ingham, Australian Chairman, The Guild of Air Pilots and Air Navigators (GAPAN). THE SAFESKIES 2005 CONFERENCE With the theme: “Past Lessons - Future Safety”, SAFESKIES 2005 continues a twelve year tradition of providing a respected, credible, independent, low-cost, international aviation safety forum 27 -28 October, Hyatt Hotel Canberra. Air safety experts from Australia and around the world will bring new ideas and fresh approaches to aviation safety for airlines, air and ground crews, general aviation, flying training, regulators, military aviation, maintenance organizations; unions, airport operators and consumers. The Keynote Address will be presented by Mr Bruce Byron AM, Director of Aviation Safety and CEO, CASA, outlining “The CASA Safety Program, new initiatives in a time of change” and the full list of speakers is shown in the adjacent panel. This is a wonderful opportunity to participate, discuss and professionally interact with speakers, other air safety practitioners and international aviation leaders. The SAFESKIES story and the 2005 program, is updated at www.safeskiesaustralia.org. Safeskies is a not-for-profit organisation founded by the Chartered Institute of Logistics and Transport, Canberra. It is managed by a committee of unpaid aviation experts. It has a solid international reputation for providing a neutral platform for aviation safety discussion and learning. The program provides ample opportunities for networking. SIR REGINALD ANSETT MEMORIAL LECTURE | As the prelude to SAFESKIES 2005 International Aviation Safety Conference October 2005, SAFESKIES presents, P A R L I A M E N T H O U S E , O C T O B E R 2 6 Bringing innovative technical vitality and intellectual curiosity, delivering a message with substance and depth, reflecting the tenor of SAFESKIES 2005, “Burt” Rutan will deliver this year’s – Mr E.L. “Burt” Rutan the man behind SpaceShipOne, winner of the Ansari X Prize of US$10 million, and designer of this first privately built re-useable rocket ship. He is also the designer of the Global Flyer, the first single engine, single pilot aircraft to circumnavigate the world, non-stop, without re-fuelling: Sir Reginald Ansett Memorial Lecture Parliament House, Canberra. 26 October 2005 Note; Mr E.L.”Burt” Rutan will not speak at the actual Safeskies Conference. (Safeskies registration covers a Dinner in the Mural Hall, Parliament House.) CONFERENCE DETAILS SAFESKIES 2005 To register or receive further information, please contact: PHONE & FAX + 61 (0) 2 62363160 E-MAIL [email protected] www.safeskiesaustralia.org Stand out from your competitors Advertise in Flight Safety Australia and reach 90,000 in the aviation industry. For bookings call Mary-Lou O’Keeffe 02 6217 1375 ADVERTISEMENT what went wrong FLYING OPERATIONS EDITOR Mark Wolff CONTRIBUTING EDITORS Gareth Davey – Safety rules James Ostinga – What went wrong? Peter Saint – ATSB supplement email: [email protected] JOURNALIST Merran Williams Slippery: Down the strip sideways 18 GPS for dummies: Tips and techniques 34 Blackout: Saved by the Sabre 21 Wrong way: TCAS interpretation 38 Mix up: Wrong tank selection 24 Runway incursions: A worrying trend 41 Sleep hygiene: Healthy habits 43 ADVERTISING CO-ORDINATOR Mary-Louise O’Keeffe DESIGN & LAYOUT Delene White DESIGN - ATSB SUPPLEMENT David Hope EDITORIAL ADVISORY PANEL Geoff Kimber, Eugene Holzapfel, Steve Tizzard, David Yeomans, Russell Higgins Chief executive officer, CASA Bruce Byron GENERAL MANAGER, AVIATION SAFETY PROMOTION, CASA Kim Jones CORRESPONDENCE Address correspondence to: Flight Safety Australia GPO Box 2005 Canberra ACT 2601 ph: 131757 fax: 02 6217 1950 email: [email protected] Distribution Bi-monthly to 90,000 aviation licence holders and cabin crew in Australia and Australian territories. Contributions Stories and photos are welcome. Please discuss your ideas with editorial staff before submission. Note that CASA cannot accept responsibility for unsolicited material. Warning: This educational publication does not replace ERSA, AIP, airworthiness regulatory documents manufacturers’ advice or NOTAMs. Operational information in Flight Safety Australia should only be used in conjunction with current operational documents. Information contained herein is subject to change. The views expressed in this journal are those of the authors, and do not necessarily represent the views of the Civil Aviation Safety Authority. YOUR WHAT WENT WRONG STORY could win you $1,000 Notice on advertising Advertising appearing in Flight Safety Australia does not imply endorsement by the Civil Aviation Safety Authority. Changed your address? Fill in the form in this issue, post (no stamp required) to: Reply Paid 2005 CASA GPO Box 2005 Canberra ACT 2601 How to enter the competition 26 RIGHT STUFF CABIN CREW Colour separations and printing by Offset Alpine. ©Copyright 2005, Civil Aviation Safety Authority, Australia. Copyright for the ATSB supplement rests with the ATSB. All requests for permission to reproduce articles should be directed to the editor (see correspondence details above). Registered printpost: 381667-00644. ISSN 1325-5002. High achiever: Award winner 27 Evacuate: Speed saves 44 CASA CONTACTS COVER STORY AIRWORTHINESS CASA Service Centre Postal: PO Box 836 Fortitude Valley Qld 4006 ph 136 773 fax 07 3842 2580 email [email protected] Airlines offices Canberra Airline Office Bolt from the blue: Lightning strikes CASA Building Cnr Northbourne Avenue & Barry Drive Canberra ACT 2600 Postal: GPO Box 2005 Canberra ACT 2601 ph 131 757 email [email protected] 48 Sydney Airline Office Building 235 Cnr Qantas Dr & Robey St , Mascot 2020 ph 02 9366 3121 fax 02 9366 3111 email [email protected] Melbourne Airline Office Level 11, 505 Little Collins St Melbourne VIC 3000 ph 03 9927 5345 fax 03 9927 5336 email [email protected] Brisbane Airline Office Channel squeeze: Radio requirements 39 Navigator Place Hendra Brisbane QLD 4011 ph 07 3632 4056 fax 07 3632 4060 email [email protected] 51 FIELD offices LEADING EDGE West Area Office 130 Fauntleroy Ave Perth Airport WA 6104 ph 08 9366 2802 fax 08 9366 2810 email [email protected] Central Area Office 4 Kel Barclay Avenue Adelaide Airport SA 5950 ph 08 8422 2904 fax 08 8422 2900 email [email protected] Down by satellite: GPS landing systems 54 ATSB SUPPLEMENT “JAL123, JAL123 ... uncontrollable”: It’s 20 years since the world’s worst single airliner accident. Top: An amateur photo of the stricken aircraft taken from a mountain village shortly before it crashed on August 12, 1985. Above: Rescue workers were flown into the steep terrain by helicopter. Reservations House 3 Cecil Cook Ave Darwin Airport Marrara NT 0812 ph 08 8943 2999 fax 08 8943 2986 email [email protected] 28 60 Cairns Office Townsville Office readback Flack and flattery: reader feedback 10 flight notes Aviation safety news 13 ADs, AACs & SDRs Listings of airworthiness directives, airworthiness advisory circulars and service difficulty reports North Queensland Area Building 78, Mick Borzi Drive, Cairns International Airport, Cairns QLD ph 07 4042 3603 fax 07 4042 3600 REGULARS STATISTICS Australian accidents May-June • TCAS advisory • Aerial campaign management • R22 clutch failure • Fatal training flight • Collision with the ground • Seperation infringement • B206 crash • Seaplane rollover Northern Territory & Kimberley Area 14 1 Coral Sea Drive Townsville Airport QLD 4814 ph 07 4750 2672 fax 07 4750 2699 email [email protected] South Queensland Area Brisbane Office 39 Navigator Place Hendra QLD 4011 ph 07 3632 4051 fax 07 3632 4060 email [email protected] NSW Country Area Tamworth Office 52 safety check quiz Test your knowledge 56 safety rules Regulatory change 64 short final Reflections on the state of aviation 66 Cnr Rentell St & Basil Brown Drive Tamworth Airport NSW 2340 ph 02 6755 2245 fax 02 6755 2240 Canberra Cnr Nomad Drive & Rayner Road Canberra Airport Pialligo ACT 2609 ph 02 6217 1357 fax 02 6217 1446 email [email protected] Sydney Basin Area Building 628 Airport Avenue Bankstown Airport ph 02 9870 3007 fax 02 9780 3045 email [email protected] Vic/Tas Area 19 Second Avenue Moorabbin Airport Mentone Vic 3194 ph 03 9518 2751 fax 03 9518 2792 email [email protected] READBACK Wave and rotor conditions Photo:AAD I was both interested and somewhat dismayed to read the account by Glenn Nattrass of his brush with rotor turbulence (“Mountain wave wipeout”, Flight Safety Australia, May-June 2005). I do most of my flying at the Canberra Gliding Club site at Bunyan, about 15 nm north east of Cooma in NSW, flying both the Pawnee towplane and the Club gliders. We are in the lee of the Great Dividing Range, and regularly experience mountain waves during winter – indeed it is one of the attractions of the site. We also get to taste the rotor which can appear beneath the wave system, together with strong down draughts and turbulence often created by westerly winds coming down from the low escarpment immedi- ately west of our field. I am constantly surprised by the lack of understanding of these phenomena by power pilots, even by professional pilots trained to do low level operations. The flying conditions encountered by Glenn Nattrass are what glider pilots would expect from the wind and terrain described and illustrated in the article. I have read of a number of crashes in the Snowy Mountains area resulting from pilots of light aircraft failing to understand the wave and rotor conditions that can be experienced, with the aircraft unable to out-climb the downdraughts. I suggest all pilots track down and read the excellent book Meteorology for Glider Pilots by the late CE (Wally) Wallington. This includes some excellent reading on lee waves and turbulence from which all pilots would benefit. Glider or power, the air is the same for all of us. I congratulate and thank Glenn for sharing his experiences. I just hope that all the pilots that read it think very carefully about it, and look very critically at the wind and terrain conditions when next they fly. – Allan Armistead, Dickson, ACT Alive at all times Further to Len Barnard’s article (“Prop chop”, Flight Safety Australia, May-June 2005) your readers may wish to take on board the following safety information. When I was employed as a LAME by a large charter operator at Goroka New Guinea, from 1966–1972 (sometimes servicing Lens C180s) we had a serious incident involving a runaway Cessna C206. The incident began with a pilot pulling through the engine, a practice carried over from the old in-line/radial engine days. Because of the inherent dangers, the pilot had been warned to discontinue as it was not required with the modern engines. However on this day he persisted with this activity and unbeknown to him a faulty earth lead meant that the magnetos were live even though switched The LANCAIR Columbia, the fastest certified piston engined single in the world For information or a demo contact: COLUMBIA Down Under Pty Ltd Phn: 07 5485 3016 Fax: 07 5485 3017 Email: [email protected] Web: www.lancair.com.au 10 FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 READBACK off. The standard practice is to stop a fuel-injected engine by selecting the mixture to idle cut-off. Although a “dead mag” check is called for in the checklist before shutting down, it had up to this time been done in such a cavalier and hasty manner that the defects were not detected. As a result the engine fired up (the mixture was in, and throttle well advanced). The aircraft jumped the “gust chocks”, narrowly missed the pilot, and proceeded to accelerate across the tarmac at a great rate. I chased the aircraft across the tarmac and managed to put a hand to the open pilot’s door, but was unable to pull myself aboard before it accelerated away and proceeded to fly for a short distance after hitting a drainage ditch. At the same time it hit the ditch, the previous open circuit wiring to the magneto, suddenly “earthed’ and the engine stopped. The aircraft suffered severe damage upon impact with several nearby trees. While this caused some amusement for several onlookers, it could have had serious consequences for both the pilot and, upon reflection, myself. After this incident a fleet-wide check was carried out on the integrity of the magneto-earth systems of all 30 of the company’s aircraft. Around 50 per cent of the fleet had “live” magnetos, and of those 90 per cent of the C336 aircraft had defective (“live”) earth switches. The one thing that remains impressed on me from those days is the standard wording stencilled on many of the propellers: “Treat this propeller as being alive at all times.” I rest my cases. – Brad Noble, Bankstown, NSW The article demonstrates poor airmanship on the part of pilots to allow “around 50 percent of the fleet to have live magnetos”. Part of the pre take-off checks involve a magneto check and the POH for two popular types of light aeroplanes state: “RPM to 1800 magneto check (RPM drop not to exceed 150 RPM on either magneto or 50 RPM differential between magnetos)”. I would not even contemplate getting airborne if there was evidence of a live magneto during the above checks i.e. there is no drop in RPM with an individual magneto selected. Additionally, good airmanship dictates doing a magneto check prior to shutdown to determine if there is a live magneto. In doing this check there is no need to select the ignition key to the off position – if there is a drop when left or right magneto is selected in turn there is not a live magneto. Should the pilot suspect a live magneto, this should be recorded on the maintenance document and a LIVE PROP sign hung on the propeller. – Steve Tizzard, CASA flying operations inspector Look out I have not yet read the original article in your Nov-Dec 2004 issue of Flight Safety Australia about the Air New Zealand accident at Mt Erebus, Antarctica, but was interested to read John Gazely’s comments in the May- FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 11 READBACK June 2005 issue. I have followed this whole terrible saga from the time of the announcement that the aircraft was overdue to the end of all the inquiries. I have read all of the major books and articles published on the accident. In the accident inspectors report, there are some photos recovered from passengers cameras. Some of these show the sea ice in the area of Beaufort Island that were taken during the orbiting descent. The island is clearly visible on the right hand side of the aircraft. It is surmised that the crew believed they were lining up to fly down the middle of McMurdo Sound when in fact they were displaced to the left and hence flew into Erebus. Had they looked out the window and seen Beaufort 12 Island as the passengers did, they would have realised they were not where they thought they were, and could have made the necessary alterations. So, I would add to John Gazelys list of “navigational actions” – look out the window at every opportunity and see what you can learn. If the flight crew had seen Beaufort Island, they might have been able to avoid the accident. There were other opportunities to raise an alert, but sadly they too were missed. When I learned to fly as a private pilot I was taught to maintain a broad scan rather than look only ahead so I could catch any potential problems before they became a safety issue. – Dick Eade, Vanuatu FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 Port Vila, Carry on baggage As a passenger and a former pilot I have little fear of mechanical or operational problems with large commercial aircraft. However, I believe there is a problem arising from the lack of policing of the increasingly large amount of hand luggage that passengers now take aboard airliners. I used to fly, and I know the importance of safety drills, and of limiting the prospects for disorder. Large amounts of cabin luggage can spill from compartments and seriously injure passengers after a heavy landing or during severe turbulence. Also there is a danger that in any emergency many passengers will try to leave with all of their baggage, slowing any evacuation and causing panic. We need some common sense in flying, and passengers need to start abiding by airline hand luggage rules. – Harry Tower, Devonport, Tasmania Airlines are responsible for enforcing carry-on baggage limits, which are designed to ensure a safe cabin environment. At large airports there are test cradles which should be used to check if carry on baggage is over size. Comprehensive guidelines for passengers on baggage size, contents and stowage – as well as information on dangerous goods – are available from CASA’s website at casa.gov.au/airsafe under the heading passenger safety. AUSTRALIAN ACCIDENTS, MAY-JUNE Date Investigation Aircraft (ACFT) Category Location Injuries ACFT damage Description Nil Destroyed The pilot landed the helicopter and left the engine running at idle to inspect for engine oil leaks. The engine had been serviced the day before. The helicopter became airborne by itself, crashed, and was destroyed. Fatal Destroyed During approach to Lockhart River, the aircraft hit terrain, killing all occupants. Shannons Flat, NSW Nil Substantial The pilot reported the helicopter’s engine failed in flight so he initiated a power off autorotation landing to a nearby clearing. During the landing touchdown, the helicopter sustained substantial airframe and main rotor blade damage. SOCATA - Groupe Aerospatiale TB-10 Tobago Parafield, SA Nil Substantial During the downwind leg of a circuit at night, the aircraft’s left wing hit a large bird and the aircraft yawed left. The pilot landed the aircraft safely. 15/5/05 3 Champion 7GCAA Citabria Stonefield, SA Fatal Destroyed The aircraft departed Stonefield airstrip, but crashed shortly after becoming airborne, killing both occupants. 16/5/05 Beech 23 Musketeer 15km S Newman, WA Minor Substantial Shortly after takeoff, the engine power reduced to idle and the pilot conducted a forced landing into a nearby clearing, where the aircraft struck a tree. The aircraft sustained substantial damage to the right wing, fuselage and landing gear. The engine power reduction was thought to be due to a broken throttle cable. 26/5/05 5 Grumman American Aviation G-164A AgCat 1 1 km E Carnamah, WA Nil Destroyed During an engine run-up, the engine backfired and the aircraft was totally destroyed by fire. 01/6/05 5 Beech A36 Bonanza Geraldton, WA Nil Substantial During the landing roll, the landing gear collapsed, causing substantial damage to the engine, propeller and landing gear doors. 02/6/05 5 Beech A36 Bonanza Coober Pedy, SA Nil Substantial On approach, the pilot noticed indications of an electrical system problem. The pilot extended the landing gear, then all electrical instrumentation failed, denying the pilot the landing gear position indication. The pilot used a mobile phone to communicate with aerodrome ground personnel who reported that the landing gear appeared to be down. During the landing roll on runway 04, the gear collapsed. The gear and the propeller were damaged. Robinson Helicopter R22 89 km E Iffley, Qld Nil Destroyed While conducting aerial work at 200 ft, the helicopter’s engine stopped. The pilot attempted to land in a heavily timbered area but the helicopter struck two tree branches before landing right skid low. The helicopter rolled to the right and was destroyed. The pilot reported possible fuel contamination from drum refuelling. 13/6/05 5 Hughes 269A 4 km WNW Maroochydore, Qld Nil Substantial The helicopter was on a training flight which included a range of sequences including quick stops. As the trainee pilot lowered the collective after the first quick stop at 50 ft AGL in mid flare, the engine failed. The instructor assumed control and continued the flare to the ground. He manoeuvred the helicopter over an area of dry, sloping ground and pulled the remaining collective pitch, but the helicopter hit the ground heavily in a level attitude. The right skid collapsed, the rotor blades struck the tail boom and the helicopter rolled over. A new engine had just been installed in the helicopter. Before the accident flight, the helicopter had been checked in the hover at low and high power followed by a flight that included a full power check during a climb to 4,000 ft and circuits into confined areas. 13/6/05 Mooney M20R Southport, Qld Nil Substantial While passing 60 ft on final approach, the aircraft encountered windshear and the pilot was unable to arrest the aircraft’s descent. The aircraft landed heavily, the nose landing gear collapsed and the propeller struck the runway. Robinson Helicopter R22 BETA Yarrie Homestead, WA Nil Destroyed ‘The helicopter had been started and the pilot left the helicopter to return to the hangar. The collective was on friction lock. The friction lock failed and the helicopter became airborne and flipped over. 05/5/05 5 Robinson Helicopter R22 19 km N Biloela, Qld 07/5/05 2 Fairchild Industries SA227-DC Metroliner 12 km NW Lockhart River, Qld 12/5/05 4 Eurocopter International Pacific EC120B 12/5/05 5 5 05/6/05 5 5 22/6/05 5 Disclaimer: Information on accidents is the result of a cooperative effort between the Australian Transport Safety Bureau (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. 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. FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 13 FLIGHT NOTES CASA photo library New procedures: Standard radio calls from November 24, 2005. Changes at non-towered aerodromes Aviation policy makers are close to finalising changes to operations at non-towered aerodromes that are due to take effect from November 24, 2005. The changes are expected to introduce a set of standardised positional radio broadcasts in and around non-towered aerodromes. The new standards are being introduced as part of implementation of the National Airspace System (NAS), an airspace reform program that has been underway since May 2002. The NAS is based on the US airspace system. The expression “non-towered” is borrowed from the vocabulary of the US airspace system and describes any aerodrome where there is either no air traffic control or air traffic control is unavailable at certain times. Civil Aviation Regulation Aviation Risk Management Training Aerosafe Risk Management Pty Ltd has been a leading provider of risk management training and services in the aviation industry for the last eight years. Over the past six years Aerosafe has trained around 3500 people in a variety of courses ranging from risk management and aviation human factors to accident and incident investigation and aviation governance principles. As a Registered Training Organisation we can offer quality accredited courses in the elds of risk and safety management. 2005 Course Schedule Aviation Risk Management Aug 22-23 Nov 28-29 Sydney Melbourne Aviation Safety Management Systems Aug 30-31 Sydney Nov 7-8 Nov 9-11 (Advanced) Sydney Sydney Oct 18 Sydney Aviation Governance (for Executives) The cost for registration is $650 per person plus GST. If participants wish to undertake the assessment an additional fee will be charged in order to gain accreditation. A 20% discount is offered when four or more people from the same organisation register on the same course. For further details please contact our Training Department on (02) 8336 3700 or alternatively email [email protected] (CAR) 166 must be amended before the new procedures come into effect. Aerodromes with a high traffic density – initially all existing mandatory broadcast zones (MBZs) – will retain the requirement for all aircraft to carry and use a radio. The new procedures will allow all radio-equipped aircraft to perform straight-in approaches at any non-towered aerodrome, provided certain procedures are followed. Education and training material is due to be sent to all AOC holders and then to all pilots ahead of the changes. A series of information forums is being planned for pilots and operators. To find out where they are being held check the DOTARS website on http://www. dotars.gov.au/airspacereform and follow the links for “information forums”. Drug and alcohol testing A review of options for drug and alcohol testing has found that safety benefits would flow from a testing regime for safety sensitive personnel. The review, conducted by CASA and Commonwealth Department of Transport and Regional Services policy advisers, was triggered by an ATSB investigation of a fatal Piper PA-32-300 accident on Hamilton Island in September 2002, in which the pilot and five passengers died. The ATSB concluded that recent cannabis use and postalcohol impairment could have contributed to the accident. The report, released as a draft for final comment in May 2005, includes in its recommendations: a proposal for industryrun testing; increased testing RMIT University has aviation choices for you Master of Business Administration (Aviation Management) Graduate Certificate – Aviation Safety and Risk Management If you’re in the aviation industry but need a challenge, RMIT University has choices for you. The MBA (Aviation Management) at RMIT offers unique areas of study and research that build on your personal and professional experiences. RMIT’s MBA will prepare you for national and international management roles in the aviation industry.Make a start this July and make your career soar to new heights. Further your career from wherever you are with the new one year part-time Graduate Certificate in aviation safety and risk management. Offered through distance education, exciting opportunities are on the horizon in areas such as safety auditing, safety training and consulting. For more information contact: Margaret Tein, program leader, Tel. 9925 8068 or email [email protected] ➔ www.rmit.edu.au 14 FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 FLIGHT NOTES Lycoming recalls crankshafts US-based engine manufacturer, Lycoming, has issued a mandatory service bulletin (MSB 566) recalling crankshafts installed in Lycoming engines manufactured, rebuilt, overhauled or repaired after March 1, 1999. The MSB is applicable to selected engine models of the 540 and 360 series. The affected crankshafts have a serial number format of “V5379” followed by a 3 to 5 digit number, work of Australian Churchill fellows since the scheme was set up 40 years ago. The winner of the 2005 Bruce Byers Churchill Fellowship was announced in July. The award, in memory of CASA crashworthiness specialist, Bruce Byers, was given to Matthew Shepherd, Air Traffic Control training supervisor with Airservices Australia. Byers was a recipient of the Churchill Fellow- ship in 1997. Shepherd’s project will investigate the delivery methods and philosophies of refresher training for air traffic controllers. He intends to visit air traffic service organisations in the Netherlands, Luxembourg, Switzerland and Canada. Shepherd’s report will be published on the Winston Churchill Memorial Trust’s website (www.churchilltrust. com.au). The website records the but not all “V5379” crankshafts are affected. Some Lycoming crankshafts were recalled in 2002 and 2003 but this is the biggest recall to date. Individual operators and certificate of registration holders should assess the MSB against their maintenance schedules and policies. Under Australian law, a mandatory service bulletin issued by a manufacturer is not compulsory unless mandated by an Australian airworthiness directive (AD); however, if an aircraft is maintained under the manufacturer’s schedule of maintenance, then the MSB is compulsory, even before issue of an AD. Lycoming has confirmed that it will replace the affected crankshafts at no cost and will consider reimbursing owners for removal and replacement labour costs. The US Federal Aviation Administration (FAA), the regulatory authority for Lycoming engines, has released a notice of proposed rule making (NPRM) along with a draft airworthiness directive mandating recall of affected crankshafts. The FAA has invited industry comment on the proposed AD through its website. Australian operators can lodge their comments on the website http://www. regulations.gov/. (Please select Federal Aviation Administration as agency and search for docket 2005-21864). Submissions must be lodged before August 22, 2005. The Australian Civil Aviation Safety Authority (CASA) plans to issue an airworthiness directive immediately after the FAA AD comes into force. The FAA is likely to require a compliance schedule recommended by the manufacturer, and CASA will probably mandate the same compliance schedule (replacement of affected crankshafts in the next 50 hours or six months of operation, whichever comes first). To ensure you can continue to fly affected aircraft CASA Churchill Fellowship winner Courtesy: Byers family powers for the ATSB to test for drugs and alcohol following non-fatal accidents and incidents; and suggestions that police testing powers at state and federal level be widened to include aviation, along similar lines to existing testing powers applying to road users. The draft report warns that prescription medication and over-the-counter medications can also have significant safety effects. The review team has invited responses to the draft report from all interested parties by early August 2005. Recommendations are due to go to the Minister for Transport and Regional Services, Warren Truss, in September. The late Bruce Byers. FLIGHT SAFETY AUSTRALIA JULY-AUGUST 15 FLIGHT NOTES recommends operators and aircraft owners plan to replace affected crankshafts ahead of the issue of an AD. Security for light aircraft The US Federal Aviation Administration (FAA) has proposed a fine of $1.5 million against Atlantic Coast Airlines, now doing business as Independence Air, for operating aircraft without required scheduled maintenance. The fine is believed to be one of the largest ever proposed against an airline by the FAA. In a July news release, the FAA said Atlantic Coast failed to conduct a required heavy maintenance “C” check on one of its Canadair Regional Jets (CRJ), then operated the aircraft 16 Jason Whitebird FAA proposes $1.5 million penalty Big fine: Atlantic Coast, now rebadged Independence Air, is facing one of the largest ever penalties proposed by the FAA. on some 455 additional flights without completing the inspection. The FAA also says the company operated several of its aircraft on more than 7,400 flights between May and October 2004 without removing and replacing expired emergency locator transmitter batteries; and several more aircraft on more than 3,600 flights without performing required inspections and tests FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 on a variety of systems and components. The company has 30 days from receipt of the proposed penalty letter to respond to the FAA. The FAA will review the response of Atlantic before deciding on the final fine. In Australia, the safety regulator refers allegations to the courts, which decide on the appropriate penalties. Requirements for the security of light aircraft have been issued by the Department of Transport and Regional Services (DOTARS). Information on the requirements can be located at http://www.dotars. gov.au/transsec/atsa/resources/ index_downloads.aspx To ease compliance with the requirements, CASA issued Airworthiness Bulletin AWB 02-08, which can be viewed at http://casa.gov.au/airworth/ awb/02/index.htm Questions about the acceptability of any proposed solutions should be addressed to DOTARS operations centre, ph 1300 132 400, fax: 6274 6089, email:Transport.Security@ dotars.gov.au. FLIGHT NOTES Action plan for aerospace industry Government and industry are joining forces to further integrate the Australian aerospace industry into the global aerospace manufacturing and design supply chain. A stakeholders reference group (SRG) has been formed to allow Fed up with FOD A regional aviation industry group has warned that damage to aircraft from foreign object debris (FOD) at aerodromes is rising. Chairman of the Australasian aviation ground safety council (AAGSC), Mark Farrar, says the growing problem is increasingly caused by waste from build- industry to have a say about the safety regulator’s certification process. The reference group is designed to streamline the efficiency of CASA certification process. The industry development push focuses on strengthening research and industry capabilities in engineering design, airframe structures and advanced composite materials. The vision is to increase annual exports five-fold to $3.5 billion by 2012. The move follows issue of a report, “Aerospace industry action agenda”, which was released under the auspices of the Department of Industry Tourism and Resources in November 2003. A copy of the report can be found at www.ditr.gov.au (search under aerospace industry action agenda). ing and cargo operations aerodromes. He singled out plastic wrapping and sheeting as a particular threat to safety. “There is a high risk of large plastic sheets or bags, being discarded on airport aprons or dumped in open bins, will be blown onto taxiways or runways and eventually being sucked into jet engines”. The AAGSC has released a FOD management video and is distributing a series of posters, as part of a renewed safety education campaign. Farrar said aerodrome operators must ensure that systems are in place to prevent FOD as a result of building works and general operations. The video is available via the AAGSC website (www.AAGSC. org) for $40. Automation grant The Queensland Government is providing $3.53 million to the Queensland University of Technology and the CSIRO to help establish the Australian Research Centre for Aerospace Automation (ARCAA). The research facility for the centre will be built at Brisbane International Airport, and will employ 40 staff including PhD students from QUT. The most important training, operational and safety issues currently facing the airline industry in the Asia-Pacific region will be addressed. You will get the latest information, knowledge and skills to help you conduct more cost-effective, efficient, safe and compliant operations. Exhibitors and delegates can register on-line at www.attops.com Low delegate fees apply for early registrations. CONTACT Email [email protected], phone +61 7 3860 0900 or visit www.attops.com BRISBANE CONVENTION & EXHIBITION CENTRE BRISBANE AUSTRALIA FLIGHT FLIGHT SAFETY SAFETY AUSTRALIA AUSTRALIA JULY-AUGUST MAY-JUNE 2005 17 WHAT WENT WRONG SLIDING DOWN THE STRIP Photo: Rob Fox A Twin Otter pilot explains how he managed to slide through 180 degrees when he landed at a bush strip in Papua New Guinea. I was a new Twin Otter captain working in Papua New Guinea, and I was enjoying my job immensely. With 2200 hours total time I knew that I still had a lot to learn, but I was relaxing into the job and looked forward to each day’s flying. On the day in question I was rostered to fly from Port Moresby through the gulf country in western Papua New Guinea and return. As a new captain I had been doing my fair share of the “Gulf Run”, and things had been going pretty smoothly. My co-pilot for the day, Thomas, had been flying the Twin Otter for a lot longer than I had. I liked him as he was cautious by nature and genuinely wanted to be the best pilot he could be. However, I felt he was a bit too hesitant and I looked forward to boosting his confidence by giving him as much flying and autonomy on his sectors as I could. The memory of sitting in the right hand seat and having someone constantly nagging me to operate according to their every 18 FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 personal idiosyncrasy was still fresh in my mind. As the weather was good, I offered the first sector to Thomas. Our departure was without incident and we were soon cruising to our first port of call, a coastal strip called Iokea. About half-way there, Thomas hesitantly suggested that he thought I should carry out the approach and landing, as he had not landed in Iokea for some time. This typified his lack of confidence. In the prevailing conditions (CAVOK) and with his experience on type, there was no reason he should have any difficulty landing in Iokea. The only feature of the strip that presented any real threat was its length of 544 m. However, this is ample for a Twin Otter, and a normal landing would use only about half that length. I probed Thomas to see if there was any other reason he was reluctant to make the approach. There was none, so I said I saw no reason for him not to land the aircraft. I assured him that I would monitor the ap- proach carefully and let him know if I was unhappy. On downwind, I checked the condition of the strip on our left. It looked much the same as it did on my last visit there a couple of days before: green grass and the slightly tattered windsock showing the wind was calm. We would be landing into the east, the normal direction that allows a touch down right at the threshold, rather than over the high palm trees on the eastern perimeter of the field. Time to act: On final I noted that our speed was just two or three knots above the nominated speed, but that was acceptable. In the last part of the approach Thomas let the aircraft get very slightly high, so we crossed the threshold at about 30 ft – a bit higher than I would have liked, but not outside acceptable tolerances. However, as he flared a little high and began to float down the runway, I felt myself suddenly become uncomfortable. WHAT WENT WRONG Finally, when the main wheels brushed the ground and he did not immediately apply reverse, I knew it was time to act. At this stage, there was no reason to expect that we could not stop normally, but it would require full reverse and moderate braking, as we were now significantly further in than normal. I took control and reached up (the engine controls are on the ceiling in the Twin Otter), applying full reverse in the same action. As I did so I felt the aircraft sliding sideways, and realised that the strip, despite appearances, was very slippery. With reverse applied and a line of trees at the far end of the strip, going around was not an option. I had no choice but to brake, but at the rate we were travelling, we were clearly going to go off the end of the runway. I applied the brakes but nothing happened, except that we were now clearly in a skid, sliding down the strip with the nose of the aircraft gradually drifting off to the left. I tried everything to control our direction and somehow slow the aircraft down. I released the brakes and tried a more gentle application (which took a lot of willpower) while working in asymmetric reverse on the thrust levers. As we slowed, the effect of reverse thrust diminished, so that it became impossible to keep the aircraft straight. Much to my horror we started sliding off the strip to the left while slowly executing a pirouette. Kikori As the nose of the aircraft was pointing back down the runway – the way we had just come – I made a desperate last attempt to stop our slippery slide and applied takeoff power. It was a horrible feeling going backwards and sideways into the trees with the engines screaming. I was waiting for the sound of the aircraft hitting branches but it never came. Much to my horror we started sliding off the strip to the left while slowly executing a pirouette. We came to a stop with a lurch and the aircraft see-sawed a bit but did not fall on its tail, which I was sure it would. I pulled the power off quickly, and sat for a second in cautious amazement. Everyone was OK, and I mentally checked to see if any limits had been exceeded, or other damage done. Thomas cowered in the right-hand seat, looking apologetic. By looking out the right cockpit window we could see the right wingtip had slipped neatly between the overhanging branches of the trees, without touching a leaf. I realised I had to say something to the passengers, so I picked up the handset and said “Ladies and gentlemen, welcome to Iokea. As you can see, the strip is a little slippery here today, and I apologise for the unorthodox nature of our arrival. However, it does mean that we now have a very short distance to taxi to the parking area. Thanks for your understanding.” I added this last quip as I realised the last part of our slide and final rapid stop had put the aircraft in a position so that it pointed directly at the parking area, just a short distance away. We parked and shut down, and I went to examine our skid marks. At our eventual stopping point the aircraft had been going sideways more than I had realised, and the very soft earth had ruts about 30 cm deep. If the wheels had not “dug in” this way, then we would have slipped off the edge of the strip and into the trees for sure. I still look back and thank my lucky stars for being let off so lightly that day; but I guess it did teach me that sometimes a string of small inaccuracies can lead to major problems with very little warning. As for my co-pilot, I did my best to reassure him that it was not his fault; even an aircraft making a perfectly executed approach would have had difficulty stopping normally in those conditions. Even so, I don’t think the experience added much to his confidence. $1000 winner Best entry Baimuru Ihu Kerema Iokea Kairukyu 0 Juanita Franzi Hisiu 100km Port Morsby FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 19 Photo: Rob Fox WHAT WENT WRONG ANALYSIS: TWO-PILOT OPERATIONS Typically, before being checked to line, a trainee first officer or captain will fly for a period with a captain who has been approved as a training pilot, a procedure that is usually specified in company documentation. In the case of a first officer, this period of supervision will continue until the training captain is satisfied that the pilot has reached a level of capability that ensures he or she can be fully effective in all assigned responsibilities, including operational decision-making. When a line captain and a checked and qualified co-pilot are scheduled to fly as a crew, the line captain might normally expect that the co-pilot has been checked as being fully capable. Though many line captains may have little or no instructional background, they are still expected to share the flying with the co-pilot (as in this case), using their own judgement on whether or not to intervene. A common practice is to nominate a pilot flying and a pilot not flying (PF and PNF). These roles are rotated between the captain and the first officer on an agreed basis, commonly “leg for leg”. Training pilots often have an instructing background, and where they do not, they usually undergo additional training to ensure they can make competent assessments of pilots under training. They should be able – as are most experienced instructors – to judge how far an undesirable in-flight situation should be allowed to develop before they must intervene. 20 FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 In normal operations and on normal runways, a “taking over” decision would rarely be a critical issue, especially in an aircraft with the Twin Otter’s landing and takeoff performance capabilities. However in bush flying on short and often narrow airstrips with unpredictable surface conditions, the margin for error can be considerably reduced. The apparent lack of confidence of the co-pilot, should have triggered increased alertness and possibly a decision by the captain to take over the pilot flying role earlier. Pilots who are accustomed to single pilot operations usually develop a sound ability to perceive when an approach has gone wrong, and to make an almost instinctive decision to go around. But that ability to observe and decide is likely to be less automatic and instinctive if the pilot is watching someone else fly the aeroplane. The time taken to make a decision and implement it is likely to be slightly longer. SOPs: Another factor in this event was that the apparent lack of confidence of the copilot should have triggered increased alertness and possibly a decision by the captain to take over the pilot flying role earlier. These two factors came together when the captain allowed the co-pilot to wander outside limitations. At a deeper level, it is the standard operating procedures (SOPs) of the company that should have prevented this from occurring. The policies of a typical regional airline could serve as a helpful guide for operators developing or enhancing their SOPs for two-crew operation. They include: • 75 hours of line training is required before a line captain or first officer is rostered to fly with a non-training line first officer or captain. • Line captains and first officers are trained to exactly the same standard. • A syllabus is defined in the training and checking manual. The pilot progresses through the syllabus until reaching a defined level of competency. • Operation is defined within strict published parameters, outside which intervention is automatic. These are listed in the operations manual and include parameters such as glideslope and localiser deviation limits, deviation of two dots below the T-VASI, reference airspeed, vertical speed, bank angle and aircraft configuration. • A procedure in which the PNF gives a warning – such as “airspeed”. If there is no corrective action the warning is issued again. If there is still no reaction the PNF takes control. • A “stabilised approach policy” where, if the PF is in an unstable approach, a goaround should be initiated. • A policy that specifies that only the captain is permitted to conduct the landing at high risk airfields with known phenomena such as wind shear, high gusts, severe turbulence or inhospitable terrain. • Using the best possible means of receiving accurate reports on airfield conditions. WHAT WENT WRONG Photo: Rob Fox BLACK OUT I had just graduated to overhead the field and You’re cruising at 41,000 ft – suddenly you as an Air Force pilot commenced the Instrument wake up in an unusual attitude at 20,000 ft. and was doing a Sabre Letdown from 16,000 rather Fighter pilot, Byron Bailey, reports. conversion course. The Sabre than 20,000 ft as called for on the was a huge leap forward from the Standard Instrument Approach. Vampire, the aircraft I had trained on. The tower controller was the only ATC Several weeks into the course my class was unit on duty that evening and they didn’t programmed for a night, high-altitude navihave radar, so I hoped my secret was safe. gation exercise. I flew the ADF letdown and I was mightily I also began to feel light headed and had difSix people had started the course, though relieved when I touched down and taxied in ficulty concentrating. I had selected 100 per two had recently been taken off the course to the ramp. cent oxygen earlier in the flight, but I wasn’t because they did not meet the flying requireWhen I signed the technical log I wrote in convinced I was suffering hypoxia. Rememments. Our chief instructor had made it clear the unserviceability column that the aircraft bering that hyperventilation (overbreathing) that we would be gone too if there were any pressurisation was not working properly produces the same symptoms as hypoxia, and more mistakes. – that it was very noisy and the heating was is a more likely event in stressful situations, I So it was with some trepidation that I taxied very inadequate. convinced myself that my fear was causing me out alone (there were no dual Sabres) and deI went to bed that night with a headache, to hyperventilate, so I tried very hard to conparted into the black moonless night. and worried that someone might find out trol and regulate my breathing. As I got airborne, I remember thinking that about my stuff-up – if they did, it would cerit was noisier than usual, but I concentrated tainly be the end of my fighter flying. About 10 minutes on the task at hand and was soon at 41,000 ft The next day I went to the hangar and before descent point I and cruising at Mach 0.83. I had a hard time checked up on the status of my unservicegetting the aircraft to hold a steady trimmed ability report. I discovered that the canopy was feeling vague and altitude as the drop tanks on the wings made seal (an inflatable lining that seals the canopy confused. I knew I was the Sabre somewhat unstable in the pitch axis to the aircraft enabling the cabin to maintain in trouble. at altitude. a pressurisation of around 18,000 ft) was Every now and then I removed a flying damaged and unable to inflate! About 10 minutes before descent point I glove to check my fingernails for the bluish As a result, I had spent a considerable was feeling vague and confused. I knew I was tinge that denotes hypoxia but the not-soperiod of time exposed to a probable cockin trouble. Suddenly I came to with a start – I bright light of my helmet-mounted torch pit pressurisation altitude of nearly 41,000 ft was in an unusual attitude passing 20,000 ft. made it difficult to tell one way or another. I while breathing 100 per cent oxygen through I realised that I had blacked out but with difwould turn the helmet light off and sit there in my oxygen mask. ficulty (and luck) I managed to recover the the dark concentrating on my flying (Sabre’s Now, breathing 100 per cent oxygen at an situation after several attempts by 16,000 ft. did not have autopilots) and navigation but I altitude of 35,000 ft ambient oxygenates the After a couple of minutes I started feelhad a growing sense of unease that something brain to an equivalent level of 10,000 ft withing a lot better and decided to continue the was not right. out oxygen. Every 1000 ft above 35,000 ft reflight as planned so I proceeded at 16,000 ft I was increasingly cold and apprehensive. sults in a considerable and increasing degree FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 21 WHAT WENT WRONG of hypoxia. It is likely that my situation resulted in me being exposed to an equivalent, without oxygen, of most probably well in excess of 20,000 ft. I forget the tabulated time in minutes of useful consciousness at 20,000 ft but it appears I exceeded this time and blacked out as a result. It is possible that I had been losing altitude without realising it and that the blackout was not deep. Fortunately, a recovery was possible on the 100 per cent mask oxygen once the aircraft reached lower levels. My inexperience, especially on type, and the absence of a cockpit altitude warning or indication (only a pressurization on/off switch), were certainly instrumental in the events. Further, a mindset that convinced me I was a coward and therefore hyperventilating, and a desire to accomplish the mission at all costs, could have resulted in my early demise. I was saved by the forgiving flying characteristics of the Sabre. If I’d been in a less-stable aircraft, like the Vampire or the Mirage, it’s unlikely I would be here today. $500 Highly commended 22 FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 WHAT WENT WRONG CASA photo library This pilot is lucky that this flight did not have a tragic outcome. It serves to remind us all that hypoxia is an ever-present threat. When things began to go wrong, the pilot thought that his symptoms were due to hyperventilation. At face value, this was a reasonable assessment, given the circumstances of the flight (high pressure, stress, anxiety, no instructor, night flight). However, it is an often-stated maxim in aviation medicine that hypoxia should always be considered first. Any symptom at altitude should have you thinking of hypoxia, and dealing with that issue quickly, since it’s the most dangerous, time-limited problem. Even if you think there is another cause of your symptoms, such as hyperventilation, you should still apply oxygen straight away. This is the fail-safe course of action. There is little doubt that the pilot’s hyperventilation was in this case due to hypoxia, caused by a defective cabin pressurisation system. The pilot’s analysis is quite correct. Normally, the low-differential pressurisation system of military fighter aircraft should keep the occupant at a cabin altitude of more or less 18-20,000 ft while the aircraft’s actual altitude is 35,000 ft and above. A pressurisation system failure exposes the occupant to a high ambient altitude, which in this pilot’s case was 41,000 ft. At 41,000 ft breathing 100 per cent oxygen, the pilot is physiologically equivalent to being somewhere between refers to the time between the development of an oxygen problem and the point at which a pilot can no longer take effective corrective action. At 18,000 ft, the TUC is about 20 to 30 minutes, decreasing to about 10 seconds above 40,000 ft. The TUC in this pilot, breathing 100 per cent oxygen at 41,000 ft, is difficult to estimate, but due to the cold and activity levels, he may have been anywhere from 15-20,000 ft physiologically. It’s a little scary to think that hypoxia can still occur despite breathing 100 per cent oxygen. The fact this aircraft did not have an autopilot turned out to be fortuitous. Had the aircraft been on autopilot, it would not have descended to a lower, more oxygen- 5* 0/ .& % * $ " - 4 0 rich altitude. The pilot would have flown on unconscious at 41,000 ft, only descending when there was no more fuel. Fortunately for the pilot in this story, the handling characteristics of the Sabre meant that after he lost consciousness and was no longer actively flying, the aircraft entered a gradual, recoverable descent. It’s worth noting that headache is a typical after-effect of hypoxia, as are fatigue and lethargy. Given what the pilot had been though, it’s little wonder that he was head-sore after the flight! Oxygen will only protect you for so long at high altitude without the additional benefit of either a pressurised cabin, pressurised breathing air or a pressure suit. It is important that you know the symptoms of hypoxia, and maintain a heightened sense of awareness of your physical feelings at altitude. If you suspect that you are suffering hypoxia, take corrective action immediately. Don’t look for colour changes to your nails and lips – light conditions in the cockpit are often poor. Symptoms of hypoxia vary from individual to individual. If you do not feel well, oxygen will do you no harm – and it may well save your life. This is especially true of high altitude flights. When in doubt, suspect hypoxia. Dr David Newman is an aviation medicine consultant and the Managing Director of Flight Medicine Systems Pty Ltd, www. flightmed.com.au. A CASA-produced educational video, “Oxygen first” explains how to recognise the symptoms of hypoxia and take appropriate action. Order online at casa.jsmcmillan.com.au. $* &5 *" HYPOXIA FIRST 10-15,000 ft on normal air, since the partial pressures of oxygen in the lung are about the same. Ten thousand feet is, of course, the critical altitude threshold for hypoxia. The signs and symptoms of hypoxia become more likely to occur if there are a few other risk factors added to the equation, such as cold temperatures and physical activity. Both of these factors were present. Time of useful consciousness (TUC) : "7 ANALYSIS: 0' "64 5 3" -* " "/ %/ /% & 8 ;& " - " FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 23 WHAT WENT WRONG ENGINE ON, ENGINE OFF A bank-run pilot learns first-hand the perils of improvised procedures. By Mark Bennett. Photo: Rob Fox B 24 FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 Standard fuel management procedure in the Baron was to takeoff, climb, descend and land with the main tanks selected. The idea was that the outboard or auxiliary tanks should only be selected in cruise. It should be noted that although the aircraft has four tanks, there are only two fuel gauges on the panel. A toggle switch allows you to select the fuel gauge to the tank currently in use. Needless to say, if you forget to select the switch to the tank you are using, you will not know how much fuel you have left. One of our runs took us via several ports from Bankstown to Coonabarabran and back again in the afternoon. I soon realised that if I only selected the auxiliary tanks in cruise – as recommended – there would be an excess of fuel in those tanks when I got back to Bankstown in the evening. A more desirable situation would be to use virtually all of fuel from the auxiliaries earlier, and therefore have a known quantity in the mains for the last couple of sectors home. Of course, the only way to do that was to select the auxiliary tanks during climb and descent. I would switch back to the mains as part of my pre-landing checks and almost without fail, there would be just a few gallons left in the auxiliaries when I joined the circuit at Mudgee on the way home in the afternoon. Alternating engine failure and surge continue as fuel supply from the auxiliary tanks fluctuates. Right engine fails. Left engine regains power. Shortly after takeoff left engine fails, aircraft yaws. Rudder applied. Cockpit placard fitted between the fuel selector handles (Source : Beech Baron B55 manual) Adverse effects: Fuel flow problems led the Baron’s engines to take turns at failing. Juanita Franzi ack in the 1990s I flew bank runs from Bankstown aerodrome for a Sydneybased operator. The company had about a dozen light twins, most of them B55series Barons. I’d been flying commercially since 1988 and, with about 2000 multi hours, I considered myself to be safe and efficient. It was a good job and most of us were happy to be building our hours on the way to a prized airline interview. Our employer was reasonable, and any cowboy behavior was frowned upon. We always planned IFR regardless of the weather, and were even paid the award. Having said that, it’s almost inevitable that single-pilot freight drivers, left to their own devices, will devise their own ways to get the job done as “efficiently” as possible. In our operation there was no formal check and training, save the mandatory annual instrument rating renewal. In my case, one of these improvisations nearly got me killed. B55-series Barons have four fuel tanks, – two main and two auxiliary tanks. This differentiates them from the B58 series, which has just two main tanks. The two extra tanks didn’t pose any obvious problems, especially as this arrangement is common to a great many light twin aircraft. WHAT WENT WRONG This left me with the main tanks approximately ¾ full for the final two sectors home. On the day of my incident, I approached the circuit at Mudgee as I had done countless times before. The wind was light and variable, so I joined a standard downwind for runway 04. As I selected the gear down I was momentarily distracted by a radio call from another aircraft. That sorted, I proceeded to land. Turnarounds were fairly tight in those days: pull up on the apron, shut down the right engine, agents come running over, bags go in the back, thumbs up, crank up the engine, and we’re gone. As the winds were light, I decided to make a short backtrack and takeoff in the opposite direction on runway 22. Turning at the end, a cursory glance at the gauges showed the tanks were about ¾ full. The gauges were in the green so I applied full power. The D55s have the big engines, so acceleration is wonderfully brisk. Before long we were at takeoff safety speed, in this case approximately 90 kt. Stall warning: No sooner had the wheels left the ground than the left engine failed! There was quite a yaw and I corrected with rudder. Almost immediately, the right engine failed. The left engine then roared back to life with all the consequent adverse aerodynamic effects. The left engine then failed again, and then the right engine roared back to life! What we now had was two 520-cubic inch Continentals at full throttle taking turns at surging as large gulps of fuel and then air were sucked in. While all this was going on the runway had passed behind me and I was at 100 ft with the airspeed well below blue line and approaching Vmca. The stall warning was starting to chirp, and I was moments away from losing control. The area ahead was not suitable for a forced landing, though I have to admit I didn’t even consider it. All this had taken mere seconds, but even now I can see it clearly in slow motion as if it occurred yesterday. There’s nothing like a life threatening moment to focus the mind. The previous distraction in the circuit had led to a breakdown in my pre-landing checks and I had inadvertently left the auxiliary tanks selected. As luck would have it, I had seen this before – albeit at a safe altitude – and the large fluctuations in fuel flow had caught my attention. AUX 31 GAL OFF MAIN 37 GAL MAIN 37 GAL CROSS CROSS FEED FEED AUX 31 GAL OFF USE AUX TANKS AND CROSSFEED IN LEVEL FLIGHT ONLY Fuel management: The B55 – series Baron has four fuel tanks – two mains and two auxiliaries Cursing myself as the events unfolded, I reached down to change the tanks. Once I had a spare hand I turned on the auxiliary boost pumps. Thankfully, with seconds to spare, the engines responded quickly and evenly and the old Baron climbed sweetly away. Flying experience is certainly a many faceted thing. It can lead to complacency and the adoption of potentially dangerous practices. It can also equip us with the resources to deal with some very difficult and confusing situations. Because I had previously experienced the onset of fuel exhaustion, I was ANALYSIS: ON THE LINE As the author rightly points out, a significant contributing factor in this incident was his failure to follow the recommended procedures set out in the pilot’s operating handbook and the operations manual. But that’s just one factor. Most incidents are caused by a series of safety breakdowns, and this one was no exception. What systems did the company have in place to ensure that its pilots were aware of and adhered to standard operating procedures? Implementation of a simple “route check” system – where the chief pilot periodically accompanied line pilots on operational flights – may have identified the non-standard fuel management procedure and corrected it. A route check system may have also identified weaknesses in the pilots’ conduct of aircraft checklist procedures. It’s probably fair to say that the checks in this instance were conducted haphazardly. It’s quite common in this type of operation for checklists to be conducted able to react very quickly to a dangerous situation of my own making. There’s an old saying that you live and learn. I know of several accidents that have been attributed to fuel starvation by incorrect tank selection. Tragically, some were fatal. The procedures are laid down in operations manuals and pilot operating handbooks and are quite often the result of bitter experience. If we choose to ignore the mistakes of others, and casually deviate from the rules, we do so at our peril. $500 Highly commended from memory. Of course, memory-based checklists are more fallible than written checklists, particularly when workload is high, or if the checklist is interrupted by something “more pressing”. In this story, the pre-landing check was disrupted by a radio call and consequently the fuel selection check was overlooked. After a short turnaround the fuel selection was again overlooked. Did the pilot use an improvised pre-takeoff check? If the chief pilot conducted regular checks of the line, it’s probable these potentially hazardous procedures would have been identified and eradicated. Fortunately, when the engines failed due to fuel starvation, the pilot had the experience and skill to avert an accident. The final link in the chain of events was broken. I’m sure the pilot chief pilot, and management of the company would agree that it would have been better if the chain had been broken earlier. It certainly would have saved the pilot some unnecessary stress. – Maurie Lewis, CASA flying operations inspector. FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 25 what went wrong? YOUR STORY Simply write about an incident you’ve been involved in, and send it to Flight Safety Australia, GPO Box 2005, Canberra ACT 2601 or email [email protected] $1,000 Each issue we’ll publish the best story and award the author $1,000. Runners up win $500 each. could win you and help others learn from your mistakes Articles should be between 600 and 2000 words. If required the author’s identity will be kept confidential. Entries will be judged by CASA appointed experts. Stories on incidents or accidents that are the subject of a current official investigation are ineligible for entry. If an investigation has been completed, entrants are required to reference that investigation. Entries will be edited for style and length. The panel’s decision is final and no further correspondence will be entered into. THE RIGHT STUFF High achiever The Sir Donald Anderson award recognises the best female ATPL exam result. H Courtesy Avondale College ayley Wilson, a 19-year-old instructor and Avondale College graduate, has won an award for being Australia’s best performing female pilot in professional air transport licence exams last year. Ms Wilson received the Sir Donald Anderson Trophy at a ceremony at the annual conference of the Australian Women’s Pilots Association (AWPA) in Wangaratta, Victoria, in April. The Civil Aviation Safety Authority and AWPA sponsor the award. “It came as a bit of a surprise, but I was thrilled,” says the 19-year-old. Ms Wilson averaged about 85 per cent on the exams. Ms Wilson started flying in 2002 as a Year 11 student at Avondale High School, graduating from Avondale College with two Diplomas of Aviation last year. She now works as a flying instructor for the college’s School of Aviation at its base in Cooranbong, New South Wales. Aviation appeals to Ms Wilson as a career because of the variety and interest of the work. “You’re never behind a desk, it’s so different every day. It’s challenging, rewarding and exhilarating – a great profession!” she says. Her aim is to become a pilot with the Royal Flying Doctor Service, so she is keen to build up her hours, especially in remote areas. Hayley Wilson, winner of the Sir Donald Anderson trophy. A highlight of her studies was a stint of outback flying that gave her multi-crew experience and an understanding of remote area navigation. “These flights gave me a good idea of what commercial operations are really like in terms of money saving and time saving and doing things efficiently,” Ms Wilson says. “I also learned the importance of effective communication. This will help me if I get into a multicrew environment.” Avondale’s chief flying instructor Garry Photo:John Tanner NLA bution to Australian aviation. Fraser congratulated Ms Wilson on her achievement: “The ATPL exams are tough. You need an understanding of the material, not just rote knowledge of it.” Ms Wilson credits theory teacher Reg Lister, with providing a supportive environment that helped her achieve her best. “Reg was amazing, I couldn’t have done it without him. He just has this way of telling you things so you understand it. And if you don’t get it, he has more than one way to explain it. He just keeps trying and trying and trying until you get it.” he won the Oswald Watt Memorial Medal for “the Born in 1917, Anderson served in the RAAF during most valuable contribution to aviation by an Aus- the Second World War and joined the Department tralian”. Anderson was awarded the CBE in 1959, of Civil Aviation following his demobilisation in 1946. and created a Knight Bachelor in June 1967. He swiftly rose through the ranks, becoming superintendent of Air Traffic Control by 1948. He was widely recognised as one of the world’s foremost negotiators of international air transport As chairman of the International Civil Aviation Or- agreements. During his term as Director-General, ganization’s third session of the rules of the air and he led many Australian delegations in Australia and air traffic control division, he was instrumental in overseas to negotiate international traffic rights for defining the principles upon which world standards Qantas. Sir Donald Anderson ceased duty as Direc- The Sir Donald Anderson trophy is awarded to for air traffic control were determined. The symbol tor-General of Civil Aviation on September 30, 1973, the woman pilot considered to have made the of this achievement was Annex 11 of the Chicago and commenced as chairman of Qantas on October most meritorious academic progress towards Convention on Civil Aviation. 1, 1973. He died on December 1, 1975, aged 58. Sir Donald Anderson the achievement of professional aviation quali- In 1956, at the age of 39, he was appointed Aus- fications. It commemorates Anderson’s contri- tralia’s Director-General of Civil Aviation. In 1957 Source: The Airways Museum & Civil Aviation Historical Society. Reproduced with permission. FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 27 COVER STORY JAL 123: AUGUST 12, 1985 520 LOST It’s 20 years since the world’s worst single airliner accident. Macarthur Job and Steve Swift report. J apan Air Lines’ 747SR, registered JA8119, completed four uneventful inter-city trips on Monday, August 12, 1985, arriving back at Tokyo’s Haneda Airport at 5.17 pm. Its next service was Flight JAL123 to Osaka, 215nm (400 km) south-west of Tokyo. A senior training Captain was in command, supervising the upgrading of a former 747 first officer. With 509 passengers and 15 crew aboard, JAL 123 took off at 6.12 pm. The planned route was via the island of Oshima, 50 nm southwest of Tokyo, cruising at FL240 (24,000 ft). At 6.25, the controller saw the emergency code 7700 suddenly appear beside the 747’s radar target. Seconds later the aircraft called, requesting an immediate return to Haneda. Controller: “Roger – approved as requested.” JAL123: “Radar vector to Oshima, please.” Controller: “Turn right, heading 090.” But instead of making the expected turn back towards Oshima, the aircraft gradually turned to a north-west heading. Controller: “Negative, negative...confirm you are declare [sic] emergency?” JAL123: “That’s affirmative!” Controller: “Request your nature of emergency?” There was no immediate reply. Controller: “JAL123 – fly heading 090 radar vector to Oshima.” JAL123 (tensely): “But now uncontrol! [sic]” FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 28 News that the flight was in trouble leaked to the media. Japanese television conducted a live-to-air telephone interview with an eyewitness watching the 747. He described it as “wavering and having trouble keeping to its flight path”. Meanwhile the aircraft had turned north towards the mountain ranges forming a spine along the main Japanese island of Honshu. Then, just on sunset at 6.56 pm, as its altitude fell to 8400 ft, the controller was horrified to see the target vanish from his screen. At 6.34 pm the company called the 747. Company operator: “JAL123 – this is Japan Air. Tokyo control received an emergency call 30 miles west of Oshima Island.” The flight engineer responded, obviously under pressure: “Ah ... the R5 door is broken. Ah ... we are descending now...” Company operator: “Roger – does the Captain intend to return to Tokyo?” JAL123: “Ah ... just a moment ... we are making an emergency descent ... we’ll contact you again. Ah ... keep monitoring.” Out of control: The 747 continued north about 25 nm, then began a gradual turn north-east in the direction of the US Air Force base at Yokota, 77 nm distant. It was maintaining around 22,000 ft above scattered thunderstorms and rain showers. When 45 nm west of Haneda Airport, the aircraft entered a descending turn to the right, completing a full circle before straightening out on an easterly heading towards the airport. Its descent then continued, but at 13,500 ft one of the crew called in an agitated voice: “JAL123, JAL123 – uncontrollable!” Tokyo control: “Roger – understood. Do you wish to contact Haneda (approach)?” JAL123 (frantically): “Ah ... stay with us!” JAL123 (now down to 9000 ft): “JAL123 – request radar vector to Haneda!” Controller: “Roger – I understand. It is runway 22, maintain heading 090.” Still descending, the 747 now gradually turned to the left on to a heading of about 340 degrees. It was below the level of mountains that now lay in its path. Controller: “Can you control now?” JAL123 (desperately): “JAL123 – uncontrollable. JAL123 – ah uncontrol. JAL123, uncontrol [sic].” Approach: “Your position ... ah ... 45 miles north-west of Haneda.” JAL123 (anxiously, with altitude read-out now 13,000 ft): “North-west of Haneda – ah – how many miles?” Approach: “According to our radar, 55 miles north-west. I will talk in Japanese – we are ready Photo:AAP photo: newsweek COVER STORY Sprawling (above): The wreakage of Japan Airlines Flight 123 on the slopes of Mount Osutaka. Clearly visible is part of a wing. Aftermath (inset right): Rescue workers with debris from the accident. to recover its balance to the right. It was flying just like a staggering drunk.” Because of the inaccessibility of the area, it was not until 9 am, more than 14 hours after the crash, that civil defence workers reached the site. Fog had forced a temporary suspension of mountain flying, but when conditions improved, army paratroopers arrived aboard Chinook helicopters, rappelling down to where the wreckage lay. The disaster was now revealed. Flying a westerly heading, the Boeing 747 had descended into a pine forest near the top of the northern face of the 5400 ft Mt Osutaka, a narrow, steep-sided east-west ridge, exploding into flames and breaking up as it bounced along the ridge line. There was no sign of survivors. In Tokyo, the fearful news was confirmed to waiting media – the highest death toll ever in a singleaircraft accident. Well down the mountain face, a fireman stood on the steep slope surveying the wreckage. Suddenly he saw something that looked like an arm waving! Sure enough, a young woman, conscious though suffering a broken Photo: AAP Photo:AAP for your approach anytime. Also Yokota landing is available – let us know your intentions.” There was no reply. The 747’s height was now decreasing again and, by 6.54 pm, its altitude read-out was 11,000 ft. Approach called the aircraft again, advising its position was “50 miles – correction 60 miles” north-west of Haneda Airport. But again there was no response. A minute later, its target suddenly deviated 90° to the right and, as its altitude readout rapidly decreased, it entered a tight turn of less than 2 nm radius. Then, just on sunset at 6.56 pm, the controller was horrified to see the target vanish from his screen. Further calls to the 747 went unanswered. Moments later, a military jet reported “a huge burst of flame in the Nagano Mountains”. Impact in the mountains: It was dark by the time two search helicopters reached the area through showery weather. Attracted by a fire blazing near the top of the 5400 ft Mt Osutaka in inaccessible ranges more than 60 nm north-west of Tokyo, one helicopter pinpointed the site of the crash, reporting flames “over an area about 300 m square”. One witness, surprised at seeing an airliner above his remote mountain village, described its erratic flight. “All of a sudden, a big aeroplane appeared from between mountains,” he told police. “Four times it leaned to the left, and each time it tried pelvis and a fractured arm, was pinned between two sets of seats. Not long afterwards there was more good news – a 12-year-old schoolgirl was found wedged in a tree, suffering nothing more serious than cuts and bruises. Even more was to come – rescuers discovered another young woman and her daughter beneath wreckage. Both suffered fractures. All four survivors had been seated among the last seven rows of seats. Medical staff found some victims had clearly survived the impact but, wearing only light summer clothes, had died of exposure during the night. Investigation: The aircraft had been worked hard, flying 25,000 hours in the course of 18,800 cycles. Did this demanding utilisation show up some unknown flaw? The only clue to the loss of control was the tense radio transmission that the 5R cabin door – the rear most door on the starboard side – was “broken”. Could the door have broken away and struck the tail, disrupting the multiple hydraulic systems that actuate the aircraft’s control surfaces? FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 29 COVER STORY There was no sign of survivors. In Tokyo, the fearful news was confirmed to waiting media – the highest death toll ever in a single-aircraft accident. 5 The finding of the door amongst the wreckage with its latches in the closed position only deepened the mystery. Why had the flight crew referred to it as “broken”? Could structural distortion of the fuselage have caused the door warning lamp to light up?. A photograph of the stricken aircraft, snapped from a mountain village shortly before the 747 crashed, provided new and dramatic evidence (see cover photo). A portion of its vertical fin, together with the section of the tailcone containing the auxiliary power unit (APU), was missing. The photographic evidence was confirmed when a 5 m piece of the aircraft’s fin was found floating in the bay where the aircraft had been passing when the emergency developed. Could the APU’s gas turbine have disintegrated, rupturing the hydraulic lines to the rudder and elevators? While Boeing and US investigators were on their way to join the Japanese team, other important evidence was emerging. One of the surviving passengers described what took place in the rear passenger cabin. She was an off-duty JAL flight attendant, sitting only four rows from the rear of the cabin. “There was a sudden loud noise, somewhere to the rear and overhead,” she said. “It hurt my ears and the cabin filled with white mist. The vent hole at the cabin crew seat also opened.” The white mist was characteristic of sudden cabin decompressions. The “vent hole” was one of the modifications made to wide-bodied aircraft as a result of the Turkish Airlines DC-10 disaster near Paris 11 years before in 1974. (See Flight Safety Australia, March-April 2005). “There was no sound of any explosion,” the witness continued, “But ceiling panels fell off, and oxygen masks dropped down.” Then she felt the aircraft going into a “hira-hira” (Japanese for a falling leaf). Investigators soon discovered the flight data recorder (FDR) and cockpit voice recorder (CVR). A read-out of the FDR, and a transcription of the CVR tape, confirmed the flight attendant’s report. The explosive decompression occurred a few seconds past 6.24 pm, soon after the 747 reached its cruising level. After the aircraft was cleared to return to Haneda, the Captain exclaimed: “Hydraulic pressure has dropped!” The failure of the 747’s multiple hydraulic control systems completely deprived the crew of primary control. Stabiliser and aileron trim were also rendered useless, and the yaw COVER STORY damper was no longer effective. With the aircraft’s stability also seriously impaired by the loss of a substantial part of its fin, it began combined “phugoid” and “Dutch roll” oscillations, settling into a pitching, yawing, and rolling motion. The pitching, in cycles of about 90 seconds, was taking the aircraft from about 15° noseup to 5° nose-down, with vertical accelerations varying between +1.4 g and -0.4 g. Variations in airspeed and altitude during the cycles were averaging around 70 kt and 3000 ft, with peaks of as much as 100 kt and 5000 ft. The yawing and rolling motion was much faster, the aircraft alternately rolling 50° either way in cycles of about 12 seconds. Delicate handling: Holding the aircraft’s attitude by increasing and decreasing power, the crew also achieved limited directional control by applying power asymmetrically. At 6.29 pm they achieved a bank to the right, turning the aircraft on to a northerly heading while maintaining an altitude between 23,000 and 25,000 ft. Desperate efforts: The altitude excursions reached a peak, with the nose pitching down and the aircraft diving from 25,000 to 20,000 ft in a little over half a minute as the airspeed rose from 200 kt to 300 kt. Just as quickly the motion then reversed, the speed falling off again to 200 kt as the nose rose and the aircraft began climbing again. Preoccupied with trying to maintain control, the flight crew had overlooked donning their oxygen masks. Nearly 10 minutes had passed since the decompression and they were undoubtedly suffering a degree of hypoxia and some deterioration in judgement. But at the flight engineer’s prompting, this was remedied. The oxygen took effect quickly, for the pilots now limited the pitching excursions to about 2000 ft in altitude and 60 kt in airspeed. But they could do nothing to dampen the continuous rolling from side to side. The CVR revealed the pilots’ increasingly desperate efforts to control the aircraft. Over and over again, the Captain instructed the co-pilot to “lower the nose”. Just before 6.39 pm, the flight engineer suggested lowering the undercarriage to help stabilise the motion, but both Captain and co-pilot countered: “We cannot decrease the speed!” A minute later, with the pitch oscillations reduced to about half, the pilots succeeded in turning the aircraft towards Haneda Airport, 42 nm distant. As they did so, the flight engi- neer, seizing the opportunity as the airspeed fell below 200 kt at the top of a pitch-up, selected the undercarriage down. Although the change of longitudinal trim required an immediate increase in engine power, the increased drag dampened the pitching, reducing the amplitude of the airspeed and altitude excursions as the aircraft entered a descent of about 3000 fpm. But the drag also dampened its response to directional control and, instead of continuing towards the airport, it entered a turn to the right, still descending. But after turning through 360 degrees, the pilots regained some measure of directional control at 15,000 ft. Their reprieve was shortlived – the aircraft began turning again, this time to the left. Now below 9000 ft and still descending, the 747 was heading north again towards mountainous country. “Hey – there’s a mountain – up more!” the Captain called anxiously. The co-pilot carefully applied more power, trying to juggle the aircraft’s attitude. But with the undercarriage down, this failed to check the descent. Captain: “Turn right! Up! We’ll crash into a mountain!” With the application of more power, the aircraft pitched nose-up, gaining 2000 ft, while the airspeed fell from 210 to 120 kt. Captain (urgently): “Maximum power!” But the coarse application of power trig- gered the phugoid oscillation again. Captain: “Nose down ... nose down!” The co-pilot reduced power again and the nose pitched down. The aircraft was plunging to below 5000 ft with the airspeed rising quickly to around 280 kt, before recovering from the dive at a loading of 1.85 g. The aircraft then climbed even more steeply to about 8000 ft and, as its airspeed fell sharply, the stall warning began sounding. Captain (dismayed): “Oh no!” (urgently): “Stall! Maximum power!” Calls from Tokyo, Approach and Yokota were ignored as the crew fought to prevent the 747 plunging out of control. The final 108 seconds of the CVR revealed a string of increasingly desperate instructions calling for “Nose up”, “Nose down, and “Flap” as the pilots tried to prevent the aircraft falling out of control. Finally, as it entered a tightening descending turn to the right, the ground proximity warning system began sounding. Fourteen seconds later there was the sound of the aircraft striking tree-tops, followed three seconds later by the sound of the crash. Wreckage examination: It was clear that the explosive decompression, the pre-impact damage to the fin and rudder, and the loss of all four hydraulic systems, were somehow linked. But what was the link – and what had precipitated it? As a precautionary measure, the Japanese Fatal flight: The explosive decompression occurred soon after the 747 reached it’s cruising level (point of rupture). The crew lost primary control as a result of loss of hydraulic control systems. FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 31 COVER STORY Photo: Kjell Nilsson UPPER Tear stop straps Bulkhead 4.55 m diameter DESTRUCTION OF THE REAR PRESSURE BULKHEAD Tear stop straps Tear stop straps Tear stop straps UPPER BULKHEAD Line of cracks Line of cracks Upper doubler plate splice Fracture UPPER LOWER UPPER LOWER Bulkhead 4.55 m diameter Bulkhead 4.55 m diameter LOWER Line of red line shows the rear tail cone part Tail cone blown off: A Japan Air Lines 747 SR. The cracks of which was destroyed when the rear pressure bulkhead failed. UPPER BULKHEAD UPPER BULKHEAD Fracture Fracture LOWER BULKHEAD LOWER BULKHEAD Tear stop Tear stop straps straps Tremendous force: The rear pressure bulkhead (shown left in blue) must contain tremendous LOWER Lower doubler force from the pressure difference at altitude between the cabin and outside air. BULKHEAD plate splice The 4.55 m bulkhead is constructed of reinforced aluminium alloy sheets in a domed shape to resist pressure.The line of cracks (right) formed mid way between the upper and lower parts of the dome. Upper doubler plate splice Upper doubler plate splice Lower doubler plate splice Lower doubler plate splice Line of cracks: A side view of the cracks formed prior to rupture of the bulkhead. The bulkhead was destroyed after the cracks ran past the tear stop straps. INCORRECT REPAIR CORRECT REPAIR UPPER NORMAL BULKHEAD Fillet seal JA8119 REPAIR Upper doubler plate LOWER Rivets NORMAL BULKHEAD NORMAL Fillet seal BULKHEAD Fillet seal UPPER UPPER Stiffener Filler sealant CORRECT REPAIR CORRECT Doubler plate REPAIR Gap filled with filler sealant JA8119 REPAIR Lower doubler plateJA8119 REPAIR Upper doubler plate Up Upper doubler plate Stiffener Forward Over-loaded rivets: A “section” through the bulkhead showing normal construction (left) Stiffener Rivets a correct repair (centre) and an incorrect repair (right) that ledGap to the Filler sealant filledJAL with123 tragedy. In the wrong repair, technicians tried to connect two doubler filler plates, which forced the sealant middleRivets row of rivets to carry tooFiller much load. sealant Gap filled with Lower doubler plate Doubler plate filler sealant ER LOWER FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 32 Doubler plate Upplate Lower doubler Forward Up Civil Aviation Board ordered inspections of all 69 of Japan’s 747s. Boeing, in a telex to 747 operators world-wide, suggested they inspect the aft portion of the pressure hull. Airworthiness authorities world-wide issued airworthiness directives. Although Boeing 747s had no history of bulkhead failure, a major bulkhead fracture seemed to fit the evidence. Pressurised air, escaping from such a fracture, could have burst the fin. The rear pressure bulkhead was certainly badly damaged. But had the damage all been sustained in the impact? Although Boeing investigators argued that the design had been tested to a simulated service life of 20 years, and that the wreckage exhibited no evidence of corrosion, a profound shock lay in store. Examining the wreckage, Boeing’s structures engineer picked up a broken off section of pressure bulkhead plating. It had been repaired, and the repair didn’t look right. Electron microscope photographs of the fracture surfaces of the doubler plate revealed striations indicative of metal fatigue. The discovery posed two vital questions: Why was the bulkhead repaired in the first place? And why had it been wrongly repaired? An examination of JAL maintenance records revealed the rear fuselage of the crashed 747SR had scraped the ground during a nose-high landing seven years before. The impact had been severe enough to remove skin panels and crack the rear pressure bulkhead. The aircraft had been grounded for a month while Boeing engineers supervised repairs at JAL’s maintenance facility. The repair included replacement of the lower part of the rear fuselage and a portion of the lower half of the damaged bulkhead. Close examination of the bulkhead repair showed that two separate doubler plates, instead of one continuous one, were used as reinforcement. The result was excessive load on one row of rivets. JAL’s maintenance planning manager said the repairs were examined by the Japanese Civil Aviation Bureau, and the aircraft test flown after the work was done. No shortcomings were detected. Moreover, in the seven years the aircraft had flown since, six 3000 hourly “C-checks” had been carried out. Yet these had found nothing. Lessons: Boeing changed its 747 design to make it more forgiving to failures like this in the future – in other words to improve its “fail safety”. The manufacturer strengthened tear-stop straps in the bulkhead to stop cracks running. It improved venting of the tail compartment behind the bulkhead to reduce pressure if a bulkhead failed. And it provided a cover for an internal access hole to prevent pressurised air from entering the vertical fin. COVER STORY to the approved data, check with the designer. In JAL 123’s case, the Boeing repair team did not communicate well enough with their own company’s designers. Internal communication can be a problem for large companies. Operators should ask for assurance that the advice they are getting (including the NTO, or no technical objection) has engineering support, especially the support of company regulatory delegates. It is a good idea to check your old repairs. Be suspicious of all structural repairs. Be especially concerned about patches that are unusually old, large or thick. And be alert for small cracks emerging from under the edge of a patch repair. Look for signs of loose or working rivets, and be wary of stains streaking from under a patch. They might be the signature of pressure or fluid leaks. And take any available opportunity to check internally for cracks hidden under external repairs. An improperly treated scratch on the aircraft pressure vessel skin, especially if covered under a repair doubler, could be hidden damage that might develop into fatigue cracking, eventually causing structural failure (see “Hidden hazard”, Flight Safety Australia, September-October 2003). Diamond standard maintenance Diamond standard maintenance is based on a systematic analysis of how fatigue is likely to affect all the safety-critical parts of the airframe. The analysis has five elements: Site: Where could cracks start? This is a predictive element that requires analysis, testing and service experience, if available. Scenario: How will cracks grow? For example, will there be one or many? Will they interact? Will cracks in one part start cracks in another? Detectable: What is the smallest detectable size, considering the nature of the inspection method and other factors? Once you know this you can more effectively design your crack detection regime. Beware of optimism: For every lucky find of a small crack, there may be many more misses of large ones. Dangerous: As a crack continues to grow, sooner or later it starts to become “dangerous”, because the structure is about to lose the strength we want to assure. Duration: This is the time it will take a crack to grow from “detectable” to “dangerous”. It is the “safety window”. The inspection interval must be narrower, and must account for uncertainty and variability. Airworthiness authorities worldwide are By Steve Swift A t an international conference on aeronautical fatigue held in Hamburg, Germany, in June this year the concept of diamond standard maintenance received a lot of attention. Site Scenario Dangerous Detectable Duration Crack size The “diamond”: a new way of describing the “damage tolerance” rules for managing structural fatigue. Dangerous Duration Anyone operating a large airliner should check their compliance with Airworthiness Directive AD/GENERAL/82 Amdt 1. The scope of this airworthiness directive is likely to expand in the future. Finally, JAL123 warns owners and maintainers that fatigue cracks can stay hidden, even from the most thorough general maintenance. You need to adopt a systematic approach (see “Diamond standard maintenance” below). That’s why airworthiness authorities around the world are progressively requiring aircraft manufacturers to upgrade the maintenance programs they publish for the types they support. And that’s why Australia’s safety regulator insists that aircraft owners follow them, unless they have done a similarly systematic engineering analysis to justify the safety equivalence ofSite their alternative. Scenario Fatigue is indiscriminate and inevitable. If not carefully managed, it can result in catastrophe for any aircraft, largeDangerous or small, repaired Detectable or not. Macarthur Job is an aviation writer and Duration aviation safety specialist. Steve Swift is a CASA structural engineer. Crack size Modifications were also developed to prevent a total loss of hydraulic fluid from the four independent hydraulic control systems if the lines were severed for any reason, and to provide additional protection for control cables. Boeing had thought about most of these things when designing the 747, but events proved they had not tested them sufficiently. Aircraft manufacturers have since learned the value of testing to prove design assumptions. The JAL 123 tragedy reminds us how unforgiving structural fatigue continues to be in aviation, long after the infamous Comet crashes of the 1950s. Accidents resulting from structural fatigue have killed thousands, including many in Australia: In 1945, a Stinson A2W lost a wing, killing 10; and in 1968, a Vickers Viscount lost a wing, killing 26. In 1990, an Australian-built Nomad lost a tailplane, killing the pilot. Anyone repairing an aircraft needs to carefully follow approved data. To those repairing the bulkhead of the Japan Airlines’ 747, the improvised doubler plate repair probably looked strong enough – and it was, for a while. But, the fatigue aspects of a design are not always obvious. If you can’t install the repair exactly Dangerous Duration Detectable Time The time between inspections must be shorter than the “Duration”. So, for safety, we must know “Detectable”, “Dangerous” and how fast a crack will grow. working with aircraft manufacturers and operators to put in place diamond-standard maintenance programs for all aircraft, including their repairs and modifications. Diamond standard maintenance programs are usually called airworthiness limitations or supplementary inspection documents (SIDs). With two out of three Australian aircraft having seen a quarter century of hard service, the dangers of fatigue are ever present. There is no room for complacency. For a copy of the full paper on diamond standard maintenance (called “Rough Diamond”), and other safety-related papers and reports on structural fatigue, visit CASA’s web site. FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 Detectable Time 33 FLYING OPERATIONS Some tips and techniques for VFR pilots on how to get the best from GPS. By Mike Smith. M y logbook shows October 11, 1990, when the world watched the United States and its allies face off Iraq over its invasion of Kuwait, as my first flight with a GPS receiver on board. The unit was a Trimble Trimpack, one of the first GPS receivers available to the civil community. It had a very basic display, required all waypoints to be manually entered by latitude and longitude using two toggle switches and it consumed batteries at an alarming rate. The GPS satellite constellation was incomplete, and the system only worked for part of my flight from Cooma to Mudgee and back that day, in what I still remember as very serious IFR conditions. Yet, even with those limitations, the experience sparked an enthusiasm for the technology and the revolution in aircraft navigation capability it promised. The first Gulf war started in earnest in early 1991, when pictures of soldiers using the very same types of GPS units as mine flashed around the world – it was exciting to see cutting edge military technology make its way so quickly into the light aircraft cockpit. In a country as vast as ours, with limited navigation aid coverage and broad 34 FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 expanses of featureless terrain, it is little wonder Australian pilots were quick to embrace GPS technology. It is rare today to talk to a pilot who doesn’t use GPS regularly. Whether it’s a basic portable receiver or a sophisticated panel mounted unit with a moving map display, GPS is as ubiquitous today in the light aircraft cockpit as the mobile phone has become in the general community. But the comparison of GPS with the mobile phone doesn’t end there: Just like mobile phones, GPS receivers have evolved to include a bewildering array of features and functions buried in layers of software and accessed by buttons with a seemingly endless number of available operations. Not surprising, then, that many pilots never go beyond the “direct-to” function of the navigator. True, the direct-to function, along with the display of track and groundspeed, are probably the most used and loved features of GPS navigators, especially by the VFR pilot. But by taking a little time get to know your particular unit, you can open an outstanding capability designed to make your flying simpler, safer and more enjoyable. Let’s look at a few tips and techniques you can try next time you fly with your GPS. You really do need an intimate understanding of the functions of your particular navigator and how to access them to get the most out of it in flight. Some of the less used features can be a great help when things get busy and the flight isn’t going as planned. I have a Garmin 430 in my Cessna 172, which it combines the GPS navigator with a VHF radio and a VOR/ILS receiver. The 430, like many of the mid-to high-end units, integrates these devices and allows you to look up frequencies and tune the VOR/ILS and the VHF radio using information from the GPS database and the current position. The “nearest” function can locate the closest airport – which can be very handy in the event of, say, a rough-running engine or a sick passenger. The unit can display and automatically tune the CTAF or tower frequency, the VOR or ILS frequency and even the frequency for activating the airport lighting. Most GPS units have a simulation mode to allow you get to know their operation from the comfort and safety of your own home. Some of the manufacturers have good computer based simulators either supplied with the unit or available for download on their websites. Spending a few hours with these simulations is an obvious place to start and should be considered essential before flying with a FLYING OPERATIONS new or unfamiliar receiver. Once you become familiar with the basics, such as the location and functions of the various controls and the display, you can think about the features you are likely to use and, depending on the unit, you can customise the display and the set-up of the receiver to match your taste. I have a hand-held unit that has aviation, marine and automotive modes. It has a very good automotive database that includes street directory and Yellow Pages information and can provide turn-by-turn guidance. In automotive mode I usually set metric units, but this is not suitable for aviation use so I have to change units to suit when changing modes. Since most GPS receivers are made for the US market, the manufacturer’s default settings may not be what you need; for example, the US uses inches of mercury for reporting barometric pressure while we use hectopascals in Australia. Settings: The set-up parameters to check before you go flying include distance and speed in nautical miles and knots, barometric pressure in hectopascals (some units call this millibars), map datum should be WGS-84 and altitudes should be in feet. While most pilots will find these basic settings are pretty much the standard, customising the display is more a matter of personal taste. Depending on the number of data fields available on the particular unit, I like to have groundspeed and current track displayed and, if there are enough fields left, ETA and bearing for the next (active) waypoint. I prefer to display track-up if I have a moving map, but I know pilots who like to see north facing up on the map. A GPS map of airspace boundaries, can be useful when planning to fly around airspace or determining where to call for clearance, but it’s important to have a current database and to cross-check against current AIP charts. Tailoring other features, such as how towns, roads, rivers and railways are displayed and understanding how to zoom and de-clutter the map display are also useful skills to learn before flight. Because there is generally no need to submit a flight plan to Airservices Australia for most VFR flights – and since the GPS can do a lot of the work for us the temptation to limit flight planing to simply checking weather and NOTAMs can have us launching into the wide blue yonder without a good appreciation of the route we intend flying, the tracks and distances involved and the lie of the terrain and airspace around us. Incidentally, even though ATC doesn’t need a plan for most VFR flights, submitting a plan will make it much easier for everyone if you need to get a clearance into controlled airspace, if you want to get flight following – where, on request, ATC will provide you with (free) radar-derived information to improve your situational awareness – or if you have to change category to IFR. … the temptation to limit flight planing to simply checking weather and NOTAMs can have us launching into the wide blue yonder without a good appreciation of the route we intend flying … So, whether you start by drawing the track on your chart, or you use one of the many computerised flight planners, this part of the planning process shouldn’t be overlooked. Make sure you know the airspace you will fly through or close to, and consider the effect of the forecast wind on your plan, especially the fuel requirements. Wise use of GPS can help you avoid airspace violations and can alert you that you should divert for fuel when ground speeds haven’t worked out as planned. However, pilots with GPS on board still violate controlled airspace and still run out of fuel, and this suggests some basic planning inadequacies. When you’re done, enter the complete plan into the GPS. If you have a handheld, you can do this while you’re planning, as an aid and cross check of your bearing and distance measurements. When you cross check your flight planned bearings and distances against those computed by the GPS, they should match up. If they don’t, double check the waypoints you’ve entered and the tracks you have drawn and measured on your chart. By entering the complete plan into the system, rather than simply going direct to the first and successive waypoints, you’ll have had the opportunity to pick up any gross planning errors, and, you’ll have more time in flight to look out the window, enjoy the scenery and scan for traffic. GPS can also provide us with a simple means of checking the accuracy of the magnetic compass. When you are taxying the aircraft in a straight line, you can compare the GPS track with the compass indication. On the ground and free from the effects of wind, the GPS track is the aircraft’s heading and should match the (corrected for magnetic variation and compass error) compass reading. GPS has changed the way most of us fly, both IFR and VFR, and I think it’s worth acknowledging that, when using GPS, the usual discipline we need to apply to the navigation task is often forgotten. Just like any other aircraft system, the GPS can fail in flight and you may have to revert to other methods of navigation. OUT there FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 35 FLYING OPERATIONS You should augment GPS navigation with traditional methods, following your progress on the appropriate chart and keep an accurate flight log. You could also tune and identify the VORs and NDBs along your track and cross check all the available navigation information. Your records of fixes, groundspeeds, track and estimates should be very accurately recorded and that means if you have to revert to more basic navigation, you have good information to start from. Basic DR should easily get you to the next waypoint as long as you are diligent in keeping an accurate log. A GPS receiver can still malfunction. But this is a rare event. You can detect failure using common sense, maintaining situational awareness and questioning unexpected changes in distances or tracks. It’s nice to see so many new aircraft coming into Australia with very capable avionics installations integrated as standard fit. Many new Cessna aircraft are being delivered with the Garmin G1000 integrated avionics system Just like any other aircraft system, the GPS can fail in flight and you may have to revert to other methods of navigation. that integrates the flight instrumentation, navigation, communication, surveillance and autopilot functions into a single device. Cirrus and Lancair aircraft are certified with the Avidyne system, an avionics suite that provides similar capability. Conventional gyroscopic instruments are replaced by solid-state attitude and heading reference systems. Ultralights and home-built aircraft are also gaining sophisticated cockpits including “glass” panels for navigation and systems display. Whether you are using a basic GPS handheld receiver, or you’re flying the latest integrated avionics system, you’ll get the most out of your unit if you take the time to thoroughly understand the system and practise using it regularly. You’ll stay safe if you don’t allow the avionics capability to distract you from the basic flying task. Remember the old adage: aviate, navigate and communicate. For further information on the aviation use of GNSS (GPS) see the CASA CAAP 179A-1 (0) at http://casa.gov.au/download/CAAPs/ ops/179a_1.pdf. Mike Smith is a commercial pilot and LAME. GPS CHECKLIST FOR VFR FLIGHT 1 Get familiar with your GPS navigator on the ground before you go flying. You will then get the most from its capabilities and have more time to attend to other flying chores, look out for traffic and appreciate the view. If your GPS has a quick reference guide, keep it handy. 2 Always do a thorough flight plan and load the plan into the GPS before you takeoff. When planning, use current documents and remember to check location and head office NOTAMs. Carry the appropriate charts with you in flight. 3 Check the GPS receiver pre-flight. Make sure that the database is current or make a mental note not to rely on the accuracy of any database derived information for your flight. 4 Ensure that there is no interference with your GPS from other aircraft equipment and other aircraft contents such as mobile phones, laptops and electronic games. 5 If you’re using a handheld or portable receiver, check the batteries or aircraft power connection. Make sure you carry spare batteries. Mount the GPS unit in the aircraft so 36 FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 it can be readily operated and so that it doesn’t interfere with the operation of any other aircraft equipment. Connect an external antenna if you have one. 6 Be particularly careful not to place a portable unit where it can interfere with the magnetic compass. Take care with any power or antenna cables as these can also interfere with the compass. 7 Don’t just rely on the GPS for navigation. Follow your flight’s progress on your charts and keep an accurate flight log. Monitor all of the aircraft’s navigation aids that you are qualified to use. 8 If you do divert from your plan, be particularly careful with the direct-to function. Remember to cross check airspace boundaries and terrain on your charts. 9 Don’t fixate on the operation of the GPS in flight. VFR flight requires most of a pilot’s attention is focused outside the aircraft. WHAT FLYING WENT OPERATIONS WRONG WRONG WAY TRK 100 M MD80 –FL290 9 B767 –FL290 12 15NM 40 The traffic collision avoidance system (TCAS II) traffic display can be misinterpreted. 2 NM By John Law and Eurocontrol specialists. T II isand a last resort safety net deFigureCAS 1: B767 MD80 signed to prevent mid-air collisions. When it computes a risk of collision the system alerts the flight crew and provides instructions to resolve conflicting paths (resolution advisories, or RAs). The main purpose of the TCAS II traffic display is to help flight to visually locate aircraft in the vicinity. Unfortunately some flight crew are tempted to make their own traffic assessment based on the TCAS display, and to manoeuvre ahead of ATC instructions. This can be dangerous as the TCAS 11 traffic display is easy to misinterpret. That is because the display gives you only partial information, has limited accuracy, and is based upon a moving reference. A run through some actual events where problems have occurred due to misinterpretation of the TCAS II traffic display illustrates DC10–FL350 the nature of the problem. 1.6NM Trajectory if the first ATC instruction was followed MD80 –FL290 B767 –FL290 B747–FL350 15NM Figure 6: Aircraft trajectories converge at 90º 2 NM Figure 1: B767 and MD80 Loss of separation: The first event involved a loss of separation as a result of an inappropriate turn. A B767 (heading 100 degrees) and a MD80 (heading 217 degrees) were maintaining FL290 on crossing tracks (see figure 1). The B767 would have passed about 15 nm behind the MD80 (see dotted line on figure 2 1 12 were still 1). For radar separation, when they .5 4 80 nm apart, the controller instructed both +05 aircraft to maintain their headings. 05 05 6 One minute 0 before the tracks would have NM 6 4 .5 1 2 00 crossed, the controller gave traffic information to the B767 pilot: “Eleven o’clock, from left to right, same level, aircraft type MD80 … 25 nm, converging”. The B767 pilot started to monitor a target, which was on the left-hand side of the TCAS traffic display. As he assessed that the other traffic was converging head-on, the B767 pilot asked: “Where is this twelve o’clock traffic going?” The controller responded with updated traffic information. However, the B767 pilot then said: “We’re going to take a heading here of 120 degrees while starting a turn to the right.” Due to this turn – in the wrong direction – the horizontal separation reduced quickly and a traffic alert (TA) was triggered on both aircraft. The B767 pilot started to descend and said, “We’d like to go to [FL] 270”. Afterwards, to justify his decision to turn, the B767 pilot told the controller that “the traffic was coming right up, so we [turned] to avoid the traffic”. The inappropriate turn reduced separation to only 2 nm. Why did the B767 pilot to turn contrary to the ATC instruction? And why to the right? Figure 2 shows how the situation was shown on the controller’s radar display and on the B767 TCAS traffic display at the time of the initial traffic information. On the controller’s display, the 3-minute speed vector (magnetic track and speed) clearly showed that the B767 was going to pass behind the MD80 (which was faster – 520 kt ground speed for the B767 versus 470 kt ground speed for the MD80). But this was not obvious on the TCAS traffic display. The B767 pilot was misled because of the difficulty involved in anticipating how the situation would evolve solely from the information presented on the TCAS traffic display. The B767 pilot related a target on the TCAS traffic display to the initial traffic information. What the B7767 pilot saw was a 2 1 12 target moving apparently on opposite track, .5 4 slightly on the left. Hence his question to the +05 controller: “Where is 05 this traffic 05 12 o’clock 6 going?” 0 NM 6 4 .5 1 2 47 ABC123 B767 290- 52 XYZ456 MD80 290- 00:00 +00.25 Figure 2: Controller’s radar display (top) and B767 TCAS traffic display (above). Figur When the target was at the 12 o’clock position and less than 20 nm, the B767 pilot decided to turn right to avoid the target on the TCAS traffic display (“We’re going to take a heading 120” – see figure 3). TRK 040 M The pilot was unable to relate the direc3 the controller’s tion of the traffic in traffic an6 nouncement to the information provided by the TCAS traffic display, so he did not take it 40 into account. But to the controller, it was obvious that the turn to the right would create a loss of separation. Because of the turn to the TRK 100 M right, the target remained on the left-hand 00 side on the TCAS9 traffic display, apparently 12 still on opposite track, and a TA was then Figure 9: Confirm 30 degrees left? triggered. The pilot then decided to descend TRK 040 M (“We’d like to go to 40 270” – see figure). A loss of separation then occurred. 3 6 Challenge to ATC 00 instruction: In the second event a B747 pilot challenged an ATC 40 separation. A DC10 turn instruction for (heading 100 degrees) and a B747 (heading 040 degrees) were level at FL350 – and on a 47 course (see figure 6). Two and a half collision ABC123 00 crossing, the controller minutes before the B767 29052 degrees instructed the B747 pilot to turn 30 XYZ456 Figure 10: Confirm 30 degrees left? left to achieve a separation of 5 nm behind MD80 290- saw the DC10. However, the B747 pilot a target on the left at the same level on his TCAS traffic display. He asked the controller,00:00 “Confirm 30 1degrees2 left?”12He thought – wrongly – .5that a left turn (which would 4 +05 Figure 2: Controller’s display (top) actually have resolvedradar the situation) would and B767 TCAS traffic 6 05display (above). 05 have created 0 a collision risk (see figures 8 NM 6 FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 4 .5 1 2 37 (1 Figure 7 +00.25 Figure FLYING OPERATIONS TRK TRK100 100 100M M M TRK 999 999 111 222 00 00 00 00 00 00 00 00 00 47 47 47 ABC123 ABC123 ABC123 B767 B767 B767 290290290- 52 52 52 XYZ456 XYZ456 XYZ456 MD80 MD80 MD80 290290290- TRK 100 M MD80 –FL290 B767 –FL290 9 radar Figure Figure 3: 3:Controller’s Controller’s Controller’s radar radardisplay display display 12 Figure 3: 52 52 52 XYZ456 XYZ456 XYZ456 MD80 MD80 MD80 290290290- TRK 100 M 52 52 52 XYZ456 XYZ456 XYZ456 MD80 MD80 MD80 290290290- 47 47 47 ABC123 ABC123 ABC123 B767 B767 B767 290290290- 47 47 47 ABC123 ABC123 ABC123 B767 B767 B767 290290290- +00.50 +00.50 +00.50 111 222 40 40 40 40 40 40 2 YZ456 YZ456 Z456 MD80 D80 D80 9000- (top) (top) top) ve). ve). e). 999 111 222 40 40 40 +00.25 +00.25 +00.25 TRK TRK120 120 120M M M TRK TRK TRK100 100 100M M M TRK TRKTRK 100 100 M M +01.35 +01.35 +01.35 9 9 radar 1display Figure Figure5: 5: 5:Controller’s Controller’s Controller’s radar radardisplay display Figure 2 12 9 radar 1display Figure Figure4: 4: 4:Controller’s Controller’s Controller’s radar radardisplay display Figure 2 15NM and 9). 40 Thirty seconds later the B747 pilot said, “If we turn 30 degrees left, we will be aiming to00 wards another aircraft2atNM our level.” Meanwhile a short-term conflict alert was (1) (1) (2) (2) (3) (3) (1) (2) (3) triggered and the controller instructed the 1: B767 and MD80 DC10Figure to descend. The controller then provided traffic(3) infor(3) (3) 47 ABC123 mation to the B747 pilot who asked: “Which B767 heading290would you like us to take?” The con52 (2) (2) 30 (2) XYZ456 troller repeated his instruction to “turn left MD80 degrees”. This time, the B747 pilot accepted 290the instruction and initiated a left turn, but it (1) (1) (1) is too late to maintain separation. The B747 pilot reported a “TCAS advisory”. Figure Figure7: 7: 7:Aircraft Aircraft Aircrafttrajector trajector trajectories ies iesconverge converge convergeat at at90º 90º 90º Figure 00:00 The minimum distance reached was 1.6 nm. Later the2:B747 pilot asked the controller Figure Controller’s radar display (top)to and B767 TCAS for traffic (above). explain the reason thedisplay turn. The controller replied that there was conflicting traffic at the same level. The B747 pilot answered: “We are filing [a report] … you sent us straight [towards] the aircraft”. TRK 040 M 3 (1) (2) 00 40 3 1.6NM (2) B747–FL350 Figure 6: 9: Aircraft trajectories converge Figure Confirm 30 degrees left? at 90º TRK 040 M FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 3 6 +0 +01.3 Fig Figur TRKTRK 000 040 M M (3) Trajectory if the first ATC instruction was followed 40 40 track actually appears to be converging at a 45° angle on the TCAS traffic display. The same issue occurs 00 when an aircraft is catching up on a slower aircraft flying in the 00 same direction. In this situation, the target is apparently displayed as an intruder on an opposite direction track. The interpretation of an intruder trajec47 52 ABC123 tory on the TCAS traffic display is even more XYZ456 B767 MD80 290- the aircraft is manoeuvring difficult when 52 290XYZ456 because vary 47 the bearing of the intruder will MD80 ABC123 290significantly even if its heading is steady. B767 290In addition, the lack of either a speed vector or knowledge of the intent of the other aircraft can make it more difficult to interpret the 00:00 +00.50 TCAS traffic display. It is also hard to work 2: Controller’s display (top) out inFigure advance if you areradar onradar a display collision course Figure 4: Controller’s and B767 TCAS traffic display (above). or whether separation will be maintained. For example, when an extended range is selected, the size of the target symbol can be large, corresponding to a few nautical miles. Therefore, the TCAS display is much less precise than the (3) 6 DC10–FL350 38 40 Analysis of the incident confirmed that if the B747 pilot had complied with the initial ATC instruction to turn, a 5 nm horizontal 00 been achieved (see separation would have dotted line on figure 65). TRK TRK000 000 000M M M TRK There are three factors which contribute to traffic display misinterpretation: the nature 3 3333 moving reference33display, 347 of the TCAS the ABC123 B767 of TCAS bearing informalimited accuracy 290(1) (1) (1) 20 20 52 20 tion and00 the partial traffic picture XYZ456 given by 00 00 MD80 the system. (2) (2) (2) 29000 00 00 Moving reference: The reference for the (3) (3) (3) TCAS traffic display 00 00 is the aircraft’s own po00 sition, which is constantly moving (unlike the controller’s radar display, which has a Figure Figure8: 8: 8:Closure Closure Closureappears appears appearsto to tobe be beat at at45º 45º 45º Figure +00.25 fixed reference). This gives a display where theFigure targets are shown in relative motion, a 3: Controller’s radar display major cause of TCAS traffic display misinterpretation. The most significant illustration of this is when two aircraft are converging at 90 degrees. Figures 7 and 8 show that the symbol of an aircraft on a 90 degree crossing (1) Figure 7: Aircraft trajector ies converge at 90º 33 6 3 20 40 (1) 00 (2) 00 (3) 00 00 Figure 9: Confirm 30 degrees left? Figure 8: Closure appears to be at 45º TRK 040 M 3 6 Figu MD80 MD80 MD80 –FL290 –FL290 –FL290 999 B767 B767 B767 –FL290 –FL290 –FL290 1121 22 FLYING OPERATIONS 15NM 15NM 15NM 40 40 40 TRK 040 M 3 22NM 2NM NM (1) (2) TRK 000 M (3) 00 00 00 rules for use of TCAS display 3 3 6 3 (3) ICAO PANS-OPS, Doc 8168 states: “Pilots shall not manoeuvre their aircraft in response to traffic advisories (TAs) only.” (1) 20 40 Figure Figure Figure 1:1:1: B767 B767 B767 and and and MD80 MD80 MD80 00 This point is emphasised in the guidelines for pilots: (2) ICAO ACAS 11 training (2) “No manoeuvres are made based solely on4747 the shown on the 47 information 00 ABC123 ABC123 ABC123 ACAS display.” (3) B767 B767 B767 00 Figure 9: Confirm 30 degrees left? TRK 040 M 3 Note that in the event of a conflict of advice between a TCAS RA and an ATC instruction, the TCAS RA should be followed. 6 00:00 00:00 00:00 40 00 Figure 10: Confirm 30 degrees left? controller’s radar display. Partial traffic picture: Although the TCAS DC10–FL350 DC10–FL350 DC10–FL350 traffic display helps pilots to detect the pres2 12 flight crews ence of intruders 1in close vicinity, 1.6NM 1.6NM 1.6NM .5 Trajectory Trajectory Trajectory ififthe ifthe the should not be over-reliant on 4the display. It first first first ATC ATC ATC instruction instruction instruction +05 supports visual acquisition; it is not was was was followed followed followed 6 a replace05 05 0 out-of-window scan. One of the ment for the 6 main reasons for this is that the traffic picture B747–FL350 B747–FL350 B747–FL350 provided by .5 the TCAS traffic display is only 4 partial. TCAS only detects intruders with Figure Figure Figure 6:6:6: Aircraft Aircraft Aircraft trajectories trajectories trajectories converge converge converge at at at 90º 90º 90º 1 2 an active transponder, and does not provide traffic identity information. Figure 11c So there can be aircraft in the vicinity even if there is no target on the TCAS traffic display. As a result flight crews can get a wrong idea of their traffic situation. Two recent events illustrate the potential problem. A controller advised a pilot approaching his cleared flight level that further descent would be after 4 nm due to traffic. The pilot answered: “We have him on TCAS.” However, he misidentified the target because the actual NM 111 .5.5.5 222 +05 +05 +05 05 05 05 05 05 05 000 444 666 444 111 Figure Figure Figure 11a 11a 11a 12 12 12 NM NMNM 666 .5.5.5 29029029000 525252 ICAO standards only include (1) phraseology to report resolution advisories XYZ456 XYZ456 XYZ456 (RAs). Therefore, pilots should not report “TCAS contact” or “We haveMD80 it on MD80 MD80 290290290TCAS” after traffic information from ATC. Indeed, such a report provides Figure 7: Aircraft trajector ies converge at 90º Figure 8: Closure appears to be at 45º no added value to ATC. conflicting aircraft had a transponder failure; it was shown to the controller on primary radar only. In another incident, a pilot reported that a TCAS technical fault displayed an intruder in descent whereas he could see a climbing fighter. Actually, TCAS operated perfectly: there were two fighters, the one descending was transponding but the one climbing was not. TCAS surveillance range may be reduced to 5 nm in high density airspace. Therefore, pilots could observe aircraft in the vicinity, which might not be shown on the TCAS traffic display. Even if aircraft are detected by TCAS, they may not be displayed. Some installations limit the number of displayed targets to a maximum of eight. In addition, the TCAS traffic display options provide altitude filtering (for example, “NORMAL” mode only shows targets within +/- 2700 ft from the aircraft). Limited accuracy: The TCAS II bearing measurement is not very accurate. Usually, the error is no more than 5 degrees but it can be greater than 30 degrees. Due to these errors the target symbol on the display can jump. Figures 15a, 15b and 15c show the TCAS traffic displays of an event recorded during a TCAS II trial. There were 3 intruder aircraft, 111 .5.5.5 222 +05 +05 +05 05 05 05 05 05 05 000 666 444 111 Figure Figure Figure 11b 11b 11b 444 666 .5.5.5 222 12 12 12 NM NMNM +00.25 +00.25 +00.25 in the 12 o’ cController’s lock position, butdisplay separated by 500 Figure Figure Figure Figure 2:2:2: Controller’s Controller’s radar radar radar display display (top) (top) (top) Figure Figur3 and and B767 B767 B767 TCAS TCAS TCAS traffic traffic traffic display display display (above). (above). (above). ftand vertically. However, the intruder at +05 (500 ft above) appears at 6 seconds intervals, on the right of the group of targets (10a) and then on the left (10b), before being shown in the correct 12 o’clock position (10c). In the worst case, bearing error could cause a target on oneTRK side of the TRK TRK 040 040 040 MM M aircraft to be dis(1) (1) (1 played on the other. This emphasises the 333 666 danger of undertaking a horizontal manoeuvre based solely on the TCAS traffic display. Note that TCAS II40 does 40 40 not need bearing information for collision avoidance RAs. Manoeuvres initiated solely on the information shown on the TCAS traffic display have often degraded flight safety. Therefore, 00 00 00 pilots should not attempt to self-separate, nor to challenge an ATC instruction, based on in- Figure Figure Figure Figure 9:9:9: Confirm Confirm Confirm 30 30 30 degrees degrees degrees left? left? left? Figure Figure 7:7:7 formation derived solely from the TCAS trafTRK TRK TRK 040 040 040 MMM fic display. It is the controllers’ responsibility to 666 separate aircraft.333 TCAS II will trigger an RA if there is a risk of collision between aircraft, and in this case 40 40 40 the TCAS RA should be followed. John Law is Mode S and ACAS program manager, Eurocontrol. 00 00 00 Source: ACAS II bulletin no 6, March 2005. Reproduced with permission. Competency standards for use of TCAS IIConfirm are available at casa.gov.au/fcl/syllaFigure Figure Figure 10: 10: 10: Confirm Confirm 30 30 30 degrees degrees degrees left? left? left? bus.htm. 111 .5.5.5 222 +05 +05 +05 05 05 05 05 05 05 000 444 666 666 444 .5.5.5 111 222 12 12 12 NM NMNM 222 Figure Figure Figure 11c 11c 11c FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 39 3 NEW posters on how to prevent runway incursions All 3 posters for $5 Order your copies today at http:// casa.jsmcmillan.com.au �������������� ������������������� ����������������������������� ������� �� ����������� ����������������������� ��������� ����� �� ���� ������������������� ���������������������������������� ��������������������������������������� ��������������������������������������� ��������������������������������������� �������������������� ����������������������������������������� �������������� ����� ���� ���������� ��������������������������������������� ������������������������������������� � � � � � � � � � � � � � � � ��� � � � � � � � � � ������������ ������������ �������� ����������� ��������� ��������������� ������������ ����������� ����������������� ������������ �� ������������� �� �� � �� � � �� ���������� ������ ��� �������������������������������������������������������������������������� ������������������������������������������������������������������������ ��������������� ����������������������������������������������� FLYING OPERATIONS RUNWAY INCURSIONS Why are they occurring and how to avoid them. By Ben Mitchell. CASA Photo library W hile Australia continues to be one of the safest places to fly, a worrying trend with serious consequences is emerging at our general aviation aerodromes. New figures from Airservices Australia show that runway incursions at major general aviation aerodromes are continuing to increase despite a greater awareness of the problem among pilots. The national figures show the number of runway incursions has been rising steadily since the end of 2001 and are now at record high levels. Of the major GA aerodromes examined by Airservices, Bankstown recorded the highest number of these events while Archerfield had the lowest number of incursions. The factors behind these events vary, but there are some common threads identified by Airservices Australia: •Complex airfield design. Just because international long-haul aircraft are not using the aerodrome doesn’t mean the layout will be simple. Smaller aerodromes can have lengthy and confusing taxiways that are difficult to navigate. There have been some cases, for example, where a runway has been mistaken for a parallel taxiway. •Missed airfield markings. Signs can be missed due to the limited field of view from the cockpit of taxiing aircraft or the impact of weather conditions such as sun glare. In poor weather, a slower more methodical taxi to the runway is recommended. •Varying airfield layout. Not every runway complex is laid out or marked the same way. At some locations, gable markers and taxiway holding points are aligned; at some they are separated by significant distances; and at some locations, the length of taxiway between holding points for parallel runways is not long enough to allow for large twin engine aircraft. •Ambiguous and/or misunderstood air traffic control phraseology. The only terms that should be used by air traffic controllers are: ENTER / CROSS / LINE-UP / CLEAR / TAKE-OFF. For any other phrases or misheard instructions, pilots should ask for clarification from the tower. •Switching off in the cockpit. While the flying phase of the journey may be over, the flight itself does not end when the wheels touch the tarmac. Pilots should stay alert until they have cleared the runway complex and shutdown the aircraft. •Training aerodromes. Inexperienced pilots may be slower to react or understand air traffic control clearances or have an under-developed sense of situational awareness. •No ground control. Pilots operating from aerodromes without a tower surface movement control service do not have the protection of an “extra” set of eyes. Greater vigilance is required to prevent accidental incursions. •Traffic and radio Transmission congestion. Complex traffic environments usually mean increased communication between the tower and aircraft. Often transmissions can be overtransmitted, garbled, or hurried – all of which can lead to misunderstandings. •Change of plans. Last minute changes to landing or takeoff plans have led to a number of accidental runway incursions around Australia. Pilots should always be prepared for a FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 41 FLYING OPERATIONS last minute change of runway or taxi route. •Inadequate training. Aerodromes contain numerous markings, signs and ground-based instructions that can easily be confused or misunderstood. Instructors should ensure their students know the aerodrome signs and what they mean. Student pilots should ask if they don’t recognise an aerodrome sign or marking. •Physiological impacts. Tiredness, for example, can cause confusion or a lowered awareness of potential threats. Other causes include first solo nerves and non-compliance with procedures (that is, the pilot failed to monitor the aerodrome terminal information service [ATIS] or ground frequency). Ground operations can be the most demanding and complex phase of flight. As a general rule, detailed prior planning is the best way to prevent runway incursions, but there are several other simple measures that will help significantly reduce their likelihood. Aerodrome familiarisation is the key to reducing the incidence of these events – if you know where you’re going and how you’re going to get there taxiing should be relatively straight forward. Aerodrome diagrams are extremely helpful and readily available from Airservices Australia and other commercial vendors. You should review these diagrams before taxiing or landing and keep the diagrams readily available during taxiing. You should be alert to aerodrome vehicle and pedestrian activity and plan the taxi route noting runway cross- ings or parallel runways that could be easily confused. Effective pilot/controller communications will also help ensure safe surface operations. If possible, monitor radio communications for a short time before commencing to taxi to establish a mental picture of aircraft movements and intentions. Keep communications clear and concise – if you don’t understand an instruction, ask for clarification. Controllers would much rather repeat a message or clarify an instruction than watch two aircraft collide. You should also have a frequency management plan and know where to change frequency. Extra vigilance: You can also follow some basic cockpit procedures and techniques to help reduce the likelihood of an accidental incursion. Avoiding unnecessary conversations in the cockpit during surface operations, constantly scanning for traffic, making the aircraft visible through the correct use of lights and asking the tower for assistance will help. You should also make sure your radio is operating correctly before commencing taxiing. Check the audio panel, volume control, and squelch settings prior to taxiing and never stop on an active runway and ask for directions. Clear the runway first and then ask for assistance. Staying alert when the visibility is low or impaired is also critical. Extra vigilance is required when visibility decreases and the ability for pilots and controllers to maintain a desired level of situational awareness becomes significantly more difficult. Pilots should be aware that tower controllers are there to help. If you’ve lost situational awareness or think you may have missed a sign, make a call. Continuing to taxi when you’re unsure of where you are or where you need to go could have disastrous consequences. There have been some near misses at some of the major general aviation aerodromes and only by working together will we reduce and hopefully eliminate the problem. To conclude, here is a simple checklist to help avoid runway incursions. Do not approach a runway or helipad until you: •Have the current aerodrome terminal information service (ATIS). •Are monitoring the correct frequency and the radio works. •Know where you are. •Know where you intend to go (even if it is initially just out of the landing area). •Know how you intend to get there. •Know what is happening around you (check base, final of all relevant runways, check actual runway, monitor frequencies for any special operations). •Have a simple contingency plan in case things change (taxi back to the run-up bay and rethink the plan or simply ask ATC for assistance). Fortunately, there have been no fatal accidents at controlled aerodromes as a result of runway incursions in Australia, but the potential for a serious incident is high. Ben Mitchell is an Airservices Australia aerodrome operations specialist. CASA Photo library Demanding: Ground operations can be the most complex phase of a flight. Detailed planning is required 42 FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 FLYING OPERATIONS hygiene Sleep can be improved by what researchers are calling good sleep hygiene. Cary Thoresen reports. C ivil aviation order (CAO) 48 requires pilots to report fit for work and to declare their unfitness if necessary. Increasingly, occupational health and safety legislation is requiring both employers and employees to adequately manage the fatigue risk inherent in all workplaces. Clearly employees must use their time away from the workplace for recovery, in order to return to work well rested and alert. Sometimes this objective has to be met in the face of competing social obligations and domestic responsibilities. You will need to plan ahead and communicate with others to balance these demands – it is important that you make family members aware of your need to obtain sufficient recovery sleep before returning to work and that you seek their cooperation in meeting this need. some tips on how to stay refreshed and alert Better work and leisure time habits A good pre-sleep ritual A better sleep environment Diet Some scientists say that high protein/low fat foods may assist with alertness and that simple carbohydrates and sugars contribute to poor performance. In any event, healthy eating will improve all aspects of your life. Wind down Set some time aside to relax before you go to bed. You could have a hot bath (the drop in body temperature afterwards will mimic the circadian temperature decrease associated with sleep), read a magazine, drink warm milk or herbal tea, or do some mild stretching or breathing exercises. Make sure you are comfortable If you are disturbed by a restless bedmate, perhaps you need a larger bed, or a different type of mattress. You may need to experiment with different pillows to ensure your neck is comfortable. Limit caffeine and alcohol Even though alcohol can act as a sedative, it interrupts normal sleep patterns. Bearing in mind that you process one drink per hour, try to have a zero bloodalcohol level by the time you want to sleep. Also be aware that caffeine will interfere with sleep, making it lighter and more fragmented. Don’t drink caffeinecontaining drinks – including soft drinks – for several hours before bedtime. Don’t smoke Nicotine is a stimulant and makes it hard to fall asleep. Don’t smoke immediately before bedtime. Expose yourself to bright light after waking This will help to regulate your body’s “biological clock”. Getty Images Exercise earlier 20-30 minutes of exercise a day can help you sleep better. But don’t exercise within a few hours of bedtime because the stimulation can make it harder to fall asleep. Check your iron level Iron deficient women tend to have sleep problems; a supplement can help. Bedtime rituals When you are trying to sleep somewhere other than your own bed, it is important that you follow your usual bedtime rituals. That might include getting changed, cleaning your teeth, laying out clothes, or whatever. The important thing is that your mind is prompted into recognising these activities as being a precursor for sleep. Do not eat a large, heavy meal before bed This can cause indigestion and interfere with your sleep cycle – you should not eat within two hours of bedtime. Avoid over-the-counter sleep aids There is little evidence that over-thecounter sleep aids are effective. In some cases, like with antihistamines, the medication may have a long action that can cause daytime drowsiness. Check that any prescribed medicines you are be taking do not interfere with sleep. If you have concerns, talk to your doctor. Restrict bedroom activities In order to maximise your sleep, it is important that the bedroom only be used for sleep and sex. Avoid work or stressful activities in the bedroom. Control temperature and light You sleep best in a temperature range of 17-24 C. Bright light (including outdoor daylight in any weather) switches off the synthesis of melatonin. The normal evening rise in the hormone melatonin coincides with decreasing core body temperature and the usual sleep period. Therefore exposure to light will convince the body it is wake time. In some cases it may be necessary to combine some of these techniques with the short term use of medication, to overcome ingrained or acute problems. This must not be done without the knowledge and supervision of your doctor. Cary Thoresen is a flying operations inspector and fatigue risk management specialist for CASA. Sources: “Sleep Right. Wake Bright” Sanofi-synthelabo 2005; “Sleep in the 24-Hour Society”, Dr Philippa Gander 2003; US Centre for Healthy Ageing. FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 43 CABIN CREW “Evacuate. Evacuate. Evacuate.” When you need to get out of the aircraft – fast. H Speed saves: Assertive behaviour by cabin crew speeds up evacuation. 44 FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 ow do you reproduce the chaos of a real aircraft evacuation in trial conditions? In the 1980s UK researchers working with the Civil Aviation Authority (CAA) ran a series of tests with and without an incentive payment to the first 30 volunteers who exited a Trident Three aircraft. The prospect of scoring an extra 5 pounds, on top of the 10 pounds they were already being paid for taking part in the evacuations, came close to mirroring the desperation of a real-life scenario. As 60 people battled to be first through the doors, clothes were torn, shoes left behind and legs and arms stuck between seats. Some tests had to be abandoned halfway through because people became wedged in doorways, causing a build-up of pressure behind them. In the tests run without the 5-pound incentive, people worked more cooperatively and left the aircraft in an orderly manner, much like people react in a precautionary disembarkation. The researchers observing the exits were dressed in flight attendant uniforms for the tests. They had done some airline cabin crew training and directed the evacuation as cabin crew members would, dictating the exits to be used and pulling people in the right direction and clearing them from obstructed doorways. They were jostled and knocked by the rush of bodies, and in at least one case, almost pushed out of the aircraft. In situations like this, cabin crew assertiveness is the key to speeding up evacuation. In 1994, a joint CAA-Federal Aviation Administration (FAA) study tested passengers evacuating from a 60-seater 737 simulator with several different scenarios: two assertive cabin crew directing the evacuation; one assertive cabin crew; two non-assertive cabin crew and no cabin crew present during the evacu- ation. The results were clear. The passengers exited the aircraft much faster when assertive crewmembers called them to the exits and encouraged them to move through as quickly as possible. The non-assertive cabin crew asked people to come to the exits, and gave no physical assistance unless someone was in danger of falling over as they reached the vestibule area. The European Transport Safety Council report that cited this study recommended incorporating assertive behavior techniques into recurrent training, and suggested that assertiveness measures would be useful for cabin crew selection. “One flight attendant, on her own, tried the command ‘move it’ during the demonstration; we then realised that ‘hurry’ was a little too polite and not strong enough.” The words and tone of voice used when ordering an evacuation can also have an effect. Lisa Kolodner, an aviation safety inspector (cabin safety) for the FAA, says that when the FAA conducted a test evacuation, cabin crew were directed to use the commands, “release seat belts, leave everything, come this way, hurry, hurry”. “One flight attendant, on her own, tried the command ‘move it’ during the demonstration; we then realised that ‘hurry’ was a little too polite and not strong enough. A more urgent undertone was helpful,” Kolodner said. It’s also vital for cabin crew to act assertively when passengers try to take their personal be- CABIN CREW seriously injured during an emergency evacuation at Sydney Airport in 2003, when a slide deflated while she was on it. She landed heavily on the tarmac, receiving a fractured vertebra. Passengers taking luggage – or wearing high-heeled shoes – also risk damaging the escape chute as they slide down. An Australian Transport Safety Bureau (ATSB) investigation into the accident was unable to conclusively determine why the slide deflated. However, the ATSB report noted that deflation occurred 32 seconds after inflation, after a number of passengers had used the slide. The ATSB also found there had been some confusion among cabin crew as to whether it was more important to get passengers off the Boeing 747-438, whose brakes had caught fire on landing, even if they were carrying cabin luggage – or insist the luggage be left behind. Some flight attendants let people take their be- longings with them, while others followed operator procedures and forced people to leave their baggage on the aircraft. Fortunately the fire had self-extinguished by the time the evacuation got underway. The 368 people on board left the aircraft within 90 seconds, even though not all emergency slides were available. The incident highlights the problems faced by cabin crew when people try to take belongings with them when evacuating. Do they insist the baggage is left on board and risk a confrontation that could delay other passengers? Do they confiscate the baggage and risk having it piling up in exits, aisles and crossovers? Do they toss the baggage out of the aircraft where it might injure someone on the ground? There are no right answers to these questions. It’s up to cabin crew to make a judgment at the time, based on the specific situation. The priority is getting passengers out of the aeroplane as safely and quickly as possible. Cabin crew should not compromise their position in the doorway to retrieve a bag. Are you listening to me? Cabin crew are used to the glazed looks that appear on passenger faces when the safety briefing gets underway. AP Photo/Mark Baker longings down escape chutes. Response to a frightening situation can lead people to cling to the familiar, such as cabin luggage. If they were thinking rationally, it might not be worth as much as their life – but in an unexpected emergency, familiar objects can take on a deeper significance. In a Flight Safety Foundation (FSF) report, Robert Molloy, research analyst for the US National Transportation Safety Board (NTSB), said an evacuation study revealed that large framed pictures, crutches and a guitar were among items taken by people during real emergency evacuations. “After one recent accident involving an active fire burning and crash forces that split the aeroplane fuselage, one person told the NTSB, [he] had to go back to get [his] violin,” Molloy said. “In interviews after that accident, others said that the flow had been slowed by people trying to grab their backpacks. One passenger blocked access to the exit for a whole row of passengers while he was trying to get his briefcase.” Passengers taking luggage – or wearing high-heeled shoes – also risk damaging the escape chute as they slide down. A woman was Sydney evacuation: A Boeing 747-400 passenger jet sits at its arrival gate at Sydney Airport with its escape slides activated after the captain ordered passengers to evacuate when smoke was detected coming from one of the brakes on Wednesday July 2, 2003. One of the slides deflated during the evacuation, injuring a passenger. 45 FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 CABIN CREW Safety briefings are based on several assumptions: passengers will always read or pay attention to pre-flight instructions; they will understand the instructions; they will remember them; and they will apply them in an emergency situation. Unfortunately this has not always proved to be the case. Recently a US airline released results of its surveys of passengers who were involved in 18 aircraft evacuations between 1997 and 1999. The main reasons given for lack of attention to safety briefing were that the passengers: • Had seen the briefing previously. • Believed the content was common knowledge. • Were reading during the safety briefing (or listening to recorded music). • View of safety briefing was obstructed. • Repetition meant they believed they had already learned the safety information. SPIN Crowd control Emergency procedures are coming under increased scrutiny as very large transport aircraft come into service. S ometime early next year, the giant new A380 Airbus will face one of its biggest challenges – safely evacuating more than 800 passengers and crew within 90 seconds. Successfully deplaning so many people out of such a large aircraft rests on the design of the emergency evacuation equipment, design of the cabin areas, and the ability of cabin crew to successfully marshal people to the right place. One concern with the A380 design is the two-storey configuration that has more than 300 people on the upper deck, 8 m from the ground. Early tests showed that some people balked when they got to the top of the doubledecker slide – it just seemed so far off the ground. Since then, the slides have been redesigned with sides high enough to block the view of the ground on each side. The slides are also flatter at the top, so passengers are already on their way down before they register the steepness. 46 FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 CASA cabin safety inspector, Russell Higgins, has been working with regulators and Airbus Industrie to identify cabin safety issues that could affect the A380. “We’re looking at a very large number of passengers on an upper deck which we haven’t seen before,” he says. “We’ll look at things like potential migration of passengers from the upper deck down those very wide staircases to the main deck. This could be a problem because it has the potential to create a bottleneck effect down on the main deck at those forward doors where those extra passengers could end up.” Higgins says this could require mitigating factors such as cabin crew stationed at the top and bottom of the stairs to redirect passengers. He sees good passenger management as the key to ensuring that cabin crew can direct a successful evacuation. “It’s not just dealing with your own door – if the flow of passengers is drying up at your door and you see there’s a blockage – it’s looking around and having the presence of mind to change your commands to adapt, to redirect people away from that clog to your freeflowing exit.” An 18-month study by the Joint Aviation Authorities (JAA) in Europe recommended cabin crew do the following to overcome the special problems presented by large aircraft cabins: • Develop an adequate mental picture of the whole cabin, and provide passenger guidance to prevent spatial disorientation. • Visually assess obstruction of aisles, crossaisles and situations at the opposite side of the cabin or in remote areas of the cabin. • Conduct empty-cabin checks. • Visually assess the aircraft attitude, the usability of the slides (including whether they extend to the ground) and ground conditions at the base of slides. “All very large transport aircraft (VLTA) cabin crew members should have the same Extended mode Top deck: Rigorous tests will be required to make sure that all 800 passengers – 300 on the upper deck – are able to evacuate the A380 within 90 seconds. Normal mode A380 slides: The A380 evacuation system uses extendable slides to handle variation in door sill heights. • Underestimated the probability of survival following an accident, and didn’t see there would be a need to use the safety equipment. • Saw themselves in a passive role, where cabin crew manage safety and airlines are responsible. • Were unaware of the underlying reasons for the safety instructions. • Were too optimistic, believing that nothing would happen. • Experienced social pressure to ignore the safety briefing to show others they were seasoned travelers. • Overestimated their knowledge of safety aspects and didn’t realise that safety equipment could differ from one aircraft to another. • Were unaware that in an emergency situation, passengers should follow specific procedures. Exit seat: International Air Transport Association (IATA) guidelines for seating passengers level of emergency training and be interchangeable in their abilities to conduct crowd control, use passenger-communication systems and conduct evacuations from the upper deck and the main deck,” the report said. It also noted that emergency procedures might need to be expanded to include marshalling the 800-plus passengers once they are on the ground, while rescue and firefighting operations are being carried out. Currently, cabin crew are expected to stay on the aircraft until all the passengers have left. However, there have been situations where passengers were hit by rescue vehicles after being evacuated from an aircraft. The report commented that the minimum number of cabin crew might need to be reassessed for VLTA. The JAA report also warns that its experiments showed that passengers became unpredictable in emergency situations. “The situation could rapidly become out of control with all the cabin crew busy at their own doors… Large numbers of passengers behaving in an uncontrolled manner, perhaps in the presence of smoke or with the airframe in an uneven attitude, may inevitably lead to serious injuries and possible fatalities.” The report saw effective communication as the best defence against VLTA evacuation problems. “A complete communication loop (including efficient message-feedback for common in exit rows emphasise the need for all air carriers to have clear policies about exit-seat assignments. The guidelines stress that cabin crew are responsible for reseating passengers, regardless of seat assignments by check-in agents, if they become aware that the passenger is mobility-impaired or too young. Australian regulations allow cabin crew to restrict exit row seating to passengers who appear to be “reasonably fit, strong, able and willing to assist the rapid evacuation of the aeroplane in an emergency”. The Civil Aviation Safety Authority encourages airlines to provide procedures that enable cabin crew to conduct “structured personal conversations” with people seated in exit rows, beyond the general oral briefings given to all passengers. Some cabin crew even test people sitting in exit rows to check that they have thoroughly read and absorbed the emergency exit procedures. situational awareness) and standardized VLTA emergency phraseology will be especially important,” the report said. Higgins said the regulators were looking at VLTA evacuation tests to identify potential new problems, rather than going over old ground. ... emergency procedures might need to be expanded to include marshalling the 800-plus passengers once they are on the ground, while rescue and firefighting operations are being carried out. “We know a lot about evacuations so we’re looking for unique things we haven’t seen before. We’re hoping to have video from cameras inside the cabin made available to us after the A380 evacuation. A lot more will come out of that than watching people evacuating from aircraft for 90 seconds. We’ll analyse those videos, concentrating on the critical areas, and draw conclusions accordingly.” Sources: “Specialists Study Evacuation Challenges of Very Large Transport Aircraft” (July-August 2004) Cabin Crew Safety, Flight Safety Foundation: www. flightsafety.org/ccs_home.html The VERRES report: fseg.gre.ac.uk/fire/VERRES_ Project.html Getty Images CABIN CREW Safety briefing: Surveys show that many passengers are not paying attention This ensures that passengers can hear, understand and speak the language used by the crew. It also gives passengers a chance to ask questions and find out why the procedures are necessary, and to indicate their willingness to assist in an emergency. Tests carried out by the CAA in the 1980s also assessed the difficulties faced by passengers exiting from Type III over-wing exits. This followed fatal aircraft fires where passengers died despite being seated close to the exits while other people seated further away survived. The ease of operation of an escape exit, whether passengers can easily open it, and whether they know where to put the exit hatch after its removal, affected the speed of evacuation. An FAA review of worldwide research into evacuations noted that the reason for passengers having difficulty with the exit was not caused by the design, but by lack of instruction. “Information materials, such as safety briefing cards, related to emergency evacuation activities have been poorly rendered, as passengers either cannot understand the intent of the materials, or do not seem obliged to read and follow the instructions.” The importance of getting passengers to understand their responsibilities when sitting in exit rows was highlighted recently in an Embraer 190 evacuation test. The aircraft failed certification because a person seated next to an over-wing exit had not followed the safety briefing and did not know what to do when the evacuation started. The test had to be rerun. Sources: “Many Passengers in Exit Seats Benefit from Additional Briefings” (May-June 2001); “Attempts to Retrieve Carry-on Baggage Increase Risks During Evacuation” (May-June 2004), Cabin Crew Safety, Flight Safety Foundation: www.flightsafety.org/ccs_home.html. Increasing the Survival Rate in Aircraft Accidents, Dec 1996, European Transport Safety Council. ATSB Report BO/200302980: www.atsb.gov.au/aviation/ occurs/occurs_detail.cfm?ID=578. “The Human Factors Evaluation of Emergency Evacuation Systems”, Helen Muir and Claire Marrison, European Cabin Safety Conference 1990: www.caa.co.uk. The VERRES report: fseg.gre.ac.uk/fire/VERRES_Project. html. 47 FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 AIRWORTHINESS Bolt from the blue Airliners are hit by lightning an average of once a year, and strikes t o lighter aircraft are common. Lance Thorogood and Lightning Technologies specialists report. W hen the air transport industry was in its infancy in the 1930s, designers thought that lightning was harmless. People at all levels in the nascent aviation industry believed that only damage lighting caused was the common holes that sometimes burned through trailing edges. They thought that lighting was rendered largely harmless because transport aircraft were made mainly of aluminium, an excellent electrical conductor. Then, on August 31, 1940, a Pennsylvannia Central Airline Douglas DC-2 crashed near Lovettsville, Virginia in the US. The investigation identified lightning as a probably cause – at the same time the aircraft was struck, a tool shed beneath the aircraft’s position was also struck. Government agencies set up a task force with airlines and manufacturers to study the effects of lightning on aircraft. The task force and later research programs sponsored by the US Department of Defence and the Federal Aviation Administration developed a range of lightning protection standards. These included electrical bonding capable of carrying lightning currents, spark-free fuel filler caps and access panels and lightning arresters for long-wire radio antennas. The lightning problem was thought to be solved. Then in 1959 a Trans World Airlines Lockheed Constellation with 59 passengers and 9 crew aboard exploded during climbout from Milan, Italy. A lightning strike led to multiple explosions in the aircraft’s fuel tanks. All passengers and crew perished. And again in 1963, a Pan American World Airways Boeing 707 airliner was stuck and exploded in flight. Eight crew and 73 passengers died. 48 FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 Authorities renewed research on lightning effects, focussing on aircraft fuel system. The work ran from the 1960s through to the early 1970s. It resulted in improvements in fuel tank structural design, vent design and outlet location criteria, flame suppression techniques and improvements in testing. Pilots should note any lightning strikes in the aircraft’s maintenance release to alert maintainers to the possibility of damage. The fuel used in both of these accidents was the highly volatile JP-4. This prompted industry to move to Jet A, a kerosene fuel with a much higher flash point. To protect control surfaces, aircraft are now designed to allow the lightning current to flow through the skin from the point of impact without interruption. Flexible bonding straps or “jumpers” (see diagrams) are often installed across aircraft control-surface hinges to dissipate lightning. Shielding and surge suppressors now ensure that lightning does not threaten avionics and wiring. All aircraft must now meet a certification standard for lightning protection – including standards for the airframe, engines, fuel systems and avionics. Design standards continue to evolve to take advantage of new materials and technologies. Without these protection standards, aircraft risk catastrophic damage in the event of a lightning strike. The key standards are designed to handle the direct effects, where the lightning directly “attaches” to the airframe as a result of the electromagnetic attraction of the aircraft’s surfaces. Evidence of a lightning attachment will be melted or pitted areas on the surface; occasionally the lightning will go straight through the surface, forming a hole as a result of what technicians call a melt-through. Pilots should note any lightning strikes in the aircraft’s maintenance release to alert maintainers to the possibility of damage. Maintainers who discover any surface lightning damage should go to the aircraft manufacturer’s approved data to determine repair strategies. If pitting or burn-through is seen, look for the other burns, usually at the aircrafts extremities. Look for evidence control cable vitrification. Even if the damage looks minor, such as small pits, you cannot know what else the lightning might have affected; for example, a small pit on the propeller could propagate to a larger fault over time, resulting in propeller system failure. Any lightning strike can damage protection equipment, which is usually designed to fail. Inductive voltages along protective bond straps can be minimised by keeping the straps as straight and short as possible. The rules to follow are: • Use conductors with enough cross-sectional area to carry the lightning current. • Keep bond straps as short as possible, consistent with requirements for flexibility and strain relief. • Avoid bends of more than 45 degrees, or other features that result in reversal of the current direction. AIRWORTHINESS bond strap control surface wing the ball chain used to retain the cap. Such ball chains are still found on gravity filler caps, and should always be replaced with a non-conducting lanyard. Light aircraft owners and operators should not loosen fuel caps to make them easier to open. This is because part of the lightning protection design requires sufficient tension to help to prevent lightning propagating into the fuel tank. Maintainers dealing with pipe couplings should be aware that relative motion between surfaces, or the introduction of dirt or residue, can drastically change the current-carrying capacity of a coupling. Electrical bond straps are sometimes installed across poorly conducting pipe couplings, but should not be relied on to prevent arcing at the couplings that they bypass. Tests have shown that they do not eliminate the possibility that some current in the coupling could lead to sparking even with the bond strap in place. It’s a good idea to do an aircraft compass swing because a lightning strike may result in incorrect readings of the compass card. Approved aircraft equipment installed according to design rules will provide protection from lightning damage. Unapproved parts or non-aviation equipment may fail. Even with today’s lightning protection standards, things can still go horribly wrong. In 1976, a Boeing 747 operated by the Iranian military, enroute from Tehran to Madrid with 17 people on board, crashed as a result of a lightning strike. As the aircraft was flying through a heavy thunderstorm, lightning struck the nose area of the B747 and exited the left wing tip. The lightning concentrated at the rivet joint and bond strap at the wing rib. The energy surge was sufficient to ignite the fuel vapour in the number one fuel tank. The wing separated and the aircraft was destroyed. All aboard perished. The accident investigation was unable to determine whether the aircraft’s lightning protection systems were sufficiently well maintained. Straight strap – good bond strap control surface wing • Avoid all sharp bends. • If two or more parallel straps are used, separate them sufficiently (usually by 30 cm or more) to minimise magnetic force effects. These rules should be followed for all lightweight conductors, such as metal air tubes or hydraulic lines that must carry significant portions of the lightning current. Flight critical installations should be tested to verify their adequacy. Because of weight restrictions, the strength and rigidity of some metal components typically found at extremities of an airframe – such as wingtips, flaps and ailerons – may not be sufficient to resist deformation by magnetic forces from the lightning currents concentrated in these locations. Such deformations do not usually impair safety of flight, but they may require repair or replacement. Normally only severe lightning currents will cause this kind of damage. Fuel system protection: Correct design and maintenance of lightning protection for the fuel system is vital in preventing fuel vapour ignition. This goal is challenging because thousands of amperes of current must be transferred through the airframe when an aircraft is struck by lightning. A tiny spark of less than one ampere may release sufficient energy inside a fuel tank to cause an explosion. Prevention of fuel ignition from lighting is usually done using one or more of the following approaches: • Containment – designing the structure to contain the over-pressure from an explosion without rupturing. • Inerting – controlling the atmosphere in the fuel system to ensure that it cannot support combustion. • Foaming – filling the fuel system with a material that prevents a flame from propagating. • Elimination of ignition sources – designing the fuel tank structures and system components and installations so that lightning does not produce any ignition sources. Fuel caps are usually found in a location unlikely to be struck by lightning – even so, the cap can still be hit. Caps are designed to ensure that the lightning strike will not propagate through to the fuel tank. A lightning-protected cap typically has a plastic insert so that there are no mating metal surfaces across which lightning current might flow and cause arcing. If a lanyard is required it is made of plastic since one source of sparking on filler caps has been found to be along Sharply bent strap – bad good good Bond strap same length Bond strap longer than as air gap – good air gap – good bad < 45º Acute angle – bad bad Sharp bend – bad Parallel current vectors in same axis create minimal magnetic force likely break here opposite forces Lance Thorogood is a CASA airworthiness specialist. Sources: Lightning protection of aircraft, Fisher, Perala, Plumer, Lighting Technologies Inc, 2004. Course notes, Lighting Protection of Aircraft, Lightning Technologies Inc, April 2005 edition. Strike a light Overleaf: Advice for pilots Sharply bent strap – bad FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 49 AIRWORTHINESS Strike What pilots should know about lightning. S trike incidence data show that there are more lightning strikes to aircraft below about 20,000 ft than above this altitude, and that jet aircraft are being struck at lower than cruise altitudes, that is during climb, descent or hold operations Strikes occurring above around 10,000 ft are associated with positive and negative charge centres in a cloud, or between adjacent clouds. Some lightning strikes below about 10,000 ft probably result from cloud to ground flashes. So the data seem to indicate that an aircraft must be within or beneath a cloud to be struck. Incidence data also show that most strikes occur in or near regions of precipitation. The amount of lightning activity is related to how much precipitation there is, and the presence of vertical air currents (turbulence). Nevertheless strikes have been reported to aircraft flying 25 nm from the nearest radar returns or precipitation. There are no confirmed reports of aircraft being struck by lightning when operating in clear air longer distances from clouds. Avoidance: Commercial and military pilot training and procedures instruct pilots to avoid thunderclouds of regions of precipitation that Flash dance Final entry Initial entry Initial exit 50 FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 Final exit 15— Mature stage 14— + 13— + 12— + + + 11— + + + + 10— + + 9— + + 8— + 7— + + 6—------------------------------------------+ + T= –15ºC 5— + + + 4—------------------------------------------+ + T= approx 0ºC + + 3— + + + 2— ------------------------------------------T= + 1— Corona space charge +++ + + ++ + + + + + ++ + + + kilometers lightNInG can be seen or are apparent on radar. However, the limitation of radar for avoiding lightning associated with clouds is that radar usually only picks up rain, not the cloud itself. So aircraft can experience occasional encounters with hail, and with lightning, without warning. Fortunately, new generation radars have features that detect wind shears and other forms of precipitation. Data from the airlines strike reporting projects show that lightning strikes to aircraft in the US and Europe occur most often during the spring and summer months when frontal weather conditions that produce thunderstorms and other regions of convective activity are most prevalent. There are varying opinions about what detour distance pilots should apply to avoid turbulence and lightning. Most commentators agree that pilots should use distances commensurate with the capability of the radar available. A typical lightning avoidance policy could be: • When the temperature at flight level is 0°C or higher, avoid all echoes showing sharp gradients by at least 5 nm. • When the temperature at flight level is less than 0°C, avoid all echoes showing sharp gradients by at least 10 nm. • When flying above 23,000 ft avoid all echoes (even if no sharp gradients are indicated) by at least 20 nm. A lightning strike is imminent when a combination of the following conditions is present: • Flight through or near unstable air, a sta- Highly charged: Electrical charge within a cumulonibus cell. An initial strike can be up to 200,000 A, equivalent to the current required to run 20,000 single-bar heaters or 800,000 light bulbs (60W). tionary front, a cold front, a warm front or a squall line. • Within a cloud. • Ice types of precipitation. • Air temperature near 0°C • Progressive build-up of radio static. • St Elmo’s fire (when dark). • Turbulence. • At altitudes between 5000 ft and 15,000 ft (most prevalent at around 11,000 ft). • Climbing or descending. If you believe a lightning strike is likely, you should: • Avoid areas of heavy precipitation. • Change altitude to avoid temperatures near 0°C. Adapted from Lightning protection of aircraft, Fisher, Perala, Plumer, Lighting Technologies Inc, 2004. For details of lightning protection training go to www. lightningtech.com Lightning usually attaches to or enters an aircraft at one point – often an extremity – and exits from another. That is the current flows into one point of the aircraft and out of another. The entry point may be either an anode or a cathode, that is, a spot where electrons are either entering or exiting the aircraft Because most aircraft fly further than their own lengths within the lifetime of most flashes, the location of the entry point changes as the flash reattaches to other points aft of the initial entry point. The location of the exit points may also change particularly if the initial exit point is at a forward portion of the aircraft. Therefore for any one flash, there may be many entry or exit points. AIR WORTHINESS CHANNEL nel spacing by looking it up in the equipment handbook and by checking the number of decimal places on the display and the selectable channel steps. The frequency displayed on the majority Channel separation is being reduced to handle more traffic. Some radios will need to be updated. By Charles Lenarcic. T he number of VHF channels available for aircraft operations is to be increased by reducing the separation between channels from 50 kHz to 25 kHz over the next four years. Airservices Australia, which assigns frequencies in the aeronautical VHF band in Australia, is reducing channel separation to provide more interference-free frequencies. At the same time, the aviation safety regulator is proposing new rules for frequency stability to reduce interference. The changes are likely to affect radios over 30 years old, and will be phased in over the next four years. If you own or operate an aircraft you will need to check out your radio to make sure it can handle 25 kHz channel separation and will meet the proposed frequency stability standards. The rollout of 25 kHz channel separation starts in November this year for high-level airspace – class A, above FL180 in radar and above FL245 in non-radar areas, concentrating at first on areas of high density traffic. From November 2006 Airservices will start assigning 25 kHz channel spacing frequencies in other areas of high traffic density (mainly class C, D and E airspace) as needed. According to Airservices, 25 kHz will only be introduced in class G (including CTAF) after other frequency planning options are exhausted. Until 2009 operators will be able to continue using radios with 50 kHz channel separation as long as their equipment is able to tune to the frequencies used in the area of operations. To understand the impact of these changes aircraft owners and operators will need to identify the type of VHF radio equipment fitted to their aircraft. You will need to know two things about your radio: the channel spacing and the frequency tolerance. Channel spacing: You can find out the chan- Figure 1: Examples of panel mounted radios with two decimal place displays. of radio control panels provides either two or three decimal places when displaying the selected frequency. Most older radios in Australia will display two decimal places as shown in the example in Figure 1 and can have either 50 kHz or 25 kHz spacing. The Table below gives examples of radio displays with 2 decimal places that show the differences between 50 and 25 kHz spacing. If the radio displays 3 decimal places it supports 50 kHz, 25 kHz and possibly 8.33 kHz. Figure 2 shows a panel mounted Nav/Comm Operating frequency (kHz) 118.000 118.025 118.050 118.075 118.100 118.125 118.150 118.175 118.200 Able to Able to receive and receive and transmit transmit on 25 kHz on 50 kHz spacing spacing 118.00 118.02 118.05 118.07 118.10 118.12 118.15 118.17 118.20 Channel spacing steps. 118.00 118.05 118.10 118.15 118.20 Figure 2 – Example of a panel mounted radio with a 3 decimal place display. with three decimal places displayed in the left hand (comm) display. Frequency tolerance: Valve type, crystal control and early transistor radio technology of the 1960s and 1970s are unable to keep the transmitter part of the radio stable and sharp enough to transmit on the right frequency without spilling signal over to adjacent frequencies. In other words, with these older technologies there is a risk that the frequency that you are transmitting on could vary enough to jam other users. To require aircraft radios to meet the new radio frequency stability and tolerance standards, CASA will issue a notice of proposed rule making (NPRM) designed to bring in a modern transmitter frequency tolerance standard for VHF transmitting radios of 30 parts per million or 0.003 per cent. The proposed would affect aircraft operating in all classes of airspace – including Class G – from November 2009. It is likely that all radios with 100 kHz channel separation, and some radios with 50 kHz separation, would be unable to meet the new specifications. However, as some radios with the current 50 kHz separation could support the proposed tighter frequency tolerance standards, CASA may consider allowing operators to use these radios in low traffic density areas of Australian airspace for a number of years. If you have a radio with 50 kHz separation and can operate with limited channels, a modification to your VHF radio or to the communications side of popular nav/comm units enabling them to meet the 0.003 per cent frequency specification may be available. There are several ways to find out the stability specification, or frequency tolerance of your radio: • Look up the radio’s technical specifications. • Contact the manufacturer, if the manufacturer is still in business. • Ask your avionics maintenance organisation at the next scheduled maintenance. Charles Lenarcic is CASA’s principal engineer, avionics. 51 FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 AIRWORTHINESS DIRECTIVES ADs July 7, 2005 Part 39-105 - Lighter Than Air There are no amendments to Part 39-105 - Lighter than Air Part 39-105 - Rotorcraft Bell Helicopter Textron Canada (BHTC) 206 and Agusta Bell 206 Series Helicopters AD/BELL 206/154 Amdt 1 - Freewheel Aft Bearing Cap Bell Helicopter Textron Canada (BHTC) 222 Series Helicopters AD/BELL 222/2 Amdt 1 - Quick Disconnect Dual Controls - CANCELLED Bell Helicopter Textron Canada (BHTC) 407 Series Helicopters AD/BELL 407/28 Amdt 1 - Freewheel Aft Bearing Cap Eurocopter AS 332 (Super Puma) Series Helicopters AD/S-PUMA/58 - Swashplate Bearing Attaching Screws AD/S-PUMA/59 - Ice and Rain Protection - Electrical Multi-Purpose Air Intakes Eurocopter EC 120 Series Helicopters AD/EC 120/14 - Tail Rotor Driveshaft - Rear Driveshaft Friction Ring Eurocopter SA 360 and SA 365 (Dauphin) Series Helicopters AD/DAUPHIN/68 Amdt 1 - Main Gearbox Base Plate AD/DAUPHIN/79 - Life Raft Installation Kawasaki BK 117 Series Helicopters AD/JBK 117/23 - Main Rotor Blades with Bolted Lead Inner Weights Fairchild (Swearingen) SA226 and SA227 Series Aeroplanes AD/SWSA226/86 Amdt 2 - Wing Spar Centre Web Cutout Part 39-105 - Below 5700 kgs Cessna 208 Series Aeroplanes AD/CESSNA 208/17 - Flight into Icing Conditions AD/CESSNA 208/18 - Emergency Power Lever Shear Wire Pacific Aerospace 750XL Series Aeroplanes AD/750XL/2 - Electrical Wiring Modification AD/750XL/3 - Wiring Loom Protective Sleeve AD/750XL/4 - Fuselage Frame at Station 384.62 AD/750XL/5 - Outer Wing Attachments Pilatus PC-12 Series Aeroplanes AD/PC-12/46 - Landing Gear Components Reims Aviation F406 Series Aeroplanes AD/F406/12 - Rudder Pulley Bracket AD/F406/13 - Landing gear AD/F406/14 - Rudder Hinge Brackets and Bearings Part 39-105 - Above 5700 kgs Airbus Industrie A319, A320 and A321 Series Aeroplanes AD/A320/176 - Centre Fuel Tank Bonding AD/A320/177 - Left and Right Wing Fuel Tank Bonding AD/A320/178 - Trimmable Horizontal Stabilizer Actuator Airbus Industrie A330 Series Aeroplanes AD/A330/13 Amdt 3 - Life Limits/Monitored Parts AD/A330/30 Amdt 3 - Argo-Tech/Intertechnique Vent Float Valves AD/A330/45 Amdt 1 - Wing Rib 6 AMD Falcon 50 and 900 Series Aeroplanes AD/AMD 50/33 - Central Engine Mast Rivets Boeing 717 Series Aeroplanes AD/B717/1 Amdt 2 - Horizontal Stabiliser Jackscrew AD/B717/4 Amdt 2 - Rudder Trim Control AD/B717/5 Amdt 1 - Spoiler Hold-Down Actuator Supports AD/B717/9 Amdt 1 - Wing Rear Spar AD/B717/13 Amdt 1 - Horizontal Stabilizer Outer Skin Panels Boeing 727 Series Aeroplanes AD/B727/149 - Elevator Rear Spar - 2 - CANCELLED Boeing 737 Series Aeroplanes AD/B737/238 Amdt 1 - Digital Transient Suppression Units AD/B737/244 - Engine Strut Seal Boeing 747 Series Aeroplanes AD/B747/281 Amdt 1 - Upper Deck Floor Beam Upper Chord and Web AD/B747/323 Amdt 1 - Nose Wheel Well Top and Side Panel Webs and Stiffeners Boeing 767 Series Aeroplanes AD/B767/146 Amdt 1 - Horizontal Stabiliser Pivot Bulkhead Bombardier (Boeing Canada/De Havilland) DHC-8 Series Aeroplanes AD/DHC-8/101 - Fire Bottle Electrical Connectors British Aerospace BAe 125 Series Aeroplanes AD/HS 125/175 - Emergency Radio Wiring British Aerospace BAe 146 Series Aeroplanes AD/BAe 146/35 Amdt 2 - MLG Door Hinge Bracket British Aerospace BAe 3100 (Jetstream) Series Aeroplanes AD/JETSTREAM/96 Amdt 1 - Landing Gear Rod Spherical Bearing 52 FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 AD/JETSTREAM/100 - Landing Gear Radius Rod Cylinder Cracking Cessna 750 (Citation X) Series Aeroplanes AD/CESSNA 750/2 - Chafing of APU Fuel Tube Assembly Embraer EMB-120 (Brasilia) Series Aeroplanes AD/EMB-120/29 Amdt 3 - Elevator Trim System Fokker F28 Series Aeroplanes AD/F28/89 - APU Enclosure Drains and Wiring Fokker F100 (F28 Mk 100) Series Aeroplanes AD/F100/65 - Fuselage ELT System Antenna AD/F100/66 - Wing Rear Spar Lower Girder AD/F100/67 - APU Enclosure Drains and Wiring AD/F100/68 - Passenger Service Unit, Speaker, Oxygen and Blind Panels Attachments Part 39-106 - Piston Engines There are no amendments to Part 39-106 - Piston Engines Part 39-106 - Turbine Engines CFM International Turbine Engines - CFM56 Series AD/CFM56/7 Amdt 4 - Fan Disk Inspection General Electric Turbine Engines - CF6 Series AD/CF6/57 Amdt 1 - HPT S2 NGV Distress Pratt and Whitney Turbine Engines - JT8D Series AD/JT8D/12 Amdt 2 - High Pressure Compressor Disc Tie Rod Hole AD/JT8D/18 Amdt 2 - Second Stage Turbine Disc AD/JT8D/21 Amdt 1 - High Pressure Compressor Spacers AD/JT8D/22 Amdt 5 - Combustion Chamber Outer Case AD/JT8D/27 Amdt 2 - First Stage Compressor Hub AD/JT8D/31 Amdt 1 - No. 7 Fuel Nozzle and Support Assembly AD/JT8D/34 Amdt 1 - 4th Stage LPT Hub Inspection AD/JT8D/38 Amdt 1 - Critical Life-limited Rotating Engine Components Rolls Royce Turbine Engines - RB211 Series AD/RB211/32 Amdt 2 - Stage 5 Compressor Disc Inspection Turbomeca Turbine Engines - Arrius Series AD/ARRIUS/7 Amdt 1 - High Pressure Turbine AD/ARRIUS/8 - Free Turbine Overspeed Protection System Turbomeca Turbine Engines - Astazou Series AD/ASTAZOU/4 - Return to Service for Civil Use AD/ASTAZOU/5 - Return to Service for Civil Use Turbomeca Turbine Engines - Turmo Series AD/TURMO/6 - Return to Service for Civil Use Part 39-107 - Equipment Airconditioning Equipment AD/AIRCON/13 Amdt 3 - Kelly Aerospace Fuel Regulator Shutoff Valves & Cabin Heaters Propellers - Variable Pitch - Hartzell AD/PHZL/44 Amdt 9 - Propeller Attachment Bolts Propellers - Variable Pitch - Hoffman AD/PHOF/2 Amdt 3 - Propeller Hub ADs August 4, 2005 Part 39-105 - Lighter Than Air There are no amendments to Part 39-105 - Lighter than Air Part 39-105 - Rotorcraft Bell Helicopter Textron Canada (BHTC) 206 and Agusta Bell 206 Series Helicopters AD/BELL 206/158 - Fuel Distribution System Bell Helicopter Textron Canada (BHTC) 222 Series Helicopters AD/BELL 222/1 - Retirement Lives - Fatigue Critical Components - CANCELLED AD/BELL 222/9 Amdt 1 - Engine Chip Detector Lights AD/BELL 222/14 Amdt 1 - Horizontal Stabiliser Assembly AD/BELL 222/16 - Tail Rotor Boost Cylinder Support Bracket - CANCELLED AD/BELL 222/26 Amdt 1 - Main Rotor Grips and Pitch Horns AD/BELL 222/28 - Rotating Ring - Drive Pin Hole AD/BELL 222/29 - Drive Hub Studs AD/BELL 222/30 - Swashplate Drive Link P/N222-010-460101 AD/BELL 222/31 - Tail Rotor Blade AD/BELL 222/32 - Main Rotor Yoke - 2 AD/BELL 222/33 - Main Rotor Pendulum Weight Support Eurocopter AS 332 (Super Puma) Series Helicopters AD/S-PUMA/51 Amdt 1 - Tail Rotor Hub Bearing Eurocopter AS 350 (Ecureuil) Series Helicopters AD/ECUREUIL/111 - Untimely Firing of Squibs AD/ECUREUIL/112 - Cabin Vibration Damper Assembly Eurocopter AS 355 (Twin Ecureuil) Series Helicopters AD/AS 355/87 - Untimely Firing of Squibs AD/AS 355/88 - Cabin Vibration Damper Assembly Schweizer (Hughes) 269 Series Helicopters AD/HU 269/111 - Lateral Control Trim Actuator Assembly Sikorsky S-76 Series Helicopters AD/S-76/8 Amdt 11 - Retirement Lives - CANCELLED Part 39-105 - Below 5700 kgs Rockwell (N American) & Autair (Noorduyn) AT-6, BC-1A, SNJ, T-6G, Harvard, & AT-16 Series Aeroplanes AD/AT-6/1 Amdt 1 - Wing Attach Angles Pilatus Porter PC-6 Series Aeroplanes AD/PC-6/40 - Electric Trim Actuator Attachment Bracket - CANCELLED AD/PC-6/51 Amdt 1 - Stabiliser-Trim Attachment Components - Inspection/Replacement PZL 104 (Wilga) Series Aeroplanes AD/WILGA/4 - Elevator Control System Rotational Control Rod Part 39-105 - Above 5700 kgs Airbus Industrie A319, A320 and A321 Series Aeroplanes AD/A320/167 Amdt 1 - Airborne Ground Check Module Airbus Industrie A330 Series Aeroplanes AD/A330/20 Amdt 1 - Leading Edge Slat Type A Actuators AD/A330/38 Amdt 1 - Liquid Crystal Display Units AD/A330/51 Amdt 1 - Escape Slides & Slide Rafts Electrical Harness Routing Boeing 717 Series Aeroplanes AD/B717/5 Amdt 2 - Spoiler Hold-Down Actuator Supports AD/B717/17 - Brake Fuses Boeing 737 Series Aeroplanes AD/B737/161 Amdt 1 - Repetitive Inspections AD/B737/198 Amdt 1 - Centre Tank Fuel Pumps AD/B737/202 Amdt 1 - Centre Fuel Tank Limitations Boeing 747 Series Aeroplanes AD/B747/35 Amdt 1 - Front Spar Pressure Bulkhead Chord AD/B747/198 Amdt 1 - Main Entry Door Stop Support Fitting AD/B747/329 - Galley Cart Lift Control Panels Boeing 767 Series Aeroplanes AD/B767/146 Amdt 2 - Horizontal Stabiliser Pivot Bulkhead Bombardier (Canadair) CL-600 (Challenger) Series Aeroplanes AD/CL-600/65 - Control Column Microphone Jack Modification - FAA STC SA4900SW Bombardier (Boeing Canada/De Havilland) DHC-8 Series Aeroplanes AD/DHC-8/102 - Pitot Static System Contamination British Aerospace BAe 146 Series Aeroplanes AD/BAe 146/115 - Elevator Bearings Fokker F27 Series Aeroplanes AD/F27/158 - Main Landing Gear Drag Stay Units Short SD3-60 Series Aeroplanes AD/SD3-60/66 - Elevator Trim Tab Balance Weight Brackets - CANCELLED AD/SD3-60/68 Amdt 1 - Elevator Trim Tab Balance Weight Brackets Part 39-106 - Piston Engines Thielert Piston Engines AD/THIELERT/5 - Clutch Friction Plates Part 39-106 - Turbine Engines AlliedSignal (Garrett/AiResearch) Turbine Engines - TFE731 Series AD/TFE 731/33 - LPT Stage 1 Nozzle and Disks AlliedSignal (Garrett/AiResearch) Turbine Engines - TPE 331 Series AD/TPE 331/62 Amdt 1 - Reduction Gear and Shaft Assembly Allison Turbine Engines - 250 Series AD/AL 250/87 - Containment Ring General Electric Turbine Engines - CF6 Series AD/CF6/58 - Electronic Control Unit Software Rolls Royce Germany Turbine Engines - BR700 Series AD/BR700/4 Amdt 1 - Engine Electronic Controller AD/BR700/6 - Independent Overspeed Protection Rolls Royce Turbine Engines - Tay Series AD/TAY/8 Amdt 2 - Engine LP Fuel Tube Rolls Royce Turbine Engines - Dart Series AD/DART/31 - Intermediate Pressure Turbine Disc Turbomeca Turbine Engines - Arrius Series AD/ARRIUS/9 - Correct Position of Adjusted FCU Fuel Filter Part 39-107 - Equipment There are no amendments to Part 39-107 - Equipment SELECTED SERVICE DIFFICULTY REPORTS Aircraft above 5700 kg AIRBUS A330-303 (7321) FUEL CONTROL/TURBINE ENGINES - HARNESS FAULTY The No 2 engine spooled down but recovered after approximately 3 to 4 seconds. An investigation found the problem was caused by a faulty engine electrical harness (W8B). Intermittent internal short circuit led to N1 rollback. No external chafing was found on the harness. BOEING 717-200 (2820) AIRCRAFT FUEL DISTRIBUTION SYSTEM - PIPE FRACTURED Left-hand wing tank forward boost pump outlet pipe broken at the pump end. BOEING 767-336 (7220) TURBINE ENGINE AIR INLET SECTION - BOLT SEPARATED The left-hand engine aft spinner assembly to support ring attachment bolt and washer came adrift. An investigation found other attachment bolts loose. BOEING 737-838 (2910) HYDRAULIC SYSTEM, MAIN - HYDRAULIC SYSTEM MALFUNCTIONED The No1 and No2 engine driven hydraulic systems indicated low pressure. An investigation found foreign debris in pneumatic system providing pressure to hydraulic reservoirs. The vent caps were blocked with debris. SAAB SF-340B (3230) LANDING GEAR RETRACT/ EXTENSION SYSTEM - PIN FRACTURED The nose landing gear retraction pin fractured. The pin attaches nose landing gear retraction actuator to nose landing gear strut. BOMBDR DHC-8315 (2731) ELEVATOR TAB CONTROL SYSTEM - BOLT INCORRECT FIT The elevator spring tab control system bolts securing spring shaft to anchor were incorrectly installed and not tensioned. One nut liberated from bolt was found in the leading edge of the right-hand elevator. Suspected manufacturing fault which was found during fleet inspection following defect on another aircraft. BOEING 737-476 (2751) TRAILING EDGE FLAP POSITION INDICATING SYSTEM - INDICATOR FAULTY Trailing edge flap position indicator faulty. BOEING 737-8FE (4920) APU CORE ENGINE - SEAL FAILED An APU bleed air system became contaminated with oil causing contamination of airconditioning packs. The contamination was caused by the failure of APU load compressor seal. BOEING 767-338ER (2421) AC GENERATOR-ALTERNATOR - IDG FAULTY Right-hand Integrated Drive Generator faulty. BOEING 737-476 (2751) TRAILING EDGE FLAP POSITION INDICATING SYSTEM - INDICATOR FAULTY Trailing edge flap position indicator faulty. BOEING 737-7BX (7314) ENGINE FUEL PUMP - PUMP LEAKING 510001350 The No1 engine driven fuel pump was leaking. An investigation found the leak was caused by deterioration of impeller shaft “O” ring seal. BOEING 737-838 (2910) HYDRAULIC SYSTEM, MAIN - TUBE CRACKED 510001346 The hydraulic “A” system pressure supply tube was cracked and leaking, with a loss of hydraulic fluid caused by metal contamination of the hydraulic system. BOEING 767-338ER (3010) AIRFOIL ANTI-ICE/DE-ICE SYSTEM - VALVE FAULTY LH wing anti-ice valve suspected to be faulty. BOEING 747-438 (7830) THRUST REVERSER - MOTOR FAILED The No4 engine thrust reverser motor failed with major internal damage. A major air leak was found next to the thrust reverser motor shutoff valve, causing damage to the wiring that connected the motor to the engine. Further investigation found the thrust reverser feedback cable was stiff to operate. The shutoff valve housing appeared to be deformed. BOMBDR DHC-8202 (2730) ELEVATOR CONTROL SYSTEM - BUSHING MISSING 510001357 The left-hand inboard elevator hinge bushing was missing. This was found during inspection. SAAB SF-340B (3230) LANDING GEAR RETRACT/ EXTENSION SYSTEM - PIN FRACTURED The nose landing gear retraction pin was fractured at the threaded end. Retraction pin attaches nose landing gear retraction actuator to nose landing gear strut. BOEING 737-8FE (4920) APU CORE ENGINE - SEAL FAILED 510001351 APU bleed air ducts were contaminated with oil from failure of APU load compressor seal. FOKKER F28-MK0100 (2310) HF COMMUNICATION SYSTEM - COUPLER FAULTY The No2 HF coupler was faulty. FOKKER F28-MK0100 (7830) THRUST REVERSER SOLENOID FAULTY The left-hand thrust reverser secondary lock solenoid was faulty. AIRBUS A330-201 (3244) TIRE - TYRE FOD The main landing gear No4 tyre sustained foreign object damage during taxi. The tyre pressure fell from 225psi to 145psi. BOMBDR DHC-8315 (2721) RUDDER TAB CONTROL SYSTEM - SWITCH BURNT The rudder trim rotary switch (2722-S1) burnt/overheated due to internal short circuit. Related wiring in the trim control panel assembly also burnt/overheated. AIRBUS A330-201 (3230) LANDING GEAR RETRACT/ EXTENSION SYSTEM - FITTING BROKEN Support fitting for the right hand main landing gear unlock hydraulic pipe was broken causing the line to leak. BOEING 737-7BX (2760) DRAG CONTROL SYSTEM CABLE BROKEN The ground spoiler interlock cable was broken at the upper end of cable adjacent to the ground spoiler interlock valve. It is suspected that very stiff bearing operation due to moisture ingress into the bearing liner has led to fatigue and ultimately failure of the cable rodend. CVAC PBY-6A (8530) RECIPROCATING ENGINE CYLINDER SECTION - MANIFOLD SEPARATED The right-hand engine No9 cylinder induction manifold separated from the cylinder and was found lying in the lower cowl flap area. An investigation found that the manifold attachment nut had backed off allowing the manifold to pull out of the cylinder and rear case. FOKKER F28-MK0100 (3242) BRAKE - SEAL INCORRECT PART The brake unit seal PNo NAS1611-228 was not listed in component parts catalogue. An investigation found that the seals had been superceded by seal PNo ABP002-228. BAC 146-100 (3230) LANDING GEAR RETRACT/ EXTENSION SYSTEM - NLG SERVICEABLE The nose landing gear failed to retract. An investigation found the NLG pin still installed. BOMBDR DHC-8315 (3417) AIR DATA COMPUTER SENSOR OUT OF LIMITS Digital Air Data Computer (DADC) PS and PT sensors out of tolerance. BOMBDR DHC-8202 (5514) HORIZONTAL STABILIZER, MISCELLANEOUS STRUCTURE – BOOT DAMAGED The right-hand outer tailplane rudder boot was torn and lifting in area located in front of the elevator horn. BEECH 1900D (7261) TURBINE ENGINE OIL SYSTEM - TURBINE ENGINE OIL PRESSURE LOSS The right-hand engine lost oil pressure. Engine shut down when oil pressure dropped to 60 psi. BOEING 737-86N (7230) TURBINE ENGINE COMPRESSOR SECTION - PIN LOOSE During the fan lube inspection of the fan hub, four forward booster spool pins were found to be visibly loose. After a torque check of the remainder, a further five pins were found to be loose. BOEING 737-838 (2897) FUEL WIRING DAMAGED The No2 aft fuel pump low pressure light illuminated and the circuit breaker tripped. An investigation found the fuel pump wiring was badly burnt at the earth pig tail ferrule. It appears that when the wiring harness was manufactured, one or all three phase power wires to the pump were cut during the crimp preparation. When the earth pig tale ferrule for the metal sheath over the top of the three phase wires was crimped, it provided a path to short the three phase wires to earth. SERVICE DIFFICULTIES > Online reports www.casa.gov.au/airworth/sdr > Fax 02 6217 1920 > Free post Service Difficult Reports, Reply paid 2005, CASA, Canberra, ACT 2601 Aircraft below 5700 kg CESSNA 210N (2710) AILERON CONTROL SYSTEM BEARING FAILED The aileron control system forward bearing failed. The bearing is located in the control yoke mounted on the firewall. PIPER PA-31350 (3230) LANDING GEAR RETRACT/ EXTENSION SYSTEM - LINK CRACKED The nose landing gear down link was cracked. EMB EMB-110P1 (7200) ENGINE (TURBINE/TURBOPROP) - TURBINE ENGINE OVERTORQUED The right-hand engine was overtorqued to 2000 lb. An overtorque inspection was carried out and no defects discovered. It was caused by a pilot’s incorrect starting technique. BEECH 95-C55 (6122) PROPELLER GOVERNOR - PIPE CRACKED The left-hand engine propeller governor rigid oil line cracked on flare. An investigation of the same line on the right-hand engine also found it unserviceable. CESSNA 404-CESSNA (8500) ENGINE RECIPROCATING - PISTON ENGINE FAILED The left-hand engine ran rough and then failed. PAC CT-4B (8520) RECIPROCATING ENGINE POWER SECTION - CRANKCASE CRACKED The crankcase No2 main bearing saddle cracked in two places in one crankcase half and one place in the other crankcase half. The No2 main bearing deteriorated and breaking up caused metal contamination of oil system. PIPER PA-31350 (8520) RECIPROCATING ENGINE POWER SECTION - CRANKSHAFT BROKEN The left-hand engine crankshaft was broken at No2 main bearing cheek. SWRNGN SA-227DC (2720) RUDDER CONTROL SYSTEM - BEARING FAILED The captain’s rudder pedal bellcrank PNo 27-72055013 bearing failed and the bellcrank bolt PNo AN4-21 sheared. BEECH 58 (3230) LANDING GEAR RETRACT/EXTENSION SYSTEM - RELAY SUSPECT FAULTY The landing gear electric motor dynamic relay was suspected to be faulty. The landing gear gearbox overtravelled and bottomed out causing the gearbox to lock up and prevented the landing gear from extending electrically. The landing gear had to be manually extended using excessive force to turn the extension handle. PIPER PA-23150 (5751) AILERONS - SPAR CRACKED Left-hand aileron spar and doubler located behind the hinge attachment and control input hinge cracked in two places. The spar had been previously repaired and it is suspected that the repair was poorly designed and not strong enough. The aileron had been removed for a bearing replacement. GIPLND GA8 (6111) PROPELLER BLADE SECTION PROPELLER BLADE FAILED The propeller blade tip separated in flight. Severe vibration caused engine to seize during emergency landing. The aircraft is registered and operating in Canada. Rotorcraft ROBISIN R22 BETA (6310) ENGINE/TRANSMISSION COUPLING - BEARING ROUGH RUNNING The engine to transmission freewheel assembly bearing was running rough. MDHC 369E (6510) TAIL ROTOR DRIVE SHAFT - DRIVE SHAFT BROKEN The tail rotor driveshaft failed. Damage was caused to the tail rotor driveshaft and tailboom with some minor damage to a bracket above the driveshaft located 304.8mm in front of the tailboom to fuselage joint. The rear of the boom has internal damage. Further investigation found the tail rotor inboard teeter hinge bolt PNo 369A1602-3 slightly bent. ROBISIN R44 (7820) ENGINE NOISE SUPPRESSOR MUFFLER UNSERVICEABLE Muffler assembly deformed around the exhaust pipe. ROBISIN R22BETA (6310) ENGINE/TRANSMISSION COUPLING - DRIVE BELT DISTORTED Engine to transmission drive system “V” belts stretched. TO REPORT URGENT DEFECTS CALL 131757 AND ASK FOR THE SERVICE DIFFICULTY REPORT SECTION OR CONTACT YOUR LOCAL CASA AIRWORTHINESS TEAM LEADER. FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 53 LEADING EDGE BY SATELLITE Satellite navigation technology looks set to extend to precision approaches and automatic landing. A bout 150 nm from Seattle Airport, the ground based augmentation system (GBAS) kicks in, providing GPS corrections and integrity verification information to the Boeing 737-800. Captain Thomas Imrich, Boeing’s chief pilot, research, selects GBAS, known colloquially as GLS (GPS landing system). In the cockpit as an observer on this demonstration flight is CASA’s Ian Mallett, a technical advisor on the International Civil Aviation Organization’s Navigation Systems Panel. “From the pilot’s point of view, GBAS is just like an ILS,” says Mallett, who, along with CASA flying operations inspector Rob Collinge, is charged with keeping the Australian civil aviation safety regulator up to speed on the new technology. “The pilot selects GLS and everything after that is automatic. The system has a greater range than an ILS and can provide missed approach guidance.” CASA is investigating ground based augmentation systems as an alternative to existing precision approach and landing technology. Australia has been quick to take up satellite navigation since CASA approved its use as an IFR enroute navigational aid more than ten years ago. A recent CASA survey revealed that 85 per cent of Australian-registered aeroplanes used GNSS in one form or another. Usage ranges from the highly-integrated systems in the new Boeing 737-800 aircraft through to the handheld mini-receivers in ultralights. The technology will get a boost in a few years when the European Commission’s Galileo satellite constellation starts operations. This system will complement GPS, run by the US Air Force, and Global Navigation Satellite System (GLONASS), operated by the Russian Ministry of Defence. Galileo, which will include 30 satellites orbiting in three planes about 23,000 km above the surface, will improve satellite signal accuracy and availability to civil users world wide. 54 FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 Last year the United States and European Commission signed a deal that would see GPS and Galileo operating in harmony rather than competition. However, GNSS alone is accurate to about 15 m, good enough for enroute navigation and non-precision approaches. CASA recently gave approval to Qantas and Virgin to fly GNSS non-precision approaches throughout Australia. But GNSS is not accurate enough for precision approaches, which require positional data with an accuracy of 2-3 m. WAAS And the atomic clocks on satellites sometimes go haywire. If one satellite is malfunctioning, the coordinates it conveys to the receiver could be out by as much as 600 nm, with potentially drastic consequences. The holy grail for satellite navigation planners has been to correct the errors and to validate the integrity of the system. That’s where augmentation technology comes in. Augmentation can occur using equipment on the aircraft, within the satellite system or with ground based technology. In the medium EGNOS MSAS Growing coverage: GNSS Satellite based augmentation systems (SBAS) are being deployed across the world. Australia can already receive the signals from the US SBAS augmentations beingJapan deployed across WAAS CAPTION: system via GNSS the INMARSAT Pacific ocean systems satellite. are Recently successfully theits world. Australia already receive the signals the US WAAS launched MTSAT as partcan of their SBAS program. Europefrom has EGNOS and India the theof INMARSAT Pacific ocean satellite. Recently Japan GAGANsystem systemvia both which should be partially visible in Australia. successfully launched its MTSAT as part of their SBAS program. Europe has EGNOS India the GAGAN both of which uses should be partially of GNSS computes theand positional and time systems term, augmentation a combination visible in Australia. data for an object from the differences in the time of flight of radio waves from at least four satellites to the receiver. However, the ionosphere, a layer of charged particles 130 to 190 km above the Earth’s surface, slows the radio signals down, skewing the position and time information. These errors are amplified or annulled depending on the geometry of the satellites. GNSS constellations such as GPS and Galileo. The aviation industry, Airservices Australia and CASA are working on the long-term strategic decisions on which one will be the most economical and beneficial to Australia. The options are being examined by the Australian strategic air traffic management group (ASTRA). ABAS: Some commentators see aircraftbased augmentation systems (ABAS) as the LEADING EDGE first step in extending the use of GNSS to other phases of flight. “ABAS are based on dedicated IFR aviation receivers that incorporate integrity protection as part of their basic function,” says Mallett. The receivers check the accuracy of GPS readings by comparing them with data from one or two additional satellites. If errors, whatever the source, are detected from a particular satellite, the suspect datastream is eliminated from the computations. CASA recently gave Qantas approval to undertake RNP (required navigational performance) approaches and departures in Queenstown, New Zealand, using an ABAS system that combines GPS with inertial navigation. SBAS: Satellite-based augmentation systems use dedicated high-orbit geostationary satellites to get ranging, integrity and correctional information from a GNSS ground-monitoring network. SBAS can deliver much higher availability of service than the core satellite constellations with ABAS alone, according to the International Civil Aviation Organization’s GNSS manual. “In certain configurations, SBAS can support approach procedures with vertical guidance … In many cases, SBAS will support lower minima than that associated with nonprecision approaches, resulting in higher airport usability. “Almost all SBAS approaches will feature vertical guidance resulting in a significant increase in safety.” An SBAS approach does not require any SBAS infrastructure at an airport, the report adds. The main disadvantage is the cost per receiving unit – about $10,000. Four SBAS systems are under development. They are the European geostationary navigation overlay services (EGNOS); the Indian GPS and geostationary Earth orbit augmented navigation system (GAGAN); Ground-based augmentation system Multi-mode receiver VDB datalink Corrections and final approach segment data Ground based augmentation: A single GBAS ground station provides approach and landing services to all runways at an aerodrome. The GBAS works out corrections for satellite information and transmits information to aircraft over a VHF data broadcast (VDB) datalink. The SBAS communication satellites transmit the information via a GNSS “look alike” signal to the aircraft. This signal is on the same frequency as a GNSS signal, and to the aircraft receiver looks the same but carries the correctional and integrity data. The geostationary satellite also acts like an additional GNSS satellite by providing a ranging signal to enhance navigation availability. the Japanese multi-functional transport satellite-based augmentation system (MTSAT); and the United States wide area augmentation system (WAAS). The use of SBAS in Australia could get a push from the recent launch of Japan’s MTSAT geostationary satellite system. This constellation of satellites over the equator will next year start broadcasting SBAS augmentation information that can be used in Australia. However, to use SBAS would require operators to fit a new standard of receivers to their aircraft (technical standard order [TSO] C145/6). CASA is working on “only means” navigation approval for these SBAS-capable receivers. TSO C145/6 receivers have better computer capability and improved design, along with RAIM (receiver autonomous integrity monitoring) detection. They can also detect and exclude particular satellites transmitting erroneous signals. GBAS Ground-based augmentation systems deploy a ground station at the airport to listen to the GNSS satellites. A ground station, made up of equipment to receive satellite signals and broadcast data, costs around $1 million. It transmits local information on GNSS corrections, integrity parameters and approach data to the aircraft on the VHF band. “A GBAS installation ensures that the signal has a high level of integrity needed for precision approach landing systems,” says Mallett. “The installation can support multiple runways at the airport and could be used by neighbouring airports and heliports as well.” Qantas, Sydney Airport, Airservices Australia and CASA are examining the installation of a GBAS station at Sydney Airport for operational tests and systems development. Already a GBAS system is in place on Norfolk Island. Airservices installed a trial unit at Melbourne airport recently. It provided an extended precision approach capability from Melbourne to the nearby Essendon, Moorabbin and Avalon aerodromes. The air traffic service provider is also working on a GRAS (ground-based regional augmentation system), which provides even wider coverage than conventional GBAS. International standards have now been developed for GRAS and are enshrined in ICAO Annex 10. Despite these advances, aviation is slipping from its position as the key innovator in GNSS technology. New applications are fast finding their way into road transport and train scheduling. The international financial market has even taken up GNSS to accurately record the time of transactions. The big hurdle for Australian aviation is an industry-wide decision on which satellite augmentation technology to adopt For more information, see www.astra.aero. 55 FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 ✓ SAFETY CHECK VFR OPS 1. Acceptable methods of cancelling SARWATCH are by: (a) Telephone to the ATS centre. (b) Radio to CENSAR, by radio to FLIGHTWATCH, by telephone to CENSAR. (c) Telephone to CENSAR, by radio to the ATS centre, by relay from another aircraft. 2. The standard pressure region is: (a) Airspace above 10,000 ft where the altimeter subscale is set for 1013.2 hPa. (b) Any airspace where the altimeter sub-scale is set to 1013.2 hPa. (c) Airspace above A050. (d) The region on the declared density altitude chart where the pressure is 1013.2 hPa. 3. As a general rule, loading a conventional low-winged aircraft so that the centre of gravity is as far aft as permissible will result in a: (a) Faster cruise because the downwards lift developed by the tail will be minimised. (b) Slower cruise because additional upwards lift must be generated by the tail to counter the aft centre of gravity. (c) Slower cruise because the trim drag will be increased. (d) Faster cruise because the parasitic drag will be increased. 4. A significant point located 22 nm north east of Nyngan (YNYN) is entered in a NAIPS flight notification as: (a) 045022YNYN. (b) YNYN045022. (c) 04522YNYN. (d) YNYN 022045. 5. You are taxiing at a level aerodrome with an elevation of 2450 ft with the altimeter subscale set to the QNH supplied by the A real life saver... Aerotape - a visual signalling device made from high tech glass bead reflective material and packaged into a shirt pocket sized lightweight sturdy casing. Aero tape provides a strong signal at 3000 feet Be seen...Be found More info at www.aerotape.biz or buy online at www.airservicesaustralia.com/store/accessories.asp & select accessories 56 FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 Test your aviation knowledge automatic weather station. The altimeter passes an error check if it reads: (a) 2560 ft. (b) 2550 ft. (c) 2650 ft. (d) 2340 ft. 6. For a day VFR flight over a distance of 120 nm to an aerodrome with an elevation of 450 ft, an alternate would be required when: (a) The aerodrome forecast indicated SCT cloud at 1000 ft. (b) The aerodrome forecast indicated SCT cloud at 1200 ft. (c) The aerodrome forecast indicated BKN cloud at 1000 ft. (d) The aerodrome forecast indicated BKN cloud at 1500 ft. 7. A “wheelbarrowing” accident is an unofficial term used to describe damage due to loss of directional control: (a) In nose-wheel aircraft caused by loading with the centre of gravity beyond the forward limit. (b) In nose-wheel aircraft caused by the pilot applying forward pressure during the landing or takeoff ground roll, which transfers load to the nose wheel making the aircraft directionally less stable. (c) In tail-wheel aircraft caused by excessive elevator input when raising the tail. 8. When using a PAPI system (installed on the left hand side of the threshold) on an approach, the indication given by the four lights for the correct approach path is, from left to right: (a) White, white, white, white. (b) Red, white, red, white. (c) White, white, red, red. (d) Red, red, white, white. 9. You are conducting a VFR flight to a CTAF aerodrome with an elevation of 500 ft when your radio fails. The minimum distance vertically from cloud that applies in these circumstances for VFR is: (a) 1500 ft. (b) 1000 ft. (c) 500 ft. (d) Clear of cloud only. ✓ SAFETY CHECK S A F E T Y C H SAFETY CHECK SAFETY CHECK E C K IFR OPS HOLDING PATTERNS & SECTOR ENTRIES 1. Draw a diagram of the holding pattern from the following information: TR IN: 270 Turn: Right Time: 1 minute DME LMT : 4 2. The holding pattern in Question 1 (other than the DME limit) is a standard holding pattern. (a) True. (b) False. 3. When approaching the holding fix, which of the following is used to determine the sector entry to fly? (a) The aircraft’s track to the fix. (b) The aircraft’s heading to the fix. (c) Either the aircraft’s heading or track to the fix. 4. When determining the sector entry, a zone of flexibility of ±5° is permitted on the sector boundaries. (a) True. (b) False. For questions 5 to 10 refer to your holding pattern diagram in Question 1. 5. An aircraft is inbound to the holding fix, heading 120 for track of 130. What sector entry will be flown? (a) Sector 3. (b) Sector 2 (offset or “teardrop”). (c) Sector 1 (parallel). 6. An aircraft is inbound to the holding fix on a heading of 030 for a track of 020. What sector entry will be flown? (a) Sector 3, based on the track. (b) Sector 2, based on the heading and on passage over the fix intercept a 30° removed track of 060. (c) Sector 2 or 3 based on the 5° flexibility permitted on the track. (d) Sector 1. 7. An aircraft is inbound to the holding fix on a heading of 195 for a track of 205. What sector entry will be flown? (a) Sector 1 only. (b) Sector 2 only. (c) Sector 2 or 3. (d) Sector 1 or 3. 8. An aircraft is inbound to the holding fix on a heading of 315 for a track of 300. What sector entry will be flown? (a) Sector 1. (b) Sector 2. (c) Sector 3. 9. If a holding pattern is flown, then which of the following is the correct commencement of outbound timing? (a) On reaching outbound heading. (b) When abeam the holding fix. (c) When abeam the fix or when the abeam position cannot be determined, from completion of the outbound turn. (d) When overhead the fix. 10. When will the aircraft be turned back inbound to the fix? (a) At the time limit. (b) At the DME limit. (c) At a DME that ensures the turn is completed inbound before reaching the DME limit. (d) At the time or DME limit, whichever occurs first. FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 57 ✓ SAFETY CHECK Test your aviation knowledge MAINTENANCE 1. In a simple hydraulic brake system, the force applied by the brake calliper to the wheel disc (rotor) is greater than the force applied to brake pedal because of the: (a) Difference in crosssectional area of the master cylinder piston compared with the piston in the brake calliper. (b) Difference in fluid volume between the master cylinder and wheel cylinder. (c) Fluid losses in the connecting pipe work. (d) High viscosity of the hydraulic fluid. 2. The purpose of a compressor bleed valve is to: (a) Move compressor discharge air away from the combustor to reduce the airflow and decrease the stall margin. (b) Bypass air from stages of a compressor to increase the airflow through the stage and thus reduce the tendency for compressor stall. (c) Bypass air from earlier stages to later stages of the compressor to increase compressor efficiency at low speeds. (d) Unload the compressor during high power operation. 3. Beta control refers to a power range in a turboprop engine where: (a) The propeller has moved from the fine pitch stops towards coarser pitch solely under the control of the propeller governor. (b) The propeller has moved from the coarse pitch stops towards finer pitch solely under the control of the propeller governor. 58 (c) During low speed or ground operations, the propeller pitch angle is under the direct control of the pilot. (d) During high speed operations, the propeller pitch angle is under the direct control of the pilot. 4. The function of an oil cooler thermal bypass valve is to: (a) Open on rising pressure if the oil cooler is partially blocked. (b) Close on rising pressure if the oil cooler is partially blocked. (c) Sense the oil temperature and open on rising temperature. (d) Sense the oil temperature and close on rising temperature. 5. Chines are designed as part of some aircraft nose wheel tyres to: (a) Assist in deflecting surface water away from the aircraft fuselage. (b) Cause the wheel to rotate slightly before ground contact. (c) Raise the aquaplaning speed. (d) Lower the aquaplaning speed. 6. If the distance between opposite main wheel rims at the forward edge is less than at the rear edge, the wheels are said to have: (a) Positive caster. (b) Negative caster. (c) Toe-in. (d) Toe-out. 7. An o-ring marked with a blue stripe or dot is intended for use with: (a) Vegetable-based hydraulic fluid to MIL-H7644. (b) Mineral-based hydraulic fluid to MIL-H5606. (c) Phosphate ester- FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 based hydraulic fluid to MIL-H-8466. (d) Skydrol. 8. A backup ring in a hydraulic system is installed on the: (a) Pressure side of an o-ring and prevents distortion. (b) Pressure side of an oring and prevents extrusion of the o-ring. (c) Opposite side of the o-ring to the pressure and prevents extrusion of the o-ring. (d) Opposite side of the o-ring to the pressure and reduces leakage due to imperfections in the seal. 9. Abnormal wear in the centre of a tyre tread is a probable indication that the tyre has been: (a) Subjected to excessive braking. (b) Subjected to aquaplaning. (c) Under-inflated. (d) Over-inflated. 10. A MS20470AD4-4 rivet is: (a) 1/8 inch in diameter and 1/2 inch long. (b) 1/8 inch in diameter and 1/4 inch long. (c) 1/4 inch in diameter and 1/2 inch long. (d) 1/16 inch in diameter and 1/2 inch long. Questions provided by Australia-Pacific Aviation Services ✓ SAFETY CHECK S A F E T Y C H SAFETY CHECK SAFETY CHECK E C K Getty Images Getty images WHAT’S THE MESSAGE? Write an amusing caption of up to 25 words for a chance to win $100. Send your entry to: Flight Safety Australia, GPO Box 2005, Canberra ACT 2601 or email to: [email protected] by 15 July 2005. Last issue’s winning caption: “I did not know there was a wing class.” David Pike, Fremantle WA QUIZ ANSWERS VFR 1 (c) VFG page 212. 2 (a) AIP GEN 2.2. 3 (a) The tail on conventional low-wing aircraft develops downward lift which reduces as the centre of gravity moves aft. This downward lift requires additional lift from the wings which comes at the expense of more induced drag. 4 (b) ENR 1.10 Appendix 2. 5 (b) If the site is below 3,300 ft the limit is ± 100 ft. VFG page 69 6 (c) Alternate required if more that SCT below 1500 ft. Cloud in area forecast is given AMSL. 7 (b) Wheelbarrow accidents are caused by incorrect landing techniques such as trying to force the aircraft on to the ground too early (insufficient hold-off), approaching too fast or pushing forward on the controls to correct a bounce. The main-wheels typically leave the ground and damage usually involves the nose wheel, engine, engine mounts, firewall and propeller. 8 (c) VFG page 87. AIP AD 1.1 paragraph 5.1.2 9 (b) The requirement just to be clear of cloud below 3000 ft AMSL only applies if radio is carried and used. VFG page 192. IFR 1. TR IN Turn Time DME LMT 270 Right 1 4 2. (a) AIP ENR 1.5-20, para 3.1.3. 3. (b) AIP ENR 1.5-23, para 3.3.1. 4. (a) AIP ENR 1.5-23, para 3.3.1. 5. (c) AIP ENR 1.5-23, para 3.3.1 figure 3.2a. 6. (b) AIP ENR 1.5-23, para 3.3.1 figure 3.2a, ENR 1.5-24, para 3.3.3. 7. (d) AIP ENR 1.5-23, para 3.3.1 figure 3.2a. 8. (c) AIP ENR 1.5-23, para 3.3.1. 9. (c) AIP ENR 1.5-24, para 3.3.4. 10. (d) AIP ENR 1.5-24, para 3.4.1c, para 3.5.1. MAINTENANCE 1. (a) The ratio of the areas of the cross sections of the two pistons determines the force applied by the brake. 2. (b) Compressor stall involves the aerofoils within the compressor and is promoted by high pressure ratios across the stage combined with low flow through it. Bypassing air rather than forcing it into the next stage increases the flow and reduces the tendency for the compressor to stall. 3. (c) The propeller blade angle is frequently termed beta. The beta range is so named because then the blade angle is being controlled directly rather than by a governor attempting to maintain a constant speed. The beta range is used mostly for ground operations and often locked out in flight although some aircraft are capable of using beta on the approach.. 4. (d) When the oil is cold the valve opens; this allows oil to bypasses the cooler and so reach operating temperature more quickly. 5. (a) Chines are annular protrusions moulded into the tyre side wall. 6. (c) Caster refers to the angle from the vertical of the axis around which the wheel rotates due to steering movement. 7. (b) Answers (c) and (d) refer to the same fluid, which requires butyl rubber seals; vegetable based fluids use natural rubber seals. 8. (c) Without a backup ring an o-ring tends to extrude into the clearance space away from the pressure side. 9. (d) Under-inflation tends to wear the outer edges of the tread; aquaplaning produces areas of lighter coloured rubber from the action of steam (reversion). 10. (b) The digit before the dash is the diameter in 1/32 inch and the last figure is the length in 1/16 inch. FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 59 The Australian Air Executive Director’s Message Aviation research findings The ATSB’s aviation research efforts in 2004-05 have generated some important and interesting findings, including those in a range of reports issued in June 2004-05. Weather-related general aviation accidents remain one of the most significant causes for concern in aviation safety. An ATSB study of 491 weather-related occurrences was the first of its type to compare different pilot behaviours in the face of adverse weather. The results suggest that the mid-point of the flight can be a ‘psychological turning point’ for pilots, irrespective of the absolute flight distance involved. The results also emphasised that a safe pilot is a proactive pilot and that dealing with adverse weather is not a one-off decision but a continually evolving process. An ATSB study of 63 twin-engine power loss accidents from 1993-2002 found the accident rate associated with power loss in twin-engine aircraft to be almost half the rate for single-engine aircraft, except for fatal accidents, which had similar rates. In 10 of the11 fatal twin-engine power loss accidents, an in-flight loss of control followed the power loss, compared with only three of the 52 non- fatal accidents. Historically, diabetic pilots have been permanently disqualified from flying duties but some now receive limited flying certification if they are well supervised. The ATSB report on Diabetes Mellitus concluded that an aeromedical policy will be effective if it is based on an appropriate risk management strategy, taking account of all relevant issues. The ATSB report on risks associated with aerial campaign management is the subject of a separate feature article in this supplement. The other 2004-05 ATSB aviation research reports are available on the ATSB website (www.atsb.gov.au). Kym Bills, Executive Director Australian Transport Safety Bureau PO Box 967, Civic Square ACT 2608 Telephone: 1800 621 372 Email: [email protected] Website: www.atsb.gov.au An Aviation Self Reporting Scheme (ASRS) form can be obtained from the ATSB website or by telephoning 1800 020 505. TCAS traffic advisory near Hamilton Island O N 20 June 2005, the ATSB released its final investigation report into a close proximity occurrence involving a Boeing 737 and a 717 near Hamilton Island, Queensland. On 17 July 2004, at about 1619 EST, a Boeing Company 737-476 (737), registered VH-TJH, was inbound to Hamilton Island from the south-east for a landing on runway 14. The Hamilton Island Aerodrome Controller (ADC) instructed the crew to descend to 4,000 ft due to the pending departure of a Boeing Company 717-200 (717), registered VH-VQB, from runway 14. The ADC instructed the crew of the 717 to maintain 3,000 ft, to make a right turn to track to Mackay and that they were clear for takeoff. After takeoff, at about 2,000 ft, the crew of the 717 received a TCAS traffic advisory and saw the 737 crossing from left to right on descent. The 717 crew’s perception was that the expected track of the aircraft would place them on, or close to, a collision course so they turned left and descended to avoid the 737 by passing behind it. Analysis of air traffic control recorder data and aircraft flight data revealed that at 1619:15 after the 717 had turned left, the lateral and vertical distance between the aircraft was 1,112 m and 700 ft (737 above the 717). The occurrence highlighted the importance of using unambiguous radiotelephony phraseology to avoid misunderstandings and the need for pilots and controllers to remain vigilant at all times especially when the dynamics of a situation require action to be implemented early to ensure that aircraft safety is not compromised. Airservices Australia advised several safety actions in place following the incident or planned for implementation. The Group Tower Manager responsible for Hamilton Island has reinforced the need, through the Tower Manager, to ensure that the automatic terminal information system strip matches the actual ATIS broadcast. Also a review of the visual separation requirements in the Manual of Air Traffic Services (MATS) was conducted to assure that all pertinent limitations were referenced and determined that no changes to MATS were required. A further Airservices safety action will involve a performance check being completed every month for the first 3 months after an air traffic controller gets an initial rating, then at 6 months, and then the checking regime will be in accordance with the requirements in the Civil Air Traffic Services Operations Administration Manual. ■ Australian Transport Safety Bureau r Safety Investigator I Lesson from a case study of aerial locust control N 2004, there were two wirestrike accidents in New South Wales involving helicopters undertaking locust control operations. The first accident occurred in October 2004 near Forbes and resulted in minor injuries to one occupant and extensive damage to the helicopter. The second accident occurred in November PHOTO: Australian Plague Locust 2004 near Dunedoo and terised by: a significant and possibly urgent resulted in the death of two community need requiring the coordioccupants. A third occupant was seriously nation of significant numbers of resources injured and there was extensive damage and organisations; a degree of irregularity to the helicopter. A third accident, near or unpredictability in the timing and the Mudgee in November 2004, involved a size of the operation; aerial operations with helicopter that was being used for locust a relatively high hazard level; and a regularly control, although the helicopter was not changing and unpredictable operational involved in locust control activities at the environment throughout the course of the time of the accident. campaign. The Australian Transport Safety Bureau These characteristics potentially increase (ATSB) began formal investigations into all risk to the organisation and its staff. Locust three accidents and a research investigation control organisations are closely involved into the systems used by Government in aerial operations and can therefore organisations to manage contracted aerial influence the level of risk of the operations. operators for locust control in order to Many complex organisations operating identify issues that may enhance future in a hazardous environment, such as aviation safety. major public air transport companies, Locust control operations are presented recognise the influence they have on safety. as a case study, but it is intended that While they may subcontract many safetyorganisations managing other aerial critical aspects of their operations, these operations with similarities to locust organisations still maintain an interest in the control, such as aerial fire control, other pest safety of these operations and proactively management operations, and emergency manage safety beyond what is required by service operations, may also find the concepts regulation. Similar methods can be effective presented in this analysis useful. These types for mitigating risk in aerial campaigns. of operations, collectively referred to in the Locust control organisations and other report as ‘aerial campaigns’ are charac- organisations involved in aerial operations with similar characteristics may benefit from developing some of the characteristics identified in High Reliability Organisations (HROs). HROs work in complex high-hazard environments but with relatively low numbers of accidents and incidents. These organisations have been identified as having an ‘organisational mindfulness’ which is defined by: an attitude that recognises failures as symptoms of a problem in a system and as learning opportunities for the organisation; encouraging diverse views and approaches to identify a diverse range of risks and solutions; ensuring there are ‘big picture’ people within the organisation; a commitment to resilience when facing unexpected dangers through appropriate organising at times of increased risk; and a deference at times of increased risk to expertise rather than traditional management structures. After the two helicopter accidents associated with locust control in NSW in October and November 2004, the organisation overseeing these operations has advised the ATSB that it has taken considerable steps towards safer operations by developing more comprehensive safety management systems. The organisation has consulted widely with aviation industry bodies, aerial operators and other government departments and has developed risk controls based on a risk management approach to the entire locust control campaign. ■ FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 61 Australian Transport Safety Bureau Risks associated with aerial campaign management: Australian Transport Safety Bureau Safety briefs •••••••••••••••••••••••• •••••••••••••••••••••••• R22 clutch shaft failure Fatal training flight at Bankstown Collision with ground Occurrence 200501655 – Preliminary Report Occurrence 200304589 Occurrence 200501656 On 13 April 2005, at 0930 EST, the pilot of a Robinson R22 Beta helicopter, VHHXU, was conducting cattle mustering operations near Mareeba, Qld, when he felt a significant airframe vibration and elected to immediately land the helicopter. Following a safe landing and during engine shut-down, the clutch shaft that transfers drive through to the main rotor gearbox failed. The pilot, the sole occupant of the helicopter, was not injured. The helicopter maintenance provider reported the failure to CASA, through the Service Difficulty Reporting system. A representative from CASA subsequently notified the ATSB of the failure, because of its apparent similarity to a failure sustained by R22 helicopter VH-UXF on 28 September 2003 that resulted in two fatalities and the destruction of the aircraft. The failed clutch shaft, yoke, flex-plates and sprag clutch assembly were obtained by the ATSB. Laboratory examination of the clutch assembly confirmed the fracture of the clutch shaft at the connection to the yoke that transferred drive to the main rotor gearbox. The fracture had resulted from the growth of torsional fatigue cracking from an origin within the first bolt hole between the yoke and shaft end. Fracture of the clutch shaft results in the loss of all drive to the helicopter main rotor. As a result of the September 2003 accident, CASA published airworthiness directive AD/ R22/51, requiring the one-off disassembly of yoke-to-shaft connections and the inspection for cracking and bolt hole fretting damage. Maintenance documentation indicated AD/ R22/51 was carried out on VH-HXU in August 2004. The investigation is continuing. ■ On 11 November 2003, at about 1240 EST, a student pilot undertaking multiengine aircraft training was accompanied by an instructor pilot in a Piper PA-34-200 Seneca, VH-CTT. The flight was to include asymmetric flight training. At 1610 CST, on 18 April 2005, a Cessna Cutlass, VH-LCZ, became airborne at Warooka aircraft landing area (ALA) SA. The pilot retracted the landing gear then heard the stall warning horn. The pilot lowered the nose of the aircraft which started a gradual descent, impacted the ground and came to a stop adjacent to the runway. There were no reported injuries. The pilot was conducting his second flight from Warooka ALA to Wedge Island ALA. The pilot noted a house and powerlines at the southern end of the airstrip on his previous departure but decided to take off to the south and climb at the best angle of climb airspeed, which is 67 kt indicated airspeed (KIAS). The take-off run was normal and the aircraft became airborne approximately 220 m from the end of the runway at 60 KIAS. As the aircraft became airborne the pilot retracted the landing gear which swings downward approximately two feet as it starts retracting. The aircraft flight manual stated that the landing gear should not be retracted unless there was insufficient runway remaining to do a wheels down forced landing. The stall warning horn provides a continuous tone through the aircraft speaker 5 to 10 kt above the stall speed. The pilot lowered the nose of the aircraft but there was insufficient height to accelerate the aircraft. The safety margin between the lift-off speed and the stall speed may have been eroded by the effect of any `swing’ in the wind during the retraction of the landing gear, and the potential for any increase in drag associated with the retraction of that gear. There was insufficient height when the stall warning horn activated for the pilot to regain climb speed. ■ 62 FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 Mudgee Guardian The flight departed and they were turning onto the final approach to runway 11 Right, for a fourth touch and go, when the aerodrome controller (ADC) saw that the aircraft’s landing gear was not extended. Witnesses reported that when the aircraft was almost over the threshold to runway 11R it commenced to diverge right while maintaining a low height. They reported that when the aircraft was abeam the mid length of the runway, it’s nose lifted and the aircraft banked steeply to the right before impacting the ground in a near vertical nose-down attitude. A fire ignited after the impact. The instructor vacated the aircraft through the right door after the aircraft came to rest. The student was fatally injured. The instructor received severe burns and was treated in hospital for three and a half weeks before succumbing to those injuries. The investigation found a number of engineering anomalies in the engines, but these were considered to not have affected the circumstances of the occurrence. The investigation found control of the aircraft was lost at a height from which recovery was not possible. The reason for the loss of control could not be determined. ■ Infringement of separation standard Occurrence 200501482 Seaplane rollover on takeoff Occurrence 200304546 Occurrence 200500216 A Bell helicopter Company 206 (B206), registered VH-FHY, and a Robinson Helicopter Company R44, registered VHYKL, were travelling in company returning to Kununurra WA from a fishing charter to the Cape Dommett area of far north Western Australia. At 1735 EST on 20 January 2005, a Cessna Aircraft Company A185F floatplane, registered VH-SBH, with one pilot and three passengers on board was taking off on a water departure for a charter flight from Rose Bay aircraft landing area (ALA) to Palm Beach, NSW. Shortly after becoming airborne, the aircraft rolled 45 degrees to the left causing the left wing to strike the water. The aircraft became inverted and was substantially damaged. The four occupants escaped with minor injuries. The aircraft became airborne at 45 to 50 kt. At approximately 30 ft above the water, the aircraft commenced an uncommanded left roll that the pilot was able to correct with full right aileron input. The aircraft then commenced a second uncommanded left roll that he was unable to correct with control inputs and the aircraft’s left wing subsequently struck the water. Given the rapid nature of the event and the need to exit the inverted cabin quickly, the passengers did not retrieve the life jackets which were stowed underneath their seats. The Pilots Operating Handbook (POH) indicated a stall speed of 55 kt at a mid range centre of gravity. The POH also showed a maximum demonstrated crosswind for takeoff and landing of 13 knots. The investigation found that the crosswind for the accident flight would have been in the vicinity of 19 to 24 knots and that conditions were conducive to wind shear and mechanical turbulence. The Civil Aviation Safety Authority advised the Australian Transport Safety Bureau that new draft safety regulations require that each occupant of a seaplane or amphibian that is taking off from or landing on water wear a life jacket equipped with a whistle and a survivor locator light. The operator advised that it was introducing a range of safety measures including, but not limited to, monitoring of weather conditions, wearing of life jackets, and limitations on operations in wind conditions greater than 30 kt. ■ Approximately seventeen minutes into the journey, the pilot of the lead helicopter, the B206, received a broadcast from the pilot of the R44 stating that 'I’m going in hard'. The pilot of the B206 immediately turned his aircraft around in a tight right turn and after assuming a reciprocal heading, observed a mushroom cloud of smoke rising from a nearby ridge. The pilot of the B206 immediately broadcast a mayday to Brisbane Centre and began to orbit the site. Brisbane Centre asked the pilot of the B206 to look for people moving about around the wreckage; none could be seen. With no signs of life visible, and unable to identify a safe place to land, the pilot of the B206 then continued to Kununurra. The first rescue team into the site confirmed that all four occupants had received fatal injuries. The accident was not considered survivable. The onsite investigation accounted for all major components of the helicopter at the crash site. The centre of gravity was found to be outside the forward limit, and the operating weight at the time of the occurrence was found to exceed the maximum allowable operating weight for that helicopter type. The short radio transmission by the pilot of the R44 did not allude to a specific problem. In the absence of witness reports of the occurrence, and the lack of physical evidence due to post-impact fire, the reason(s) for the descent from cruise altitude, and the subsequent impact with terrain could not be established. ■ FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 63 Australian Transport Safety Bureau The occurrence involved a Boeing Company B747-338 (747) aircraft, registered VHEBW, with a crew of 16 and 346 passengers, which was being operated on a scheduled passenger service between Sydney, Australia, and Auckland, New Zealand on 9 April 2005. The copilot was the handling pilot for the flight. As the 747 was on approach to runway 23 right (23R) at Auckland, the Auckland Tower and Terminal controllers observed an unidentified aircraft tracking towards its approach path. They instructed the crew of the 747 to discontinue the approach and to turn the aircraft right, on climb to 3,000 ft. The aircraft subsequently entered instrument meteorological conditions (IMC) at an altitude of 3,000 ft. The crew reported that shortly after, and while still in IMC, they received a TERRAIN, PULL-UP warning from the aircraft’s enhanced ground proximity warning system (EGPWS). The pilot in command took control of the aircraft and commenced an immediate climb in accordance with the operator’s procedures. The crew advised air traffic control that they had received a ‘GPWS terrain warning’, and that they were climbing the aircraft to 5,000 ft. At the same time, a New Zealandregistered 747 was making an instrument approach to runway 23R, and had been cleared to descend to an altitude of 4,000 ft. As the Australian-registered 747 was climbing to 5,000 ft, it passed about 1.9 nm behind the New Zealandregistered 747, which was descending through 4,500 ft. The required separation standard of 3 nm laterally or 1,000 ft vertically was infringed. No avoiding action was taken, or was required to be taken, by either crew. The Transport Accident Investigation Commission of New Zealand is the accident investigation authority conducting the investigation into this occurrence, and will publish the final report on its website at www.taic.org.nz ■ Helicopter crash near Kununurra SAFETY RULES CURRENT Legislative Change Projects in progress See webpage rrp.casa.gov.au/rulechange for details Legislative changes continue in parallel with the development of new Civil Aviation Safety Regulations, generally because of their urgency (usually for safety reasons) or unnecessary impositions on the aviation industry and CASA. Known as legislative change projects, the amendments they propose affect the Civil Aviation Act, the 1988 CARs, the 1998 CASRs, CAOs and the 1995 Civil Aviation (Fees) Regulations. Legislative change projects are treated independently of the Regulatory Reform Programme because of their advanced state of development and/or safety-related urgency. Airspace, Air Traffic Control, and Aerodromes PROJECT NO. TITLE AS 99/05Special Category 1 (SCAT 1) approach system on Norfolk Island AS 01/04Oversight of Automatic Dependent Surveillance (ADS) Trials AS 02/02Complete standards, approvals and associated training to allow GNSS NPAs, Stabilised NPAs using FMS, APV Baro-VNAV and GNSS based APV approaches to be used by the Australian industry AS 03/01Development and implementation of Ground-based Regional Augmentation System (GRAS) in Australia AS 03/03CASA facilitation of NAS Characteristic 29 – NonTowered aerodromes AS 04/01CASA support for the TSO-C146a Test Programme AS 04/02Review of CASR Part 173 Manual Of Standards (MOS) – Instrument Flight Procedure Design AS 04/03Future mandate for Automatic Dependent Surveillance–Broadcast (ADS-B) avionics in Australia AS 04/04Post-implementation review of air traffic services licensing AS 04/05Post-implementation review of air traffic services training providers AS 04/06Post-implementation review of aeronautical telecommunication service and radionavigation service providers AS 04/07Post-implementation review of air traffic service providers AS 04/08 Australian Aircraft Equipment Survey AS 05/01AIP Book Legislative Support AS 05/02Standards for Helicopter Landing Sites (HLS) Certification PROJECT NO. TITLE CS 04/01Develop standards for helicopter time-in-service recording devices CS 04/03Review/Amend CASR Parts 21-35 airworthiness standards CS 04/05Mandatory Compliance with Country-of-Origin ADs CS 04/06Applicability of weight and performance limitations to special category aeroplanes CS 04/08Review of equipment and process control standards CS 05/01Certification requirements related to the design, manufacturing and airworthiness of UAVs Flight Crew Licensing PROJECT NO. TITLE FS 03/01Periodic review and ongoing amendments to include endorsements for new aircraft types and models introduced to Australia FS 04/01Post-implementation review of CASR Part 67 – Medical Standards FS 05/01Guidance on issuing aerobatic approvals and permissions FS 05/02Multi-engine aeroplane flight training FS 05/03Guidelines for night VFR training and proficiency 64 FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 Flying Operations PROJECT NO. TITLE OS 99/13Interim Reclassification of Operations for small volume cargo-only flights and parachuting operations OS 00/11Carriage of Life Jackets and other issues related to the operation of Twin Engine Aeroplanes (per ATSB report – 30 October 2000) OS 01/09Use of Night Vision Goggles (NVG)/ Night Vision Devices (NVD) by helicopter operators OS 01/10Review of existing rules for Classification of Operations OS 02/03CASA Fatigue Risk Management Systems OS 02/06Development of guidelines for the certification, airworthiness and operation of electronic flight bag (EFB) computing devices SS 03/01Extended Range Operations (ETOPS) OS 03/02Heads-up Guidance Systems (HGS)/Heads-Up Displays (HUD) Operations Standards OS 03/03CASA’s Privacy Policy/Legislation for the release of Personal Information OS 03/05Experimental aircraft – operating limitations OS 03/07Conditions imposed on an AOC – arrangements with an interposed entity OS 03/08Transitional provisions for AOCs under CASR Part 119 OS 04/01Review/Amend Compliance Management of Commercial Ballooning OS 04/03Post Implementation Review (PIR) – CASR Part 101 OS 05/01Post Implementation Review (PIR) – CASR Part 92 OS 05/02Multi-engine standards helicopter operational performance OS 05/03Administrative and operational requirements related to Light Sport Aircraft OS 05/04Disclosure of certain issues associated with dormant AOCs OS 05/05Maximum fuel capacity – Single Place Gyroplanes Maintenance and Maintenance Personnel PROJECT NO. TITLE MS 01/02System of Maintenance MS 01/04Authorised release certificate and component/part definitions MS 04/01XReview of CASR Part 45 – Display of nationality and registration marks and aircraft registration identification plates MS 04/02Installation and use of aircraft components during maintenance MS 04/05Appointment of persons to issue maintenance release MS 05/01Appointment of the Head of Aircraft Airworthiness and Maintenance Control (HAAMC) – AOC entry control process MS 05/02Maintenance of Light Sport Aircraft (LSA) MS 05/03Transitional requirements for aircraft registration under CASR Part 47 Standards Support PROJECT NO. TITLE SS 04/01Procedures/Guidance for CASA’s Internal Technical Delegations SAFETY RULES Ground warning systems mandated Gareth Davey provides some background to the requirements. In the early 1990s the International Civil Aviation Organization (ICAO) identified 260 controlled flight into terrain (CFIT) accidents around the world between 1978 and 1991 involving over 5500 passengers and crew fatalities. This prompted ICAO to recommend that States require fitment of ground proximity warning systems (GPWS) to all turbine engine aeroplanes if authorised to carry more than 9 passengers. As a result CASA proposed mandating fitment of GPWS in 1994. The consultation process resulted in a January 1, 1999 implementation date for all applicable charter and regular public transport flights in Australia. Industry representations convinced CASA to allow this deadline to be ex- AOC fleet additions streamlined Charter operators will now find it simpler to satisfy CASA requirements to add aircraft (<5,700 kg MTOW) to existing fleets. The safety regulator has amended Civil Aviation Order 82.1 to allow charter operators to add different models (for example, Piper PA 31) of aircraft to a have your say The Standards Consultative Committee advises CASA on regulatory change. TO CONTACT YOUR INDUSTRY REPRESENTATIVE http://rrp.casa.gov.au/scc/ or telephone 02 6217 1248 tended subject to operators fitting the new enhanced GPWS (known then as EGPWS and now called TAWS – terrain avoidance and warning system). Operators were given until 1 October 1999 to fit standard GPWS equipment, or 1 January 2001 if installing TAWS with appropriate crew training. In 2000, with the second deadline fast approaching, CASA regulatory managers became aware of industry hardship due to the unavailability of Supplemental Type Certificates for TAWS installations. (The Federal Aviation Administration in the US had a similar implementation difficulties and consequently delayed theirs until March 2005.) CASA extended Australia’s TAWS deadline to July 1, 2005 for all affected aircraft. More than 80 air operators, domestic and international, complied with the 1 July deadline. Only 3 did not have the equipment fitted in time and their passenger-car- rying operations were constrained. CASA did not allow any exemptions and for good reasons: TAWS substantially reduces the risk of CFIT accidents; affected operators had been given five years to comply, and to relax the rule now would have been unfair on the many operators who did install TAWS and train their crews on time. type already on their Air Operators Certificate (AOC) without the need to apply to CASA for a variation to their AOC. The enhanced operational flexibility reduces processing time without affecting safety. Operators wishing to add a new type (for example Cessna 402) of aircraft are still required to apply to CASA to vary their AOC. Existing requirements for the provision of appropriate operating information, pilot training and recording of maintenance control information for each model are retained, and are further detailed in the CAO amendment. For further information call the CASA Service Centre on 136773. ing Australian flight crew, in line with the licensing requirements of other transport sectors. Since they were introduced in July 2004 CASA has issued over 6000 photo licences, and staff in the Authority’s central office have been working overtime to process the large number of applications received from existing licence holders as well as from new licence applicants. Applicants for photo licences should expect to collect them from their local post office as CASA is sending all new licences by registered mail. In the envelope will be two documents: • A new flight crew licence, perpetually valid unless cancelled or suspended; and • A laminated aviation photo identification card, valid for 5 years. The licence must be signed by the pilot, and both documents carried when exercising flight crew privileges. If pilots change their address or have an additional licence or rating issued, they will receive an updated licence but not a new photo ID card. Application forms for photo licences are available on the CASA website at casa.gov. au/fcl/photo/ by e-mailing photoid@casa. gov.au or by writing to Photo ID, CASA, GPO Box 2005, Canberra, ACT 2601. Apply now for your photo licence Pilots who want to fly after December 31, 2005, you need to apply soon for your photo ID. All flight crew and special pilot licence holders will be required to carry new photo identification licences when flying after December 31, 2005. Photo licences have been introduced to provide a more secure means of identify- Terrain monitoring A radar altimeter is the simplest terrain monitoring device. GPWS offers an improvement by using a combination of radar and aircraft monitoring systems to tell pilots when the aircraft might collide with the ground. TAWS offers higher protection for passengers and flight crew by predictively matching aircraft position with a terrain database to give an earlier warning. EGPWS is the product name for a TAWS system manufactured by AlliedSignal (Honeywell). FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 65 SHORT FINAL Is GA in fatal decline? A wide ranging review of activity in general aviation provides some answers. I f you were to take note of the views of some commentators on the state of general aviation (GA) in Australia, you would be forgiven for thinking that nonairline activity in this country is going down the tube in a hurry. Parts of the specialist media regularly bemoan the state of GA, and complaints about the state of GA are heard often at aerodromes across the country. But is GA really undergoing a dramatic decline? A newly released profile of GA activity by the Bureau of Transport and Regional Economics (BTRE), a Commonwealth Government agency within the Department of Transport and Regional Services, outlines some facts. BTRE report number 111, General Aviation: An Industry Overview, was released in April this year. The Bureau’s last major report on GA activity was released in 1996. The report first sets out the current state of GA, then moves to analyses of trends since the mid-1990s. The study considers both VH-registered aircraft and sport aircraft, including ultralights, gliders and hang gliders. Commercial: The report found that hire and reward – or commercial – GA makes up about two-thirds of general aviation flying hours. In 2004 there were 715 active operators, employing about 4700 people and turning over $1.05 billion on relatively low operating margins. GA businesses earned around $70 m in exports in 2003-04. The BTRE research revealed modest growth in activity in the commercial GA sector between 1993 and 2002, with total hours increasing over the period by 3 per cent. Aggregate charter flying hours have grown by 9 per cent over the decade; however, charter hours in fixed wing aircraft grew by only 0.2 per cent, while rotary wing charter hours jumped by 67 per cent. Flight training hours in VH-registered aircraft have followed a relatively level trend over the decade to 2003. Underlying this, there was 12 per cent growth in rotary wing training hours, and a 5 per cent fall in 12000 10000 Aircraft 8000 6000 4000 2000 0 1993 1998 2003 Aircraft engaged in private flying 1993–2003 66 FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 Gliders Hang Gliders Ultralights VH Amateur built VH Production fixed wing training hours. The report showed aerial agriculture hours increased over the first half of the decade to 2003, and then declined, possibly reflecting farm product trends and the drought. Recreational and private business: Private business and recreational flying makes up the other 35 per cent of flying hours in GA (680,000 hours). Overall, the BTRE found a small decline in recreational and private business flying between 1993 and 2003, with total private flying hours falling by 2 per cent. Sport aircraft flying hours rose 52 per cent, while private business and recreational flying decreased 20 per cent. Growth areas over the past decade include: •Home-built aircraft flew an additional 3,000 hours, a 116 per cent increase. •Flying hours by type-certified, rotary wing aircraft rose by 8600 hours, up 131 per cent. •An additional 38,500 hours was flown by hang gliders – a rise of 45 per cent. Change drivers: Despite some areas of growth – and some notable declines – the BTRE report concludes that over the past decade, “… general aviation activity trends have been flat.” The BTRE report says that the key drivers of change in GA are rising costs and increased competition. Overall the number of aircraft operating is rising, albeit slowly, as the accompanying table from the BTRE shows. You can download a copy of the BTRE report at www.btre.gov.au/publications.aspx. NOTICE TO ALL AIR OPERATOR CERTIFICATE CERTIFICATE OF APPROVAL LICENCE AND AIRCRAFT REGISTRATION HOLDERS Do you plan to renew, make changes to, or apply for an Air Operator’s Certificate, Certificate of Approval, Licence or Aircraft Registration during September? If the answer to this question is yes then please ensure your application is made BEFORE SEPTEMBER. The Civil Aviation Safety Authority is upgrading its aviation database system during September and only urgent matters will be dealt with during this month. From October the new system will be in place and business will resume as normal. For further information please visit our website at: www.casa.gov.au/airs WHAT WENT WRONG Knowledge is vital. RGM/QBE30779 Getting to grips with emergency gear extension, International Comanche Society proficiency program. # Chuck Yeagher attributes his survival in the world of flight testing to an obsession with understanding aircraft systems before he flew each type. Maintenance: Use a LAME who knows and understands your aircraft. Differences are often subtle but it only takes a subtle oversight to cause a problem. QBE Aviation believes knowledge and proficiency are vital for safety. That's why we support type clubs and the training they offer. You can never know too much! Publications: Comprehensive publications supplying more information than aircraft manuals are usually available. Get them and study them. Endorsements: Find somebody who really knows the type. You'll gain far more knowledge and avoid mistakes. Proficiency: Join a type club to find out more about all these matters - they are a great source of knowledge and referral. Contact details for you and your broker: NSW Ph: (02) 9299 2877 VIC & Head Office Ph: (03) 8602 9900 Queensland SA, WA, NT Tasmania Print Post Approved 381677-00644 If undeliverable please return to: CASA Address Update GPO Box 2005, Canberra, ACT, 2601 AUSTRALIA Ph: (07) 3871 3941 Ph: (08) 8331 7827 Ph: (03) 6229 6576 A Division of QBE Insurance (Australia) Limited ABN 78 003 191 035 SURFACE MAIL Fill out the details below and post in an envelope (no stamp required) to: CASA Address Update Reply Paid 2005 Canberra ACT 2601, Australia ARN/Licence no. The details provided will update your contact information held by CASA. For inquiries telephone 131 757 Name Postal Address Town/Suburb Residential Address Town/Suburb State/Country Phone (bh) ( Fax ( ) POSTAGE PAID AUSTRALIA Postcode ) Phone (ah) ( ) Mobile Email Your signature (or authorised agent) required Date FLIGHT SAFETY AUSTRALIA JULY-AUGUST 2005 68