jul-aug05 - Civil Aviation Safety Authority

Transcription

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 safeskies@bigpond.com
www.safeskiesaustralia.org
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what went wrong
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High achiever: Award winner
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Evacuate: Speed saves
44
CASA CONTACTS
COVER STORY
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Bolt from the blue: Lightning strikes
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48
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Channel squeeze: Radio requirements
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email brisbaneairlines@casa.gov.au
51
FIELD offices
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ph 08 8422 2904 fax 08 8422 2900
email central@casa.gov.au
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 nt@casa.gov.au
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 northqld@casa.gov.au
South Queensland Area
Brisbane Office
39 Navigator Place Hendra QLD 4011
ph 07 3632 4051 fax 07 3632 4060
email southqld@casa.gov.au
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 nswcountry@casa.gov.au
Sydney Basin Area
Building 628 Airport Avenue
Bankstown Airport
ph 02 9870 3007 fax 02 9780 3045
email sydneybasin@casa.gov.au
Vic/Tas Area
19 Second Avenue
Moorabbin Airport Mentone Vic 3194
ph 03 9518 2751 fax 03 9518 2792
email victasmail@casa.gov.au
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:
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Phn: 07 5485 3016
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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-
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
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.
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 training@aerosafe.com.au
(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
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(Aviation Management) Graduate Certificate –
Aviation Safety and Risk Management
If you’re in the aviation industry but need a challenge,
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research that build on your personal and professional
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For more information contact: Margaret Tein, program
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14
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
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 info@attops.com, 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
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.
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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
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
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
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 ;& " - "
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
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.
25
what
went wrong?
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author $1,000. Runners up win $500 each.
could win you
and help others learn
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Articles should be between 600 and 2000 words. If required the author’s
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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.
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]”
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?
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.
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
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
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.
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
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
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
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
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
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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
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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,
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have often degraded
flight safety. Therefore,
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to
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the TCAS RA should be followed.
John Law is Mode S and ACAS program
manager, Eurocontrol.
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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
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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
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
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.
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
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
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
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
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
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
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
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
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
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
AD/B727/149 - Elevator Rear Spar - 2 - CANCELLED
AD/B737/238 Amdt 1 - Digital Transient Suppression Units
AD/B737/244 - Engine Strut Seal
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
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
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
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
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
AD/B717/5 Amdt 2 - Spoiler Hold-Down Actuator Supports
AD/B717/17 - Brake Fuses
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
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
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
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.
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
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
✓
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
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56
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).
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.
(a) Sector 1 only.
(b) Sector 2 only.
(c) Sector 2 or 3.
(d) Sector 1 or 3.
(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.
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-
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: fsa@casa.gov.au 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.
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: atsbinfo@atsb.gov.au
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. ■
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. ■
61
Risks associated with aerial
campaign management:
Safety briefs
••••••••••••••••••••••••
••••••••••••••••••••••••
R22 clutch shaft failure
Fatal training flight at Bankstown
Collision with ground
Occurrence 200501655 – Preliminary Report
Occurrence 200304589
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
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
Seaplane rollover on takeoff
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. ■
63
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
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).
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
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
)
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)
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Your signature (or authorised agent) required
Date
68

jul-aug05 - Civil Aviation Safety Authority

Transcription

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