86

May–June 2012
Rotary revolution | helicopter safety
If wings could talk | new monitoring systems
 2012

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 CONTENTS
Issue 86 | May–June 2012

IBI TED
PROH

08 23 46 DANGinEthReOTeUrriStory
a way of life

FEATURES REGULARS
08 Rotary revolution 02 Flight bytes
Helicopter safety is more than Aviation safety news
just rules and regulations
16 ATC Notes
20 Pad not paper News from Airservices Australia
Electronic flight bags
18 Accident reports
58 23 Prohibited, restricted, 18 International accidents
dangerous 19 Australian accidents
Military restricted areas
31 Airworthiness section
26 Exhausted at home 34 SDRs
Avoid compromising your 39 Directives
fuel reserves
46 Close calls
29 Introducing the 46 How slow can that baby go?
prototype matrix tool 48 Aerobatic assumption
Online help for owners and 50 Disciplined to the end
operators of ageing aircraft
52 ATSB supplement
30 Heavy metal balancing act News from the Australian Transport
Ground handling safety Safety Bureau

31 If wings could talk 66 Av Quiz

New electronic systems tell all Flying ops | Maintenance
IFR operations
40 Keep your boots on 70 Calendar
One of these days these boots
are going to ... Upcoming events for May – September

44 Sharing the sky ... trikes 71 Quiz answers

Part two in this series 72 Coming next issue
58 Severe gradient: deep stall Product review
A violent temper outburst in a New ADS-B booklet
crew room precedes disaster

63 The enemy within

Dangerous goods in the cabin
02
FLIGHT BYTES
Aviation safety news

FLIGHT BYTES
Director of Aviation Safety, CASA | John F McCormick
Manager Safety Promotion | Gail Sambidge-Mitchell
Editor, Flight Safety Australia | Margo Marchbank
Writer, Flight Safety Australia | Robert Wilson
FAA’s 1500-hour rule Sub-editor, Flight Safety Australia | Joanna Pagan
The United States Federal Aviation Administration (FAA) has Designer, Flight Safety Australia | Fiona Scheidel
announced a proposal to substantially raise the qualification
ADVERTISING SALES
requirements for first officers who fly for U.S. passenger and Phone 131 757 | Email [email protected]
cargo airlines. Advertising appearing in Flight Safety Australia does not imply
endorsement by the Civil Aviation Safety Authority.
The proposed rule would require first officers to hold an airline
transport pilot (ATP) certificate, requiring 1500 hours of pilot CORRESPONDENCE
flight time. Currently, first officers are required to have only Flight Safety Australia GPO Box 2005 Canberra ACT 2601
a commercial pilots certificate, which requires 250 hours of Phone 131 757 | Fax 02 6217 1950 | Email [email protected]
Web www.casa.gov.au
flight time. The proposal would also require first officers to
have an aircraft type rating. CHANGE OF ADDRESS
To change your address online, go to www.casa.gov.au/change
The Senate subcommittee on aviation operations, safety and For address change enquiries, call CASA on 1300 737 032.
security is taking submissions on the proposal. Flight Safety
Foundation president and CEO, Bill Voss, called for a revision to DISTRIBUTION
the 1500-hour rule when he testified in March. Bi-monthly to 89,730* aviation licence holders, cabin crew and
industry personnel in Australia and internationally.
‘Unquestionably, Congress and victims’ loved ones had their
hearts and minds in the right place when they urged a hard- CONTRIBUTIONS
and-fast 1500 hour requirement for new commercial pilots, Stories and photos are welcome. Please discuss your ideas
with editorial staff before submission. Note that CASA cannot
but from the outset the Foundation expressed concern that
accept responsibility for unsolicited material. All efforts are made
simplistic hour requirements placed an undue focus on the to ensure that the correct copyright notice accompanies each
quantity, not quality, of flight training,’ Voss said. published photograph. If you believe any to be in error, please
notify us at [email protected]
‘If a flight crew needs to have a specific skill set, steps should
be taken to ensure the knowledge is obtained through training NOTICE ON ADVERTISING
or previous experience. Mandating an arbitrary number The views expressed in this publication are those of the authors,
and do not necessarily represent the views of the Civil Aviation
of hours makes the dangerous assumption that specific
Safety Authority.
knowledge will be obtained simply by hours in the air. This
Warning: This educational publication does not replace ERSA,
leaves too much to chance. I am glad to see the FAA and AIP, airworthiness regulatory documents, manufacturers’ advice,
industry adding some real substance to the new rule that goes or NOTAMs. Operational information in Flight Safety Australia
beyond hours.’ should only be used in conjunction with current operational
documents. Information contained herein is subject to change.
Voss also raised concerns about the impact these new rules
would have on international carriers. ‘For the first time, the FAA Copyright for the ATSB and ATC supplements rests with the
will promulgate a rule that the rest of the world will not able to Australian Transport Safety Bureau and Airservices Australia
respectively – these supplements are written, edited and designed
follow,’ he noted in reference to the requirement for an ATP for independently of CASA. All requests for permission to reproduce
the second-in-command. any articles should be directed to FSA editorial.

Source: FAA and FSF media releases

© Copyright 2012, Civil Aviation Safety Authority Australia.

Registered–Print Post: 381667-00644.

Printed by IPMG (Independent Print Media Group)
ISSN 1325-5002.

*latest Australian Circulation Audit Bureau figures Sept 2011

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 03
Flight Safety Australia
Issue 86 May–June 2012

Part 145 deadline

Mark 26 June 2013 in your diary if you administer an
organisation that maintains regular public transport (RPT)
aircraft and aeronautical products.
It is the day when organisations maintaining RPT aircraft and
aeronautical products will need to gain a Part 145 approved
maintenance organisation approval under CASA’s new suite
of maintenance regulations. It is also the day when all RPT air
operator’s certificate holders will need to gain a continuing It was the first time an unmanned aircraft as large as Ikhana—
airworthiness management organisation (CAMO) approval and with a 20m wingspan, a take-off weight of more than 4500kg,
all remaining CAR30 aircraft maintenance organisations (AMO) and a cruising altitude of 40,000ft—has flown while equipped
providing maintenance training and examination services will with ADS-B. In the U.S. the FAA will require all aircraft operating
need to gain a Part 147 maintenance training organisation in certain airspace to adopt this technology by January 2020.
(MTO) certificate.
Being equipped with ADS-B enables NASA’s Ikhana to provide
much more detailed position, velocity, and altitude information
UAS + ADS-B = NASA
about itself to ATC, airborne pilots of other ADS-B-equipped
NASA’s Dryden Flight Research Centre flew its Ikhana MQ-9 aircraft flying in its vicinity, and its pilots on the ground.
unmanned aircraft with automatic dependent surveillance-
Source: NASA media release
broadcast (ADS-B), for the first time on 15 March 2012.

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04
FLIGHT BYTES
Aviation safety news

Large CTAFs become broadcast areas In order to introduce standard procedures when operating
in these areas, the existing large areas defined by lateral
Changes to Australian CTAFs made in early 2006 removed boundaries will be converted to broadcast areas under
their airspace volume aspect and replaced it with non-towered CAR 99A (1) (b).
procedures, where the CTAF simply became the common
traffic advisory frequency. Additionally, it is proposed to apply an upper level to these
laterally defined areas to:
The many large-area CTAFs and MBZs around Australia not
associated with a particular aerodrome or landing site were • the base of CTA or 5000ft, whichever is the lower, or
also removed, generating a need for special procedures to be • 8500ft if the area lies below low-level Class E airspace.
developed. The result was a large un-named laterally defined The label will be amended to read ‘For operations in this area
area, with an associated label: For operations at aerodromes SFC - <altitude> use CTAF <frequency>‘
and landing sites in this area use CTAF <frequency>.
• The defined boundary removes ambiguity as to when the
These areas quickly became known as ‘large CTAFs’. frequency change to CTAF should occur
Operations at non-towered aerodromes are still widely • The vertical limit creates an airspace volume, removing
referred to as ‘CTAF procedures’ when ‘operating in a CTAF’. another area of ambiguity
The term ‘CTAF frequency’ is also common currency • This standardises frequency management procedures

and, unfortunately, these terms can still even be found in
• It formalises procedures already being widely employed
operational documentation.
• It does not introduce significantly new procedures
This misconception is exacerbated by ‘large CTAFs’. The fact
• Broadcast areas have been employed at Lake Eyre and
that lateral boundaries are marked on charts gives rise to
at Avalon to overcome specific frequency management
the perception that they define frequency (or even airspace)
issues.
areas, creating frequency management issues. The changes are expected to come into effect on the
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 05
Flight Safety Australia
Issue 86 May–June 2012

Flying Training Panel The panel has also discussed instructor mentoring at length,
and the Air Force is providing some assistance with this.
The industry-chaired Flying Training Panel, set up to provide Sean Bellinger and John Douglas gave presentations on the
strategic direction to CASA on flying training and checking, different ways in which the RAAF and the Royal Aero Club
has been meeting quarterly for the last seven years. The panel of WA approach mentoring. It is hoped CASA can develop
consists of Sally Scott (chair) representing northern Australia some programs to assist small and large schools to encourage
and smaller schools; Terry Summer, the helicopter industry; instructor mentoring.
Professor Paul Bates, Griffith University; WGCDR Sean
Bellinger, RAAF; John Douglas, WA, representing larger Further meetings will be held in May, August and November
flying schools; and Matthew Anderson, executive charter. 2012.
In the next few months, a representative from the heavy airline
area will replace the panel’s previous chair, Ken Broomhead, New test for laser-dazzled pilots
who served for five years. CASA members are Roger Weeks, The UK CAA has developed a self-assessment tool for flight
Ian Ogilvie and John Grima. crew, to determine the likelihood and level of eye damage
The last meeting, in February, covered the review of the final following a laser attack on their aircraft. The Aviation Laser
draft of the instructor rating CAAP, among others. Helicopter Exposure Self-Assessment tool is available free of charge
industry safety has also been an ongoing focus, in a bid to online from www.caa.co.uk/medical as a downloadable file
reduce the industry’s accident rate. Terry Summers, who is that pilots can print and use. Hard copy cards will also be
with the Flight Safety Foundation’s helicopter section, has been available. The basis of the test is a 10cm² grid that, when
advising CASA on ways in which the safety of helicopter flying viewed from 30cm away, can be used to detect whether a
training can be improved. This has flowed through to Part 61, laser attack has affected a pilot’s vision.
currently in the final stages of development. Source: UK CAA
06
FLIGHT BYTES
Aviation safety news

ICAO considers lithium battery questions After the Dubai incident, Transport Canada, the US Federal
Aviation Administration and the UK Civil Aviation Authority
The International Civil Aviation Organization is to consider new analysed the likelihood of further fire accidents to US-
safety standards for air transport of lithium batteries in the registered aircraft. The assessment predicted six accidents,
wake of increased concern over the potential for in-flight fires. at least four battery-related, in the 10 years to 2020.
Following a meeting in Montreal in February, the organisation’s The model also suggested that, in an extreme case, there
dangerous goods panel has put forward recommendations could be as many as a dozen accidents.
that large shipments of batteries be treated and labelled However, during the Montreal meeting the Rechargeable
as dangerous, and that shippers be trained to prepare them Battery Association rejected the analysis as ‘flawed’ and based
correctly. on ‘faulty data and assumptions’.
The standards also involve airlines performing acceptance The Air Line Pilots Association International (ALPA), and the
checks and pre-loading inspections, while pilots would be International Federation of Air Line Pilots’ Associations have
notified of the location of any battery shipment on board backed the tighter regulations.
an aircraft.
Source: Flight Global
Such provisions, if approved, would come into effect from the
beginning of 2013. http://www.flightglobal.com/news/articles/icao-to-
consider-new-safety-standards-for-air-transport-of-lithium-
The transport of lithium batteries has been a discussion batteries-368651/
point for several years, but the loss of two Boeing 747-400
freighters—a UPS jet in Dubai and an Asiana aircraft near
Jeju—to in-flight fire in the space of 10 months has intensified
the debate, as both were carrying batteries.
 07
Flight Safety Australia
Issue 86 May–June 2012

Group promotes cabin safety CAA launches safety campaign for electric
mobility aids
The Asia Pacific Cabin Safety Working Group is a forum
for cabin safety professionals in the region to share their After several safety incidents over recent years involving
knowledge and experience. electric mobility aids the United Kingdom Civil Aviation
Authority (CAA) has launched an industry-wide campaign
The group meets three times a year, mainly in Australia, but
to highlight the safety requirements and obligations for the
sometimes in New Zealand, and all cabin crew members,
preparation and loading of electric mobility aids, including
trainers, safety officers and safety investigators are welcome
wheelchairs and scooters, onto passenger aircraft.
to attend and/or give presentations.
In 2008 an electric mobility aid caught fire as it was
At the most recent meeting, at Aviation Australia in Brisbane,
being unloaded at Manchester Airport. From subsequent
over 50 attendees, from Australia, New Zealand, Nauru and the
investigations, it appeared that the device’s electrical circuits
Solomons, heard informative talks on topics including SMS
had not been protected from inadvertent operation prior to
in the cabin, crew welfare on layovers, turbulence, managing
loading. Loose baggage probably nudged the control joystick
fatigue, and aviation rescue firefighting, with time for open
and engaged the motor, which eventually ignited. The CAA has
discussion, networking and research and development.
since received numerous other reports of similar incidents.
For more information visit http://www.asasi.org/apcswg/
As part of its campaign the CAA has produced a training video
newindex.htm
that runs through each step of the process – from booking the
flight, to checking in, to loading an electric mobility aid into the
aircraft hold. The video, ‘One Team, One Goal,’ is available free
of charge and copyright free at www.youtube.com/UK_CAA
Source: UK CAA

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08
FEATURE
Helicopter safety

Rotary revolution
New regulations Mastering the constantly interacting controls of There would also be a strong focus on operators
any helicopter is widely acknowledged as both establishing procedures, training and recency
promise to
a challenge and an achievement. Those who do requirements that are most appropriate to the
broaden the it for a living are justly proud of their skill and circumstances and complexity of their operations.
focus of helicopter judgement. But the next phase of helicopter safety
Helicopters involved in aerial work would have a
safety to look goes beyond mastering the sorcery of cyclic and
dedicated set of operational regulations under the
at operational collective: it considers the safety of the helicopter
proposed new CASR Part 138, due to be finalised
operation as a whole.
and organisational in 2013.
standards. Civil Aviation Safety Regulation Part 133 is the
But sections of the helicopter business are already
Some helicopter proposed new rulebook on commercial helicopter
operating in a stringent new environment of
air transport operations, scheduled to be finalised
operators are at the end of this year.
safety management systems, constant oversight
already flying in and multiple safety audits. Generally they are
It proposes a single standard for air transport not complaining because they are making more
this new world.
operations, whether unscheduled or scheduled— money, flying more hours and operating more
Flight Safety so that there will no longer be different safety safely than they used to. These operators work
Australia speaks and operational standards for charter and regular in varied fields, but have several characteristics
to some of them. passenger transport operations. (This change is in common.
also proposed for fixed wing operations under the
proposed CASA operations regulations Parts 135 Commitment to safety management
and 121.)
Former navy helicopter pilot and instructor, Mark
Part 133 helicopter operators would require Ogden, manages aviation operations for oil
certification under CASR Part 119, which has exploration and production company, Oil Search.
several specific requirements such as: He says the resource industry requires operators
to have robust safety management systems.
1. operational risk management under
‘The rules don’t require it in Australia yet, but
a safety management system
the resource industry is stepping ahead of the
2. fatigue management requirements regulations,’ Ogden says.
for flight crew and other personnel
Ogden is a convert to SMS. ‘It is an integral
3. recurrent training and checking of part of ensuring your processes are correct,’ he
flight crews under the operator’s says. ‘For example: if you have implemented an
training and checking system either SMS the issue of fuel standards should look after
in-house or provided by an arrangement itself, almost.
with a Part 142 certified training and
checking provider. However, SMS requires operators to pay attention
to the fine print—which not all do. As a manager of
Under Part 133, helicopter operators would also
aviation contracts this is one of Ogden’s bugbears.
have to establish safety-based outcomes for
‘Individual resource companies have their own
overwater flights and the equipment requirements
standards and expectations which they write into
for such operations.
the contract. What I often find is that the aviation
 09
Flight Safety Australia
Issue 86 May–June 2012

company doesn’t address those requirements in the The work demands extreme precision, not just
contract. There are standards that they are expected in flying, but also in operational planning and
to conform with but they’re not referenced in crew cooperation.
the operator’s documentation—or in practice,’
High voltage power transmission lines create
Ogden says.
electric fields, which can cause arcing with any
Ogden understands that writing SMS documentation object that comes close to them. Aeropower
may be too much for a small aviation contractor calculates the strength of these fields for every
to do. But they should, at least read any externally powerline flight. The helicopter must not approach
produced operations manual,’ he says. closer than this minimum distance before
the lineworker has bonded to the wire (known
‘I’ve audited companies and said; “your ops
as a phase in the electrical industry) with a
manual says you do this; do you?” and they say
conducting stick.
“Oh”. They don’t even know what’s in their ops
manual because they didn’t write it. David Salmon, Aeropower’s general manager,
says the company works to both aviation safety
I have no problem with that so long as the company
best practice and the standards required by
for whom it’s written is intimately involved with
the electric power industry. ‘Electrical industry
its writing.’
standards are exacting because accidents with
Aeropower is an Australian airborne electrical high voltage electricity are usually fatal,’ he says.
contractor that specialises in airborne maintenance ‘The systems, procedures and standards of the
for the electrical industry. Its work includes powerline electrical industry are accepted as what you have
patrol, inspection, construction, stringing, insulator to have.’ Photo: Aeropower
washing and live-line maintenance. Live-line
Alex Schuttloffel, Aeropower’s chief pilot says: ‘we
maintenance on powerlines carrying up to 1000
are an electrical company that just happens to be
kilovolts is done either hot stick—with an insulating
airborne. We are governed by the high standards
‘If you’ve got
stick—or bare hand, where the lineworker touches procedures and
of the electrical industry and of aviation.’
the line. In bare-hand work, the lineworker and
the helicopter are instantly charged with the line’s ‘Every simple task we do has a massive job
methods you’re
electrical potential, but do not get an electric shock pack attached. For every hour of operations we going to have fewer
because they are not grounded. This is the same do, there’s probably a week’s work. It has to be accidents because
reason that birds are able to perch on high voltage that way so we all know the work instructions you have a safer
powerlines; however, both pilot and lineworker have backwards and forwards.’ work culture. And
to wear conductive mesh Faraday suits to equalise
the electric potential over their bodies.
‘When we deal with other companies in the aviation that saves you
industry and we show them our risk assessment money. An accident
Aeropower is one of the top ten companies or AutoCAD, their response is “you guys have so
costs millions;
worldwide specialising in this exacting form of much paperwork!”’
aerial work. compliance is an
Salmon says a safety management system is the
issue of $300,000
key to making operations near live power lines
acceptably safe. a year.’
10
FEATURE
Helicopter safety

Aeropower has had an SMS in operation are five or 10, and many of them casual pilots,
since 2010, although Salmon says the how do you make sure information is getting to
company had adopted many SMS practices them? How do you make sure they’re complying
years earlier. with procedures, and how do you make sure they
are reporting to you?’ he says.
I’m convinced it saves dollars,’ Salmon says. ‘If
you’ve got procedures and methods you’re going
to have fewer accidents because you have a
Airworthiness, maintenance and the
safer work culture. And that saves you money. An cost of doing business
accident costs millions; compliance is an issue of The fastest way to provoke indignation, and
$300,000 a year.’ possibly indigestion, in a serious, professional
There are other, non-quantifiable costs of helicopter pilot is to raise the subject of cost
accidents, Salmon says. ‘We’ve found in the cutting. The running costs of all current helicopter
industry that it takes along time to be accepted; types are well established and easily discovered.
an accident or incident would put us back to Yet aviation users continue to beat contracts down
square one.’ to price levels incompatible with profit or safety.
The lowest figure mentioned to Flight Safety
Kevin and Sandy Clark operate MI Helicopters out Australia was $130 an hour offered by a rogue
of Roma, in central Queensland. The company (and now out of business) Robinson R22 operator.
provides helicopter services to companies and
government agencies working in the coal seam Ill-informed and stingy clients can become the weak
gas area of the Surat basin. link in aviation safety operators say. ‘Government
Photo: Aeropower
agencies are the worst,’ MI Helicopters’ Sandy
MI Helicopters has had an SMS up and running Clark says.
since 2010. Kevin Clark said it was a necessary
response to the continual auditing that came with ‘They don’t seem to realise that helicopters
An SMS isn’t just working for the resources industry. ‘We get six cost money to maintain. But you have to do it.
about safety: done external audits a year from all our clients; it means Maintenance is important as you have lives up in
we’re continually raising the bar,’ he says. the air and a business to run.’
correctly, it will
help your business Adopting an SMS brought a change of attitude, Aeropower general manager, David Salmon, says
Clark explains. ‘There’s no more “she’ll be right”. ‘I’ve lost contracts for $50 an hour to operators
because you’ll
Now we feel that we’re not quite where we want to who have fewer crew members: only a pilot
understand what and linesman, no observer. There’s a difference
be with safety, but we’re working on it. The SMS
you’re doing and the is a living document, and we are improving and emerging between power transmission, which is
risks being faced.’ adding to it on a daily basis.’ the high voltage sector, and power distribution,
which is low voltage local lines.’
An often-heard query about SMS is how its web
of structures and responsibilities can be scaled to Of one government client Kevin Clark said: ‘They
be manageable by a small aviation organisation. only want to fly in an (Robinson) R44, but then
Ogden says the best small operators are already they want to load it up. The R44’s a good machine
implementing many SMS principles informally. – if you only put two people in it.’ Other resources
He sees scaling up as a greater challenge than industry clients allow MI (which runs an R44, Bell
scaling down. Jet Ranger, Long Ranger and AS350 Squirrel) to
decide what machine it uses for a contract.
‘When there’s only one pilot, telling himself what
they’re supposed to be doing is easy: when there
 11
Flight Safety Australia
Issue 86 May–June 2012

As well as bidding rates down, ill-informed ‘I find an operator will focus on an incident and
clients—or as happens more frequently now, their fix that incident rather than look to see if it is
brokers—can become a weak link in aviation safety. symptomatic of a bigger problem, Ogden says.
A common theme was that government aviation You have to focus on the big picture – for example
buyers did not comprehend safety innovations, such if a helicopter lost a sling load the easy thing would
as the Spidertracks, real-time flight tracking system be to say “pilot error”, but more thoroughly, you
used by MI, and the Air Maestro operations software might look at the pilot’s hours over the preceding
used by both Aeropower and MI. ‘They simply don’t week, and what types those were on, and where
read contracts,’ Salmon says. the sling release controls were, or even the design
of the sling release switching.
An aviation services broker recently announced
to Sandy Clark that the client was dividing the ‘That’s the big change in the industry now—the
aviation contract into several areas to be serviced resource companies themselves have a strong
by separate companies—in one stroke ending MI’s safety emphasis. It’s systems based, and they
history of flight data collection on the tender. expect their contractors to be systems based
as well.’
Ogden is always wary of apparent helicopter service
bargains. ‘When a price is too low my first question Kevin Clark found engaging with the resources
is “what’s not being done?” Nine times out of 10 it’s industry after years spent running a mustering
maintenance,’ he says. business in the Channel country and tourist
helicopter business on the Fraser coast meant
‘You have to recognise that an operator has to make
looking at safety in its broadest sense.
a profit—and that profit has to take into account the
future company investment in equipment. ‘The first thing we did was employ a dedicated
quality assurance and safety manager and worked
However, Ogden is convinced many helicopter
through the industry’s requirements for onshore
operators do not know what it costs to operate their
operations. That’s the thing; safety culture takes
equipment. ‘They confuse cash flow with profit,’
time, it doesn’t happen overnight.’
he argues.
Clark says MI’s administrative workers are
In aviation, business knowledge is part of safety
members of the safety team: ‘they refuel the
knowledge,’ Ogden says. ‘An SMS isn’t just about
aircraft, do all the job bookings and liaise with
safety: done correctly, it will help your business
clients—it takes the load off the pilot and lets them
because you’ll understand what you’re doing and
focus on what their main job is.’
the risks being faced.’
‘If you have someone in a room, speaking to a
The systematic approach: thinking client and doing the organisational work that takes
beyond the pilot’s seat load off a pilot. The alternative is up to three hours
paperwork after a day flying—it eats into their rest
Ogden sees a tendency in many aviation suppliers to time, which over time, adds to their fatigue.’
develop their safety practices by reacting to accidents
and incidents. This is good, and necessary, he says, The payoff for simplifying pilots’ lives came during
but not sufficient. Often the reaction focuses only on this year’s Queensland floods.
a few immediate causes of the event. The frantic pace of flood relief flying tested MI’s
safety systems, Clark says.
Photo: Aeropower
12
FEATURE
Helicopter safety

As days turned into weeks he came to appreciate The importance of mentoring

some of the safety practices of his resources and training
industry clients.
Alex Schuttloffel of Aeropower maintains ruthlessly
‘Sometimes I think they’re over the top, but they’ve high standards. ‘If you have a pool of pilots,
got some very good ideas. They’ve got a system those capable of safely flying powerline patrols
where you step back. You get to a job, but you would be 10-12 per cent of that pool. Powerline
never rush. You step back and look at the entire electrical work would be one to two per cent of
scene—you end up saying, “there’s my hazard”.’ the total pool, if that. The only way for Aeropower
One afternoon, observing the bustle of refuelling to maintain a pool of pilots is for the company to
operations after a long day of flying evacuations develop them itself. This it does with an ab-initio
and supplies, it occurred to Kevin Clark that it was flying school, run as much to identify suitable
a good time to step back. pilots as to generate cash flow.

‘The pressure wasn’t on so much, and I said, “let’s ‘Mentoring is the key to developing good pilot,’
take a step back everybody. Shut down when you Schuttloffel says. ‘It is the majority of my job.’
refuel—just walk around and clear your head”.’ He looks for a few key factors in a pilot. ‘It’s
Other operators take an even broader view of somewhat to do with their flying ability, but it’s
what’s safety related. Peter Holstein, chief pilot of massively to do with their command decision
Aerowasp Helicopters, in Camden, NSW, argues ability: their maturity, their outlook and their
that the helicopter industry’s lack of a professional problem-solving skills.
Photo: Mark Ogden association is ultimately an impediment to safety. The only requirement I have of any pilot in a
‘The industry needs a voice—at the moment it’s a company I am running is they must have the
bunch of individuals,’ he says. ability to think more than two minutes ahead of
the aircraft.’
‘We also needs a body as a means of developing
our own policies, … and as a point for the regulator Peter Holstein agrees mentoring is the key. ‘There
to come to, for advice and consultation.’ are so many things that only mentoring can pass
on. You’ll find out by default anyway, but there’s a
Holstein says a well-run professional association
whole pile of stuff you can learn so much quicker
would exploit the expertise of the best pilots
from a combination of your own experience and
and operators by making it available to the
having a more experienced mentor,’ he says.
entire industry.
Ogden describes the chief pilot as the linchpin of
A reputable professional association would also
any helicopter company.
act to ‘level the playing field’ among helicopter
operators, by publishing standards, cost guides ‘They’re the guy, or girl who has to set the standards
and recommended practices. and see that they’re adhered to,’ he says.
They’re the bones who are the link between the
frontline pilots and the management.
As long as the chief pilot is strong and ensures
standards are in place then you can have junior
line pilots.
Photo: Aeropower
 13
Flight Safety Australia
Issue 86 May–June 2012

But chief executives and managing directors have However, Holstein says the unique nature of tourist
a clear responsibility—to support the chief pilot. operations can be its own problem. While short
flights, averaging 12 minutes in some locations
The Australian Transport Safety Bureau’s report
are a good way to clock up plenty of takeoffs,
into the crash of an R44 helicopter at Gunpowder,
approaches and landings, tourist flying can let
near Mt Isa in Queensland in February 2006 had
other skills wither. ‘I heard of a pilot who had 1200
this to say about the importance of mentoring. The
hours, but hadn’t done a navex since he obtained
pilot who died in the accident had fewer than 500
his commercial pilot’s licence. Every day he was
hours experience.
VFR over familiar terrain, and only in good weather,
‘A chief pilot is usually an experienced pilot who is because tourists don’t want to go up on a rainy
able to draw from that experience to anticipate the day. Mentoring is the key.’
risks likely to be present in a particular operation
with regard to the features of the geographic Translational phase: conclusions
area, task-related pilot workload and the expected and prediction
environmental conditions. In tasking relatively
inexperienced pilots, the chief pilot is able to Commercial helicopter safety has been client
facilitate safety by imposing practical limits on driven in recent years. The power and resources
passenger numbers or weight that provides the industries are two successful examples of how the
pilot with a healthy margin of safety.’ industry can meet high safety expectations.

But pilots have to get their hours somehow. Schuttloffel makes a revealing comment. ‘With
As the helicopter industry has developed, this these (resources) organisations, all you hear
Photo: Mark Ogden
is often done through tourism and joyflying. is “zero harm, zero harm”. When we go to BHP
Sydney Harbour, the Gold Coast, Ayers Rock/ and Rio, we see companies that have the same
Uluru and the Twelve Apostles in Victoria are this mindset we do. We sit around the table and talk all
industry’s hotspots. day because we’re on the same level.’ ‘Mentoring is the
The challenge for the rest of the helicopter industry key to developing
Schuttloffel is scathing and says he would probably
not employ a pilot with most of their hours on is to evolve, Ogden says. He sees the move to good pilots,’
tourist flights: ‘there’s no mentoring. That critical systematic safety as the third distinct phase in Schuttloffel says.
stage between 105 and 500 hours will set how the industry’s history. It’s a revolution on par with ‘It is the majority
someone develops as a pilot. Between 500 hours the last major change, when ex-military pilots and
turbine helicopters entered the industry in large
of my job.’
and 1000 hours will confirm them. Either they’ll be
good and getting better, or bad and getting worse.’ numbers after the Vietnam War.

Clark, while happy to no longer be in the tourist ‘The helicopter industry can be its own worst
flying business says it can be a good way to enemy. Images of crashed helicopters are the last
develop low-time pilots—if the supervision is thing the industry needs. It needs to take on the
close. ‘It is a good way of getting pretty easy flying proceduralisation and standardisation that has
that builds confidence without introducing many given airline transport its safety record.
nasty surprises. It’s a controlled environment: ‘This may be anathema to a lot of bush pilots, but
going from A to B at a specified height.’ we will have to proceduralise and standardise the
helicopter industry in order to get the work, and
make it work.’

14
FEATURE
Helicopter safety

In raw terms, flying in a helicopter is less safe than flying in an

aeroplane. Between 2001 and 2010 VH-registered helicopters
in Australia had 456.9 accidents per million flight hours and
56.8 fatal accidents per million flight hours. VH-registered
Helicopter safety is similar and aeroplanes of all types had 292 accidents per million hours
different to aeroplane safety. It has flown and 30.5 fatal accidents per million hours.
its own distinct characteristics, Per flight hour this makes a helicopter occupant 1.56 times
more likely to be in an accident than a person in an aeroplane,
but the same underlying trends.
and 1.86 times more likely to have a fatal accident.
But this draws no distinction between different types of
helicopter flying. As with aeroplanes, there is a hierarchy of
risk. Private flying is the most risky, for both types, followed
by flying training, aerial work and charter. Helicopters have
distinctly higher fatal accident rates in all categories.
In terms of the number of deaths: 13 people were killed in
charter helicopter accidents between 2001 and 2010. This
equates to about 17 fatalities per million hours. Aeroplane
charter accidents killed 30 people the same period, equating
to about 7.6 fatalities per million hours. In terms of the number
of fatal accidents, helicopters had 5.1 per million flight hours;
aeroplanes 3.2.

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 15
Flight Safety Australia
Issue 86 May–June 2012

Some sectors of the helicopter business in these years had a The helicopter area is a fast-growing segment of Australia’s
zero fatal accident rate. Nobody died in a twin-engine helicopter aircraft register, which leads to the perception in some quarters
crash in Australia between 1986 and the 2011 crash at Lake that most of them are new, or low-time aircraft. In fact about
Eyre, which killed the pilot, Gary Ticehurst; television reporter, 39 per cent of the Australian helicopter fleet is more than 20
Paul Lockyer; and camera operator, John Bean. years old. (The oldest are three Bell 47s, made in 1962.)
While it could be grimly argued that helicopter maintenance
However, overall the ATSB found that between 2000 and 2009
has an inverse connection with fleet age—poorly maintained
rotary-wing air transport has a fatal accident rate per million
helicopters almost never become old helicopters—ageing
hours that was about five times higher than fixed-wing air
helicopters raise issues of serviceability of ancillary systems
transport aircraft.
and the lower standards of airworthiness and crashworthiness
An intriguing statistic collected by the European Aviation that applied when they were built.
Safety Agency found 34 per cent of helicopter accidents
happened during en-route flight, and 68 per cent of fatal For more information
helicopter accidents happened in this phase of flight. This
was significantly higher than accidents that occurred while ATSB Aviation Occurrence Statistics 2001-to 2010
hovering (24 per cent). www.atsb.gov.au/media/2485752/ar2011020.pdf

International surveys reveal some structural differences

between the helicopter industry and aeroplane transport.
The International Helicopter Safety Team found 80 per cent
of helicopter operators had fleets of fewer than five aircraft.
Many operated several types, reflecting the relative diversity
of helicopter manufacturing.

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ATC notes

Runway incursions
how you can help prevent them
Runway incursions are a significant safety concern for Airservices and the
broader aviation industry, with over 200 incursions reported last year across the
28 airports with an air traffic control tower.

A
s a member organisation of the Australian ƒ although the number of runway incursions
Runway Safety Group (RSG), Airservices at each airport was highest for local
is committed to reducing risks to operators due to the number of aircraft
aviation in the aerodrome ground environment. movements, the rate of incursions by
One of the key initiatives of the RSG is the transient pilots was also high
implementation of Local Runway Safety Teams
ƒ aerodrome design was identified by
(LRSTs) at all towered airports. LRSTs allow local
pilots as contributory in over 55 per cent
airport operators and representatives to identify,
of incidents
discuss and resolve local runway safety issues
at their particular location and to raise issues to ƒ 43 per cent of pilots were not referring to an
the RSG if they require assistance. aerodrome chart

ƒ many pilots were unfamiliar with airport

Following a runway incursion, Airservices
signage and markings, with quite a few
sends the aircraft operator a survey to gather
believing that the holding point was the
information on pilot experience levels, causal
edge of the sealed surface of the runway
factors and opinions on what can be done to
‑ it will be set back from there
prevent a recurrence. The pilot’s confidentiality
is assured and Airservices only uses this ƒ taxiing across runway undershoots/
information to improve safety outcomes. overshoots or the use of non active runways
as taxiways, featured highly
The response rate for the survey is currently
around 25 per cent. While this rate is low, ƒ several pilots implied that perceived and/
valuable information has been obtained from or real pressure to depart the active runway
pilots which has allowed us to assess current after landing and/or to get to their intended
risk controls and to develop strategies for location on the airfield quickly, contributed
reducing future occurrences. to the incident

ƒ there were several instances where pilots

Analysis of the runway incursions and survey
were confused with their taxi clearance
responses has highlighted the following themes:
(particularly at some of the more complex
ƒ most incursions involve General Aviation airfields, or where amended clearances
aircraft and occur at ex-GAAP airports were provided) but did not seek
confirmation, prior to taxiing.
Tips to avoid runway incursions
ƒ Plan your taxi ƒ A clearance is required to enter, cross
and taxi on any runway (including runway
ƒ Ensure you understand airfield markings,
undershoots and runways not in use)
signs and lights
ƒ Use standard phraseology from AIP
ƒ Use an accurate aerodrome chart for
ground operations ƒ If you are unsure about your clearance, or
your location, immediately check with air
ƒ Unless directed otherwise by ATC,
traffic control
a clearance to land on any runway
authorises you to cross any intersecting For more information on Runway Safety, the
runway during that landing (it does not RSG or LRSTs at your aerodrome, contact
automatically allow you to vacate using an [email protected].
intersecting runway as a taxiway)

Airservices has also developed guides on a range of safety topics on our website at:
www.airservicesaustralia.com/publications/safety-publications
18
Accident reports
International accidents | Australian accidents

International accidents/incidents 30 January – 9 April 2012

Date Aircraft Location Fatalities Damage Description
30 Jan Antonov 28 10km from Namoya, 3 Written off Cargo aircraft (first flight 1989) destroyed after it crashed into a forest
Democratic Republic on approach to Namoya Airstrip. Two of the five occupants apparently
of Congo survived the crash. The manufacturer reported that the airworthiness
certificate of the aircraft had expired on June 12 1993.
9 Feb DHC-6 Twin Male International 0 Substantial Float-equipped passenger aircraft (first flight 1968) sustained damage
Otter 20 Airport, Maldives during a water landing at the sea plane base in heavy rain.
12 Feb Airbus Porto Alegre-Salgado 0 None Passenger aircraft en route from Montevideo to Sao Paulo-Guarulhos
A320-232 Airport, Brazil diverted to Porto Alegre after an ‘unruly’ male passenger entered the
cockpit. It took several people to subdue the 28 year old, who had
apparently suffered a psychotic attack.
12 Feb Grumman Bukavu-Kavamu 4+2 Written off Gulfstream corporate jet failed to stop on the runway after touch down,
G1159C-IV Airport, Congo rolled down an embankment and broke in half. There was no fire but both
pilots, two of the seven passengers and two farmers on the ground were
killed. Photos showed flaps down and both thrust reversers activated.
17 Feb Let L-410UVP Tanay Airfield, 0 Written off The aircraft was on final approach on a training flight when its
Kemerovo, Russia undercarriage hit the cabin of a passing truck, which then collided with
another vehicle on the road. The aircraft made a forced landing and the
occupants were unhurt.
28 Feb Cessna 208B Manaus-Aeroclube 1 Destroyed The aircraft (first flight 1999) failed to gain height after takeoff from the
Grand Caravan Airport, Brazil 860m long runway, collided with a pole and came down in a wooded area
2km west of the airport, killing the pilot, the sole occupant.
1 Mar Cessna 750 4km E of Egelsbach 5 Destroyed The corporate jet (first flight 2003) was on approach when it came down in
Citation X Airport, Germany a wooded area, broke up and burst into flames, killing everyone on board.
7 Mar Boeing 737-522 El Obeid Airport, 0 None Sudan Airways Flight SD413 was en route to Khartoum when a 19-year-
Sudan old passenger broke into the cockpit, threatened the crew with a knife and
ordered the pilot to fly to Uganda. The hijacker was overpowered and the
flight diverted to El Obeid.
8 Mar BAe-3112 Ronaldsway Airport, 0 Substantial Starboard undercarriage of aircraft (first flight 1988) collapsed on landing,
Jetstream 31 Isle of Man, UK causing it to swerve off the side of the runway.
9 Mar DHC-6 Twin Laguna Caballococha, 0 Substantial Float-equipped aircraft (first flight 1971) landed hard in a lagoon.
Otter 300 Peru Right-hand pontoon collapsed and the aircraft sank.
15 Mar Convair CV-340 San Jan-Luis 2 Written off Crew of cargo aircraft (first flight 1953), carrying mainly bread, declared
Muñoz Marin Airport, an emergency shortly after takeoff, saying that smoke was coming from
Puerto Rico one engine. ATC cleared landing, but the aircraft came down in a lagoon to
the east of the airport, and sank in 30-50ft of water.
15 Mar C-13J-30 Mount Kebnekaise, 5 Destroyed Royal Norwegian Air Force transport plane (first flight 2010) on a defence
Hercules Sweden exercise flew into the side of a glacier in cloud and strong wind.
15 Mar Cessna 501 Franklin-Macon 5 Destroyed The corporate jet (first flight 1982) touched down half way down the
Citation I/SP Airport, North runway. The right wing touched the runway and the aircraft rolled over and
Carolina, USA caught fire, killing all its occupants.
29 Mar Fokker 50 Wau Airport, 0 Substantial Passenger aircraft (first flight 1992) suffered a landing accident and its
South Sudan nose gear and LH main gear collapsed. The five crew members sustained
minor injuries. Pilots reportedly had to be aware of a displaced threshold
because a portion of the runway was being covered with tarmac.
2 Apr ATR-72-201 2.5km SW of Tyumen 31 Destroyed Passenger plane (first flight 1992) took off, climbed to 210m and then
Airport, Russia banked to 35° L, followed by a 50° RH bank. It struck a snowy field about
2.5km past the end of the runway, broke up and burst into flames. Both
engines were apparently working properly at the time of the accident but
the aircraft had not been de-iced ‘because the crew did not insist on it’.
The temperature was – 1° Celsius and the dewpoint – 1° Celsius, and
runway conditions were described as ‘wet or water patches, contamination
51 per cent to 100 per cent, deposit less than 1mm deep, friction
coefficient 0.60. One passenger presumed dead was apparently admitted
to intensive care under the wrong name and only identified a week after
the accident.
9 Apr DHC-8-311Q Kigoma Airport, 0 Written off Passenger plane (first flight 1997) suffered substantial damage in a takeoff
Tanzania accident, but there were fortunately no fatalities. The RH wing separated
inboard of the No. 2 engine, which then twisted upside down and to
the side, causing the front of the engine to penetrate the fuselage at the
underwing emergency exit.  
 19
Flight Safety Australia
Issue 86 May–June 2012

Australian accidents/incidents 4 February – 31 March 2012

Date Aircraft Location Injuries Damage Description
4 Feb Robinson R44 II Nowra Aerodrome, Fatal Destroyed Shortly after liftoff, the helicopter was observed to be in a hover at
025° M 19km, NSW about 20-30ft above ground level. Soon after, control of the
helicopter appeared to be lost and it crashed, killing both occupants.
Investigation continuing.
6 Feb Cessna 182P Shute Harbour (ALA), None Substantial During approach, the aircraft ran out of fuel and the pilot made a forced
Skylane W M 2km, Qld landing on a road. After touchdown, the right wing struck the ground and
the aircraft was substantially damaged.
15 Feb Fairchild SA227- Brisbane Aerodrome, None Substantial At 0127 local time, a Fairchild SA227-AT (Metro) aircraft departed from
AT Metroliner Qld Brisbane Airport for a test flight following maintenance. There were
two pilots and no passengers on board. While returning to the airport,
the crew advised ATC that they had a landing gear problem. The crew
conducted two flyovers of the airport to allow maintenance engineers
to observe the aircraft, and the engineers confirmed that the landing
gear was still retracted. The crew decided to land the aircraft with the
landing gear retracted, and a full emergency was declared. The aircraft
landed at 0232. The ATSB deployed two investigators to the site to
inspect the aircraft and obtain its flight data recorder and cockpit voice
recorder for analysis. Other investigation activities will include a review
of the aircraft's maintenance records and interviewing the flight crew.
Investigation continuing.
21 Feb Robinson R22 Springsure (ALA) None Substantial Helicopter crashed en route to a rural property to carry out
Beta (Beauchamp Station), aerial mustering.
Qld
23 Feb Czech Sport Tooradin (ALA), 081° M Minor Substantial The aircraft became slow during final approach and the pilot attempted
Aircraft A.S. 48km, Vic to conduct a missed approach. However, the wingtip contacted the
SportCuiser ground as the pilot applied power. The aircraft subsequently stalled
and crashed.
29 Feb Amateur-built Gold Coast Aerodrome, None Substantial During landing, the aircraft flipped. The pilot reported that the grass
CH200 275° M 30km was longer than he anticipated.
(Beechmont), Qld
8 Mar Robinson R22 Tamworth Aerodrome, None Substantial During agricultural operations, the helicopter struck powerlines
Beta 110° M 13km, NSW and crashed.
12 Mar Piper PA-24-260 Albury Aerodrome, NSW None Substantial During initial climb, the engine failed. The pilot made a forced landing
Comanche with the landing gear retracted. The pilot reported that he had selected
the incorrect fuel tank, resulting in fuel starvation.
18 Mar Bell 206B (III) Port Hedland None Substantial During approach, the helicopter's engine failed and the pilot made a
Jetranger Aerodrome, 070° M forced landing. An engineering inspection revealed that the engine had
4km, WA failed due to fuel starvation.
19 Mar Air Tractor AT-504 Moree Aerodrome, None Substantial During the initial climb, the aircraft stalled and crashed.
010° M 11km, NSW
31 Mar Piper PA-31-325 Point Cook Aerodrome, None Substantial During the landing roll, the aircraft overran the runway and the main
Navajo Vic landing gear collapsed. The pilot had flown from the runway earlier
in the day but had not checked the wind again prior to landing.
Unfortunately, it had changed to a tailwind.

Australian accidents
Compiled from the Australian Transport Safety Bureau (ATSB).
Disclaimer – information on accidents is the result of a cooperative effort between the ATSB and the Australian aviation industry. Data quality and consistency depend on the efforts of industry
where no follow-up action is undertaken by the ATSB. The ATSB accepts no liability for any loss or damage suffered by any person or corporation resulting from the use of these data. Please
note that descriptions are based on preliminary reports, and should not be interpreted as findings by the ATSB. The data do not include sports aviation accidents.

International accidents
Compiled from information supplied by the Aviation Safety Network (see www.aviation-safety.net/database/) and reproduced with permission.
While every effort is made to ensure accuracy, neither the Aviation Safety Network nor Flight Safety Australia make any representations about its accuracy, as information is based on
preliminary reports only. For further information refer to final reports of the relevant official aircraft accident investigation organisation. Information on injuries is not always available.
20
FEATURE
Electronic flight bags

Pad, not paper

New technology is bringing the concept of the

electronic flight bag to life
The aircraft flight manuals, operations Across the fleet, this saving would
manuals, aeronautical charts, route amount to more than 1.2 million litres of
manuals, checklists, logbooks, weather fuel every year. Qantas and Jetstar are
information and licences a commercial conducting electronic flight bag trials at
pilot requires can make their flight bag the time of writing.
a hefty piece of luggage. The idea of
The frantic pace of development in
replacing all this paper with a portable
computer technology has created a
electronic device is not new (Flight
problem for regulators. How do you
International first reported the term in
regulate something that changes beyond
2001, and early versions of the concept
recognition every few years?
were in use by European airlines in the
1990s), but the recent arrival of small, CASA’s solution is to regulate not what
versatile and powerful tablet computers the technology is, but what it does.
has boosted its popularity. ‘It’s clear that electronic flight bags
In 2011, United Airlines announced (EFBs) make the everyday job of pilots
it would issue tablet computers to its easier—if it’s easier it also has to be
11,000 pilots, with the aim of completely safer,’ CASA’s large aeroplanes standards
replacing paper documentation. The officer, Mal Read, says.
airline said the change would save ‘Last year the ICAO reconvened the EFB
about 17kg of luggage for each pilot by group, because the definition of an EFB
replacing the 12,000 pages carried in a had significantly changed, from a laptop
typical flight bag. computer to a tablet.
 21
Flight Safety Australia
Issue 86 May–June 2012

There was a recognition that regulators Instead, CASA is proposing to adopt ICAO’s concept of four levels of functionality.
need to consider that change.’
‘Function level 1 is basically a document viewer. The software has
Read is part of the team drawing up
CASA’s civil aviation advisory publication F1 to be from an approved source, in accordance with the regulations,’
Lenarcic says.
(CAAP) on electronic flight bags.
‘We felt it wasn’t particularly useful for us
to regulate on a class of EFB, but instead ‘Function level 2 adds some software, such as weight and balance
frame the regulations around what the F2 and performance calculators. Again, the software has to be approved
by CASA, or distributed by an approved supplier.
devices are used for,’ he says. ‘ICAO has
come to the same conclusion, that it will
regulate function rather than hardware or
software type.’ ‘Level 3 is similar to Level 2, except that you can read data from the

Under the former FAA classification

F3 aircraft. Altitude temperature, airspeed, fuel, for example. And you
could feed this data into your performance calculations. The link
system (FAA AC20-176A) there were could be hardware or wireless, but it’s a one-way link from aircraft
three types of electronic flight bag. to device.
Class 1 covered hand-held devices;
Class 2 referred to devices temporarily ‘Function level 4 is effectively the old Class 3, a two-way link with
fixed to the aircraft with a bracket; and
Class 3 refers to devices fully integrated
F4 the aircraft, although we now have the technology for the tablet to
be a stand-alone unit wirelessly linked to the aircraft.’
with the aircraft systems. CASA
principal engineer for avionics, Charles
Lenarcic, says technology has made
this classification obsolete. ‘It’s possible
to have a hand-held device that could
communicate wirelessly with aircraft
systems—how would that be classified?’
he asks.

Esterline CMC Electronics’ SmartDeck® integrated avionics suite

You are not allowed to rely

Above: Esterline CMC Electronics’ 10.4 inch Class 2 on it as your sole source of
PilotView® Electronic Flight Bag (EFB) installation
on BBJ. Photo courtesy ABC Completions
navigation or documentation,’
Right: Esterline CMC Electronics’ 10.4 inch ... ‘However EFBs are very
Class 2 PilotView® Electronic Flight Bag (EFB)
useful in enhancing a pilot’s
situational awareness.’
22
FEATURE
Electronic flight bags

‘We’re introducing the regulations suite Another important operational detail Lenarcic says CASA’s intent is to
in stages,’ Read says. ‘The first stage set out in airworthiness bulletin AWB create regulation that maximises the
is to allow pilots and companies to 00-17 is that electronic devices used advantages offered by new technology
make use of EFBs. Levels 1 and 2 will for flight operations should not be used while minimising the risks.
be introduced first. We hope to have for personal purposes at all. This is to
‘We are working with industry to
a CAAP published by June this year. lessen the risk of data corruption or
balance safety and convenience.
We will require AOC holders to develop software crashing.
This becomes vital when you consider
procedures and guidance for using EFBs
Lenarcic also points out that, currently, the pace of technological change
in their operations manual; other users,
there are no approved retail suppliers and the possibilities that Wi-Fi and
that is private pilots, should follow the
in Australia for VFR navigation charts Bluetooth connections to the aircraft
guidance in the CAAP.’
in electronic form. You are not allowed would allow.’
Lenarcic says the procedures AOC to rely on it as your sole source of
‘We are all for EFBs, but they are the
holders develop will have to cover navigation or documentation,’ he
same as any other electronic device.
potential issues with EFB use. ‘One explains. ‘However EFBs are very
There are issues of reliability and
scenario that is very easily imagined is useful in enhancing a pilot’s situational
stability. When you really need it,
of a flight crew stopping overnight during awareness.’
can you be sure it’s going to work?
a change in the AIRAC (Aeronautical
Using GPS-equipped portable devices Like any device, they are subject to
Information Regulation and Control)
as the primary means of navigation has Murphy’s law and you need to have
cycle. On the next flight the following
some hidden dangers that few pilots something else to fall back on.’
day there may be a difference between
appreciate, Lenarcic says, ‘the tablet
the effective date in the aeroplane’s ‘What was in the realm of science
computer’s GPS is not a certified unit.
navigation data and the data in the tablet fiction five years ago is reality now.
How can you be sure of the integrity
computers carried by the pilots. Which The way we want to do it is to have
of the position information?
database takes precedence? Operators a structure that can accommodate
will have to work out how they deal Secondly, the tablet display is not any imaginable device, from a tablet
with and document this.’ certified—how do you know it is computer to electronic paper.’
accurately displaying the data it is
receiving?’ he asks.

Flight testing the iPad

In February 2011, US charter company, Executive Jet Management,
became the first operator approved by the US Federal Aviation
Administration to use the iPad for flight operations. Wired magazine
reported that the decision followed a rigorous testing program.
Chart company, Jeppesen, and Executive Jet Management did tests,
including rapid decompression from a simulated altitude of 51,000ft, and
electromagnetic tests, to ensure the tablet did not interfere with aircraft
systems. The tests involved 250 flights by 10 aircraft.
Jeppesen product manager, Jeff Buhl, told Wired the Apple iOS operating
system and the Jeppesen app proved ‘extremely stable’ during testing.
The device would quickly recover from the ‘unlikely’ event of a software
crash, he said. He gave a time of ‘four to six seconds from re-launch to
previous state’. There were no software crashes during the trial.
Photo: Jeppesen training manual
 23
Flight Safety Australia
Issue 86 May–June 2012

Katherine Aviation chief pilot, Leigh RAAF Tindal, in the Northern Territory, and its close
neighbour, Darwin, play home and host to many
Ruxton, and Squadron Leader Damien local and international military aircraft squadrons.
Fairhurst of 452 Squadron Tindal RAAF Tindal is home to 75 Squadron, housing
F/A-18 Hornets; while Darwin, apart from being
Flight, on why pre-flight planning is
a busy RPT and general aviation hub for the
essential for flying in the Top End, area, plays temporary home to Australian and
international personnel.
with its potentially deadly military
restricted areas Both Tindal and Darwin are feeder stations to
the restricted areas located around the Top End.
Airspace infringements (which used to be known
as violations of controlled airspace, or VCAs)
affecting military operations range from aircraft
just ‘clipping’ military-controlled airspace to
aircraft flying over live firing ranges. Operations
within military restricted areas can include high-
speed fighter jets conducting random manoeuvres,
aircraft dropping live munitions, or even ground
troops using live munitions. Air-to-air, ground
bombing and other activities using live and inert
ordnance are commonplace.
The restricted areas are there to keep both the
military and general users safe and separated.
Delamere weapons range, located southwest of
Tindal and surrounded by restricted airspace, is
just one example. Activation times, block altitudes
and other details are readily available in a number
of documents, and NOTAMs advise much of the
information ahead of time but, unfortunately, this
does not stop aircraft infringing these areas.

I B I T E D
P ROH

DAlifNeGinEthReOTeUrrSitory
a way of
24
FEATURE
Military restricted areas

TINDAL AIRSPACE (TNX) Planning to survive

C415/12
1. Careful preparation (remember the
CTR DEACTIVATED 6 Ps) starts with gathering all available
SUBJECT TO RECALL AT SHORT NOTICE. information. The material above is a
CTAF PROCEDURES APPLY very good start. Valid weather reports
FOR FURTHER INFO TEL: 0408 221 783 and NOTAMs for your route are vital.
FROM 04 020454 TO 04 022330
2. Note which areas a direct track would
C413/12 REVIEW C402/12 have you pass through. This may be your
R248B ACT preferred track, but might not be available
MILITARY FLYING because it infringes prohibited, restricted,
10000FT AMSL TO FL600 dangerous (PRD) areas.
FROM 04 022330 TO 04 050730
3. Decode the NOTAMs so that you can
DAILY 2330/0730 reference the information in flight, write
C412/12 REVIEW C401/12 the activation times in local time beside
R248A ACT DUE MIL FLYING each specific area, and underline or
SFC TO 10000FT AMSL highlight the altitudes.
FROM 04 022330 TO 04 050730 4. Pay close attention to the times when
DAILY 2330/0730 you plan to transit through the region,
C411/12 REVIEW C400/12 remembering that delays and head winds
will have a snowball effect on your ETA.
R247 ACT
Add multiple buffers to your plan.
MILITARY FLYING
SFC TO FL600 5. Work on options to fly around the area.
FROM 04 022330 TO 04 050730 This may be a defined transit path such
DAILY 2330/0730 as the Victoria Highway Corridor to the
southwest of Tindal, or an IFR tracking
These are some examples of information available point such as Bones, south of Tindal.
to plan and stay safe. Pick up an en route chart, You do not need to hold an IFR rating to
track via an IFR waypoint. Plot the points
VFR navigation chart, visual terminal chart, ERSA or
on your WAC to aid in either a planned
Jeppesen chart and have a closer look at these areas.
diversion, or last-minute change.
6. Use all the tools available, including
charts and ERSA.
 25
Flight Safety Australia
Issue 86 May–June 2012

In flight
1. Restricted areas, although NOTAMed with
times, may be activated or deactivated at
very short notice. Use VHF radio, or as
more common in the area for coverage, HF. This scenario, based on a true story, occurred in military restricted
Find out exactly whether the area is active areas extending up to 200nm west of RAAF Base Tindal during a
or otherwise. major multi-national air combat exercise. It involved multiple fighter
2. Plan forward for an estimated time to exit jet aircraft operating with live munitions into the Delamere bombing
an area. If you can’t exit before it activates, range. All restricted areas were activated by NOTAM, with an AIP
don’t enter the space. SUP current, and the local aviation community had also been briefed
before the exercise.
3. Communicate with other aircraft in the
vicinity to help your planning. Multiple A light aircraft at Tindal contacted Tindal ATC requesting clearance for
VFR and IFR aircraft conduct charters a VFR flight from Tindal direct to Kununurra. The clearance was not
throughout the whole area. Use their pilots’ issued because the requested route transited active restricted areas
local knowledge. and the participating fighter jet was about to depart, so there was no
Just owning an ERSA or full set of Jeppesen time to accommodate the request. Tindal ATC offered two alternate
documents is absolutely useless if you do not use clearances. One was more direct, but at low level; and the other
them and correctly interpret the information. provided the requested higher altitude, but required additional routing
around the active restricted areas. The pilot said he was unfamiliar
Know that there are right-hand circuits to with the area and the tracking points specified, and was given the
RWY 14 at Tindal in CTAF R. necessary bearing and distances from Tindal to remain clear of the
Understand that the Tindal control zone can restricted areas. He said he would use these.
become active at very short notice. As the aircraft left the Tindal CTR, ATC reminded the pilot of the
tracking needed to remain clear of the restricted areas. Some time
Just owning an ERSA or full set of later though, ATC radar showed the pilot was not navigating by the
Jeppesen documents is absolutely useless agreed bearing and distances; he was now heading straight for
if you do not use them and correctly Delamere bombing range, as were several fighter jets. Tindal Approach
attempted to relay a message to the VFR aircraft through Brisbane
interpret the information.
Centre; however, there was no acknowledgment that the VFR pilot had
received the message. Tindal Approach then also lost radar contact.
In the interests of safety, as the infringing aircraft’s position was not
known, the military mission was cancelled, and the entire military force
returned to base with full weapons loads.
The National Aeronautical Information Processing System (NAIPS) can
be somewhat confusing to pilots who do not fly frequently. Play around
with the system and familiarise yourself with it. For the above scenario,
the Tindal airfield NOTAM will be listed under the YPTN entry, while all
the Tindal airspace NOTAM will be listed under the TNX entry. Call RAAF
Coming soon! Air Traffic Control (ATC) at Tindal and ask for help in deciphering the
detail if you need it. RAAF ATC would much prefer to be asked for help
The latest additions to OnTrack are Darwin than have to investigate an airspace infringement.
and Alice Springs.
Even though if you are flying VFR in class G airspace you do not have
OnTrack is CASA’s interactive guide to to maintain radio contact with an air traffic agency, this does not mean
operating in and around Australia’s controlled that you cannot call for advice. The Tindal scenario above is a perfect
airspace, including demonstrations on how example, where there is a huge amount of class G airspace next to
to avoid airspace infringements. restricted airspace. Brisbane Centre provides a radar information
Visit OnTrack www.casa.gov.au/ontrack service to IFR flight in class G airspace and Brisbane is notified when
mid June 2012 for these new locations. Tindal is either active or inactive. A quick call to the controlling agency
for that portion of class G airspace could save you a lot of trouble.
(If you have tried all other information sources first.)
26
FEATURE
Fuel management

exhausted at home
American aviation safety instructor, Thomas P. Turner, on fuel exhaustion

A twin-engine aircraft’s pilot told I looked only at fuel exhaustion events In many of the reports the pilots (if
reporters recently he was less than for which final (‘Probable Cause’) they survived) report having made
two miles from his home airport reports are posted. I was surprised at what appear to have been thoughtful
when both engines quit. Attempting to how many fuel exhaustion reports I preflight fuel decisions. But they
land on a highway, he instead ended found: on average one every week. are also often based on rules of
up a ditch, escaping unhurt despite I noted how many occurred in or near thumb (‘my aircraft always burns XX
‘totalling’ his aircraft. the pattern for the planned destination gallons per hour’ or ‘it usually takes
airport. I learned that 55 per cent of XX hours and XX minutes to make
It seems as if every time I read about
reports occurred while the aircraft was this trip’) for considerations that are
fuel exhaustion—someone completely
in the traffic pattern at the end of a frequently variables based on power
running out of fuel—it strikes me how
cross-country flight. In many of those setting, altitude, mixture management
frequently the pilot almost makes it to
cases it was on final approach when technique and winds. In many more,
destination. Very often an aircraft runs
the engine (or engines) quit. the pilots clearly knew they were
out of fuel within a mile or two of the
running low on fuel before the gas
planned destination airport. These are all fuel exhaustion reports,
ran out, often reporting this to air
when investigation determined there
A data enthusiast, I began a traffic control or, after the fact, to
was essentially no fuel remaining
look through the U.S. National investigators. In other words, the pilot
anywhere on board the aircraft when
Transportation Safety Board (NTSB) was aware enough of the fuel state to
it crashed. So issues of switching fuel
database to see if there is any truth know trouble was near, but didn’t do
tanks near the ground, or violating
to my growing assumption that fuel anything about it soon enough to make
limitations against descent and
exhaustion is often a ‘just a little bit a difference.
landing on auxiliary fuel tanks, or fuel
more to get home’ phenomenon,
unporting in a steep slip are all outside Nearly half of all reported fuel
and if so, if there is some way to use
the scope of this record. These events exhaustions did not happen in the
this knowledge to prevent similar
were all the result of simply attempting traffic pattern of the home airport.
future events. If my initial data are
to fly farther than the fuelled range of Those events almost universally
consistent over longer timeframes, my
the aircraft. occurred somewhere during the en-
assumption may be proved correct.
route phase of a cross-country trip,
or after a missed approach and while
en route to an airport half an hour or
more away. It stands out in the data,
however, that pilots are not frequently
running out of fuel in the traffic pattern
at airports other than their home
aerodromes. When they push fuel to
the last minutes before landing, pilots
are doing so on the flight home.
 27
Flight Safety Australia
Issue 86 May–June 2012

Lessons learned Pushing towards home Fuel exhaustion is tragic … even

more so when it ends a flight
There are many positive safety lessons Why might a pilot be more likely to within moments of arriving home.
in this realisation, including: run out of fuel at the end of a trip Learn the lessons of mishap
home? Several things spring to mind: history, and avoid decisions
We can plan expected fuel burn,
but we need to actively monitor Most pilots get a ‘based aircraft’ (or failures to decide) that stretch
fuel burn in flight using as many fuel discount at their home airport. your endurance to its limit.
independent means as possible, There’s an inherent conflict
to account for changes in power between the need to fuel up for Thomas P. Turner holds an ATP certificate
setting, mixture technique, and a flight home and the fact that with instructor, CFII and MEI ratings; has a
real-world winds aloft. getting home with the least Masters Degree in Aviation Safety; was 2010
amount of fuel on board includes National FAA Safety Team Representative of
We need to consider the added fuel
burn of take-off and climb when a financial reward. the Year. He has also been a production test
pilot for engine modifications; an aviation
planning a near-maximum-range Pilots may be less likely to decide
insurance underwriter; a corporate pilot and
flight. Rules of thumb about cruise to divert for fuel on the way home.
safety expert; a captain in the United States
fuel burn rates won’t cut it when Pilots generally love to travel, but
we’re cutting it short. Air Force; and contract course developer
we all like to get home. The desire
for Embry-Riddle Aeronautical University. 
We must consider our planned to complete a trip, perhaps coupled
with incentives or stresses to be He now directs the education and safety
reserve an inviolate emergency arm of a 9500-member pilots’ organisation. 
resource. In other words, if back at the office or at home,
an in-flight check of fuel state may make us less likely to stop He is also the author of Flying Lessons,
shows you’ll begin burning into short just as we’re within 30 to a weekly online newsletter, which you can
your 30 minute-, 45 minute- or 45 minutes (our legal reserves) subscribe to by emailing: mastery.flight.
more conservative personal fuel of destination. [email protected]
reserves, you must remain in a Fuelling away from home can
position to land for gas before you sometimes be a hassle. We might
access the first portion of your not want to take the time or make
reserve fuel. the effort to fuel up if we think we
Instead of knowing when the tank can make it home with what we’ve
will run out of fuel, the timing got. Under external or self-imposed
of which may change with any pressure to get home, we’re less
number of variables, the more tolerant of delay, and can more
useful information is to know how easily rationalise going unrefuelled
much fuel remains in a tank when if for any reason we are unable
it indicates ¼ full on the cockpit (or unwilling) to get fuel at the
gauge—because that knowledge remote location.
prompts action well before an Once in cool, smooth air at altitude,
engine quits. we have a disincentive to descend
into hot, turbulent air if we can
avoid it. In winter weather, we want
to stay out of colder, and perhaps
icy, clouds down below. We don’t
want to descend to refuel.
28
FEATURE
Text here

Last year, the series targeted those in rural and regional areas – the 2012 series will feature six
metropolitan venues across Australia.
CASA supports the continued operation of ageing aircraft, as long as it can be done safely.
Come and hear the experts, who will be appearing at the following seminars:
Date City Venue
17 March Perth Convention & Exhibition Centre
10am-1pm 21 Mounts Bay Road COMPLETED
28 April Sydney Waterview Bicentennial Park
10am-1pm Australia Ave, Sydney Olympic Park COMPLETED
12 May Darwin Crowne Plaza
10am-1pm 32 Mitchell St
26 May Melbourne Convention & Exhibition Centre
10am-1pm 1 Convention Centre Place South Wharf
2 June Brisbane Convention & Exhibition Centre
10am-1pm Cnr Merivale & Glenelg Streets South Bank
16 June Adelaide Hilton Adelaide
10am-1pm 233 Victoria Square

• Venue space is limited, so bookings are essential and strictly on a first-in,

best-dressed, basis.
• To secure your place, please go to www.casa.gov.au/ageingaircraft and complete
your booking online. Please bring your booking reference to the seminar.
 s r i
cy c o
ys fr n
ct la s c
29
Flight Safety Australia
le if u e 2012
Issue 86 May–June
em gt n r a
so ht d t i
f ty e i r
m hp r f c
s a oe t i r
t i u a c a
o n r k a f
r t s e t t
a e n i A
g n o g p
e a n e a
a
r
te
n
c Introducing the prototype b
a
s
s
t
r
r
a
n m
i matrix tool i
s
e
p
g e a
e o CASA is developing an online aid for The prototype matrix tool will allow registered operators to i
m n input data specifically applicable to their individual aircraft. r
e t owners/operators concerned about the age w
n h of their aircraft The types of data inputs may include: o
t e aircraft type
r
s a CASA’s Ageing Aircraft Management Plan has covered many k
u issues, but its mission can be expressed in just one question: aircraft age
s How old is too old? It quickly emerged that there was no flight hours
t simple answer. Aircraft, like people, age at different rates,
r depending on their lifestyle, which includes factors such as certification basis
a usage, maintenance, hangaring and environment. When these cycles
l are taken into account age—and the risks associated with it—
i becomes very different from number of birthdays. system of maintenance
a As the management plan team travelled around Australia past repair work/modifications undertaken on the aircraft
n speaking to aircraft owners, operators and engineers, an
r time on the Australian register
e unsettling conclusion became clear—no one knew the answer type of operations undertaken
g to the question.
i There was a lack of available data about the current status location where kept
s of Australia’s ageing aircraft fleet. There was also a lack storage arrangements.
t of awareness in the aviation industry about the concepts
e and issues involved in aircraft ageing. ‘In many instances, The prototype matrix tool will apply appropriately weighted
r registered operators are not aware of how their individual indices to each of the criteria. These will in turn be factored
aircraft might potentially be affected by ageing issues, into an algorithm that provides a relative measurement index.
and/or what they might be able to do about it,’ a CASA internal The feedback received from industry use of the prototype tool
document reported. may be used to further refine the requirements for a potential
How to estimate the risks involved with aircraft ageing has ‘production’ version of the tool. An important point is that the
become a major part of the project. It has come up with an prototype matrix tool will not collect or save any of the data
online prototype tool to assist aircraft owners and operators: submitted by users during its trial.
the likelihood matrix. This is currently under development The prototype version of the matrix is planned to go online in
and is intended to indicate how likely an individual aircraft July 2012, to coincide with the release of a discussion paper
is to be affected by age-related problems with its airframe on ageing aircraft.
and systems. It gives aircraft operators feedback based on
objective engineering factors.
30
FEATURE
Ground handling safety

Heavy metal balancing act ‘When it came to deciding who would be asked to present the
film, Bruce was the obvious choice. ‘Having seen him in action
in another aviation mini-series and knowing that he was a
Airline captain and front man with heavy metal band Iron keen enthusiast, I could think of no-one better.’ As well as line
Maiden, Bruce Dickinson, presents a new DVD, Safety in the flying, Bruce is also a qualified crew resource management
Balance, highlighting the importance of safe and accurate Instructor.’
aircraft loading. The DVD, available free of charge, is a joint
initiative of the UK Civil Aviation Authority (CAA) and the According to Sandever, ‘the footage jumps deliberately from
UK aviation industry. various locations and aircraft as we wanted to involve as many
airlines, ground handling agents and airports as we could.
The DVD was commissioned by the Ground Handling So, viewers shouldn’t get cynical when they see Bruce go up
Operations Safety Team (GHOST), a CAA/industry group. the stairs of an Airbus A340, through a Boeing 747, down the
Jason Sandever, the CAA’s aircraft loading inspector, was steps of a Boeing 757 and into the cargo hold of an Airbus
the focal point of the project. ‘It was clear we needed to A321. It was meant to happen like that!’
make something that was not only engaging but also related The film is not intended to replace the need for formal training,
directly to the target audience,’ he says. ‘Having worked but to complement it.
within the ramp environment, I knew we had to do something
a bit different.’ Safety in the Balance is available on DVD: please contact
[email protected] for details.

REVISED BOOKLET OUT NOW!

AutomAtic DepenDent
SurveillAnce–BroADcASt

Visit the online store to get your free* copy. www.casa.gov.au/onlinestore

* Products are free of charge. However a $15 packing and postage fee applies to each order.
 31
Flight Safety Australia
Issue 86 May–June 2012

if

could

Systems to monitor aircraft health and usage are playing

a growing role in aviation safety

Health and usage monitoring systems (HUMS) let The first civilian use of the system was in 1991,
aircraft operators know what they’re doing right, in passenger transport helicopters working the
or wrong, before they find out the hard way. While oil rigs of the North Sea, between Britain and
true HUMS are confined to large expensive offshore northern Europe. It was a dangerous, but wealthy,
helicopters, similar technology is now to be found environment where any measure that could
on agricultural aircraft, single-engine aeroplanes and reduce overall risk was adopted, almost regardless
light helicopters. of cost.
A HUMS collects and records data from sensors However, decades of experience with HUMS have
and accelerometers for post-flight analysis, found it reduces costs as well as accidents. The
which can help detection of early signs of Norwegian research organisation, Sintef, described
component failure, particularly within helicopter HUMS as ‘the most significant isolated safety
rotor gearboxes. improvement measure during the last decade’.
32
AIRWORTHINESS
Health and usage monitoring systems

... the system can In the UK, where HUMS is mandatory on offshore Wackers and Korte found the HUMS used on
be a significant transport helicopters, the UK Civil Aviation the crashed helicopter ‘was unreliable in the
Authority estimates that about 70 per cent of all sense that only one in about 200 alerts could
tool in preventing helicopter drive-train faults are uncovered by the be substantiated. They also found ‘faulty
accidents, but ... latest versions of the system. sensors or other HUMS components were
the system has not considered to influence the helicopter’s
Eurocopter cites studies crediting HUMS with a 60
to be given clear per cent reduction in check flights, 25 per cent
safety and airworthiness (that was determined
prioritisation by by the technical integrity of the helicopter’s
reduction in tests, and a 20 per cent drop in the
power train).’
all of the parties level of unscheduled maintenance.
involved ... for the As a result, ‘in their handling of component failure
HUMS maker, Goodrich, says a US Army
technicians and engineers fell back on already-
greatest possible helicopter unit using its system flew 27 per cent
established routines with regard to non-safety-
safety potential to more missions on a tour of duty in Iraq than
critical component failures in helicopters.’
another unit on the same airfield flying the same
be realised.’
type of aircraft without HUMS. The Norwegian Air Accidents Investigation Board
said: ‘the investigation has shown that the safety
By recording a vibration ‘signature’ for a
potential of HUMS was not fully realised. The
helicopter and monitoring any changes to it,
accident has shown that the system can be a
HUMS can flag signs of trouble hundreds of hours
significant tool in preventing accidents, but that
before structural cracks become big enough
the system has to be given clear prioritisation by
to be detected by eye.
all of the parties involved in order for the greatest
However, HUMS is not perfect. It requires skilled possible safety potential to be realised.’
data analysis, which is complicated by the fact
A particular problem for Australian aviation, where
that many HUMS generate a considerable number
the majority of helicopter crashes involve light
of false alerts. On average, a HUMS generates
piston-engined helicopters, is that until recently
between four and 12 alerts per 1000 flight hours.
there has been no health monitoring available
The crash of an AS332 Super Puma in the for these machines. This has had two results:
Norne oil field, approximately 200km west of unnerving anecdotes about light helicopters
the Norwegian coast, in 1997, was a tragic exceeding their component flight hour limits by
example of the difficulty of interpreting HUMS data hundreds (and sometimes thousands) of hours—
and the importance of having analytical procedures and horrible accidents, where transmissions
in place. seize, or rotor blades depart, usually resulting in
A 2002 analysis by engineers, G. Wackers the death of all on board.
and J. Korte, pointed out the organisational Lightweight usage-monitoring systems are now
shortcomings. ‘First, one of the HUMS sensors available for general aviation aircraft, including
on the main gearbox housing (the one that later the Robinson R22 and R44 helicopters that
turned out to be the one located exactly over make up about half of the Australian rotary-wing
the splined sleeve that failed) was defective,’ aircraft register.
they said.
One such system was developed by former
‘It had been unserviceable for two months. racing car driver and current helicopter pilot,
Second, HUMS engineers in Stavanger Larry Perkins.
discovered in the HUMS data batches from
His motorsport experience made him aware that
previous flights, that were stored in the ground
lightweight, robust systems were available for
station, a trend in one of the parameters. The
flight data recording and reporting.
trend originated in one of the sensors on one
of the engines. ‘We’ve used computers in motorsport since1988
for just about everything,’ he says. ‘When I bought
This particular trend could only be found
a helicopter I was surprised that there was nothing
through manual retrieval and examination
of this type available.’
of the data. This was not done routinely.’
 33
Flight Safety Australia
Issue 86 May–June 2012

The Data Acquisition Alarm Monitoring system Perkins says pilots of aircraft fitted with the system
developed by Perkins Technologies is not a full are changing their piloting style to be gentler on
vibration monitoring HUMS, but instead combines the aircraft.
flight recording, engine trend monitoring and
The first group to embrace the system was
alarms when limits are exceeded.
agricultural pilots, who adopted it enthusiastically
‘It was designed to be low cost, easy to fit, and on their single-engine turbine aircraft. ‘What we
to capture the biggest issues; for general aviation found was the ag operators initially recorded
aircraft they would be exceedances in airframe or numerous G-load exceedances, but over time
engine,’ Perkins says. these have reduced markedly,’ he says.
Vibration monitoring would not be difficult to add, Clark agrees: ‘With the system on board the
he says. He doesn’t rule it out for future versions, as pilots tend to fly smoother and smarter which is
prices of computing and electronics components better on the aircraft. This is noticeable on sling
continue to fall. The three foundations for the load operation.’
Perkins system are trend monitoring, exceedance
Perkins Technologies has sold about 250 of
alarms and non-tamperable flight time recording.
its monitoring systems to costumers around
It records compressor RPM, propeller or rotor the world, including the Temora Aviation Museum,
RPM, torque, system voltage, air filter pressure, which has the technologies installed on its
engine oil pressure, turbine temperature, fuel flow, two Spitfires.
indicated air speed and air pressure. Engineers
System costs range from about $12,000 for
can download these in order to look for events and
fixed-wing turbine aircraft to $7000 for the
trends that might affect performance and safety. Vibration
simpler installation on a Robinson R22. Perkins
The system automatically logs any excessive Technologies is developing a dedicated kit for monitoring
readings in any of the systems it monitors. It also Robinson helicopters that will cost $5000 and records compressor
gives pilots a visual and audio alert that allows weigh 300 grams, as opposed to the one kilogram RPM, propeller or
them to take immediate corrective action. It acts of the current system. rotor RPM, torque,
as a non-tamperable electronic logbook, which
Other makers of lightweight monitoring systems system voltage, air
in service has proved to be more accurate than
include Alakai Technologies from the US, which filter pressure, engine
manually written logs.
offers Wi-Fi and GSM mobile phone or satellite
oil pressure, turbine
Queensland helicopter operator MI Helicopters phone links that can send data to an engineer’s
uses the Perkins system on two of its Bell computer or mobile phone; and Appareo Systems,
temperature, fuel
LongRangers. ‘The gas companies love it which offers cockpit video monitoring on one of flow, indicated air
because it records everything—so there can’t be its flight data monitoring products. speed and air pressure
any cheating of hours or exceedances,’ chief pilot
Kevin Clark says. ‘And we can use the Perkins
system as a tool to mitigate the preference of For more information
some companies for twin-engine machines.’
Drift and Vulnerability in a Complex Technical System: Reliability of
‘If you have an exceedance it records it, right Condition Monitoring Systems in North Sea Offshore Helicopter
down to three-hundredths of a second. The Transport, G. Wackers and J. Korte, 2002
maintenance guys love it too because they can www.chaosforum.com/docs/nieuws/Drift.pdf
bring it up on the computer and scroll through it.’
Optimisation of fault diagnosis in helicopter health and usage monitoring
Clark sees a potential to evolve from a system systems Johan Wiig, Doctoral thesis, l’École Nationale Supérieure d’Arts
of scheduled maintenance once such systems et Métiers, 2006
become widespread in the industry, and http://tinyurl.com/6wgomly
legislation changes. For now, you’ve still got
Alakai Technologies
to do it as per the schedule,’ he says.
http://www.alakai1.com/
‘But it’s great to know the parameters on an
Perkins Technologies
aircraft aren’t being exceeded. It’s got to help
http://www.perkinstechnologies.com.au
with maintenance costs eventually.’
34
AIRWORTHINESS
Pull-out section

SELECTED SERVICE DIFFICULTY REPORTS

7 Feb – 28 March 2012 Boeing 717-200 Pneumatic distribution system
duct split. SDR 510014432
Boeing 737-8FE APU engine fuel and control flow
divider suspected faulty. SDR 510014310
Note: Similar occurrence figures not included Several reports of ‘High Tail Temperature’ indications APU failed en route and because of lack of serviceable
in this edition (two LH system and three RH system) relating to ground support equipment at destination the aircraft
the air-conditioning/bleed air/tail anti-ice system diverted back to departure port. Investigation pointed
AIRCRAFT ABOVE 5700kg over a seven-day period. Three of these caused air to the fuel flow divider on the APU as possibly having
Airbus A320-232 Aileron control system turnbacks. During extensive troubleshooting various a hydraulic lock.
computer fault message. SDR 510014421 components replaced, including ducts found torn and
Boeing 737-8FE Detection system harness
During taxi the crew observed an elevator and aileron damaged. Temperature sensors cleaned and tested.
failed. SDR 510014410
computer (ELAC) No. 1 pitch fault. Fault self cleared. Boeing 737-476 Aileron tab control system During crew pre-flight inspection No. 2 engine fire
Operational test carried out iaw aircraft maintenance locknut loose. SDR 510014484 detection harness MW325 suffered premature failure
manual with no faults found. P/No: 3945128209 Flight crew reported that when the aileron trim (despite the aircraft being very new), causing a failed
Airbus A320-232 Flight compartment windshield switches were activated and then released, the control fire test. MEL 26-02-02 applied. Fire detection
cracked. SDR 510014295 wheel continued to move and as a result they found it harness replaced and tested serviceable and MEL
During flight RH cockpit heated windshield arcing, very hard to trim to zero. Investigation found that the removed. P/No: CA2431. TSN: 620 hours/362 cycles.
causing it to crack. P/No: NP1653118. feel and centering unit springs had not been tightened
Boeing 737-8FE Leading edge slat position
TSN: 11,151 hours/6426 cycles/39 months and the locknuts were loose. Centering unit rigging
indicating system proximity sensor faulty.
was carried out and problem rectified.
Airbus A320-232 Landing gear door actuating SDR 510014439
rod loose connection. SDR 510014390 Boeing 737-476 Flight compartment windshield Rejected takeoff and returned to gate due to takeoff
During walkaround a significant crack was found on delaminated. SDR 510014416 warning horn sounding. Takeoff warning horn sounded
the RH main door of the nose landing gear (NLG). During workshop inspection No. 5 windshield at approximately 40kt. No. 7 slat inboard proximity
Further inspection revealed that the NLG RH aft door found to have delamination on its upper LH corner. sensor replaced. Takeoff configuration warning check
rotating rod was undone due to tab washer failure. P/No: 58935841. TSN: 3683 hours. TSO: 3683 hours. carried out with no further defects. P/No: 189929.
Door assembly and defective parts replaced. P/No: Boeing 737-476 Fuselage skin cracked. Boeing 747-438 Crew station equipment system
D5281007500200. TSN: 26,189 hours/16,302 cycles SDR 510014375 seat frame loose. SDR 510014396
Airbus A330-202 Pneumatic distribution system Sub-surface cracking found during eddy current On landing, cabin crew advised that the upper deck
bleed valve faulty. SDR 510014479 inspection in aft fuselage skin lower lobe. Four crew seats located at upper deck left had come away
Engine No. 2 bleed air fault followed by engine No. 1 locations in zones 3 LH side and 1 RH side. Known from the floor mounts.
bleed air fault after thrust reduction. Alt bleed switch occurrence as per inspections by Boeing service
Boeing 747-438 Fuel transfer valve suspected
cycled and ops returned to normal. Engine No. 2 bulletins and CASA AD/B737/231.
faulty. SDR 510014336
bleed valve replaced. P/No: 6764B040000. Boeing 737-7BK Landing and taxi aids mode During cruise, ‘Aux vent valve 2 fail’ message
TSN: 5428 hours. TSO: 5428 hours. control panel faulty. SDR 510014434 appeared. Aux tank fuel did not transfer. Boeing
Airbus A330-301 Stabiliser actuator jammed. Flight crew reported No. 1 ILS system deviating by bulletin procedures carried out to no avail. Fuel in
SDR 510014489 1 to 3 degrees during approach. Troubleshooting aux tank unusable.
During maintenance functional inspections/tests on revealed that during the ILS approach course
Boeing 767-336 APU oil system smoke.
the horizontal stab trim the system failed test (LH selection of 154 resulted in a track of 152, with
selections between 150 to 160 all resulting in tracks SDR 510014374
and RH valve block checks) in both electrical and After shutdown of engines, excessive smoke observed
mechanical modes. The faulty pre-mod actuator that were out by 2 to 4 degrees. Mode control panel
(MCP) replaced and ILS system tested serviceable. coming from APU. No fire indication. Smoke stopped
was replaced and the OEM notified. Occurrence test when APU was shut down. APU oil quantity read ‘add’.
required by EASA AD 2012-0020. P/No: 4082260937.
TSN: 26,326 hours/18,569 cycles. Evidence of oil in compressor inlet but not in bleed air
Airbus A380-842 Landing gear steering system outlet or ducts.
suspected faulty. SDR 510014333 Boeing 737-838 Elevator tab control system
Boeing 767-336 Autopilot system malfunctioned.
Aircraft encountered steering problems during start lug damaged. SDR 510014474
During inspection (iaw ASB 737-27A1297) of the aft SDR 510014476
of takeoff roll and returned to gate. ECAM message During climb from FL370 to FL390, with left autopilot
faults for steering followed by loss of steering. attach lugs of the elevator control tab mechanism
the LH inboard attach lug to lug interface No. 4 found selected, the aircraft descended 300ft. On the second
BAC 146-100 Landing gear retract/extension to be out of the specified limits. Defective elevator attempt the aircraft again descended. ASIR raised due
system suspected faulty. SDR 510014329 control tab mechanism replaced as per FAA AD to altitude excursion. MELs 22-10-01 and 34-22-4
On departure landing gear selected to up but red 2010-17-19. applied to system. Troubleshooting carried out. Left
‘gear unsafe’ warning lights did not extinguish for flight control computer (FCC) replaced.
the LH and RH MLG. Gear then selected to down Boeing 737-838 Pitot/static system hose
Boeing 777-3ZGER Flight controls wiring
and locked with 3x green indicator lights. Air return, blocked. SDR 510014497
Captain’s airspeed (IAS) unreliable above 80kt. connector damaged. SDR 510014392
aircraft landed without incident. LH main gear uplock During heavy maintenance and after LH engine
operating rod to indication sensor fouling against the PAN call for air turnback. Aircraft held and fuel
burnt to reduce weight below max landing. Landing removal the MRO found pin D on connector D71107J
main gear debris guard. Debris guard only installed bent, and socket D and surrounding insulation
three months previously as part of unpaved runway uneventful. Blockage found in captain’s pitot flex line
behind P1-1. Flex line replaced. Pitot probe and left damaged. This is part of the DC power supply of yaw
gravel protection kit. Heavy weight landing inspection flight controls. P/No: CA66278101 and CA66279102.
revealed small creasing of LH fuselage between ADIRU also replaced and system leaks carried out.
TSN: 14,239 hours/1215 cycles.
frames 13 and 14. Boeing 737-838 Pneumatic distribution system
Boeing 777-3ZGER Horizontal stabiliser stringer
Beech 1900C Aileron control system clip broken. pressurisation suspected faulty. SDR 510014495
Cabin altitude warning horn sounded in cruise. corroded. SDR 510014391
SDR 510014469 During heavy maintenance, inspection corrosion
During the 1200 hour inspection of aileron balance RH duct pressure indicating zero and left air-
conditioning pack unable to maintain cabin pressure. damage found in the horizontal stabiliser
weight clips the LH and RH ailerons were both found compartment aft of station 2344. Corrosion damage
to have broken clips. Defect found with boroscope. Aircraft made an emergency descent to 10,000ft and
diverted to Melbourne. Cabin reached a maximum caused by hydraulic leakage in the horizontal
Field service kit repairs carried out iaw SB27-3928. stabiliser over both skin and stringer 40R. Skin
P/No: 101130001191. altitude of 12,500ft.
damage repaired in accordance with 777 SRM.
Beech 1900C Wing structure stringer corroded. Boeing 737-838 Weather radar system
Boeing 777-3ZGER Passenger oxygen system
SDR 510014470 transceiver failed. SDR 510014325
Aircraft suffered weather radar transceiver failure coupler incorrectly secured. SDR 510014465
During scheduled maintenance the LH and RH wing During heavy maintenance and while carrying out
fuel collection tanks were cleaned and corrosion whilst en route. Due to bad weather the aircraft
returned to departure port. P/No: 8221710001. BTC 35-110-00-01 (passenger oxygen low pressure
(microbiologic contamination under old sealant) leak check) aircraft would not hold pressure. Oxygen
was found on ‘J’ stringer. Damaged stringer sections TSN: 35,364 hours. TSO: 35,364 hours.
supply line between seats 23 and 24 found to be
removed, skins cleaned and inspected. No further disconnected, but this part of the aircraft had not
corrosion found. Repairs carried out iaw EO and SRM. previously been disturbed during the maintenance
check. P/No: 474W209012.
TSN: 14,573 hours/1290 cycles.
 35
Flight Safety Australia
Issue 86 May–June 2012

SELECTED SERVICE DIFFICULTY REPORTS ... CONT.

Boeing 777-3ZGER Wing, flap system damaged. Bombardier DHC-8-402 Air distribution system The fault code in the aircraft’s CDS indicated a failure
SDR 510014441 duct damaged. SDR 510014413 (photo below) of the No. 5 position dual distribution valve. Valve
During heavy maintenance check, inspection of During flight the aircraft suffered a pressurisation replaced and tested. TSN: 5989 hours/6781 cycles.
the RH flaperon revealed a large crack in the upper failure. Emergency/precautionary descent carried out. TSO: 5652 hours/6410 cycles.
surface outboard trailing edge area. Cause of the Maintenance interrogation of the CDS unit indicated
Bombardier DHC-8-402 Door seal leaking.
fracture currently unknown. Investigation continuing. possible failures of the pressurisation control and
SDR 510014308
New flaperon P/No: 113W6100-16 installed. monitoring units but further troubleshooting identified
Report of ‘hissing’ from forward air stair, with
TSN: 14,573 hours/1290 cycles. large splitting of the ram air duct in the empennage
pressurisation panel indications normal. Rapid
area. P/No: 8SC1450001.
Bombardier BD700-1A-10 Brake sensor failed. depressurisation occurred approaching FL160.
TSN: 4432 hours/4825 cycles.
SDR 510014398 Emergency descent followed by normal approach
After takeoff, the crew identified a fluctuating hot and landing. Investigation confirmed failure of the
brake indication on the RH outboard brake assembly. main cabin door seal. No ATA 21 fault codes in the
The crew continued with the gear extended and CDS system that would relate to this.
monitored the brake temp indicator which continued
Dornier 228-202 Landing gear retract/extension
to be erratic but with no smoke or damage evident.
system solenoid valve suspected faulty.
Problem assessed to be a failed brake temperature
SDR 510014294
sensor. This was replaced and the aircraft returned
Aircraft on approach unable to extend landing gear.
to service.
Go-around carried out and landing gear extended with
P/No: GW43610011. TSN: 896 hours/230 cycles.
emergency system.
Bombardier DHC-8-102 Fuselage structure
Embraer EMB-120 Fuel selector/shutoff valve
(general) lightning strike. SDR 510014393
Bombardier DHC-8-402 Air intake anti-ice/ contaminated. SDR 510014419
During flight, aircraft struck by lightning, resulting
de-ice system heating element burnt out. During passenger boarding the crew noticed a fuel
in loss of No. 2 DC generator. Flight crew unable to
SDR 510014288 (photo below) leak from the LH wing. Fault traced to contamination
bring it back online for the remainder of the flight.
When the ice protection was selected on the ‘Eng inside the solenoid valve located between the main
Air turnback. Second lightning strike caused loss of
Adpt Heat 1’ (engine intake bypass doors) during fuel tanks and the collector tank in the LH nacelle.
the No. 1 DC generator and left stall warning system
climb a caution light came on and the associated The contamination prevented the valve from closing
and cracked the LH cockpit side window. Immediate
circuit breaker had popped. Investigation revealed completely, causing fuel to vent overboard.
descent requested. Crew able to bring No. 1 DC
an overheating failure of the heater adaptor element. A known fault on the EMB-120 aircraft that has been
generator back on line. Aileron tip, LH side window
Intake heater replaced with no further problems. addressed by Service Bulletin (SB120-73-0009).
and LH lift transducer replaced. P/No: 17180007.
TSN: 2,005 hours/2,197 cycles. P/No: 1589003.
Bombardier DHC-8-102 Hydraulic system main
Embraer EMB-120 Navigation system relay
pump failed. SDR 510014418
failed. SDR 510014286
Loss of hydraulic pressure on No. 1 system. Air
During climb the captain’s EHSI failed, RMI No. 2
turnback. Troubleshooting found that No. 1 engine-
and NAV No. 1 failed, the first officer’s EHSI began
driven hydraulic pump had failed. Pump, shut-off
‘swinging’ and flight idle unlock lights illuminated.
valve and case drain filter replaced, engine ground
Air turnback. Two ‘aux gen bus’ control relays and
runs and leak checks carried out. Aircraft returned
one emergency DC bus relay replaced.
to service. P/No: 570347.
P/No: M8353633003L.
Bombardier DHC-8-102 Hydraulic system main
Embraer ERJ-170 Cabin cooling system aircycle
shut-off valve leaking. SDR 510014380
machine seized. SDR 510014298
Hydraulic leak from the rudder area observed during
During taxi, cabin crew reported haze and a burning
daily inspection. Shut-off valve found to be leaking.
smell in the cabin, followed by cockpit warning ‘Pack
P/No: 997305.
fail 2’ on EICAS. No. 2 air cycle machine seized.
Bombardier DHC-8-102 Landing gear position Bombardier DHC-8-402 Cargo/baggage door P/No: 10007004. TSN: 11,083 hours/8755 cycles.
and warning system proximity sensor suspected shaft worn and damaged. SDR 510014386 Embraer ERJ-190-100 AC generation system
faulty. SDR 510014425 Forward baggage hold door warning light illuminated.
pump incorrect operation. SDR 510014353
During flight the weight on wheels (WOW) caution Air turnback. Damage to the guide lugs of the
Ram air turbine did not fully deploy during an
light came on. Air turnback carried out. PSEU read door and loose and worn over-centre mechanism.
operational check for scheduled maintenance.
out performed which indicated the LH WOW inboard Worn parts replaced and door rigged. TSN: 5937
No restriction could be felt in the release handle but
sensor fault. New proximity sensor installed and hours/6857 cycles.
re-stow pump return spring not functioning correctly.
functional checks carried out. Aircraft returned to
Bombardier DHC-8-402 Engine FADEC suspected Re-stow pump replaced, RAT system tested
service. P/No: 864202.
faulty. SDR 510014376 serviceable. P/No: 591447.
Bombardier DHC-8-106 Flight control system After selecting flap zero, bleeds on, and condition TSN: 11,068 hours/7505 cycles.
wiring broken. SDR 510014362 levers to 860, passing 1000ft, the No. 2 FADEC Embraer ERJ-190-100 APU core engine plenum
During pre-flight inspection stick shakers did not caution light illuminated. Air turnback. Investigation
smoke/fumes. SDR 510014423
activate during stall warning system test. Broken wires of fault codes revealed RH engine P2.2 valve and
Crew reported oil fumes in cabin (mostly aft area)
found at both stick shaker electrical plugs. LH engine internal failure of the FADEC unit.
- worse on takeoff and at top of climb. Extensive
TSN: 8196 hours/9470 cycles.
Bombardier DHC-8-314 Hydraulic system, main investigation found oil in APU inlet plenum. No. 2
shut-off valve leaking. SDR 510014382 Bombardier DHC-8-402 Hydraulic pump engine high stage valve and APU replaced.
During daily inspection hydraulic leak observed (electric/engine) burnt out. SDR 510014422 P/No: APS2300. TSN: 11,089 hours/8306 cycles.
from rudder area. Shut-off valve found to be leaking. Just after landing the No. 3 hydraulic pump caution Embraer ERJ-190-100 Hydraulic system main
P/No: 997305. light came on. The No. 3 isolation valve was activated
tube leaking. SDR 510014349
to check the system pressure, which jumped quickly
Bombardier DHC-8-315 Flight compartment Aircraft diverted due to loss of System 1 hydraulic
to 3600psi - well above the normal range. After
windshield cracked. SDR 510014438 quantity/pressure. ‘Hyd 1 LO QTY’ advisory and ‘HYD
shutdown there was an electrical smell in the aircraft.
During flight the RH front windscreen cracked ten 1 EDP FAIL’ advisory message on EICAS, then 20
Investigation identified failure/overheating of the No. 3
minutes after windshield heat had been changed minutes later ‘Hyd 1 LO PRESS’ caution. Leak traced
hydraulic system DC motor pump.
from warm up to normal. RH windshield replaced. to chafed engine-driven pump pressure line under
TSN: 11,802 hours/13,578 cycles.
RH windscreen heat controller also replaced as a clamp in LH pylon. Permaswage repair carried out.
precautionary measure. System tested satisfactorily Bombardier DHC-8-402 Ice/rain protection EDP replaced. P/No: 19005058401.
iaw 30-41-00-02. P/No: NP15790114. system distributor valve failed. SDR 510014411
TSN: 6,040 hours/1118 cycles. When ice protection was selected ‘on’ during flight
the de-ice pressure caution light illuminated and
the left outer tail boot remained inflated. Descended
from icing conditions as a precaution. Air turnback.
36
AIRWORTHINESS
Pull-out section

SELECTED SERVICE DIFFICULTY REPORTS ... CONT.

Fokker F.28 Mk. 0100 AC power Beech 76 Flight control system cover hole worn/ downlock microswitch had failed. Switch replaced and
distribution system contactor suspected elongated. SDR 510014355 gear swings carried out. P/No: 1CH16. TSN: 23,155
faulty. SDR 510014365 ‘This is the fifth BE-76 I have found with this defect. In hours. TSO: 23,155 hours.
At engine shutdown crew noticed no electrical one aircraft the head of the bolt pulled through due to
Cessna 550 Trailing edge flap control system
power available to any components off AC BUS 2. use of the elevators, with vibration on the pivot point
shaft broken. SDR 510014345 (photo below)
Auto cross tie had not tied the two busses elongating the holes. Engineering order to fit doublers
Shaft cracked and broken at drive pin hole. Believed
together. Final troubleshooting found a broken on each side.’ P/Nos: 16940005387/16940005388.
to be due to misalignment and constant flexing that
wire to be the problem. TSN: 14,933 hours.
induces stress in the shaft. Similar problem found
Fokker F.28 Mk. 0100 Brake stator cracked. Beech 76 Landing gear retract/extension system previously on Citation 550-0347. Reoccurrence
SDR 510014406 failed to extend. SDR 510014445 prevented by repositioning the flap drive gear box to
Upon arrival, crew advised that the No. 4 brake Landing gear selected down but only showed two allow stress-free alignment. P/No: 55651915.
temperatures were high. During inspection of the greens. Gear cycled many times, including a manual/ TSN: 10,704 hours/11,573 landings.
brake assembly, large deposits of brake dust and emergency extension, with the same result (nose gear
particles from the brake discs were found and the red). Communication with ground confirmed that the
inboard stator was also cracked. As a result of NLG was retracted, with doors closed. Pilot advised to
recent brake failures any unmodified units will be make a nose gear up landing on grass adjacent to the
removed from service and the scheduled inspection runway. Nose cone and propellers damaged.
interval of these units has been reduced.
Beech A36 Elevator control system cable worn
TSN: 3521 hours/6505 cycles.
and damaged. SDR 510014372
Fokker F.28 Mk. 0100 Cabin pressure controller On carrying out AD/Beech 36/54 found cable
selector panel suspected faulty. SDR 510014486 fatigued. P/No: 3652400023HW.
During descent the flight crew reported an inability
Beech E55 Landing gear wiring intermittent
to control the cabin pressure. Engineers found no
operation. SDR 510014448
logged faults showing and carried out an operational
During takeoff undercarriage remained in down
check with no defects evident. Jet pumps cleaned
position with three greens showing. Gear recycled
and cabin air filter replaced. Both outflow valves
several times with no result. Landed without incident.
found serviceable. Cessna TU206G Seat track cracked.
Engineering investigation found circuit breaker in
Gulfstream GIV Wing attach fitting corroded. open position. Circuit breaker re-set and retractions SDR 510014485
SDR 510014494 carried out. No faults apparent. Maintenance check FAA AD 87-20-03 R2 carried out. Two seat rails
During investigation of a fuel leak heavy corrosion flight revealed no faults. cracked due to normal wear. Cracked rails replaced.
was discovered on the left forward wing attach clothes P/No: 121040821.
Beech F33A Elevator control system cable worn
pin. LH and RH aft wing fuselage attach clothes pin GAF N22C Fuel selector/shutoff valve incorrectly
and damaged. SDR 510014293
fitting replaced during previous heavy maintenance rigged. SDR 510014319
Cable in elevator control system found to be worn
due to corrosion in 1998 (at 3800 hours). RH engine flameout on approach. Aircraft on final so
with some damage - one spike (found only by rubbing
Lear 35A Pitot/static anti-ice system splice joint finger nail on cable). P/No: 33524029. no effort made to restart engine. Fuel shut off and
burnt out. SDR 510014279 aircraft landed without incident. Investigation found
Cessna 152 Elevator tab control system cable one litre of fuel in each of the RH wing fuel cells, and
RH pitot heat circuit breaker tripped climbing
corroded. SDR 510014452 93.5 litres in the LH wing. (Pilot’s calculations
through 18,000ft. Investigation isolated fault to high
During scheduled maintenance rear elevator trim should have given a 50-litre reserve on each side)
resistance/burnt out splice in wiring behind pilot’s
control cable P/No: 0400107-30 found to be heavily Further investigation of the fuel system found that
instrument panel. Wires HE8A16-B to HE9A16-B.
corroded and worn. Elevator trim control system the fuel selectors were mis-rigged and the LH engine
Saab SF-340B Aileron control system actuator removed completely, revealing several worn areas. had been slightly feeding off the RH main tanks.
motor failed to retract. SDR 510014357 Area the cable runs in makes it difficult to inspect Fuel boost pump circuit breaker found to be popped.
During C check while carrying out the functional effectively. P/No: 040010730. P/No: 8BS103.
check of aileron disconnect unit the actuator failed
Cessna 172N Aircraft fuel distribution system Gulfstream 500S Landing gear retract/extension
to retract, resulting in no disconnect.
hose leaking. SDR 510014341 system rod end failed. SDR 510014274
P/No: 8618M2. TSN: 29,388 hours/35,795 cycles.
Small fuel weep noticed. Investigation found leak Failure observed after pilot selected undercarriage
Saab SF-340B Detection system wiring worn on a fuel supply hose that had deteriorated with age. down for landing. Undercarriage extended iaw
and damaged. SDR 510014446 P/No: S14956. emergency procedures with normal locked
During approach a ‘LH ENG FIRE’ master warning indications. After landing rod-end bearing found
Cessna 172N Wing, fuselage attach fitting bolt
came on 2-3 times intermittently and then stayed to have failed. Bearing still attached to bolt and
broken. SDR 510014460
on. LH engine shut down iaw crew procedures and remainder of rod end still attached to the actuator.
With the windscreen removed for replacement, the
aircraft landed safely. Short to ground on 135VP:P2 H Failure seems to have developed from grease nipple
forward spar carry through hat section and wing
wire WG500-20 found. Small split in inner insulation threaded area with fracture extending across the
attach points were inspected in detail. At the LH wing
allowed contact between the inner conductor and the rod end. Failure believed to be a result of fatigue.
spar attach point the upper outboard AN3-20A bolt
shield. P/No: 55T92112099. No documented history of rod end replacement.
(one of four) was found broken but still in place.
The broken bolt was removed and its hole was P/No: HMX60. TSN: 28,851 hours.
AIRCRAFT BELOW 5700kg
inspected with a borescope. No evidence of corrosion. Pilatus PC12 Fire detection system clip
Ayres S2R-G10 Vertical stabiliser attach Lower outboard bolt also removed and its hole damaged. SDR 510014451
fittings rivet sheared. SDR 510014492 inspected. Both bolts renewed. P/No: AN320A. During flight red fire warning indication for LH engine
During periodic 100-hourly inspection vertical fin TSN: 2709 hours/408 months. fire illuminated. Investigation found a broken bottom
found to be loose at the front spar attach point.
Cessna 172R Main landing gear attach section clip on the firewire under the LH exhaust. New clip
Rudder and vertical fin removed and attach fitting
bushing dislodged. SDR 510014342 P/No: 9751210099 installed.
found to be completely detached from the fin front
spar due to all fifteen MS20470AD4 rivets being During routine maintenance shock absorbent material Piper PA44-180 Nose/tail landing gear attach
sheared off. Attach fitting reinstalled using AN3-A (bushing) found to be dislodged and working its way section bushing broken. SDR 510014370
bolts iaw SB AG-45 Rev B. out on RH undercarriage leg. P/No: 05412024. During maintenance NLG trunnion noticed to be
P/No: 952675. TSN: 1520 hours. TSN: 1,692 Hours. very loose at the mounting pivot bolts. Further
Cessna 441 Landing gear position and warning investigation found flange of RH outboard bush
Beech 200 Navigation system EHSI failed.
system microswitch failed. SDR 510014437 broken away from the bush body. Inspection with
SDR 510014464
During preparation for landing the LH MLG failed a magnifying glass suggested failure could be
During cruise the pilot flying noticed the EHSI go
to indicate down and locked. Gear recycled without caused by corrosion. P/No: 67026011.
blank, accompanied by a burning smell. The PIC
success. Air turnback. Manual/emergency gear TSN: 1039 hours/2166 cycles.
isolated the EHSI circuit by pulling the circuit breaker
and the smell faded. Investigation continuing. selection resulted in positive gear down and locked
P/No: 6229681001. indications. Investigation revealed that the LH MLG
 37
Flight Safety Australia
Issue 86 May–June 2012

SELECTED SERVICE DIFFICULTY REPORTS ... CONT.

Piper PA-46-350P Nose/tail landing gear attach Lycoming TIO-540-AH1A Reciprocating engine Eurocopter AS-350B Main rotor gearbox
section mount broken. SDR 510014321 piston ring broken. SDR 510014378 bearing worn and damaged. SDR 510014436
During 100-hour inspection engine mount found Oil loss/consumption (oil breather blow by) Several severely corroded rollers on main
broken where NLG actuator attached to it. Engine progressively increased over approximately 50 hours. transmission main thrust conical roller bearing.
mount removed for weld repairs and hardness and No significant problems on initial compression Bearing cup also corroded and worn.
crack detection. TSN: 1499 hours. test. Internal visual inspection showed no defects. P/No: R4913. TSN: 7019 hours/8924 cycles.
Removed No. 5 cylinder and found broken oil control
SWRNGN SA227AC Autopilot main servo Eurocopter AS-365N Main rotor head damper
ring. No damage to piston or cylinder. Engine
binding. SDR 510014482 cracked. SDR 510014403 (photo below)
operated for long periods at lower power (down to
Pilot reported rudder pedals stiff to move. During daily inspection a frequency adapter/
40%). P/No: 14H21990. TSN: 504 hours.
Investigation found autopilot rudder servo and servo vibration damper was found with significant
slip clutch binding. Capstan clutch may have also ROTORCRAFT cracks (beyond limits). P/No: 365A31101925.
been binding, with evidence of wear on the capstan TSN: 585 hours/5 months.
drive gear. Rudder servo and capstan replaced. Agusta-Bell A109A Engine/transmission
P/No: 6222366002. coupling locknut broken. SDR 510014475
On removal of the engine-to-transmission driveshaft
SWRNGN SA227AC Flight compartment lighting the nut broke into two pieces. Suspected hydrogen
power supply faulty. SDR 510014481 embrittlement. Nut had Loctite 222 applied to
During flight the lighting circuit breaker popped, the threads when installed. Some nuts removed
following a strong smell of burning in the cockpit. had ‘A’ stamped into the side and others ‘R’.
Investigation found the E182 power supply to be P/No: MS21042L4.
the cause.
Power supply P/No: PS401 S/No: 8041259 replaced. Agusta-Bell A109E Rotorcraft cooling fan
bearing failed. SDR 510014278
SWRNGN SA227AC Hydraulic system main tube Pulley drive pin found sheared in two places on the
leaking. SDR 510014483 No. 1 engine oil cooler blower fan assembly. Drive pin
During flight the ‘R HYD PRESS’ warning light close to total failure. Possible cause a pulley bearing
illuminated, followed by the ‘L HYD PRESS’ warning failure. Same defect in the fleet on past locations.
light. Hydraulic pressure dropped to a very low Blower assembly replaced. P/No: 109045501101.
reading and then fluctuated. Investigation found a TSN: 1085 hours. TSO: 1085 hours. Kawasaki BK-117B1 Emergency flotation
hydraulic pressure tube in the RH engine bay chafed section shut-off valve inadvertent operation.
on the engine oil tank causing loss of hydraulic Agusta Westland AW139 Engine oil pressure SDR 510014335
fluid. Tube and both engine-driven pumps replaced. indicator fluctuates. SDR 510014315 Float valve inadvertently activated while installing
P/No: 27810322682. During flight, engine oil pressure on No. 1 engine nitrogen bottle assembly. Three people injured and
went from green to amber and fluctuated between 8.9 required hospital treatment. P/No: 2831240001.
SWRNGN SA227AT Instrument panel switch and 9.1 PSI. Other engine parameters normal. Aircraft
panel damaged. SDR 510014300 called PAN and diverted. Fault traced to water ingress Kawasaki BK-117B2 Main rotor blade cracked.
During cruise an electrical burning smell noticed in at an electrical connector. Helicopter had been SDR 510014330 (photo below)
the cockpit. Investigation found LH forward console operating in heavy rain. All connectors cleaned, Scheduled inspection found a main rotor blade
lighted panel showed evidence of arcing. Moisture dried and sealed in the engine wiring loom. with a crack through the leading edge erosion strip.
found under the console panel thought to have caused Blade and matched partner blade sent for further
the arcing and burning smell. P/No: 2719115091. Bell 206B3 Main rotor drive system oil tube maintenance inspection. Cracked blade unrepairable
loose connection. SDR 510014312 because roving spar cracked and delaminated at the
PISTON ENGINES After a short flight, small amount of transmission critical loop area. Other two blades subsequently
oil noticed down the side of the aircraft. Line from inspected. One also cracked at the critical loop area.
Continental TSIO520M Engine fuel pump
transmission oil filter to oil cooler had oil seeping P/No: 117151451. TSN: 3503 hours/104 months.
plunger worn. SDR 510014498 from both ends. Line had been incorrectly tightened
Pad on end of plunger worn prematurely. TSO: 3503 hours/104 months.
but this did not show up on engine ground runs.
Suspected material faulty. P/No: SL61544. P/No: 206040127001.
TSN: 46 hours/2 months. TSO: 2 months.
Bell 206L 1 Rotorcraft tail boom fitting cracked.
Lycoming O-360-J2A Magneto failed test.
SDR 510014346
SDR 510014442 Upper LH tail boom attach fitting found cracked
Pilot noted higher manifold pressure than normal during routine inspection. Bell Maintenance Manual
during cruise. Magneto check found an excessive 5-00-00, 5-28, Page 96 item 3. Fitting replaced iaw
RPM drop on a faulty left magneto. P/No: 106006141. Bell SRM. P/No: 206031329103S.
TSO: 192 hours.
Bell 206L3 Main rotor control bellcrank faulty.
Lycoming O-540-J3C5 Reciprocating engine
SDR 510014360 (photo below)
piston broken. SDR 510014408 Lower bearing in the bellcrank assembly loose,
During 100-hour inspection pieces of piston skirt possibly due to incorrect or no roller staking.
found in the engine oil suction filter. No. 3 cylinder Extra play on the connected control tube meant it
found to have the broken piston. Remaining five could have jammed on surrounding supports.
pistons found serviceable with no crack indications. P/No: 206001551001.
This is the third similar occurrence of cracked O-540-
MDHC 369F Fuselage main frame cracked.
J3C5D engine piston skirts. On one occasion an
SDR 510014326
engine had been incorrectly assembled with heavy-
Engine removed for turbine assembly change.
type piston pins installed with the lighter weight-type
Complete inspection of engine bay revealed the
piston. P/No: LW13396. TSN: 1503 hours.
cracked frame. P/No: 369H253213. TSN: 4945 hours.
TSO: 1503 hours.
Robinson R22BETA Engine/transmission coupling
Lycoming TIO-540-AH1A Engine fuel pump actuator motor suspected faulty. SDR 510014338
drive shaft failed. SDR 510014415 In cruise, pilot noted clutch light came on, indicating
Engine-driven fuel pump drive shaft failure on an a fault with the actuator re-tensioning the drive belts.
engine that had previously operated at 84% power. Light stayed on for more than six seconds
Only pump to fail since reducing cruise power to so the clutch circuit breaker was pulled and the
75%. P/No: 200F5002. TSN: 1155 hours. plane landed. Investigation found fuse to be blown.
Fuse replaced. P/No: A0511.
38
AIRWORTHINESS
Pull-out section

SELECTED SERVICE DIFFICULTY REPORTS ... CONT.

Robinson R44 Main rotor mast/swash plate PWA PW125B Turbine engine oil system PROPELLERS
retaining nut cracked. SDR 510014322 pressure loss. SDR 510014443
Hamilton Standard 33LF-325 Propeller
During 100-hourly inspection four of the nuts During climb a LH low oil pressure alert (single
securing the swash plate slider tube found to be chime) presented momentarily. LH oil pressure hub worn and damaged. SDR 510014284
damaged. One missing, two cracked in half, and fluctuating between 50-35 psi and oil temp up around (photo below)
one cracked. Nuts installed new during a main 120 degrees C. PIC decided to shut down the left Aircraft lost prop control during cruise. Prop feathered
transmission change on 18/11/2011. engine and continue the flight under single engine and aircraft landed without further incident.
Batch containing these nuts withdrawn from use. procedures. No evidence of oil leakage; oil level Prop bearings corroded and heavily galled. Partial
P/No: MS21042L3. TSN: 164 hours. normal. Extensive engine troubleshooting carried seizure appeared to be due to lack of lubrication of the
out as per OEM advice and maintenance manual. moving components within the hub.
TURBINE ENGINES Oil pump pressure relief valve found to be worn
Garrett TPE33110511D Turbine engine beyond limits and replaced.
accessory drive failed bearing. PWA PW150A Engine fuel and control drive
SDR 510014457 (photo below) shaft sheared. SDR 510014281
SOAP sample inspection found metal. SOAP During climb, around 8000ft, sudden loss of power
recommended again at 25 hours with normal results on No. 1 engine experienced with yaw to left and
and a recommendation from Honeywell (engine noise of engine winding down. PAN call made and
OEM) to carry out next SOAP as normal. Aircraft aircraft returned to base. Drive shaft for fuel metering
experienced major engine failure on takeoff/climb unit had sheared, resulting in engine ‘flameout’.
73 hours later, resulting in inflight engine shut down FMU, engine flow divider and high-pressure fuel
and single-engine landing. Bearing in accessory strainer also replaced as a precaution.
drive gearbox found to have failed, taking out TSN: 7395 hours.
associated drive gears and causing oil pump and fuel
control failure. P/No: 31035851. TSN: 1645 hours. PWA PW150A Turbine engine oil system
actuator failed. SDR 510014456 Hartzell HC-C2YK1 Propeller hub damaged.
During climb crew noted No. 2 engine oil temp
SDR 510014417
red and indicating 109 degrees C. QRH procedure
Propeller became slow to respond to RPM control
followed and temperature returned to normal.
inputs and failed to maintain constant speed during
Line maintenance inspection showed failure of the
climb/descent. Propeller had hydraulic lock due to
RH oil cooler air outlet flap actuator. Actuator
oil by-passing piston and seals, severe scoring of
replaced. TSN: 11,049 hours/13,585 cycles.
cylinder bore and damaged seals.
TSO: 2010 hours/2039 cycles.
Hartzell HC-C2YK1 Propeller governor
Rolls Royce TAY65015 Fuel control/
drive gear crack indication. SDR 510014430
turbine engines regulator suspected faulty.
(photo below)
SDR 510014420
Indication of crack found in drive gear while
On takeoff LH engine failed to accelerate with
carrying out MPI during overhaul of prop governor.
rising TGT. Aircraft taxied off the runway as normal.
P/No: C4191.
Inspection/check of the 7th/12th stage, non-return
valves found 12th stage in poor condition. Check
Garrett TPE3312201A Turbine engine reduction
valve and LH engine fuel flow regulator replaced;
gear planetary gearset worn and damaged.
engine throttle control rigged and leak checks and
SDR 510014347 power runs carried out.
Engine involved in a wire strike (9.4 hours after P/No: CASC509. TSN: 30,896 hours/29,708 cycles.
overhaul). Sudden stoppage inspection required TSO: 152 hours/136 cycles.
and carried out. Abnormal wear identified on the
sun gear (accessory gearbox reduction gearing). Rolls Royce TAY65015 Turbine engine turbine
P/No: 31010682. TSO: 9 hours/6 cycles. section guide vane damaged. SDR 510014385
Stage 3 low-pressure turbine nozzle guide vanes
GE GE90115B Engine (turbine/turboprop) bolt
found damaged during a routine inspection of LH
migrated. SDR 510014389 engine. Turbine casing also damaged. Damage
During disassembly of LH fan module as part of beyond limits as per Tay 650-15 engine manual.
scheduled maintenance (and incorporation of SB) Engine removed from service and sent to repair
variable bleed valve door clevis rod end linkage shop for investigation and report.
found to be missing its retaining nut. Bolt migrated P/No: TAY65015. TSN: 41,989 hours/35,777 cycles.
out but still holding linkage in place. Nut later found. TSO: 18,876 hours/18,023 cycles
It still had run-down torque and had probably
not been torqued in the factory. OEM notified. TMECA ARRIEL1S Engine (turbine/turboprop) EQUIPMENT
P/No: 2090M60P01. TSN: 14,239 hours/1215 cycles. contamination – metal. SDR 510014287
Rescue hoist suspected faulty. SDR 510014361
TSO: 14,239 hours/1,215 cycles. Engine chip light illuminated on return to base.
During a wet winch exercise with the rescue crewman
Investigation revealed metallic debris on chip
IAE V2527A5 Engine starter sparking. and patient in the water the combination hypo
detector, magnetic plugs for M01 and M05, and
SDR 510014318 strop floated open and away from the patient. Strop
engine oil filter. Engine oil system drained and
Sparks reported from No. 2 engine during start. reported to be structurally intact but it was replaced
flushed, oil filter replaced. Post-engine run inspection
No smoke or flames observed; engine parameters found more contamination. Engine changed; damaged as a precaution. P/No: RHS1433. TSN: 66 months.
remained normal. Starter motor replaced. engine awaiting analysis of debris.
P/No: 790425A6. TSN: 4463 hours/2284 cycles.
 39
Flight Safety Australia
Issue 86 May–June 2012

APPROVED AIRWORTHINESS DIRECTIVES

27 January – 9 February 2012 AD/A330/54 Amendment 1 - elevator servo-controls
- Cancelled
Turbine engines

AD/A330/103 Main landing gear pin W1 - Cancelled General Electric turbine engines - CF6 series
Rotorcraft
2012-0020 Time limits and maintenance checks 2012-02-07 - CF6-45 and CF6-50 series low-
Bell Helicopter Textron Canada (BHTC) 206 - ageing systems maintenance - ALS Part 4 - pressure turbine stage 3 disk inspection(s)
and Agusta Bell 206 series helicopters amendment Turbomeca turbine engines - Arrius series
CF-2011-44R1 Main rotor blade
Airbus Industrie A380 series aeroplanes 2011-0182R1 Engine fuel and control - P3 air pipe -
Eurocopter AS 355 (Twin Ecureuil) 2012-0026 Wings - wing rib foot - inspection inspection/modification
series helicopters 2012-0017 Fuel - feed tank 1 and/or 4 main and
AD/AS 355/61 Amendment 1 - starter generators - Equipment
standby sump fault light flickering - operational
Cancelled procedure/replacement Radio communication and navigation
2012-0022 Starting - starter generator - check/ equipment
replacement/modification Boeing 737 series aeroplanes 2012-02-08 TCAS software update for ACSS
2012-02-09 Duct assemblies - environmental TCAS equipment
Below 5700kg control system (ECS) - rework
Cessna 170, 172, F172, FR172 and 175
series aeroplanes
Boeing 767 series aeroplanes 10 – 23 February 2012
2012-01-06 Retrofit installation of drainage tubing
AD/CESSNA 170/81 Fuel return line - Cancelled and support structure - cargo compartment forward Rotorcraft
2012-02-02 Chafing of fuel return line assembly lower lobe Agusta A119 series helicopters
Cirrus Design SR20 and SR22 series aeroplanes Bombardier (Canadair) CL-600 (Challenger) 2012-0029 Tail rotor drive shaft - replacement
2012-01-11 Engine - disbonding of induction system series aeroplanes Agusta AB139 and AW139 series helicopters
air box seal(s) CF-2012-06 Bleed air leak detection system 2012-0030 Tail rotor blades - inspection/
Diamond DA40 series aeroplanes Bombardier (Boeing Canada/De Havilland) replacement
2012-0024 Power plant - turbocharger hose - DHC-8 series aeroplanes
inspection/replacement Below 5700kg
CF-2012-08 Power lever friction brake
Piper PA-31 series aeroplanes assembly discrepancy Beechcraft 33 and 35-33 (Debonair/Bonanza)
AD/PA-31/37 Amendment 11 - airframe CF-2012-07 Cockpit ‘Engine Fire, Check Fire series aeroplanes
retirement lives Detect’ warning and ‘Fuel Off’ handle lights - AD/BEECH 33/48 Amendment 1 - forward
failure to reset elevator cable
Robin Aviation series aeroplanes
AD/ROBIN/38 Amendment 1 - oil lines and oil British Aerospace BAe 146 series aeroplanes Beechcraft 35 (Bonanza) series aeroplanes
transmitter hoses 2010-0202R2 Landing gear - nose landing gear AD/BEECH 35/74 Amendment 1 - forward
2012-0018 - Oil system - oil lines - replacement main fitting elevator cable
Fokker F28 series aeroplanes Beechcraft 36 (Bonanza) series aeroplanes
Above 5700kg
2012-0023 Doors - main landing gear doors - AD/BEECH 36/54 Amendment 1 - forward
Airbus Industrie A319, A320 and A321 inspection/modification elevator cable
series aeroplanes
Fokker F100 (F28 Mk 100) series aeroplanes Beechcraft 50 (Twin Bonanza)
2011-0155R1 (Correction) - time limits and
2012-0023 Doors - main landing gear doors - series aeroplanes
maintenance checks - fuel airworthiness limitations -
inspection/modification AD/BEECH 50/34 Amendment 1 - forward
ALS Part 5 - amendment
elevator cable
Lockheed P2V (SP-2H) series aeroplanes
Airbus Industrie A330 series aeroplanes
2012-03-51 Wing - forward lower spar cap - Beechcraft 55, 58 and 95-55 (Baron)
AD/A330/4 Amendment 2 - THSA - operational
inspection series aeroplanes
life limit - Cancelled
AD/A330/5 Elevator servo control - operational Viking Air DHC-4 series aeroplanes AD/BEECH 55/98 Amendment 1 - forward
life limit - Cancelled AD/DHC-4/1 Cracking of upper engine elevator cable
AD/A330/8 Aileron servo-control - life limits - mount brackets Beechcraft 56TC (Turbo Baron)
Cancelled series aeroplanes
AD/A330/10 Spoiler servo-control unit - inspection Piston engines AD/BEECH 56/36 Amendment 1 - forward
- Cancelled Rotax piston engines elevator cable
AD/A330/15 Amendment 1 - flap rotary actuators - 2012-0019-E Engine oil - oil pump and attachment
Cancelled Beechcraft 95 (Travelair) series aeroplanes
bolts - inspection
AD/A330/29 ‘SAMM’ elevator servo-control - AD/BEECH 95/33 Forward elevator cable
Cancelled Gulfstream (Rockwell) 112 series aeroplanes
2012-02-10 Elevator spar - inspection

continued on page 42

TO REPORT URGENT DEFECTS

CALL: 131 757 FAX: 02 6217 1920
or contact your local CASA Airworthiness Inspector [freepost]
Service Difficulty Reports, Reply Paid 2005, CASA, Canberra, ACT 2601

Online: www.casa.gov.au/airworth/sdr/
40
AIRWORTHINESS
Pull-out section

Keep your boots on (and repaired)

They are out of sight, and possibly out of mind, but two little parts of a
Cessna aeroplane can cause big problems if allowed to deteriorate.

All Cessna fixed tricycle gear single-engine

aeroplanes have flexible boots covering the
sprung rods used to steer the nose wheel.
These boots are in the open, but in an evidently
seldom-inspected part of the aircraft (which
should, however, be scanned at every daily
inspection) – right under the nose, where
deterioration over a long period may not
be noticeable. In this location the boots are
subjected to hot gases from the engine exhaust,
fatigue as they flex for each steering input during
taxi, engine oil, grit blast – and the occasional
gravel strike in dirt strip operations.
Although the nose wheel steering rod boots
are ‘out of sight’ they have an important job to
do. They have to keep noise, exhaust gas and
slipstream out of the cockpit.

The pilot said he remembered thinking that he had to get control of the A post from a US Cessna 172 forum further
aircraft, but could not make his arms and hands move. After that he explains their importance:
remembered nothing until waking up in the hospital emergency room. ‘During a scan of instruments I noticed the
The accident, in California in 1994, should be etched on the mind of every carbon monoxide detector on the panel had
owner of a fixed tricycle gear single-engine Cessna piston aeroplane in changed from its normal yellow to dark blue.
Australia. (In other words: the 150 series, 170 series, 180 series and 200 Yikes! I had never seen this before, but it was
series) The same could happen to them if a simple component in an out-of- also the first time in quite a while flying with
the-way (but still right in your face) part of the aircraft is neglected. all vents closed, as it was pretty cool outside.
It was a dramatic flight, even when described in the clinical language of the I immediately opened both fresh air vents in
National Transportation Safety Board report: ’while being radar vectored over the wing roots as well as the floor vent (and
Los Angeles International Airport, the pilot performed several 360-degree was prepared to open the window if needed).
turns. In response to the controller’s inquiry, the pilot responded that he After a few moments the color [sic] of the
wanted to look at the city lights one last time before he left. The facilities detector returned to normal as the cabin was
monitoring the flight reported that the aircraft’s course was erratic over an flushed with clean air.
extended period of time, with the erratic behaviour becoming progressively ‘Upon return to the field we removed the
worse as the flight continued. The pilot seemed to have difficulty maintaining cowling, expecting to find some kind of
his orientation, drifted significantly off his assigned airways and headings, exhaust leak ... but there were no signs of
and had done several 360- and 180-degree turns. In the latter stages exhaust around the risers, stacks etc. As we
of the flight, the controllers reported that the pilot became increasingly crawled around the plane my airframe and
unresponsive to their attempts at radio contact and air traffic control powerplant engineer pointed out the steering
(ATC) instructions.’ link boots, which I thought were simply
The US Federal Aviation Administration concluded the pilot had suffered cosmetic and designed to keep dirt out.
carbon monoxide poisoning. Examination of the aeroplane found staining Well ... I learned they do a lot more than that.
around exhaust fitment clamps, a pinhole leak in one pipe and exhaust The pair on the plane were original leather
staining of the heat box and mixer duct. The nose wheel steering boots from ‘64 and it’s remarkable they’ve lasted
had holes worn in their material. 47 years.’
 41
Flight Safety Australia
Issue 86 May–June 2012

‘In the worst case, of an engine fire, a hole in the nose wheel
steering rod boot could be a route into the cockpit for smoke
and toxic gases,’ he says.

That’s why CASA airworthiness inspector,

Brad Cowan, was disturbed when in the course
of three weeks he found three pairs of faulty
boots, on three different aircraft, maintained by
three separate organisations.
‘It was an indicator that maintenance
organisations were not picking this issue up,’
Cowan says. He had no choice but to ground
the aircraft until the faulty boots were fixed.
‘In the worst case, of an engine fire, a hole in
the nose wheel steering rod boot could be a
route into the cockpit for smoke and toxic gases,’
he says.
Cessna steering rod boots have been the
subject of an Australian airworthiness directive.
AD/Cessna/108/53 was issued in 1978 and
instructed operators to make sure the boots
on a range of Cessna types were properly
clamped, in accordance with Cessna service
letter SE 78-37. The issue of using a boot
with a hole in it was apparently thought to be
self-evident.
Luckily for Cessna owners, if original Cessna
parts are not available there are several
aftermarket suppliers specialising in FAA-
approved replacement nose wheel steering
rod boots. These replacement PMA (Parts
Manufacturer Approval) boots are typically
made in a Kevlar/fibreglass blend fabric that
promises to be both tough and flexible enough
to resist the heat, vibration and temperature
extremes of use for a substantial service life.
Cessna owners and operators would be wise to:

i) inspect their nose wheel steering rod

boots and replace them if necessary
ii) fit a carbon monoxide monitoring patch For more information:
in the cockpit
Transcript of NTSB report into 1994 carbon monoxide crash:
iii) keep CASA informed of any problems http://tinyurl.com/c2j35xh
with nose wheel steering rod boots by
submitting a service difficulty report Cessna 172 club.com post on steering boot problem:
(SDR). http://tinyurl.com/d8rjlao
42
AIRWORTHINESS
Pull-out section

APPROVED AIRWORTHINESS DIRECTIVES ... CONT.

continued from page 39

Gulfstream (Rockwell) 114 series aeroplanes Turbine engines Diamond DA42 series aeroplanes
2012-02-10 Elevator spar - inspection 2011-0020R1 Landing gear - main landing
AlliedSignal (Garrett/AiResearch) turbine gear damper-to-trailing arm joints - inspection/
Mooney M20 series aeroplanes engines - TPE 331 series replacement
2012-03-52 Tail pitch trim assembly - inspection 2012-02-06 First stage turbine disk inspection
CFM International turbine engines -
Above 5700kg
Above 5700kg
CFM56 series Airbus Industrie A319, A320 and A321
Airbus Industrie A330 series aeroplanes 2012-02-03 Engine - fan blade - replacement series aeroplanes
2011-0199R1 Auto flight/flight controls -
2012-0032 Wings - outer wing main landing gear
flight control primary computer (FCPC) - Equipment support rib 5 fitting - inspection/modification
modification/replacement
Fuel supply and metering equipment Airbus Industrie A330 series aeroplanes
Boeing 737 series aeroplanes 2012-03-06 AVStar Fuel Systems (AFS) fuel 2011-0179R1 Landing gear - main landing
2012-02-14 Engine thrust reverser aero/fire seals servo diaphragm gear retraction actuator piston rod - inspection/
of the blocker doors
modification
Boeing 747 series aeroplanes 24 February – 8 March 2012 2012-0034 Landing gear - nose landing gear
2012-03-09 Rudder power control module (PCM) (NLG) retraction actuator - overhaul
Rotorcraft
Boeing 767 series aeroplanes Airbus Industrie A380 series aeroplanes
2012-03-02 Avionics cooling Eurocopter AS 332 (Super Puma) 2011-0058R3 Pneumatic - pylon bleed duct -
series helicopters inspection/replacement
Bombardier (Boeing Canada/De Havilland) 2012-0035 Electrical power - relay 16XK
DHC-8 series aeroplanes of emergency hydro-electrical power unit - Boeing 747 series aeroplanes
CF-2012-09 Loss of the 400Hz fixed frequency inspection/replacement 2012-04-09 Scribe lines - fuselage
system due to multiple inverter failures exterior - inspection
Eurocopter AS 350 (Ecureuil) series helicopters
Embraer ERJ-170 series aeroplanes 2012-0033R1 Fire protection - fire detection Embraer EMB-135 and EMB-145
2012-02-01 Wings - inspection for fuel leakage system - modification series aeroplanes
2012-03-02 Flight manual performance limitation
Lockheed P2V (SP-2H) series aeroplanes Eurocopter AS 355 (Twin Ecureuil)
2012-03-51 Wing - forward lower spar series helicopters Turbine engines
cap - inspection 2010-0023R2 Engine and main gearbox cowling
Allison turbine engines - 250 series
Piston engines Eurocopter EC 225 series helicopters AD/AL 250/86 Amendment 3 - compressor
2012-0035 Electrical power - relay 16XK adaptor coupling
Lycoming piston engines
of emergency hydro-electrical power unit -
2012-03-06 AVStar Fuel Systems (AFS) fuel CFM International turbine engines -
inspection/replacement
servo diaphragm CFM56 series
2012-03-07 Carburettor model HA-6 mixture Robinson R22 series helicopters AD/CFM56/31 High-pressure compressor -
control sleeve 2011-12-10 (Correction) Main rotor blade Cancelled
leading edge skin 2009-11-02 (Correction) High-pressure compressor
Teledyne Continental Motors piston engines
2012-03-06 AVStar Fuel Systems (AFS) fuel Robinson R44 series helicopters General Electric turbine engines - CF6 series
servo diaphragm 2011-12-10 (Correction) Main rotor blade 2012-03-12 Number 3 bearing packing inspection
leading edge skin
Superior Air Parts piston engines Pratt and Whitney turbine engines -
2012-03-06 AVStar Fuel Systems (AFS) fuel Below 5700kg PW4000 series
servo diaphragm 2012-04-04 Fuel metering unit Part Numbers (P/Ns)
Beechcraft 55, 58 and 95-55 (Baron) 53T335 (HS 801000-1), 55T423 (HS 801000-2) and
series aeroplanes 50U150 (HS 801000)
2011-27-04 (Correction) Airspeed indicator

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 43
Flight Safety Australia
Issue 86 May–June 2012

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44
FEATURE
Sharing the sky

Sharing
the sky Pilots used to the apparent security of enclosed aircraft may find
microlights hard to take seriously. That’s their mistake: a modern

...trikes
microlight can cruise at up to 80 knots, fly at up to 10,000 feet
(with a very hardy pilot, admittedly) and, contrary to popular belief,
is allowed in controlled airspace, if appropriately equipped.
Weight shift microlights, powered hang gliders, or trikes as they’re
usually known, evolved from hang gliders in the late 1960s, but the
concept of weight shift control is as old as aviation. Otto Lilienthal,
the German glider pioneer, first developed it in the 1890s.

Microlight trikes have evolved from There are about 520 trikes in Australia, the overwhelming majority
of them factory- built aircraft. They range from single-seater
lightweight platforms used to tow hang
machines weighing 70kg empty, to tandem two-seaters with a
gliders into the air into popular light maximum take-off weight of 450kg, electric trim, glass cockpit
touring aircraft, with distinctive handling and a range of 379nm. Prices for new trikes range between
characteristics $19,000 and about $80,000.
 45
Flight Safety Australia
Issue 86 May–June 2012

Larger trikes are powered by various forms of the Ground steering is billycart-style, with a prod from
ubiquitous Rotax 912 series four-stroke engine and the left foot resulting in a turn to the right. Another
can have up to 100hp at their pusher prop. They have difference: primary engine control is by car-style
a distinctive flight envelope that any pilot sharing the foot throttle on the right foot pedal, with nose wheel
circuit with a trike should know about: as high drag, but braking on the left. An aeroplane-type hand throttle
also high power-to-weight aircraft, trikes may fly slowly, can be used as a cruise control.
but they climb and descend quickly.
Pilots with certificates issued by the two bodies that
Compared to a small general aviation aeroplane, a trike administer trikes—the Hang Gliding Federation of
will climb more steeply in the circuit and may begin its Australia (HGFA) and Recreational Aviation Australia
descent later than a GA type. This characteristic is also (RA-Aus) are allowed to fly in class G airspace
the result of a trike flying technique that carries over without a radio. However, they must conform to the
from the days when most were equipped with two- requirements of CAR 166 near certified and registered
stroke engines of less than admirable reliability. They aerodromes, meaning they must carry VHF radios—
were particularly prone to seizure from shock cooling, and the pilots must be appropriately trained and must
closed-throttle oil starvation and other mysterious use them. If they carry and use transponders they can
ailments if throttled back for a conventional descent. fly in class E airspace.
To avoid these, trike pilots were taught to make high, Trikes fly legally in the same airspace as Dash 8s in
powered approaches until they were sure of reaching Coffs Harbour, NSW, and Boeing 737s in Ballina, NSW.
their landing place—only then would they reduce power. Slower trikes with cruising speeds of 55 knots or less
fly a 500 feet circuit, but the more powerful trike types
Although modern four-stroke engines are much more
use a 1000 feet circuit, as specified in CASA’s non-
reliable (as are modern water-cooled and oil-injected
towered aerodrome procedures.
two strokes) many trikes still use this approach style.
Other flying techniques seem downright weird to fixed- Properly equipped trikes, flown by properly
wing sensibilities. Trikes are almost immune to spinning, qualified pilots fly in the circuit just as safely
but can develop an equally deadly condition—tumble. as GA aircraft, Ungermann says, adding that
A trike tumbles if a downwards-pitching moment—such trikes have advantages in visibility.
as a startled pull-back on the control bar—is induced
aggressively at the point of stall. This makes the trike Their straight and level visibility is unmatched, and
pitch forward until it becomes inverted. Once entered, although trikes are high-wing aircraft, the wing’s
a tumble is non-recoverable. The passenger pod acts sweep and the pilot’s forward seating position give
as a pendulum to keep the tumble going until the aircraft good visibility in turns.
hits the ground. Stall recovery technique consists of
Otherwise, trikes are subject to the same flight
letting the aircraft fly itself out of the stall with minimal
restrictions as similarly equipped light sport aircraft.
pitch control input and application of power.
They are allowed to fly over built-up areas, but are not
Trikes are becoming more popular, says CASA allowed below 500 feet unless landing or taking off, or
sport aviation specialist and former trike instructor, flying over private property with the permission of the
Lee Ungermann. owner. Trike pilots registered with RA-Aus need a low
level endorsement to fly below 500 feet. Trikes usually
Most trikes operate outside controlled airspace in
fly between 500 feet and 5000 feet, although they may
class G airspace, but trikes equipped with approved
be found at up to 10,000 feet, Ungermann says.
altimeters, air speed indicators, transponders and radios
are allowed to fly in class C and D controlled airspace— Trikes are unique in being administered by two
if the pilot also holds a current general aviation licence. organisations. In the past some unscrupulous pilots
have exploited this by changing organisations if
Trike controls work ‘backwards’ compared to
faced with disciplinary action. A memorandum of
conventional aeroplanes, due to their weight shift
understanding (MoU) between the HGFA and RA-Aus
steering control. To raise the angle of attack on a trike
will make this a thing of the past. Each administering
the pilot pushes the control bar forward, and vice
organisation will require the other to provide information
versa. To turn left the pilot moves the bar to the right,
on any transferring member before that person is
effectively leaning into the turn.
accepted. The MoU will also standardise flight training
and examinations between the two organisations.
46
CLOSE CALLS
How slow can that baby go?

©Lockheed Martin

How slow As a former SR-71 pilot, and a

professional keynote speaker, the
truly loved speed and effortlessly
took us to Mach numbers we

can that
question I’m most often asked is hadn’t previously seen.
‘How fast does that SR-71 fly?’
So it was with great surprise,
I can be assured of hearing that
when at the end of one of my

baby go?
question several times at any
presentations, someone asked,
event I attend. It’s an interesting
‘What was the slowest you ever
question, given the aircraft’s
flew in the Blackbird?’ This was
proclivity for speed, but there really
a first. After giving it some thought,
isn’t one number to give, as the jet
One of the world’s would always give you a little more
I was reminded of a story that
I had never shared before, and
most sophisticated speed if you wanted it to. It was
relayed the following:
and secret spy planes common to see 35 miles a minute.
Because we flew a programmed I was flying the SR-71 out of RAF
gives onlookers, and Mach number on most missions, Mildenhall, England, with my
its crew, an experience and never wanted to harm the back-seater, Walt Watson. We
to dine out on, as plane in any way, we never let it were returning from a mission over
Brian Shul tells. run out to any limits of temperature Europe and the Iron Curtain when
we received a radio transmission
or speed. Thus, each SR-71 pilot
had his own individual ‘top’ speed from home base. As we scooted
that he saw at some point on some across Denmark in three minutes,
mission. I saw mine over Libya, we learned that a small RAF base
when Khadafy fired two missiles in the English countryside had
my way, and max power was in requested an SR-71 flypast. The
order. Let’s just say that the plane air cadet commander there was
 47
Flight Safety Australia
Issue 86 May–June 2012

CruisES ABOVE a former Blackbird pilot, and told me I had better cross-check since ‘the pass’. Finally, Walter
MACH 3 (3 times thought it would be motivating for the gauges. As I noticed the looked at me and said, ‘One
the speed the young lads to see the mighty airspeed indicator slide below hundred and fifty-six knots. What
of sound) SR-71 perform a low approach. 160kts, my heart stopped and my did you see?’ Trying to find my
No problem, we were happy to adrenalin-filled left hand pushed voice, I stammered, ‘One hundred
do it. After a quick aerial refueling two throttles full forward. At this and fifty-two’. We sat in silence for
TOP SPEED over the North Sea, we proceeded point, we weren’t really flying, a moment. Then Walt said, ‘Don’t
WAS excess of to find the small airfield. but were falling in a slight bank. ever do that to me again!’ And I
2,193 miles
Just at the moment when both never did.
PER HOUR AT AN Walter had a myriad sophisticated
ALTITUDE
afterburners lit with a thunderous
navigation equipment in the back A year later, Walter and I were
of oVER 85,000 FT roar of flame (and what a joyous
seat, and began to vector me having lunch in the Mildenhall
(BReaks DOWN to feeling that was), the aircraft flew
toward the field. Descending Officers’ Club, and overheard an
ABOUT 35 MILES out into full view of the shocked
to subsonic speeds, we found officer talking to some cadets
PER MINUTE) observers on the tower. Shattering
ourselves over a densely wooded about an SR-71 flypast that he
the still quiet of that morning, they
area in a slight haze. Like most had seen one day. Of course, by
now had 107 feet of fire-breathing
former WWII British airfields, the now the story included kids falling
MATERIAL titanium in their faces as the
one we were looking for had a off the tower and screaming as
CONSTRUCTION plane leveled and accelerated, in
OF TITANIUM small tower and little surrounding the heat of the jet singed their
full burner, on the tower side of
ALLOY (ABOUT infrastructure. Walter told me we eyebrows. Noticing our HABU (the
the infield, closer than expected,
93% OF THE were close and that I should be SR-71’s nickname) patches, as
maintaining what could only be
PLANE’S EMPTY able to see the field, but I saw we stood there with lunch trays in
WEIGHT) described as some sort of ultimate
nothing. Nothing but trees as far our hands, he asked us to verify
knife-edge pass.
as I could see in the haze. We to the cadets that such a thing
got a little lower, and I pulled the Quickly reaching the field had occurred. Walt just shook his
BLACKBIRDs throttles back from the 325kts boundary, we proceeded back to head and said, ‘It was probably
carry 12,200 we were at. With the gear up, Mildenhall without incident. just a routine low approach; they’re
gallons anything under 275 was just We didn’t say a word for those pretty impressive in that plane’.
of fuel uncomfortable. Walt said we were 14 minutes. After landing, our Impressive indeed.
practically over the field but there commander greeted us, and we
Little did I realise after relaying this
was nothing in my windscreen. I were both certain he was reaching
NITROGEN IS USED experience to my audience that day
banked the jet and started a gentle for our wings. Instead, he heartily
TO PRESSURISE that it would become one of the
circling manoeuvre, in the hope shook our hands and said the
THE FUEL TANKS, most popular and most requested
of picking up anything that looked commander had told him it was
PREVENTING stories of my public speaking
ACCIDENTAL VAPOR remotely like a field. the greatest SR-71 flypast he had
career. It seems ironic that people
IGNITION ever seen, especially as we had
Meanwhile, below, the cadet are really interested in how slowly
surprised them with a precise
commander had taken the cadets the world’s fastest jet can fly.
manoeuvre that could only be
up on the catwalk of the tower in
described as breathtaking. He Regardless of your speed,
MEASURES order to get a prime view of the
APPROX 99 FEET said that some of the cadets’ hats however, it’s always a good idea
flypast. It was a quiet, still day
by 55 FEET, were blown off and the sight of to keep that cross-check up ...
with no wind and partial gray
HEIGHT OF 18 FEET the planform of the plane in full and keep your Mach up too.
overcast. Walter continued to
afterburner dropping right in front Brian Shul has had a 20-year
give me indications that the field
of them was unbelievable. Walt and career as an Air Force fighter
should be below us, but in the
BLACK PAINT I perfectly understood the concept pilot. After being shot down in
overcast and haze, I couldn’t
CONSISTS OF of ‘breathtaking’ that morning, Vietnam he spent over a year in
see it. The longer we continued
HEAT REFLECTING and sheepishly replied that they
to peer out of the window and a burns ward. His comeback
PIGMENTS had just been excited to see our
CONTAINING circle, the slower we got. With our story culminated with flying the
low approach. SR-71, which he describes in
MINUTE IRON power back, the waiting cadets
BALLS heard nothing. As we retired to the equipment his book Sled Driver. Brian is
room to change from spacesuits to also an author and is known
I must have had good instructors
flight suits, we just sat there—we for his photography, particularly
in my flying career, as something
hadn’t exchanged a single word of nature.

SR-71 Blackbird facts sourced from www.aero.com./museums/US_space_and_rocket/wmuusr04.htm

 A e ro bat
48 ion
CLOSE CALLS
Aerobatic assumption

mp t
ass u
ati c
er o b
on A
Aerobatic assumpti
Name withheld by request

Just over a decade ago I was a Grade 2 He rushed the wingover, taking the nose just a little short of the required
instructor, working at a flying school in Canberra. attitude, and then diving too steeply for the loop entry. We were about to
I was approached by a gentleman who asked overspeed the prop, so I nudged the throttle back a little to keep the revs
if he could do some aerobatic training in our under the limit. As he pitched up—at nearly 5g—he rammed the throttle
Decathlon, and have me sign him off for a solo hard forward and we sailed over the top of the loop without any relaxation
hire and fly. I’ll call him Ron, because after all of backpressure. This was not particularly surprising, and I was really
these years I honestly cannot remember his questioning those 3000 hours!
name. I asked Ron about his licensing, flight
A couple more attempts, and we were beginning to get the idea, so I thought
time etc. and discovered that he was a RAAF
I’d introduce the aileron roll. Taking over, I pattered another wingover, and
pilot, currently working in Russell Offices, and
then demonstrated the roll. Ron said he understood what I was after, so I
not particularly current. However, he had flown
handed over to him to have a go—something I promptly regretted.
Winjeels, Macchis and Iroquois among others,
and had nearly 3000 hours, so I felt pretty Ron’s wingover was again too shallow, his pitch down too steep, and the
comfortable that we would be OK. airspeed definitely too high as we finally pitched up to start the roll. I should
have taken over and stopped the manoeuvre before it got any worse, but I
I briefed Ron on the general handling and speeds
underestimated Ron’s ability to frighten me.
of the Decathlon, and then briefly discussed
wingovers, loops and aileron rolls. He had no He pitched the nose to the horizon—too low by about 10°—and then
questions, so we signed out the keys, and walked started to roll. By the time we were inverted, even Ron could see that he had
to the aeroplane for the pre-flight walkaround. messed it up. However, his fix was something to behold. Having slowed the
Ron was affable, and obviously keen to go solo in roll rate to almost zero, Ron did the one thing he shouldn’t—and I was sure
this little beastie, but tended to rush ahead a little he wouldn’t—he pushed! Unfortunately, he was also a little more forceful
of my instruction. I had to rein him in a little at than he should have been, and we both lost our headsets as the g-meter
times, and get him to work through the checklist registered minus three! I was trying to take control, but because neither of
more thoroughly. us had our headset any longer, I was yelling, and trying to overpower Ron
on the controls. The roll began again and we were beginning to recover. By
I talked him through the take-off and climb.
the time we got to wings level, we were still nose low and the little Decathlon
He was clearly rusty, as we were hardly ever
was beginning to accelerate.
in balance, and the airspeed varied 10 knots
either side of the designated climb speed, but I’m not certain which of us had initiated the roll, though I certainly had tried
he was improving nicely by the time we arrived to, but now Ron sprang to life once more and pulled hard on the stick. This
at the training area. I was pleased with his time we pulled 5g positive, and the poor, abused little Decathlon finally
improvement, but beginning to wonder about his decided that enough was enough! The snap roll was something to behold,
3000 hours of experience! I had flown with some given that it occurred about 30kt faster than normal. I wasn’t particularly
excellent military pilots and he wasn’t reflecting surprised with the roll, but it totally fazed Ron, and he froze on the controls.
their high calibre. Nevertheless, we continued This time, I punched his shoulder and yelled at the top of my voice, and he
with the sortie as planned. I demonstrated a finally got the message and released the stick. I took over and recovered
wingover and loop, and then had Ron take over from the unusual attitude, then turned the nose of the aircraft back towards
and try the same. the airport.
tic assump
tion 49
Flight Safety Australia

Aer
Issue 86 May–June 2012

oba
tic a
ssum
ption
Aerobatic assumption

We both found our headsets and donned them once again, but the trip accept everything a student says. We all have
back to the airport was made pretty much in silence, as we were both an ego, and some of us find it difficult to admit
deep in thought. I had some serious doubts about Ron’s experience, and I a lack of experience, currency or ability. I should
wasn’t about to continue the sortie until the aeroplane had been checked not have automatically assumed that Ron was up
30˚ out. I didn’t think it was damaged in any way, but I wasn’t certain that the to the task, but instead should have given him a
Decathlon could handle another roller-coaster ride. I was also wondering just full brief on the principles and considerations of
how I would go about the debrief. By the time we arrived in the circuit, I had that particular sortie. Then, having spotted the
30˚ calmed down somewhat and handed the aircraft back to Ron for the landing. first clue that things just weren’t as described,
30˚
I should have stopped the sortie immediately,
He was keen to try some circuits and I let him have a go, but to say that he
and given more instructions, or even gone back
30˚ didn’t scare me more than a little would be a lie. At least we didn’t break
to the airport for a thorough briefing. I should
the undercarriage. Three circuits were enough for me though, and we finally
have noticed a number of clues in the first few
went home. As we taxied clear of the runway, I was staggered when Ron
manoeuvres, but I’d been misled by Ron’s
suggested that he would only spend 30 minutes in the circuit! He expected
military background and assumed he would
to be going solo, in spite of all that had happened in the past 45 minutes.
be like the other military pilots with whom I’d
I had to break it to him that he wasn’t going solo, and that we needed to talk.
flown previously.
I felt bad as I tried to explain his many mistakes, and remind him that he
Subsequent inspection showed that the Decathlon
clearly hadn’t understood my instructions whilst in the aircraft. The one
had not suffered any damage, and was in every
question on my mind though, was just how many hours he really had,
way serviceable. However, it has to be said, we
because it clearly wasn’t what he had told me. It all made sense when he
were both very fortunate not to have broken the
told me that he had last flown a fixed-wing aircraft over 15 years ago, and
aeroplane, or killed ourselves. I don’t know about
the majority of his 2600 hours 120˚had been in helicopters!
Ron, but I certainly learned a worthwhile lesson
What did I learn from this experience? Well, for one, I learned not to simply that day.

120˚
ever had a 120˚

CLOSE CALL? 120˚

Write to us about an aviation incident or

accident that you’ve been involved in.
If we publish your story, you will receive

$
500 Write about a real-life incident that you’ve been involved in, and send it to us via
email: [email protected]. Clearly mark your submission in the subject field as ‘CLOSE CALL’.

Articles should be between 450 and 1,400 words. If preferred, your identity will be kept confidential. Please do not submit articles regarding events that are the
subject of a current official investigation. Submissions may be edited for clarity, length and reader focus.
50
CLOSE CALLS
Disciplined to the end

Disciplined to the end

The principles a World War II air force pilot
drilled into his son ended up saving them both,
Mark Baker writes
 51
Flight Safety Australia
Issue 86 May–June 2012

In February 2003, my father and I had taken delivery of our At around 100 feet on final and still a few hundred metres
1962 Cessna 172. I had been flying with my father continuously from the end of the runway, checks complete, a bit low in
since 1964 and we had decided to go back to basics with this the slot, full flap, I had about 2000rpm on the clock, dragging
purchase and just enjoy our weekend jaunts. the Cessna to the threshold against those huge flaps and
a headwind.
My father had inflicted his training on me since I had been able
to get into the aeroplane under my own steam. He was ex 2 In my peripheral vision I could see dad lean forward as if to
Squadron RAAF, with wartime hours in Hudsons, Liberators and pick something up off the floor. I said, ‘what are you doing?’
B-25s. He then flew with Qantas in the 50s and 60s and was an No answer. The controls suddenly became heavy and I had
unrepentant fanatic for procedures and checks. This gave me trouble in holding attitude. Eventually (only micro-seconds,
the grounding he saw fit in aviation 10 years before I gained my but it felt much longer) I had to do something. I reached
restricted private pilot’s licence on my 17th birthday. for dad and realised he was semi-conscious and vomiting,
but because he was so far back from the yoke his head
‘Aviate, navigate, communicate,’ was his motto, and I had fallen down to his knees and pushed the yoke forward.
heard this around aerodromes all my life. Sitting slightly in front of him I was struggling to lift his weight
and push him back. When I did, the force I was applying to
He also always said I should be prepared in case he became
the control column was allowed to reign free. The nose of
incapacitated, which was a bit of a worry when I was only 15
the Cessna pitched up and the airspeed decayed. I pushed
and flying with my relatively young 52-year-old father.
forward to recover attitude. The sound of the aircraft told me
Over years of aircraft ownership we have always made certain I was slow. I made a grasp for the throttle, then back to dad
that we understood the systems in our aircraft and operated to stop him from slumping forward again. I went through this
them in strict accordance with regulations and manufacturer’s cycle a few times before we were over the runway. I made one
handbooks. We had never had an incident, let alone an last grab for the throttle, closing it and touching down about
accident. We had only done one other flight in our ‘new’ Cessna half way up the strip. I pulled off as soon as I could to clear
and so decided we should get to know it a little better. the strip and get dad out of the aircraft. I was shaking.
Late in February 2003 we planned to take our Cessna from Upon reflection, and it still hurts to remember this, I guess
Warnervale, NSW to Cessnock for a short flight and some that all the time he spent training me saved the day.
circuits at each end. My father, now 82, and still fully qualified I aviated, which kept the aircraft flying. No need to navigate
and medically fit, flew the first leg to Cessnock. Upon arrival or communicate. It just came naturally. Lucky that the old
he went through his checks like so many thousands of times Cessna had such a slow stable envelope, and that I had had
before, joined circuit and pulled off two textbook touch and gos, the chance to experience it just moments earlier.
followed by a ‘group captain full stop’.
It still took me some time to get over what had happened.
We parked, shut down and swapped seats, so I was now in I know, because when I refuelled the aircraft I did it in reverse
the left-hand seat. We are both tall, but dad had longer legs order to what we had done for years, which meant that I did
than me, so I always had to move the seat forward and dad not see the stepladder I had left under the port wing. I started
would move the right-hand seat back, which meant I was sitting up, taxied off and ran over a perfectly good aluminium ladder
slightly in front of him. with the port undercart. I had ignored years of procedure.
Following procedures, and becoming more familiar with the My father, Bill Baker, died less than eight weeks later from
aircraft, I did my radio calls, lined up to a clear circuit pattern cancer of the stomach, which had gone undiagnosed until
and departed for Warnervale. On the way back I performed a that flight. But it wasn’t his last flight. On a Saturday morning
couple of steep turns and stalls, both dirty and clean, in the near the end we went up again in the Cessna that had saved
Warnervale training area. This particular 172 had very basic both our lives.
instruments and only one VHF radio, and at the factory weight
The following Monday he was gone.
when manufactured, was very light. According to the flight
manual it should stall at 43kt with full flap. To my amazement
this figure was correct and the aircraft still had full but sluggish
control at this speed and showed no signs of being twitchy. We
looked at each other and realised we had bought exactly what
we wanted.
I joined the circuit at Warnervale, landing slightly uphill into the
north. The weather was good for flying with a north-east wind
and a little turbulence coming off the trees close to the runway.
 Transport safety in
plain English
Every time we investigate an accident or

investigation report that details the sequence

of events of the occurrence along with our incidents
While our investigation reports are mainly A recent series of air
written for audiences with particular industry
has prompted the
for the wider community. For example, our ATSB to begin a safety
research investigation
to get a better
due to a rare computer glitch, were highly understanding of
relevant to both the operator and the travelling how, where and why
public. With more than 60 passengers injured these occurrences are
as a result of not wearing a seatbelt during happening.
Illustration of radar
the pitch-down, one of the obvious safety The research
messages was the importance of buckling up. investigation will
To better share these important safety
(BOS) and losses of separation assurance (LOSA)
will soon be including a one-page ‘Safety reported between 2008 and 2011. As part of
the investigation, the ATSB will compare these
investigation report. Written in plain English, occurrences against the number of aircraft
the Safety Summary simply describes: what movements and look for occurrence ‘clusters’
happened; what we found; what’s been done geographically and over time.
As well as the safety research investigation,
Of course, we will continue to produce high- the ATSB is currently investigating 11 BOS and
quality, comprehensive reports for all our LOSA-related incidents. The ATSB is reviewing
investigations. The Safety Summary will be an
additional page to quickly and concisely inform investigations and occurrence data to see if there
the travelling public and time-poor aviation
professionals.
and competency assessment in compromised
We welcome your feedback on our separation recovery techniques.
Safety Summaries. Please email us at
[email protected] if you have any
comments. will immediately bring them to the attention of
AirServices Australia.
The safety research investigation is expected to
be completed during the third quarter of 2012. To
keep abreast of any developments in the ATSB’s
investigations, you can follow @atsbinfo on Twitter
Martin Dolan
or visit the ‘Latest Investigations & Reports’ section
24 Hours Chief Commissioner
1800 020 616 on www.atsb.gov.au 
Web
www.atsb.gov.au
Twitter
@ATSBinfo Erratum: In the last issue, the article covering Investigation
Email AO-2009-012 incorrectly referred to the aircraft as an Airbus
[email protected] A380. It was in fact an A340.
ATSB investigation AO-2010-019

A fatal accident in the Northern Territory his workload and made control of the
has shown the value of using simulators
not restore power to the left engine
to discontinue the manoeuvre. The
few seconds available before the
On 22 March 2010, an AirNorth Embraer
aircraft became uncontrollable were
S.A. EMB-120ER Brasilia aircraft took
off from Darwin Airport, Northern
and deliberation before resolving the
situation.
to revalidate the command instrument
Simulated engine failures on takeoff
have been a routine part of pilot training Aerial view of the accident site
was under the command of a training
and checking captain, who occupied the and checking for decades and there
have been numerous accidents during The operator was preparing to move
copilot’s seat. The takeoff was to include
pilot training and checking to an EMB-
a simulated engine failure.
a turboprop aircraft during asymmetric 120 simulator before the accident
Witnesses reported that a few moments at Darwin Airport. Shortly after the
training in Australia happened in
after the aircraft became airborne, it accident the operator’s simulator training
1954. More recently, the ATSB and
rolled and diverged left from its take- requirements were approved and it
its predecessor the Bureau of Air
off path. As they watched, the aircraft has since completed transitioning the
Safety Investigation have published
continued rolling left into a steep nose- majority of its EMB-120 training and
several reports on accidents and
down attitude until it crashed. Both pilots
serious incidents that occurred during
died. sequences, to the simulator facility.
In the subsequent ATSB investigation, aircraft. The element of risk with such The investigation into the fatal accident
airborne practice is nothing new. at Darwin Airport did not identify any
establish the circumstances leading up organisational or systemic issues
‘In the past 20 years, there have been
to the accident. The data showed that that might adversely affect the future
three fatal twin-engine aircraft accidents
the pilot in command (PIC) had retarded safety of aviation operations. However,
following asymmetric thrust after takeoff
or a go-around,’ notes Stuart Godley,
than selecting zero thrust, to simulate asymmetric training and the importance
Manager of Research Investigations
an engine failure. That introduced a of the Civil Aviation Safety Authority’s
and Data Analysis at the Australian
simulated combined failure of the left efforts to mandate the use of simulators
Transport Safety Bureau. ‘However,
engine and propeller autofeathering
asymmetric exercises on takeoffs or
system and resulted in the left propeller
‘windmilling’. addition, the accident reinforces the
fatal accidents in the past 20 years.’ The
The increased drag from the windmilling good news is that in most cases those importance of appropriate operator
propeller increased the control forces exercises, as they existed, should no procedures, and pilot awareness of the
required to maintain the aircraft’s longer be necessary to be conducted in potential hazards and risk mitigators
real aircraft.
the speed to decrease and the aircraft asymmetric training and checking.
High-quality simulators have allowed
to bank toward the inoperative engine.
most training and checking on air
Additionally, he increased power on AO-2010-019 is available on the ATSB
transport aircraft to be transferred to
the right engine, and engaged the yaw website www.atsb.gov.au 
the safety of ground-based facilities.
damper in an attempt to stabilise the
AirAsia X takes action to airspace. The ATSB’s investigation to conduct a go-around. On the second
found that while those operational approach to land, and after turning
improve safety
non-compliances occurred prior to the
ATSB investigation AO-2010-027

Aircraft operator AirAsia X has taken approaches and not below 1,200 ft above As the copilot increased the aircraft’s
action to address safety issues in aerodrome height, they were indicators pitch attitude, the stickshaker activated
its practices after two incidents of of a minor safety issue regarding the for about two seconds. Following
operational non-compliance. These recovery actions, another go-around
incidents occurred on 4 and 29 May was conducted. The third approach was
2010, and involved the same Airbus not adequately equipped to manage conducted by the pilot in command at
A330-343E aircraft being operated on an airspeed that was about 15 kts higher
scheduled passenger services from approaches in other than autopilot than the previous approaches.
Kuala Lumpur to the Gold Coast. managed mode. The investigation found that the
In response, AirAsia X made changes to stickshaker activations were primarily the
conduct the approach using the aircraft’s result of an incorrect approach speed.
autopilot in ‘managed mode’. That mode instrument approaches, including a The approach speed generated by the
policy recommending a maximum of
planned route, complying with the lateral two approaches before diverting to an based on a landing weight that was
and vertical navigation requirements for alternative airport. The operator also
the programmed approach procedure. developed a simulator training session
However, when the autopilot did not had inadvertently entered the aircraft’s
Coast approaches and emphasised the operating weight instead of the aircraft’s
anticipated, the crew switched to preference for pilots to conduct managed zero fuel weight into the FMS.
‘selected mode’ and continued the Of course, this is not an unusual
approach. In selected mode, the required to complete this training prior to occurrence – people in every walk of life
further operations into the Gold Coast.  and every profession make typos and
target values input by the crew on the errors all the time. But for high capacity
The dangerous consequences aircraft operations, the consequences
displays. With weather complications of an incorrect data entry
arising, they attempted three approaches have been numerous take-off accidents
ATSB investigation AO-2010-081
before diverting to Brisbane. worldwide that were the result of a
A serious incident at Kalgoorlie simple data calculation or entry error by
On the second occasion on 29 May,
Airport has demonstrated the danger
that can arise from a simple error in to the highly publicised Emirates
data calculation or entry. The ATSB tailstrike accident, the ATSB undertook
route segment in similar weather
investigation into this occurrence comes a research report, Take-off performance
a Runway 32 VOR approach but were calculation and entry errors: A global
report into the 2009 Emirates tailstrike, perspective. That report documents
unable to land due to reduced visibility in
an accident that resulted in a near multiple accidents and incidents where
low cloud and rain. Following a missed
catastrophe, and that also had its seeds the calculation and entry of erroneous
approach, the crew conducted another
in the entry of incorrect data. take-off performance parameters, such
Runway 32 VOR and landed.
On 13 October 2010, a Boeing 717-200 as aircraft weights and ‘V Speeds’ were
For both approaches, the crew
(717), registered VH-NXD, was being involved. The report also describes
commenced descent from 2,500 ft
operated on a scheduled passenger several different strategies that are
at about 19 km, which was below the
designed to capture errors, and minimise
Australia. On board were 97 passengers, the likelihood that any such errors will
each of those approaches, when
lead to an accident.
between 17 and 13 km, the aircraft
was below the procedure’s segment During the approach to land at Kalgoorlie The above ATSB investigation reports are
minimum safe altitude. Airport, the stickshaker activated. The available on the ATSB website at
pilot reduced the aircraft’s pitch angle www.atsb.gov.au along with Take-off
In both incidents, the aircraft descended
performance calculation and entry errors:
to an altitude where there was no longer
minute later, the approach was no longer A global perspective. 
separation assurance from terrain and
aircraft operating outside controlled
R44 operators urged to change fuel tanks
ATSB investigation AO-2012-021 Robinson advised that about 4,000
The ATSB has issued a notice to all helicopters were initially manufactured
operators and owners whose Robinson 78 (SB 78). with the all-aluminium tanks and about
SB 78 had been issued on 20 December
aluminium fuel tanks, urging them to 2010 by Robinson, requiring that R44 worldwide. In other words, about 10 per
replace those tanks with bladder-type helicopters with all-aluminium fuel tanks cent of R44 helicopters that were initially
fuel tanks as soon as possible. This alert
comes in the wake of a tragic accident as soon as practical, but no later than
at Jaspers Brush, NSW that claimed the 31 December 2014. The background
lives of two people. information to the service bulletin stated: involving an R44 with all-aluminium fuel
The accident occurred on 4 February To improve the R44 fuel system’s
2012, when an R44, registered VH-COK, resistance to a post-accident fuel leak, also investigated an accident involving an
lifted off from Jaspers Brush Aerodrome. R44 helicopter that occurred at Cessnock,
On board were the pilot and a camera as possible. NSW on 4 February 2011. The occupants
operator, who of that helicopter survived
were going to be the initial impact with the
ground but did not survive
Bay. After lifting
off, the helicopter On 21 February 2012,
turned left and the manufacturer issued
the pilot’s door SB 78A that revised the
opened. About date of compliance to
31 December 2013. In
after liftoff, the addition, the manufacturer
helicopter abruptly released SB 82 in respect
pitched nose- of the replacement of
up then ‘slid’ existing R44 rotor brake
backwards before switches. The aim of that
the tailskid struck bulletin was to reduce
the ground. It then the possibility of the rotor
pitched forward brake switch as a possible
into a nose-down ignition source in the
attitude and rolled event of a fuel leak.
to the right before The ATSB has, in the
the main rotor interest of transport
blades struck the R44 helicopter wreckage
safety, issued a Safety
ground. Advisory Notice.
Robinson advised that the bladder-type This notice draws attention to the
the fuel tanks and lower mast area. fuel tanks provided improved resistance requirements of Service Bulletin 78A,
The fuselage then hit the ground and to post-accident fuel leaks. That and highlights the existence and content
improvement was due to their improved of Service Bulletin 82.
occupants died and the helicopter was cut and tear resistance and the ability of The preliminary report for Jaspers Brush
destroyed. the bladders to sustain large deformations
Preliminary examination of VH-COK’s without rupture. There was no Cessnock (AO-2011-016) are available on
maintenance records indicated that the Airworthiness Directive issued by either the ATSB website at www.atsb.gov.au 
helicopter was maintained in accordance the US Federal Aviation Administration
with the engine and helicopter
manufacturers’ requirements. However, it bladder-type tanks.
Avoidable Accidents
The release of Starved and Exhausted: The ATSB receives thousands of And how long will the series be? How
Fuel management aviation accidents, the many booklets will the ATSB produce?
latest in the Avoidable Accidents series of some of the occurrences get formally ‘It’s an ongoing series,’ says Dr Godley.
safety booklets, has received a positive investigated, all of the information is ‘We’ll keep expanding it until we run
retained in the ATSB’s database, drawing out of topics. These are timeless
schools, aero clubs, and many aviation a vast and detailed portrait of aviation publications, focussing on problems
operators. ‘We’re extremely enthusiastic safety in Australia. Inevitably, patterns that have been recurring for a long time.
about this series,’ says Dr Stuart Godley, emerge. ‘We have an ongoing program
the manager of the ATSB’s Research of monitoring trends,’ explains Godley, accidents that have been happening for
Investigations and Data Analysis. ‘It’s ‘and we identify the accidents which 90 years, practically since the beginning
designed to be an accessible and useful keep repeating themselves. These are of aviation, and they’re accidents that
safety resource, and we’re happy that the perfect topics for this series.’ pilots can prevent from happening. No
the booklets are being read by pilots and Each booklet is short, and to the point, matter how good the training and how
instructors.’ and focused on giving readers useful advanced the aircraft, people keep having
The Avoidable Accidents booklets information. It includes case studies the same accidents. They have been
each focus on a type of accident. describing how different pilots, of all called ‘avoidable accidents’ because they
ranges of experience, have, through are accidents that didn’t have to happen.
of accidents for these publications,’ different routes, ended up in the same As a pilot, you have a lot of control of
explains Dr Godley. ‘These are accidents types of accidents. ‘When hearing about making sure they don’t happen to you.’
which happen, not because of some an individual accident, some pilots have ‘These booklets would be useful to any
random occurrence, but because of the impulse to say “oh, they ran out of
individual actions. We’re not saying that fuel, well, that’s dangerous, I won’t do school to an experienced pilot who’s
these accidents took place because that”,’ says Dr Godley, ‘but there are
of recklessness or incompetence, far many different ways that these problems share them. We think they’re a valuable
from it. They’re decisions, planning can arise, and it’s not always a case resource, that is free.’
and preparation, risk taking, and of the obvious mistake.’ The booklets
sometimes actions or inactions that don’t describe the various chains of events The ATSB will gladly provide free copies
automatically stand out as dangerous, that have led to accidents, and then gives of the Avoidable Accidents series to
that one might take for granted, but ways that pilots can avoid suffering these anyone who would like them.
which have resulted in accidents. accidents. ‘In these booklets, it’s not just Please send requests via email to
Becoming aware of how such behaviours describing accidents. Every accident has [email protected] 
have led to accidents will hopefully guard a lesson, and these lessons learned are
you against making the same mistakes. drawn out to help other pilots.’
It’s very much a case of “forewarned is
forearmed”.’

Avoidable Accident Series

 REPCON BRIEFS

REPCON allows any person who has an aviation safety concern REPCON would like to hear from you if you have experienced

regarding any individual (either the reporter or any person referred have learnt. These reports can serve as a powerful reminder
that, despite the best of intentions, well-trained people are still
given by the subject of the information.
The goals of the scheme are to increase awareness of safety reports may serve to reinforce the message that we must
issues and to encourage safety action by those best placed to remain vigilant to ensure the ongoing safety of ourselves and
respond to safety concerns. others.

Use of mobile device to manage passenger use of PEDs the use of any device which can threaten
during takeoff and/or the descent the safety of an aircraft. It is very
phase as the cabin crew must be important that passengers listen to and
seated. The reports we receive also comply with announcements from the
Report narrative: highlight passenger reluctance and cabin crew when these restrictions apply.
The reporter expressed a safety concern attitudes towards PED usage and the
about the use of 3G mobile devices belief it is the operator’s policy and not
a regulatory requirement. However,
who is a regular traveller, observes that the operator honestly believes the
hundreds of reports that come through What may be reported with
passengers are using these devices
each year show that our cabin crew REPCON?
more and more frequently, texting and
take passenger use of PEDs at Any matter may be reported if it
inappropriate times very seriously. endangers, or could endanger the
The reporter believes that cabin crew do
safety of an aircraft. These matters
not take this safety matter seriously and In addition, the PED policy is currently
are reportable safety concerns.
often do not adequately warn passengers part of the cabin crew recurrent
to turn off electronic devices or that the emergency procedures curriculum and Examples include:
is covered in the “Standard Operating • unsafe scheduling or rostering of
Procedures” section of the training crew; or
Responses/received: day. The proliferation of PEDs has • crew or aircraft operator bypassing
REPCON supplied the operator with the made the potential much higher for safety procedures because of
non-compliance but it is not possible commercial pressures; or
version of their response: for cabin crew to check that all PEDs • non compliance with rules or
procedures.
Cabin safety has advised that a review
of our occurrence database from off. In this respect cabin crew act To avoid doubt, the following
in good faith that passengers are matters are not reportable safety
01/01/11 shows that on over 500
compliant, responsible and accountable concerns and are not guaranteed
occasions cabin crew have reported
the hazard of passengers using their themselves.
mobile phones and personal electronic • matters showing a serious and
REPCON supplied CASA with the de-
devices (PEDs) onboard. It is felt that imminent threat to a person’s
health or life
the sheer volume of reports received in operator’s response. The following is • terrorist acts
relation to passenger non-compliance a version of the response that CASA • industrial relations matters
with our PED policy illustrates that provided: • conduct that may constitute a
cabin crew are very aware of the serious crime.
regulatory requirements and company CASA has reviewed this matter with
internal subject matter experts and has Submission of a report known by the
policies on this matter and are very reporter to be false or misleading is
vigilant in ensuring compliance, examined the operator’s procedures,
an offence under section 137.1 of the
particularly during the pre-departure Criminal Code.
preparations as the cabin is being response.
secured for takeoff. ATSB comment: How can I report to REPCON?
Online:
In addition, it’s quite possible that The use of mobile phones and other
www.atsb.gov.au/voluntary.aspx
onboard passengers writing text electronic devices is restricted as Telephone: 1800 020 505
messages are constructing them they could interfere with vital aircraft Email: [email protected]
navigation systems. Current regulations Mail: Freepost 600
It is also not possible for cabin crew give aircraft crew the power to prohibit PO Box 600, Civic Square ACT 2608
58
FEATURE
Trident accident anniversary

Severe gradient:
deep stall!
Forty years ago, The London Heathrow base of British European Airways was
not a happy place in June 1972. A long-standing dispute
a violent loss of between the airline and the British Airline Pilots’ Association
temper in a crew was straining relationships. A pilots’ meeting indicated a
room was the majority in favour of strike action, but some senior pilots
considered this unprofessional.
prelude to a major
British airline In the crowded BEA crew room early in the afternoon of the
day before a second meeting, the ill feeling boiled over into an
disaster, writes angry exchange between Captain Stanley Key, 51, preparing
Macarthur Job for a flight to Brussels, and a senior first officer who was not
a member of his crew. Vehemently opposed to strike action,
the highly experienced Key was enlisting the backing of other
senior captains.
Questioned about his campaign, Key exploded in an outburst
described by some present as the most violent they had
ever heard. Although the argument subsided quickly and
Key apologised, it was plain that the proposed strike was a
source of great tension for him. Among those witnessing the
exchange was one of two co-pilots rostered with Captain Key.
It was the airline’s practice to crew its Hawker Siddeley
Tridents with a captain and two co-pilots. The captain and
one co-pilot occupied the control seats, while the third pilot
monitored critical stages of flight, from a position similar to
the flight engineer in other three-crew jets. His function was to
bring any variation from operating procedures to the captain’s
immediate attention.
The crew arrangement as Trident 1C, G-ARPI, bound for
Brussels with a full complement of 112 passengers, taxied
from Terminal 2 at 4.03pm on 18 June 1972 had Captain Key
in the left-hand seat, Second Officer J. W. Keighley, 22, in the
right-hand seat, and Second Officer S. Ticehurst, 24, in the
monitoring position.
 59
Flight Safety Australia
Issue 86 May–June 2012

The Trident’s passengers included a Vickers Vanguard crew

of three, travelling to Belgium. The first officers were in the
passenger cabin, while the Vanguard captain took the jump
seat on the flight deck behind Captain Key. There was a cabin
crew of three. The weather was mild but overcast, with some
drizzle from the 1000ft cloudbase, and a moderate wind
from the southwest.
At the holding point for runway 27 right, the Trident was
given a standard departure clearance via Dover and the
tower cleared the aircraft for takeoff. The takeoff appeared
perfectly normal.
Half a minute later, still on a westerly heading, but now
at a little over 700ft, the aircraft banked to the left towards
the Epsom NDB and entered the overcast. The crew
reported, ‘climbing as cleared’ and were instructed to
call London Control.
Seventeen seconds later, the aircraft reported: ‘Passing
1500ft’. Control then cleared the Trident to continue climbing
to flight level 60. Captain Key’s terse acknowledgement of
‘Up to six zero’ was the Trident’s final transmission.
60
FEATURE
Trident accident anniversary

Amazing sight Leading edge devices

Less than a minute later, a schoolboy, walking along the A30 The Trident was the first British civil aircraft to be equipped
Staines bypass road, five kilometres south-west of the airport, with retractable leading edge high-lift devices, then known
heard a rapidly increasing roaring above him. Looking up, as ‘droops’. Extending the droops markedly decreased the
he saw a rear-engined jet liner emerge from the base of the stalling speed. Tridents were also equipped with a stick-
cloud. Though its engines were under high power, it had little shaker stall warning system, and a stick-pusher stall recovery
forward speed and was falling almost vertically in a flat, system to lower the nose at a wing incidence approaching an
nose-up attitude. aerodynamic stall.
The boy watched, transfixed. The flat, near-vertical fall The FDRs revealed that, six seconds after Captain Key’s terse
continued until the huge aeroplane, narrowly missing a final acknowledgement, as the aircraft was climbing through
powerline pylon, smashed down into a field on the outskirts 1770ft in cloud at an airspeed of only 162kt, a crew member
of Staines with an enormous sound of impact. Bouncing, it unaccountably retracted the wing leading edge droop, putting
broke apart, the tail snapping off with the three rear-mounted the Trident into an incipient aerodynamic stall, and triggering
engines. Despite a spillage of fuel, no fire broke out. both the stick shaker and the stick pusher. This automatically
disengaged the autopilot and pitched the nose down, causing
The boy ran 400 metres to the nearest house to raise the
the stick pusher to cease as the wing became unstalled again.
alarm. Its occupant had been a nurse at a nearby hospital,
with experience in casualty, and she ran with him to render But with the autopilot now inoperative, the leading edge droops
assistance. She found only one survivor, who was deeply retracted, and the elevator trim unaltered, the aircraft became
unconscious. The extreme vertical forces had killed all tail heavy and the nose pitched up again. As a result, eight
the others outright. The survivor died in hospital without seconds after the first stick push, the stall recovery system
regaining consciousness. operated a second time. Three seconds afterwards, as this
pattern repeated itself, the stick-pusher forced the nose down
Investigation yet again. But this time its operation was inhibited—at this
No defect or evidence of malfunction was found in the highly critical point, someone turned the system off.
aircraft or its systems and it was clear that the Trident was
fully serviceable up to the moment of impact.
Stall
Deprived of the effect of the stick pusher, the Trident pitched
The Trident was not equipped with a cockpit voice recorder,
rapidly and steeply further nose-up. Losing speed, the
but read-outs of its two flight data recorders (FDRs) removed
aircraft quickly entered an aerodynamic stall, then a deep stall.
any doubts as to the aerodynamics of the accident: the
It struck the ground in this condition 22 seconds later.
Trident’s wing leading edge droops had been retracted
prematurely and the aircraft had stalled. The nose then The FDRs also showed that, up to the time the leading edge
pitched up steeply and the aircraft entered a ‘deep stall’, droop was retracted, the Trident was being flown disturbingly
a phenomenon peculiar to T-tailed aircraft, in which turbulent differently from standard BEA practice—it consistently failed
air from the stalled wing spills over the tail. Recovery from to achieve appropriate airspeeds for the various phases of
a deep stall is impossible. flight. Had the Trident’s speed been just 10–15kt higher
when the droops were retracted, recovery would have been
comparatively simple.
 61
Flight Safety Australia
Issue 86 May–June 2012

The airline’s standard procedure for London Heathrow Autopsies

departures involved taking off with 20° of flap and the
leading edge droop extended, and increasing speed to the One pointer to the solution emerged when pathologists
noise abatement safety speed, in this case 177kt. Ninety examined the bodies of the four pilots on the flight deck.
seconds after brake release, the flaps were to be selected The autopsies revealed nothing abnormal in the cases
up, and engine power reduced to noise abatement settings. of Second Officers Keighley and Ticehurst, or the
At 3000ft, the power levers were to be advanced again to supernumerary Vanguard pilot.
climb settings and, as the aircraft accelerated through But the examination of the body of Captain Key revealed a
225kt, the leading edge droop was to be retracted and severe case of atherosclerosis—a narrowing of the arteries
en-route climb established. resulting from a build-up of fatty deposits—and there was
The Trident, after lifting off at 145kt, increased speed over a tear in the lining of the wall of one artery. This tear was
the next 19 seconds, with the autopilot being engaged seven likely to have been the result of an initial rupture of small
knots below the noise abatement climb speed. But by the blood vessels in the thickened artery wall, caused by a
time the flaps were raised, the speed had decayed to 168kt. sharp rise in blood pressure, not more than two hours before
And, after engine thrust was reduced in accordance with the accident. The resulting haemorrhage, creating its own
noise abatement, the speed fell further to 157kt, 20kt below build-up of pressure, then progressively forced the artery
noise-abatement climb speed. The wing leading edge droop lining to separate.
was retracted six seconds later while the aircraft was in a Eminent cardiologists agreed that, under physical or emotional
banked turn. stress, weak blood vessels in Key’s thickened arteries had
This untimely action immediately placed the aircraft in an ruptured. The symptoms of the internal haemorrhage that
aerodynamic stall. The minimum droop retraction speed of resulted could range from a slight indigestion-like pain in the
225kt was placarded alongside the droop lever, and was well chest to collapse and unconsciousness. At the very least it
known to all Trident pilots, as was the airline’s injunction would have caused some ‘disturbance of thought processes’.
against retracting the droop during a turn. But even at this
Tension on the flight deck
stage, though engine thrust remained at only the noise
abatement setting, the Trident could have been quickly There can be little doubt that, as the Trident taxied out that
recovered from the stall if any of the following actions had afternoon, tension on the flight deck would have been high.
been taken: Key, struggling with what he probably thought was an attack
of indigestion after the altercation in the crew room, would
Increasing speed at least 10kt by re-applying climb power probably have been responding tersely under the effect of pain
Immediately extending the leading edge droop again as he went through the pre-takeoff checks with his crew.
Holding the control column forward after the stick pusher His two relatively inexperienced co-pilots could well have
operated to maintain the attitude regained by the stall mistaken their captain’s demeanour for short temper. Keighley
recovery system. had seen the captain’s vitriolic outburst, and both he and
Ticehurst were probably very much on edge—fearful of saying
Significant unknowns or doing anything that might provoke this senior captain’s
Yet not one of these actions was attempted, despite the violent temper. In this emotionally charged atmosphere, the
repeated stall warning and stick pusher functioning. It seemed co-pilots would have been extremely reluctant to point out any
the underlying cause of the tragedy lay in the answers to operational oversight.
several significant questions:
The most reasonable explanation for the Trident’s steady
Why were there such serious speed errors in flying the deterioration in airspeed was simply that Key was trying
aircraft up to the point when it stalled? to cope with increasing pain, and his concentration was
being affected.
Who was responsible for retracting the leading edge
droop and why was it retracted so prematurely? Who retracted the droop?
Why did BEA’s much-vaunted monitoring system fail to What led to the premature retraction of the leading edge droop
avert the stall—and why did the crew not recover after
was more difficult to understand. The droop mechanism is
the stall warnings?
controlled by a lever on the centre pedestal to the right of the
Why did the crew fail to diagnose the reason for the power controls quadrant, close to, but distinct from, the flap
stick pusher operating repeatedly, and why was the lever. For this reason, it was highly unlikely that Ticehurst,
system turned off at such a critical point? seated in the monitoring position, would have been responsible
for moving it.
62
FEATURE
Trident accident anniversary

While it was physically possible for Keighley, in the right- As the aircraft had been climbing normally, the unexpected
hand seat, to have retracted the droop, this was also onset of the stick shaker and stick pusher, with no change in
unlikely. Though not an experienced line pilot, Keighley was airspeed or aircraft attitude, could well have been regarded as
nevertheless competent and fully trained—training that a false alarm, perhaps somehow associated with something
included instruction in handling stalls in the Trident simulator. the captain had inadvertently done in his last moments. There
He would have been well aware that the aircraft’s speed, was a belief among BEA pilots that the system could be
height, timing and bank angle were all wrong for droop unreliable at times.
retraction.
Untimely combination
Overall, it seemed far more likely that moving the droop
lever at such a grossly inadequate airspeed and Key’s So when the stick shaker operated, apparently without reason,
physical condition were linked. Though no doubt extremely for the third time, probably interrupting whatever aid the
uncomfortable because of the increasing pain in his chest, pilots were trying to give the collapsed Key, their immediate
Key was probably aware the aircraft’s speed was too low. response would have been to inhibit the system to enable
them to cope with the medical emergency.
It was possible he could have associated this low airspeed
with a need to raise the flaps, not appreciating the fact that Had they realised the only reason was the untimely retraction
they were already fully up. With his reasoning impaired, he of the droop, or that retracting the droop, at the speed and
might have moved the droop lever, believing he was retracting attitude of the aircraft at the time, would immediately place it in
the flaps. an incipient stall, they might well have taken action to recover
before the situation became irretrievable.
Monitoring failure? Like so many major airline accidents, the loss of Trident
Still to be explained was the failure of the monitoring system G-ARPI resulted from an untimely combination of a number
to correct the error. So why was the movement of the droop of unfavourable but relatively small factors, any one of which,
lever not picked up by Ticehurst? Or even by Keighley in the if appropriately dealt with, could have averted the accident.
right-hand seat?
A postscript
Assuming Key was responsible for moving the lever, there
were two possible reasons. Firstly, if Keighley had his left Years later, after the story of the accident had been published
armrest in the horizontal position, it could have obscured his on a BBC website, a former BEA cabin crew member wrote
view of the lever. Secondly, if he had still been adjusting engine this comment:
power to the noise-abatement level, his attention would have ‘I flew as a stewardess on Papa India many times, and
been on the instruments, and his extended left arm could have also with Captain Key. Captain Key was very memorable,
hidden what Key was doing. as he was not a very pleasant or friendly captain to fly with.
Ticehurst’s failure to notice the error was harder to understand. Most second officers are very young and probably did
But at this critical moment he was probably logging the flight not have enough experience or courage to contradict
level to which they had just been cleared. The flight level 60 someone like Captain Key. In fact I don’t know anyone
entry in Ticehurst’s log, found in the wreckage, could only who contradicted him.
have been made in the seconds before the movement of the I had the impression he was not a very happy person.
droop lever. Certainly he was not a captain one would choose to fly
If Key was exhibiting signs of collapse, this could also have with. I cannot think of a more unpleasant person any crew
distracted Ticehurst, particularly if there had been some member would wish to fly with. I think it was probably
unusual reaction from the Vanguard captain. Furthermore, if the norm for him to be unfriendly with his own cockpit
Key’s final collapse had coincided with the stick shaker and crew, as well as the cabin crew. If he did have a medical
stick pusher operation, that in itself could explain the crew’s problem which caused him psychological problems, I think
failure to diagnose the reason. At the time, the aircraft was in he probably had it for a long time, or else he had severe
cloud with no visual reference. problems somewhere else in his life.’
 63
Flight Safety Australia
Issue 86 May–June 2012

The enemy within

dangerous goods in the cabin
Dangerous goods have been implicated in at least two ‘As these batteries have the potential to short circuit
aircraft crashes in the past two years. UPS Airlines flight and burn under certain conditions, the preference is to
006 in September 2010 and Asiana Airlines flight 991 have them carried in the cabin by passengers where
in July 2011 were cargo flights that crashed in similar, the risk can be better managed. Cabin crew and flight
distressing circumstances. Both planes carried cargoes crew are specifically trained in the management and
including lithium ion batteries. In both cases their crews handling of dangerous goods incidents in the aircraft
reported fire in the main cargo hold, and in both cases cabin, including those caused by lithium battery fires,
the crew were killed. and can respond quickly if an incident arises.’
Four pilots dead and two Boeing 747s destroyed is Rechargeable lithium batteries can be carried as cargo
bad enough—and the question of how many would in passenger planes, but non-rechargeable lithium
have died had a similar fire broken out in the cargo batteries (found in hearing aids and small electronic
hold of a passenger aircraft is even more sobering. devices), which are made differently and resist halon
This is one of the reasons why the International Civil extinguishers, must be packed in carry-on baggage.
Aviation Organization (ICAO) is considering new
The US Federal Aviation Administration has recorded
safety standards for air transport of lithium batteries.
17 fires or incidents with lithium batteries of both types
If approved by the ICAO Air Navigation Commission,
on passenger planes since 2004, all but one involving
these provisions will come into effect from early 2013.
passengers who carried the batteries or packed them in
There are also concerns about other dangerous goods luggage. The pervasiveness of lithium ion batteries is
on passenger planes. Recent incidents involving creating a wondrous variety of new types of dangerous
spontaneously self-igniting iPhones and a fuel-filled goods. A recent FAA summary tells of lithium-battery
chain saw in hand luggage remind us that cabin crew fires in devices as diverse as curling irons, electronic
vigilance and training are the last line of defence against cigarettes, personal air fresheners and a self-propelled
dangerous goods causing an aviation tragedy. surfboard.
Some items are obviously dangerous: the case for The frightening and potentially catastrophic nature of
keeping ammunition, radioactive or infectious material lithium-battery fires is evident, even from the terse FAA
material and flammable liquids out of aircraft cabins is summaries. For example: ‘One and a half hours into a
intuitively clear, but seemingly innocuous items such passenger flight from Buenos Aires to Miami, a small
as batteries and matches can be an insidious hazard. explosion occurred in the business class section of
As a former cabin crew instructor said, passengers the aircraft.
often have the unfortunate perception that ‘if I can buy
There were sparks, then a flash and smoke. Flight
it in a supermarket, how could it kill me?’
attendants, then the captain, responded. Battery
CASA’s Director of Aviation Safety, John McCormick, fragments were the only evidence found. It is suspected
has said that a significant area of concern for the that the battery dropped into a seat and arced against
regulator is the carriage of spare lithium batteries, a metal seat frame, causing it to explode. The ruptured
particularly in checked-in luggage in the cargo hold: battery splattered debris on overhead bins.
64
FEATURE
Dangerous goods

A fragment hit a passenger in the head, burning her hair

near her earlobe. Seven flight attendants were affected
by smoke/fume inhalation. One aircraft seat bottom and
four seat covers were damaged and replaced.’
Members of the Flight Safety Australia cabin crew
‘panel’ are aware of the issue, and how difficult it
can be to manage. Self check-in was a concern, with
one experienced cabin crew member saying, ‘I would
estimate that many people would just say “no, I am

Fighting a lithium not carrying any dangerous goods”, without actually

reading what they all are, or thinking about what they
battery fire have packed in their bags. We can only hope the
screening process is thorough, but I believe it’s not as
Lithium battery fires have distinct characteristics. thorough domestically as it is internationally.’
They have to be fought in two stages: first, by
‘I know if the person checks in bags with a ground staff
extinguishing the flames, followed by cooling of the
member, they are asked, and if cabin crew take a bag
battery to prevent spontaneous re-ignition.
from a passenger we are supposed to remember to ask
The recommended procedures for fighting a fire if they have any dangerous goods, especially those that
in a lithium-battery-powered personal electronic are permitted in the cabin, but cannot be checked in.’
device are to:
A safety manager with an international airline
1. Use a halon, halon-replacement, or water emphasises the importance of recurrent training:
extinguisher to extinguish the fire and prevent ‘We have a specific procedure for cabin crew that helps
it spreading to other flammable materials. them differentiate between one substance/item and
another in carry-on luggage. One of the audit elements
2. After extinguishing the fire, douse the device
that we are strict on is the DG awareness training that
with water or other non-alcoholic liquid to
cool it, and prevent additional battery cells check-in staff receive. That and clear information to
from heating to the point of thermal runaway. passengers are always reviewed in detail.’
(In a 2008 incident, a US flight attendant ‘The recurrent cabin crew training in realistic simulators
brought a smoking laptop battery to a safe, is important here. Staff need to understand—by doing—
albeit sticky, end using lemonade.) how to check a hot overhead locker; for example, never
use the palm of the hand to feel how hot a surface is. If
in doubt, wear oven or fireproof gloves and never swing
a door wide open if you suspect fire—allowing fresh air
into the locker (or toilet) can fuel a developing fire. The
training helps reduce confusion and panic.’
‘So far, we have had no problems with lithium batteries,’
he added. ‘A few years ago we did have a portable DVD
player melt in the passenger’s bag in the overhead bin.
No fire, but lots of smoke and some quite unpleasant
fumes as the plastic casing of the DVD player melted.
The information we have is that some non-brand makes

Further information
www.casa.gov.au/dg
FAA Technical Centre videos on approaching and fighting
laptop and lithium battery fires: http://www.fire.tc.faa.
gov/2007Conference/session_details.asp?sessionID=26
 65
Flight Safety Australia
Issue 86 May–June 2012

of electronic equipment use batteries of a poor quality

and the combination of the poor construction of the
equipment and/or the battery can be problematic.’ Lowdown on lithium
However, traditional (and less traditional) types of
Lithium ion batteries can be found in portable electronic
dangerous goods can also be offenders, as other cabin
devices (including watches, calculators, cameras,
crew explain.
cellular phones, laptop computers, camcorders) carried
‘A strong smell in the cabin was traced to a passenger’s by passengers or crew for personal use. These should
petrol-soaked shoes (the tank of his hire car had be transported only in carry-on baggage.
overflowed). We followed our airline’s SOP, bagged
Spare batteries must be individually protected to prevent
them, put in a waste bin of ice in the toilet, locked
short circuits. Each installed or spare battery must also
the toilet and monitored the bin periodically for signs
not exceed the following:
of combustion. The passenger had to borrow some
smelly (but safe) old runners, because the plane could 1. For lithium metal or lithium alloy batteries,
not leave unless everyone was wearing shoes.’ a lithium content of not more than two grams
‘On a flight many years ago, when smoking onboard 2. For lithium ion batteries, a watt hour rating
was still permitted, we were heading across to Perth in of not more than 100 Wh.
our Boeing 727-200. The food service was completed
and people were settling in for the rest of the trip.
There was a lady seated in a window seat with the
two seats next to her vacant—she was set up with Six DG points to ponder
her small bottle of wine and a glass, cigarette smoking
away in the ashtray and commencing to paint her Always remember that preventing an occurrence
is better than having to put your emergency
finger nails.
procedures training into practice.
It wasn’t too long before there was a bit of a disturbance
Familiarise yourself with the location, and method
with this lady. Her wet nails combusted (only a little
of use, of extinguishers, spill kits and isolation
bit) as she took a drag on her cigarette, but the flames materials.
were extinguished very quickly. Not sure whether in
her prioritising she chose to have another cigarette, Do not attempt to pick up and move a smoking
repaint the nails or have a drink. I think it safe to or burning device. Use appropriate firefighting
conclude that she didn’t smoke and paint her nails techniques in situ.
simultaneously again.’ Do not cover the device or use ice to cool it. This
will insulate it, increasing the likelihood that the
An ARFF station captain said that he had seen it
battery cells will reheat to thermal runaway point.
all ‘everything from a tin of paint, to body fluids, to
durian fruit’. Investigate post occurrence and apply appropriate
preventative and remedial actions.
The airline safety manager gives the issue a final
interesting perspective, ‘Nothing beats our time in Report any dangerous goods incidents to your
West Africa though, when aeroplanes were treated like safety managers and to the relevant authorities.
buses into which anything—large or small, industrially
hazardous and otherwise— was packed.’
66
AV QUIZ
Flying ops | Maintenance | IFR operations

FLYING OPS
1. In a GNSS system the signals from different satellites 5. An aircraft has been heading 350(m) in order to make
are identified by: a planned track of 355(m). If, after some time, the track
a) a unique data word at the beginning of subframe 1. made good is found to be 345(m), the planned drift was:

b) a unique data word at the beginning of subframe 5. a) 5 degrees left and the actual drift was 5 degrees left.
c) different pseudorandom noise (PRN) codes. b) 5 degrees left and the actual drift was 5 degrees right.
d) different L band frequencies. c) 5 degrees right and the actual drift was 5 degrees right.
d) 5 degrees right and the actual drift was 5 degrees left.
2. In a forecast, the code ‘PR’ translates to:
a) primary. 6. With reference to the status of a restricted area, a
conditional status of RA1 means that pilots:
b) permission required.
a) may flight plan through the restricted area and expect
c) aerodrome partially covered (describing fog).
an ATC clearance under normal circumstances.
d) prior to (describing fog).
b) must not flight plan through the area unless there
3. An ‘initial and pitch’: is a route specified in ERSA GEN FPR, or prior
agreement is made.
a) is a military term for a VFR circuit arrival in which
aircraft track to an initial point 5nm downwind of the c) must avoid the area.
runway in use. d) may plan through the area unless it is activated
b) is a military term for a VFR circuit arrival in which via NOTAM.
aircraft track to an initial point abeam the threshold of
7. Differential ailerons are those which, for a given control
the runway in use.
input, travel through a:
c) is a military term for a VFR circuit arrival in which
a) greater angle downwards than upwards in order to
aircraft track to an initial point 5nm upwind of the
reduce induced drag.
runway in use.
b) greater angle upwards than downwards in order to
d) is a military term for a VFR circuit arrival in which
reduce induced drag.
aircraft track to an initial point abeam the upwind end
of the runway in use. c) greater angle downwards than upwards in order to
reduce adverse yaw.
4. ‘The leans’ refers to an illusion during instrument flying d) greater angle upwards than downwards in order to
in which a pilot erroneously believes that: reduce adverse yaw.
a) the aircraft is in a slow spiral.
b) the aircraft is banked.
c) the wings are level.
d) the aircraft is not in balance.
 67
Flight Safety Australia
Issue 86 May–June 2012

8. When landing a typical tailwheel aircraft, ground contact 10. A form of vertigo associated with the beta rhythm of
by the tailwheel first tends to cause the trailing edge of the brain is called:
the elevator to travel: a) flicker vertigo, and may be initiated by light pulses
a) downwards, which contributes to the subsequent such as from a strobe beacon, or by light interrupted
bounce on the main wheels. by a revolving propeller or rotor.
b) downwards, which reduces the subsequent bounce on b) auto kinesis which, in a dark field, causes apparent
the main wheels. movement of a point source of light.
c) upwards, which contributes to the subsequent bounce c) the Coriolis effect.
on the main wheels. d) empty field myopia, where the focus distance of the
d) upwards, which reduces the subsequent bounce of the eye defaults to a few metres.
main wheels.

9. When taxiing a tailwheel propeller-driven aircraft,

a harsh application of brakes causes a nose-over
tendency which is:
a) not affected by thrust or taxiing speed.
b) aggravated by both thrust and taxiing speed.
c) aggravated by thrust, but reduced by taxiing speed.
d) aggravated by taxiing speed, but reduced by thrust.

MAINTENANCE
1. For a piston engine, the stoichiometric mixture ratio is 3. ATA chapter 30-30-XX refers to:
that at which: a) landing gear main doors.
a) an excess of fuel is provided for cooling purposes and b) landing gear nose doors.
the ratio is considered to be approximately 12:1.
c) ice and rain protection of pitot and static systems.
b) all components of the combustion process are used
d) ice and rain protection of windshields.
and the ratio is considered to be approximately 12:1.
c) there is an excess of fuel provided for cooling 4. Compared to a ‘cold’ spark plug, a hotter plug has a:
purposes and the ratio is considered to be a) longer distance between the centre electrode
approximately 15:1. and the gasket seat.
d) all components of the combustion process are used b) shorter distance between the centre electrode
and the ratio is considered to be approximately 15:1. and the gasket seat.
2. Operating an aircraft piston engine at the stoichiometric c) longer thread.
mixture ratio: d) shorter thread.
a) produces the best power.
5. When a piston-engined aircraft is standing on an
b) produces the best range. aerodrome with a pressure altitude of zero feet,
c) releases the maximum amount of heat energy but best with the engine shut down, the manifold pressure
power is obtained with a slightly leaner mixture. gauge should read:
d) releases the maximum amount of heat energy but best a) 29.92 ins Hg less the drop across the filter
power is obtained with a slightly richer mixture. and manifold.
b) 29·92 ins Hg.
c) 29·22 ins Hg less the drop across the filter
and manifold.
d) 29.22 ins Hg.
68
AV QUIZ
Flying ops | Maintenance | IFR operations

6. MS21080 refers to a: 9. On aircraft with vacuum-driven gyro instruments

a) rivet-nut. and a single gyro air filter, the filter is installed:

b) double lug anchor nut. a) downstream of the instruments, and the need
for filter replacement will be indicated by a low
c) single lug anchor nut.
vacuum reading.
d) corner anchor nut.
b) downstream of the instruments, and the need
7. Modifications to an aircraft are now approved under: for filter replacement will be indicated by a high
vacuum reading.
a) CASR 21.
c) upstream of the instruments, and the need for
b) CAR 21.
filter replacement will be indicated by a low
c) CAR 35. vacuum reading.
d) CAR 40. d) upstream of the instruments and the need for
filter replacement will not be indicated by a low
8. The vacuum regulator associated with gyro
vacuum reading.
instruments regulates the vacuum available to
drive the instruments by: 10. One function of a coalescer in an air-conditioning
a) controlling external airflow from the regulator to pack is to:
the atmosphere. a) impart a circular motion to the airflow to aid inertial
b) controlling external airflow into the pump input. separation of the water droplets.
c) restricting the flow into the vacuum pump. b) straighten the airflow to aid inertial separation of
d) restricting the flow out of the vacuum pump. the water droplets.
c) act as a divergent duct which increases the pressure.
d) act as a convergent duct which decreases
the pressure.

IFR OPERATIONS
WANGARATTA (YWGT) NDB 1. Your HDG is 045M. Which of the following ADF
You are inbound to Wangaratta along W438 from overhead indications would show that the aircraft is on track?
Strathbogie (SBG) NDB in IMC in an Aero Commander 685 a) ADF 1 010R ADF 2 190R.
(Grand Commander).
b) ADF 1 035 ADF 2 215.
The aircraft is operated in category B and is equipped
with VOR/ILS, TSO-approved GPS, DME and two fixed- c) ADF 1 360R ADF 2 180R.
card ADFs. You are endorsed and current on all these d) ADF 1 350R ADF 2 170R.
NAV AID approaches.
You calculate your top of descent with the RAIM loss
You are currently maintaining 7000 in cloud. The following still active.
questions relate to the descent and NDB approach. Due to
a present loss of RAIM, you are navigating by reference to 2. What is the lowest altitude to which you may descend
the ADFs, with ADF 1 on WGT and ADF 2 on SBG.
on track and in IMC?
a) LSALT of 4100ft
b) LSALT of 4400ft
c) MSA of 3000ft if a 10nm positive fix can be obtained
by means other than GPS.
d) MSA of 6300ft if a 25nm positive fix can be obtained
by means other than GPS.
You consider the 10nm MSA positive fix.
 69
Flight Safety Australia
Issue 86 May–June 2012

3. Which of the following NAV AID combinations could 7. When can the descent be initiated?
give this fix? a) Only when established within ±5° of the 337 track.
(Some possible answers would have necessitated some b) Only when established within ±5° of the 349 track.
pre-flight preparation)
c) Once on an intercept HDG for the 349 track.
a) ADF 1 and 2 on WGT and SBG respectively.
d) Once on an intercept HDG for the 337 track.
b) ADF 1 and 2 on WGT and SBG respectively, DME
Outbound now, the gear is down and locked and you are
on Albury (AY) reading 48.
descending at 600fpm with an IAS of 130kt.
c) ADF 1 (WGT), ADF 2 (SBG) VOR on Eildon Weir
(ELW) and crossing the 008 radial. 8. What is the speed range permitted for your category
d) An alternative 10nm positive fix is not possible aircraft in this segment of the approach?
along this track, so LSALT is the lowest that you a) 120–140kt
may descend to. b) 120–180kt
You now consider the sector entry at the WGT NDB. c) 85–130kt
Your HDG is still 045M.
d) 90–150kt
4. What is the sector entry based on this HDG? You complete the base turn to the final approach track
a) Sector 1 (parallel entry). at 2000ft. Your HDG is 175M.

b) Sector 2 (Teardrop or ‘Offset’ entry). 9. What ADF indication on this HDG will indicate on
c) Sector 3 (‘Straight in’ entry). However, it is possible to track and when can descent to MDA be continued?
go straight in to the approach by establishing the initial a) 000R. Descend within ±5° of final approach.
approach of 349 from overhead WGT.
b) 354R. Descend within ±5° of final approach.
d) Sector 3 (‘Straight in’ entry). However, a holding
c) 006R. Descend only when on the final approach track.
pattern would need to be flown first from the HDG 045.
d) 006R. Descend within ±5° of final approach.
5. Assuming you can obtain the 10nm positive fix and Approaching MDA now (no actual QNH has been
can thus descend to the MSA of 3000ft, it is possible obtained), cloud break occurs. Based on your drift
to divert from track and manoeuvre to position to go allowances and ground speeds throughout the flight you
straight in to the initial approach. True or False? still determine a south-easterly wind of 20kt.
a) True
10. What minima have you been able to descend to
b) False
for this approach?
Now 5nm to run to the WGT NDB, you turn to a HDG of
a) MDA 1000, visibility 3.3km
055 with the intent of intercepting the initial approach track
prior to the NDB. b) MDA 1100, visibility 3.3km
c) MDA 1070, visibility 2.4km
6. What reading would ADF 1 (tuned to WGT) show if
d) MDA 1170, visibility 2.4km
you allowed a 20° lead-in for the turn onto the initial
approach track? Landed Wangaratta.

a) 294R
b) 314R
c) 284R
d) 046R
Overhead the WGT NDB, at 3000ft, you start the timer,
turn to a heading to accurately establish the initial
approach track, and are about to lower the undercarriage
to commence descent.
70
CALENDAR
May – September 2012

Upcoming events QUEENSLAND VICTORIA

May 16 – 17 May 23
ATO Professional Development Program AvSafety Seminar – Essendon
Brisbane www.casa.gov.au www.casa.gov.au/avsafety
May 17 May 26
AvSafety Seminar – Rockhampton Ageing Aircraft Seminar – Melbourne
www.casa.gov.au/avsafety www.casa.gov.au/ageingaircraft
May 24 May 30 – 31
AvSafety Seminar – Toowoomba ATO Professional Development Program
www.casa.gov.au/avsafety Melbourne www.casa.gov.au
June 2 June 6
Ageing Aircraft Seminar – Brisbane AvSafety Seminar – Sunbury
JUNE 4 – 7 www.casa.gov.au/ageingaircraft www.casa.gov.au/avsafety
June 3 June 13
Aerial Agricultural Association AvSafety Seminar – Caboolture AvSafety Seminar – Moorabbin
of Australia Conference – Cairns www.casa.gov.au/avsafety www.casa.gov.au/avsafety
www.aerialag.com.au June 19 June 20
AvSafety Seminar – Maryborough AvSafety Seminar – Mildura
www.casa.gov.au/avsafety www.casa.gov.au/avsafety
ACT/NEW SOUTH WALES June 20
AvSafety Seminar – Bundaberg
May 2 www.casa.gov.au/avsafety WESTERN AUSTRALIA
AvSafety Seminar – Moruya July 24-26 May 1
www.casa.gov.au/avsafety Aircraft Airworthiness & Sustainment AvSafety Seminar – Kununurra
May 3 Conference – Brisbane www.casa.gov.au/avsafety
AvSafety Seminar – Merimbula www.ageingaircraft.com.au/aasc.html
May 2
www.casa.gov.au/avsafety July 28 AvSafety Seminar – Broome
May 6 Aviation Safety Education Forum – Brisbane www.casa.gov.au/avsafety
Wings over Illawarra family air show www.casa.gov.au/avsafety
May 3
Albion Park August 25 AvSafety Seminar – Derby
www.woi.org.au Aviation Careers Expo – Brisbane www.casa.gov.au/avsafety
May 8 www.aviationaustralia.aero/expo/
May 19 – 20
AvSafety Seminar – Cessnock Defence Force Air Show 2012 –
www.casa.gov.au/avsafety SOUTH AUSTRALIA RAAF Pearce
May 9 www.airforce.gov.au/airshows/
AvSafety Seminar – Scone May 9 June 19
www.casa.gov.au/avsafety AvSafety Seminar – Port Lincoln AvSafety Seminar – Karratha
May 22 www.casa.gov.au/avsafety www.casa.gov.au/avsafety
AvSafety Seminar – Bankstown May 24
www.casa.gov.au/avsafety AvSafety Seminar – Naracoorte
May 29 www.casa.gov.au/avsafety INTERNATIONAL
AvSafety Seminar – Griffith May 25
www.casa.gov.au/avsafety AvSafety Seminar – Mt Gambier May 21 – 24
www.casa.gov.au/avsafety Asia-Pacific Regional Runway Safety Seminar
May 30 Bali, Indonesia
AvSafety Seminar – Albury June 4 www.icao.int/Meetings/BaliRRSS/
www.casa.gov.au/avsafety AvSafety Seminar – Wilpena Pound
www.casa.gov.au/avsafety May 23 – 24
June 1 - 3 China Civil Aviation Development Forum
ANZSASI Australasian Air Safety Seminar June 5 Beijing, China
2012 – Sydney AvSafety Seminar – Marree www.ccadf.cn
www.asasi.org/anzsasi.htm www.casa.gov.au/avsafety
June 25 – 29
June 5 June 6 International Bird Strike Committee Conference
AvSafety Seminar – Mudgee AvSafety Seminar – William Creek Stavanger, Norway
www.casa.gov.au/avsafety www.casa.gov.au/avsafety www.ibscstavanger.org/
June 6 June 16 August 27 – 30
AvSafety Seminar – Parkes Ageing Aircraft Seminar – Adelaide ISASI 2012 43rd Annual Seminar
www.casa.gov.au/avsafety www.casa.gov.au/ageingaircraft Baltimore, Maryland USA
www.isasi.org/isasi2012.html
NORTHERN TERRITORY TASMANIA September 17 – 18
Flight Safety Conference
May 15 May 8 London, UK
AvSafety Seminar – Darwin AvSafety Seminar – Launceston www.flightglobalevents.com/flightsafety2011
www.casa.gov.au/avsafety www.casa.gov.au/avsafety
May 16 May 10
AvSafety Seminar – Katherine AvSafety Seminar – Hobart
To have your event listed here,
www.casa.gov.au/avsafety www.casa.gov.au/avsafety email the details to [email protected]
Copy is subject to editing.
Please note: some CASA seminar dates may change. Please go to www.casa.gov.au/avsafety for the most current information.
CASA events Other organisations’ events
 71
Flight Safety Australia
Issue 86 May–June 2012

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QUIZ ANSWERS
Flying ops IFR operations
1. (c) 1. (d) TR is 035 HDG 045, thus 350R (WGT) and 170R (SBG)
2. (c) GEN 3.5 para 13. ANS. b) would be correct if the ADFs were slaved, that is, RMIs.
3. (a) ENR 1.1 para 48.8. 2. (c) AIP ENR 1.5-2 para 1.4
4. (b) ENR 1.5-15 para 2.2.1
5. (d)
3. (b) * ANS a) is a position line only
6. (a) ENR para 5.3.2.2.
* AY to WGT is 38 DME + 10 = 48 DME and within VHF range
7. (d)
* ANS b) is not a minimum 45° angle for a positive fix AIP ENR 1.1-38 para 19.5.1
8. (a)
9. (b) 4. (d) AIP ENR 1.5-25 para 3.3.4
10. (a) AIP ENR 1.5-20 para 2.7.3
5. (a) AIP ENR 1.5-15 para 2.2.1
Maintenance 6. (b) HDG is 055 and TR to intercept is 349 so total angle is 66° thus a relative bearing
of 294R. Now, 20° prior to that for the lead is 314R
1. (d)
2. (d) 7. (c) AIP ENR 1.5-14 para 1.20.2
3. (c) 8. (a) AIP ENR 1.5-12 paras 1.15.1, 1.16.1 YWGT approach plate notes
4. (a) 9. (d) HDG 175M, final TR 181, thus 181-175 = 6° drift right, thus 006R.
5. (b) AIP ENR 1.5 – 14 para 1.20.2
6. (c) 10. (b) YWGT NDB approach plate straight in minima for RWY 18 without an actual QNH.
7. (a) changed from CAR 36 to CASR 21M. AIP ENR 1.5 – 33 para 5.3.2
8. (b)
9. (d) the flow will be reduced, but the pressure
will be regulated to normal values.
10. (a)
72
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