Regulars

CONTENTS
Features
8 Not safety rst, but safety always.
The rst of a series of articles on SMS implementation.
21 High-ying women
The Australian Women Pilots Association annual
conference & awards.
22 Mid-air collisions
CASAs prevention campaign
24 Cant walk. Can y.
A former pilot achieves an Australian rst.
30 Victa Airtourer feedback on
May-Junes High-G manoeuvring article.
31 Ageing composite materials
Richard Castles, one of CASAs senior airworthiness
engineers, looks at ageing and composites.
58 Tragedy at Coolangatta.
Macarthur Job on how a loading problem led to one of
Australias worst civil aviation accidents.
64 Medical certication.
Steps for renewing your medical.
2 AirMail
7 Flight Bytesaviation safety news
16 ATC Notes news from Airservices Australia
18 Accident reports International
19 Accident reports Australian
31 Airworthiness pull-out section
33. SDRs
38. Directives
44 Close Call His story: nearly history
A VFR into IMC close call special.
52 ATSB supplement
66 Av Quiz
71. Quiz answers
70 Calendar
ISSUE NO. 69, JULY-AUG 2009
Director of Aviation Safety CASA
k John F. McCormick
MANAGER, SAFETY COMMUNICATIONS
& MARKETING
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EDITOR, FLIGHT SAFETY AUSTRALIA
k Margo Marchbank
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COVER: COVER: Photograph Curtis Morton Photograph Curtis Morton
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FOR FELLOW PILOTS
I have been ying Cessna 172 aircraft
for over twenty years. When I was
doing my training on the Central
Coast of NSW it was drummed into
me to always use carby heat when
lowering revs prior to landing. I was
instructed that it is good airmanship
to use carby heat no matter where
you y. I now y out of the Gold
Coast, and have done so for twelve
years. After moving here, and doing
check ights - when its time to apply
carby heat, some instructors tell me
not to. They say it is not necessary
in warmer climates. One even
pushed the carby heat control in,
saying it takes away power. I would
be interested to hear FSA and your
readers attitude on this.
AND
FROM LOW-HOUR PILOT
I would like to get some informed
comment and discussion on some
bush pilot ying techniques.
1. A short takeoff can be
accomplished by applying takeoff
ap (Ive also heard full ap)
during the take off roll.
2. A short landing roll can be
accomplished by dumping ap
immediately after touchdown and
then getting on the brakes.
My aircraft has plenty of power and I
have taken off with full ap selected.
This resulted in a signicantly
reduced takeoff roll. I have not
measured the reduced takeoff roll. I
have also dumped aps immediately
after touchdown which certainly
glued the aircraft to the ground.
As all of these manoeuvres are
below VFE; I therefore assume that
there is no over-stressing of the
airframe. The manoeuvres are non-
standard and require concentration
and attention to detail, but are not
too difcult. I am not too sure that I
want to be in a position where I am
operating in such tight strips, but on
the other hand if I can reduce the
actual strip requirements I can then
reasonably get into tighter strips
with the same margins for safety.
SEVERAL VICTA
AIRTOURER OWNERS
CORRESPONDED
This was in response to the High-G
manoeuvring article in May-Junes
Flight Safety. For more detail on this,
see page 30.
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MAX ROGERS WROTE CONTINUING
THE DISCUSSION OF THE REAL FIRST
WOMAN COMMERCIAL PILOT
In the interests of all contenders for the title, I enclose a
copy of the page from the Department of Civil Aviations
own register, with the REAL rst woman commercial pilot
of Australia, Phyllis Arnott. Amy Johnson was granted no.
1, but the rst Australian was Phyllis Arnott. Keep up the
excellent work. Flight Safety is a highly readable and well-
presented publication.
QANTAS PILOT, ALEX SCAMPS, EMAILED
CONFIRMING THIS
Phyllis Arnott (my great aunt) gained her commercial
licence on 28th February 1931, and was therefore the rst
Australian woman to gain a commercial pilots licence.
Qantas named an A380 after her at a recent ceremony.
ED: thanks to these readers who corrected the record I think
that subjects settled.
Keep those emails and letters coming in. We value your
feedback, and while selshly perhaps, its nice to have the
positive bouquets, we need the brickbats too, so that we can
continue to improve the magazine.
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from 36 country member associations, their deepest
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In such unusual circumstances, and given the normally
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In their name and in the name of every pilot, crew
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European Cockpit Association 3 June 2009
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AIRPORT
Critics say a planned site near New
Yorks LaGuardia Airport would act as
a bird magnet. About 700 yards from
the end of a LaGuardia Airport runway,
where thousands of planes take off
and land, New York ofcials want to
build what could be the equivalent of
a bird magnet: a very large garbage
transfer station just four months
after a run-in with birds sent a jet
full of people into the Hudson River
separating New York and New Jersey.
Thats just insane, said Jeff Skiles, co-
pilot of US Airways Flight 1549, which
ditched in the water Jan. 15. We have
a lot of difculty keeping birds away
from airports as it is.
The city and the Federal Aviation
Administration insist that the 2,000
tons of garbage, which would be
hauled by truck into the 100-foot tall
facility each day and sent out again
on barges, wont entice birds because
the waste will be kept in containers or
inside the building.
The Associated Press Online @ MSNBC.
com 6:55 a.m. ET May 26, 2009
SAFETY QUESTIONNAIRE
FOR AOC HOLDERS
In late July, AOC holders with
passenger-carrying permissions will
be required to complete CASAs safety
questionnaire covering their activities
for the rst half of 2009.
The July survey is shorter and simpler
than Februarys CASA anticipates
that the survey should take AOC
holders who have maintained ongoing
data of their activities only about 15
minutes to complete.
CASAs collection of such detailed and
accurate operational data is vital to
enable us to prioritise safety oversight
activities, assess industry risks and
provide targeted safety support. AOC
holders will receive further information
before the survey begins.
NEW TOP GUNS
The Pentagon is preparing to graduate its
rst unmanned drone (UAV) pilots from
the elite US Air Force Weapons School
a version of the Navys Top Gun program
in a bid to elevate the skills and status
of ofcers who y Predators, one of the
militarys fastest growing programs.
Over the course of the wars in Iraq
and Afghanistan, the MQ-1 Predator,
and more heavily-armed MQ-9 Reaper
have become, to many people in the
Pentagon, the most important aircraft
the US has deployed.
Giving top drone pilots a shot at the best
training the military offers is one way to
ensure the most talented ofcers stay
with the program and do not return to
manned aircraft. The advanced training
was rst proposed three years ago, and
rejected, but now with 127 Predators,
31 Reapers and 400 unmanned aircraft,
the Air Force was given the go-ahead to
create the program.
Los Angeles Times reprinted in
Canberra Times, 9 June 2009
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Regular public transport operators are
undergoing a transition to the proposed
CASR Part 119, which will mandate safety
management systems for passenger
transport services using aeroplanes or
rotorcraft, and some categories of cargo
transport. It is envisaged that this will
incorporate therefore not only Australias
current 48 high and low-capacity regular
public transport (RPT) operators, but will
also include some additional 400 charter
operators. Flight Safety editor, Margo
Marchbank, in the first of a series of articles
on SMS implementation, gives an overview.
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I dont believe in safety rst, but safety
always, says CEO of Toll Aviation, Trevor
Jensen. If you say safety rst, then its very
easy to say, OK, weve considered safety,
now we can get on with the job. Whereas,
if safety always is the culture, then you
dont move away from it. Toll Aviation is
one of three pilot organisations working
closely with CASA on the implementation
of safety management systems (SMS) in
the transition to Part 119. SMS have been
on the radar for over ten years, and many
proactive RPT operators, recognising that
they are a critical part of doing business,
already have robust SMS in place. Theyve
been mandatory for certied aerodromes
since January 2007, and aerodromes with
international ights even earlier, since
2005. (Further in this article, there are case
studies of two very different aerodrome
SMS experiences. See page 12.)
NOT SAFETY FIRST,
BUT SAFETY ALWAYS
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Phase 1 Phase 2 Phase 3
Safety Policy, Objectives and Planning
Management commitment & responsibility
Safety accountabilities of managers
Appointment of key safety personnel
SMS implementation plan
Gap analysis
Documentation
Third party interface
Coordination of the emergency response plan
Safety Risk Management
Risk assesment & mitigation process Reactive Proactive/predictive
Hazard identication process Proactive/predictive/hazard
identication
Safety Assurance
Safety performance monitoring & measurement Reactive - incident & accident
vestigation

Internal safety investigation
The management of change
Continuous improvement of the safety system
Safety Training & Promotion
Training & education Key personnel All safety critical personnel All safety critical personnel
Safety communication
SMS IMPLEMENTATION PHASES 2009-2011
There are four major components to the required SMS:
Safety policy, objectives & planning
Safety risk management
Safety assurance, and
Safety training and promotion.
As part of the phased implementation of CASR Part 119, CAO 82.5
(HCRPT) and CAO 82.3 (LCRPT) were mandated in January 2009,
requiring operators to implement an SMS according to a staggered
timeline. These phases are depicted below.
Toll Aviation has a eet of 12 aircraft: two French ATR 42s; 10 Metros (eight
3s and two 23s); and three 737s contracted from Airwork NZ. And, on any
one day, they may also contract up to 50 aircraft. The company employs
115 people: 38 pilots (ten on the ATRs and the rest on the Metros); 42
engineers; 12 ground staff; and the remaining 23 in nance and admin.
Although Toll is not a CAO 82.3 or 82.5 operator, they have chosen to
implement an SMS meeting the standards and timeframes associated
with HCRPT operation. Their Metro operation is based around a number
of bank runs to centres such as Cairns, Townsville, Mt Isa, Moree,
Coolangatta and Mackay. Then there are the freight services one ATR
ies out of Brisbane to Bankstown, Melbourne
and Adelaide, while the other does the reverse
leg Adelaide to Brisbane, at the same time. The
Metros also y the Adelaide to Melbourne route.
Trevor explains that their Monday to Friday
roster appeals to many pilots for whom no
ying on weekends is a lifestyle choice. He
is very much aware of the competition Toll
faces from the major airlines, in attracting and
retaining pilots. The minute the major airlines
want pilots, we lose them, he explains, with
up to a 50 per cent turnover in the good times,
so part of the companys risk assessment is the
pressure this places on maintaining standards.
However, the current economic downturn has
a positive side decreased airline recruitment
has meant less workforce attrition. The
downturn has given us time to put our SMS in
place with a stable workforce, he says.
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The timing is also right for their SMS
for another reason. Toll Aviation arose
from three companies: Jetline, Jetcraft
and Jetcare, which have been aligned
into the one organisation over the
past 12 months. This consolidation
provided a good opportunity, Trevor
Jensen says, to work with CASA
on examining Tolls systems very
closely, as a prelude to establishing
an integrated SMS for the new
entity. An important rst step
was a thorough gap analysis.
Safety doesnt have to cost
money, Trevor explains, so Toll
used Survey Monkey (a simple y
tool for designing surveys
online, with the capacity to
then analyse the data), to
survey their pilots, engineers
and ground staff to see how
we as a group see ourselves.
Im not a salesman for
Survey Monkey, but its a
great tool which costs you
nothing. In a short time
we were able to come up
with results looking at
our compliance. This
analysis was revealing,
Trevor says. If you take
level 10 to be the level
we want to be for ICAO standards (International
Civil Aviation Organization), then for most items
we were hovering around six, but on hazard
identication, it was three out of 10.
He says that by conducting the survey and
analysing its results, they were able to be
more realistic. If we had asked ourselves, for
example, Do we have a hazard identication
system? we probably would have said,
Yes. But now, rather than just ticking the
boxes, digging deeper has identied the
weaknesses, so we know where weve got
to put our effort in. The process took Toll
Aviation three months, but Trevor says, it
gives us a very honest assessment of our
SMS readiness.
Having this data has also helped in convincing
the corporate group of the need to resource
safety management within the company
training, IT systems and so on. You can never
win an argument on emotion, but good data
can help you win.
Trevor and his team have now assessed all
the required elements, and established a
list of the tasks needed to put their SMS in
place, with the tasks allocated in a schedule
for phases 1, 2 and 3 of implementation. As
they write their manual, they can sign off on
each of these tasks. Toll is also part of the pilot
group trialling the new online SMS manual
authoring and assessment tool (MAAT).
When Flight Safety visited the company
headquarters in Brisbane, Trevor was about to
sit down with the CASA SMS project team to
begin populating the manual builder online.
In conclusion, Flight Safety asked him what he
felt were the key points of an SMS. Keep it
simple; safety has to be pragmatic, he replies.
Its not about having big manuals your SMS
documentation should reect how you do
your business. Make sure it reects what you
do. And in training and communicating about
safety, make sure the way you do it suits the
audience. Theres no point in having pages
of instruction, with the intent in the middle
of the document, if the guys dont want to
read nine pages. We have to understand our
audience a lot better, he says.
The
minute the
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The whole system is electronically based, and
with hyperlinks to the regulations, there is
always access to the source document (e.g. the
CASA, EPA or WorkCover websites). Clicking
on the link therefore takes you straight to
the most recent version. Every activity they
undertake has a safe work method statement
and risk assessment that identies hazards in
relation, not only to the activity, but the area
of operation, which may vary from day to
day. Were in the early stages of trialling a
new system, using a PDA/Blackberry, so that
you can download documentation when you
come back into the ofce. Or, in the case of
one of our pilots who may be ying outback,
he can obtain remote access to our server
24/7, Geoff explains.
He estimates that the initial certication
process, involving ve months of manpower
and downtime cost EPS about $50,000; with
ongoing audit costs (around $12,000 annually)
and annual registration fees for the three
certications of another $12,000. But Geoff
argues, It wasnt too long ago that the only
EPS HELICOPTER SERVICES
According to principal, Geoff Sprod, EPS helicopters are condent that
whatever SMS standards CASA introduces in the near future for charter
operators, they will be ready. On their website, Bankstown-based EPS
Helicopter Services Pty Ltd state their mission is: to provide a safe,
efcient, cost effective helicopter management service in support of
our clients strategies and objectives. It was this desire to maintain
an ongoing emphasis on safety, and to establish a point of difference
with competitors, which led Geoff and chief pilot, Paul Caristo, to
implement a quality assurance system.
EPS Helicopter Services own two helicopters, a Bell 206BIII Jetranger,
and their latest acquisition, a Eurocopter AS350SD2. They conduct
charter and aerial work activities that include pipeline and power line
surveys, banner towing, sling loads, re ghting and parachuting for
promotional events, to name a few.
In 2007, Paul was about a third of the way into putting the new companys
operations manual together, Geoff explains, when the pair decided,
Lets develop a fully integrated management system that would drive
the business, rather than simply having an SMS. Recognising that the
helicopter world is a highly-competitive market, and that the business
would benet from the security of ongoing contracts, they decided to
embark on securing SAI Global ISO certication. Ask any Joe on the
street, and they know what the symbols mean, Geoff explains, the
ve coloured ticks are the most recognisable QA symbols anywhere.
So EPS opted to undertake not only quality assurance (QA) (ISO 9001),
certication, but also environment (ISO 14001) and OH&S (AS 4801).
Their ve months of developing policies and procedures covering all
aspects of the business, including safe work method statements, risk
registers, risk assessments, staff training and induction, paid off. After
rectifying minor areas during the pre-audit check, they passed their
audit in October 2007, gaining their triple SAI Global certication. This
certication process ensures the system continually evolves with the
business towards best practice, and is reviewed with ongoing audits to
maintain certication.
MORE THAN TICKING THE BOXES
www.epsheli.com.au homepage
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thing that mattered was the hourly rate. Over
the past two years we have seen a change in
tender requirements, and acknowledgement
that tenderers have some form of quality,
OH&S and environmental policies and
procedures in place. And more recently, you
not only have to provide evidence of such
systems, but also any external certication.
Anyone who chooses not to go down this
road soon will be behind the competition.
For EPS the additional certication brought
direct commercial benet: a few months after
certication, EPS secured
a government contract, competing against other major operators.
While price accounted for a percentage, other factors such as quality
and environment were an issue. Their success, Geoff says, could be
attributed to the fact that EPS was the only operator with a certied
system which covered all three aspects, giving them a high score in
that component of the tender.
Over the next couple of years Geoff believes the reliance on providing
evidence of a safety management system will increase signicantly.
Additionally, a far greater emphasis will be placed on a companys
SMS as a measurement of their performance, rather than simply on
their price.
SMS & AERODROMES
Just as the current SMS Phase 1, 2 & 3 requirements
are a transition to CASR Part 119 SMS requirements
for Australian aerodrome operators followed a similar
transition. CASR Part 139 (safety standards for
Australian aerodromes) came into effect in May 2003,
with a 1 November 2005 deadline for aerodromes
with international operators; and 1 January 2007
deadline for all other certied aerodromes. Keith
Tonkin, of Aviation Projects, outlines case studies of
two very different aerodromes which implemented
new SMS.
NORTHERN PENINSULA
AIRPORT (YNPE)
BACKGROUND
Northern Peninsula Airport (NPA, formerly Bamaga/
Injinoo Airport) is located on the northern tip of Cape
York Peninsula in far North Queensland. Like many
remote communities, the ve Aboriginal and Islander
communities of the Northern Peninsula area rely
heavily on air transport for access to medical and other
essential support services. The airport is therefore a
critical element of community infrastructure.
To provide for an expected increase in operator
capability, the airport was prepared for certication
in late 2007, and received its aerodrome certicate
early in 2008. A critical condition of certication was
assurance by the Northern Peninsula Area Regional
Council, which managed the airport, that they would
provide adequate resources and funding so that the
aerodrome would meet regulatory requirements.
Not only did the SMS satisfy one of the requirements
for certication, but importantly, it was a way of
being proactive by identifying existing and potential
issues and the resources and management actions to
address them.
SMS DEVELOPMENT
The airport management had limited knowledge of
how to develop and implement an SMS. So after rst
looking at the principles and methodology of an SMS
in the CASA-developed SMS template, they participated
in a workshop to identify risks to the safe operation of
the airport. These risks and their associated treatments
were documented in a risk register and treatment plan,
in MS Excel format. By using Excel, which is readily
available, local airport management staff could view,
manage and manipulate the register document easily.
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Some of the issues identied in the development of the
SMS, and actions taken to rectify them are as follows:
1. Emergency callout Limitations because of xed-
line and mobile phones meant that the airport
manager (who also does the refuelling) was not
always contactable for callout by emergency
services such as the Royal Flying Doctor Service
(RFDS). A satellite phone was therefore provided
to the airport manager.
2. Frequency conrmation Although a Unicom
service was available, limitations associated with
staff availability and radio equipment, as well
as signicant frequency congestion on the large
CTAF(R) shared with nearby Horn Island Airport
and other airports in the Torres Strait, led to the
decision to establish Northern Peninsula Airport
as a separate CTAF(R) and to install a combined
AFRU/PAALC. This process will be concluded with
the August 2009 amendment of ERSA.
AD-HOC OR UNFORESEEN RISKS
As with any aviation activity, despite the intention
to proactively manage safety risks, unforeseen risks
requiring reactive management action occur from
time to time. Some incidents which occurred at NPA,
and how these were managed to minimise future
risks are as follows:
1. Near miss A light aircraft landed short
of the runway while conducting a circuit to
land, due to failure of the throttle cable. The
subsequent emergency response revealed
some opportunities for improvement in relation
to call out procedures, telecommunications
systems and response vehicle capabilities. The
airport manager reported these issues, which
were discussed with airport management
and other stakeholders for consideration and
implementation. Results were recorded in the
risk register and treatment plan.
2. Pavement failure ground water inltration of the
runway pavement required urgent repairs to be
carried out at short notice. This required closure
of the airport for a number of days on several
occasions, with implications to RPT operators,
emergency services etc. A full engineering design
of pavement repairs & additional drainage was
commissioned immediately. The pavement repairs
were carried out in accordance with the engineering
designs provided. The results of these activities were
recorded in the risk register and treatment plan.
Further drainage & runway pavement upgrades are
scheduled when funds are available.
STAKEHOLDER CONSULTATION
All of the above issues required engagement with
stakeholders to ensure that they understood and
accepted the risk treatments being implemented,
and that an acceptable level of safety would be
maintained. These stakeholders included aircraft
operators and agents, council staff, local community
members, regulatory authorities, suppliers and
customers.
Sometimes change can bring about unintended
consequences, so during the development of
risk treatments, stakeholders were asked for
their input regarding potential impacts to their
activities, including operational implications,
amended procedures, most appropriate means of
communication etc.
Stakeholders received information concerning the
treatment actions which had been determined,
through email broadcasts to user groups, newspaper
articles, telephone, fax, industry publications and
newsletters, NOTAMs as well as AIP/ERSA and other
information sources.
SMS ONGOING MANAGEMENT
Airport management accepts that risks need to be
managed proactively. They organise meetings of
the SMS safety committee every six months or so to
review the SMS and the risk register and treatment
plan, so that planned actions to treat known risks
happen; potential risks are identied and actions put
in place to treat them.
The meeting also tables and considers reports and
information from the previous period relevant to the
SMS, such as ad-hoc reports or other information;
and safety/technical inspection reports.
. . . it was a way of being proactive by identifying
existing and potential issues and the resources
and management actions to address them.
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SAFETY CULTURE
Increased regulatory obligations as a certied
airport under CASR 139, as well as status as a
security-controlled airport under transport security
regulations meant the community had to reconsider
its approach to the airport. Improved maintenance
of infrastructure and services, restrictions to access,
more rigorous operational procedures and increased
management involvement also required a prioritisation
of funding and human resources, so the airport
management met its regulatory requirements.
SUNSHINE COAST AIRPORT
(YBMC)
BACKGROUND
Sunshine Coast Airport (SCA), owned and operated
by Sunshine Coast Regional Council, is Australias
twelfth-largest airport by passenger numbers. It
supports jet RPT services operated by Jetstar, Tiger
and Virgin Blue; numerous xed and rotary wing
training organisations, including Singapore Flying
College; as well as aircraft maintenance and support
operations. It is a security-controlled airport with
screening requirements.
Sunshine Coast Airport is better resourced than
Northern Peninsula Airport, but has its own unique
issues because of its much greater scope and scale
of operations, and its correspondingly more
complex compliance and reporting requirements.
It is also approaching limitations in operational
capacity brought about by an unanticipated increase
in passenger numbers and the type of operations
conducted at the airport.
INTEGRATION WITH OTHER RISK-
BASED MANAGEMENT PROGRAMS
Because of the increased scope, scale and complexity
of activities it conducts and supports, Sunshine Coast
Airport manages a number of risk-based compliance
programs in addition to the SMS. These include
an environment management plan, a security risk
management plan (part of the Transport Security
Program), a workplace health and safety program
and an asset management program.
As well as these statutory requirements, all signicant
projects undertaken at the airport involve a proactive
formal risk management component.
Sunshine Coast Regional Council also requires all
signicant risks (including business continuity, nancial
and legal liability issues) to be managed as an outcome
of the airports annual performance plan.
Managing these separate programs creates a
signicant issue. They do not all have the same risk
criterialikelihood and consequence descriptors, risk
matrix, management and reporting actions required,
level of acceptable risk etc. This disparity makes
allocating resources effectively
Photo: courtesy Sunshine Coast Airport
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more difcult, and degrades the value of risk
information communicated to some stakeholders.
Working with the Australian Airports Association,
CASA developed an electronic SMS builder to
provide airports a simple means of compliance, and
a consistent basis for assessment by aerodrome
inspectors. Unfortunately the risk criteria, such as
likelihood, consequence, level of risk etc did not
align with the councils risk policy. Using the CASA
methodology, an extreme consequence (multiple
fatalities) with a rare likelihood, managed with
treatments that had limited effect resulted in a
low risk, whereas using the councils framework,
a similar scenario resulted in a high level of risk.
(That electronic SMS builder is no longer available.
See MAAT below.)
Councils risk management database also did not
cater for aviation operational safety risk. For the
airport, this was measured nancially as a cost/
revenue consequence, in safety outcomes and also
in terms of interruption to operations. So, in the
interests of simplifying compliance and program
management, the SMS is a standalone program using
CASAs template until all risk-based management
programs can be coherently incorporated into the
council system.
Risk criteria and risk assessment have to be uniform,
so that across council, various departments and
business units can communicate levels of risk
effectively.
Work is currently underway to integrate these risk
management programs, with a single database for
recording the risk register and treatment plan, so that
all risks managed by the airport can be identied,
assessed, treated, monitored and reviewed within a
single management program, using the same criteria.
This integration will make identifying, reporting and
managing risks more efcient, improve decision
making and resource allocation, and reduce training
requirements for system users.
TRAINING
There is a signicant number of staff and contractors
who conduct operations at the airport, which
has necessitated a more formalised training and
induction program as part of the SMS.
Contractors undertake a formal induction prior to
conducting works on the airport, and are subject to
ongoing scrutiny for compliance.
In their induction, new staff members receive SMS
and associated safety management procedure
training. Safety management issues are discussed at
monthly staff meetings.
Airside staff such as safety/reporting/security ofcers
and operational management staff also undertake
further training in safety procedures documented
in the aerodrome manual and standard operating
procedures manual.
For more information
Safety Management Manual
ICAO (2006). Doc.9859-AN/460 Second edition, downloadable from
www.icao.int
Also SMS training material available from the ICAO website.
Safety management systems for regular public transport operations. CAAP SMS-1(0) Civil Aviation Advisory Publication, January 2009
Integration of human factors into safety management systems CAAP SMS-2(0) Civil Aviation Advisory Publication, January 2009
Human factors & non-technical skills training for regular public transport operations CAAP SMS-3(0) Civil Aviation Advisory Publication, January 2009
Safety management making it t Feature article Flight Safety Australia March-April 2002
Manual authoring and assessment tool (MAAT) Online tool email sms@casa.gov.au for more information
www.surveymonkey.com
Online tool designed to enable anyone to create online surveys quickly and
easily. Free (for up to 100 responses stored).
www.saiglobal.com
International quality certication body, which licenses accredited
organisations with the internationally-recognised tick across ve main
areas: quality, OH&S, environment, information security and food safety.

ATC
Optimising
HF operations
nding the right
frequency
If your initial call is not answered straight away dont switch
frequencies and call AusFIC again. Tis can confuse the Flightwatch
operator who is usually busy using the intercom exchange
with ATC or talking to aircraf on another frequency. Instead,
we recommend you make a second call on the same frequency
approximately 20 seconds later to give the operator a reasonable
time to respond to your call.
Because HF can complicate voice communications its important
that all calls directed to the ground station are made according
with AIP.
Be prepared before you call a HF operator. Tey know what to
expect when taking a call and can anticipate the order the message
will be received in.
To help reduce frequency congestion when seeking in-fight
information on weather/NOTAM or submitting fight details,
only request information or give details up to the next intended
landing point. Afer landing, telephone the Briefng Ofce and
retrieve additional information needed and or give additional fight
plan details.
Remember if you need information urgently use the PAN PAN
process to alert the HF operator who will change the priority
order to process your call ahead of all other routine requests or
movement advice.
Be mindful that the HF operator acts as the relay point to ATC on
issues including requesting clearances, track deviations and the
status of Restricted Areas. Tis process can take time and depends
on ATC workload and priorities.
If you have any question about HF operations please contact the
duty Operations Supervisor of the Australian Flight Information
Centre (AusFIC) on (07) 3866 3429.
S
ound High Frequency (HF) radio operating techniques and
a solid understanding of the medium will allow pilots to
communicate better with Air Trafc Services (ATS).
Airservices Australian Flight Information Centre (AusFIC) in
Brisbane operates and maintains domestic and international
HF voice communication networks to provide ATS to the
aviation community within Brisbane and Melbourne Flight
Information Regions.
Unlike VHF communications, HF can ofen be unreliable,
unpredictable and HF noise can be distracting.
As solar radiation is the single largest infuence on HF performance,
the rule of thumb for many HF operators when choosing a
frequency is low at night and high at day. Tis is generally because
the higher elements of a frequency suite are recommended during
the day, while lower elements are more efective at night.
For example in the ranges of 3, 6 and 8 MHz, it is generally accepted
that 8 MHz works most efectively during the middle of the day.
However, this is not always the case. It is not uncommon for 3 MHz
to be the best frequency at midday depending on the distance that
the signal needs to be sent.
To fnd information on the best frequency to use at a particular time
of day and distance visit the Australian Governments Ionospheric
Prediction Service website www.ips.gov.au/Products_and_Services
Our recent feedback from some pilots who have applied this
knowledge is that it works.
AusFIC Flightwatch operators monitor eight frequencies three
domestic and fve international. To help the operator attend to your
call quickly, include the frequency that you are calling on in your
initial transmission (as per AIP GEN 3.3-10 2.11.5) for example:
Flightwatch this is Alpha Bravo Charlie on eight eight four three.
Lef: AusFIC HF international Flightwatch operator taking calls.
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Manage SARTIMEs and help us to help you
You can also nominate, modify and cancel a SARTIME by radio -
if the other preferred methods are not available. Be mindful that
when using VHF there may be delays if ATC are experiencing busy
periods. If using HF, reception can ofen vary and you may need to
repeat your details several times.
SARTIMEs do not have to be held by AusFIC. Any responsible
person nominated by you a spouse, trusted friend, your company
or fying school can hold your SARTIME. It is important to
ensure the person you nominate has a description of the aircraf you
are fying, is familiar with the details of your fight and has all your
relevant contact details. Tey must be able to provide emergency
services with accurate information if needed.
If a SARTIME held by an ATS unit is not cancelled by the
nominated time, attempts will be made to contact you. If these
communications fail, an emergency Uncertainty Phase will
be declared.
AusSAR will be notifed of the expired SARTIME and will take over
responsibility for the response. AusSAR has extensive resources
and the expertise to locate you and confrm your safe arrival or to
initiate emergency assistance.
When cancelling your SARTIME use the correct phraseology.
Always use the phrase cancel SARTIME (as per AIP GEN 3.4-
28 5.4.1). Other phrases such as cancel SAR do not adequately
distinguish VFR and IFR fights and may cause confusion.
Remember at the end of your fight to ask yourself Have
I cancelled my SARTIME?
For further information about SARTIME management contact
Fiona Lawton at safety.promotions@airservicesaustralia.com
M
anaging Search and Rescue (SAR) times and cancelling
them at the end of a safe fight is a critical responsibility of
pilots in command.
It ensures that Air Trafc Services (ATS) and emergency response
authorities such as AusSAR (Australian Search and Rescue) or the
police know that youve arrived safely. It also prevents Airservices
initiating unnecessary search and rescue activities a highly
resource intensive, and at times costly, process.
When nominating your SARTIME ensure it is long enough to
cover the duration of your fight including the time you may need
to access suitable communication facilities to cancel it. Consider
nominating an end of fying day SARTIME, rather than one for each
stage of a multi-stage fight. Having too many SARTIMEs in the
system can get confusing for all operators pilots included.
When planning a fight that does not enter controlled airspace
ensure you give ATS information about:
the aircraf callsign or identifcation
aircraf type
departure point
destination
number of persons onboard
a nominated SARTIME.
Te best way to notify, change and cancel a SARTIME held by
Airservices is by telephoning Airservices Flight Information Centre
(AusFIC) on 1800 814 931 (as per AIP ENR 1.1-89 67.2.3).
You can also lodge your SARTIME over the Internet. If lodging
your SARTIME this way, make sure you telephone the Briefng
Ofce to confrm that your SARTIME has been received.
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International Accidents/Incidents 06 April 2009 - 30 May 2009
Australian Accidents/Incidents 1 April - 29 May 2009
Aircraft Location Fatalities Damage Description
06-April Fokker F-27
Friendship 400M
Bandung-Husein
Sastranegara Apt,
Indonesia
24 Written off The Fokker F-27 was returning from a parachuting exercise. On
landing the aircraft contacted a hangar near the runway 29 threshold
and there was a 20-knot crosswind at the time of the accident.
09-April British Aerospace
Bae-146-300
Wamena, Indonesia 6 Destroyed On approach to runway 15 the Bae-146-300 entered cloud and
struck the side of Gunung Pike Mountain bursting into ames.
17-April Cessna 208B Grand
Caravan
Canaima Airport,
Venezuela
1 Written off The Cessna 208B Grand Caravan crashed shortly after leaving
Canaima due to an engine failure.
19-April Boeing 737-800 Montego Bay-Sangster
International Airport,
Jamaica
0 None After the Boeing 737-800 landed a Jamaican man burst onto the
plane, brandishing a gun. He wanted to leave the country & red
the gun once through the open cabin door. Flight attendants
managed to negotiate the early release of all 174 passengers
and two crew members. Military police came and the hijacker
was arrested.
26-April Douglas DC-3C San Juan-Luis Muoz
Marn Apt, Puerto Rico
0 Written off During taxi, the Douglas DC-3C had re in the cockpit. The crew
and cargo loader evacuated.
27-April Boeing 737-2 K9 Guadalajara-Don
Miguel Hidalgo y
Costilla Apt, Mexico
0 Substantial The crew of the Boeing 737 selected the undercarriage down on
nals to Guadalajara but did not get a down and locked indication.
They performed a y past and the tower controllers conrmed
that the undercarriage was not fully down and locked. The ight
crew carried out a belly landing on runway 28.
29-April Boeing 737-275 Massamba, Bandundu
Province, Congo
7 Written off A Boeing 737 was destroyed during an accident near Massamba
Village, Bandundu Province, Democratic Republic of Congo.
30-April Antonov 2 3 Written off The Antonov 2 made 3 attempts to land in poor weather
condition including heavy snow and hit power lines.
08-May Tupolev 154M Mashad Airport, Iran 0 Substantial The Tupolev 154M encountered bad weather. The aircraft
fuselage sustained 1.8G acceleration forces and was struck by
hail stones. The ight diverted to Mashad and landed normally.
The fuselage sustained substantial damage.
08-May McDonnell Douglas
MD-90-30
Riyadh-King Khalid
International Airport,
Saudi Arabia
0 Substantial The MD-90-30 landed on the runway veered off and the right
hand main gear collapsed.
10-May
British Aerospace
3201 Jetstream 32
Utila Airport, Honduras 1 Written off
Authorities found and conscated 1500kgs of cocaine on board
the aircraft. Reportedly the aircraft ran out of fuel in rainy
weather and attempted a forced landing.
20-May
Lockheed C-130H
Hercules
near Madiun-Iswahyudi
Airport, Indonesia
2 Written off
The C-130H Hercules was on approach when it hit four houses,
killing the occupants of one house. It then skidded into a rice
eld, and burst into ames on impact.
26-May Antonov 26
Isiro-Matari Airport,
Congo Democratic
Republic
3 Written off
The Antonov 26 was destroyed when it crashed on approach.
The three ight crew members received fatal injuries.
30-May ATR-42-500
Lahore Airport,
Pakistan
0 Substantial
The ATR-42 was substantially damaged when the nose gear
and main undercarriage collapsed. It ran off the runway, skidded
2 000ft and across a drainage ditch.
Notes: 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 nal reports
of the relevant ofcial aircraft accident investigation organisation. Information on injuries is unavailable.
Date Aircraft Location Injuries Damage Description
01-Apr Robinson R22 Beta Murwillumbah (ALA),
NSW
Nil Serious The crew were practising forced landings.The helicopter sank in
the nal stages of the autorotation - the main rotor blade struck
the tail boom.
01-Apr Cessna 152 Maryborough (Vic)
Aerodrome, VIC
Nil Serious Due to an unstable approach, the aircraft ballooned on areout
and subsequently landed hard on runway 35. The aircraft
bounced twice nosedown, collapsing the nose landing gear.
02-Apr Robinson R22 Beta Proserpine/
Whitsunday Coast
Aerodrome, QLD
Serious Serious It was reported that the helicopter collided with the runway.
The two occupants sustained injuries. The investigation is
continuing.
07-Apr Boeing 737-7Q8 Townsville
Aerodrome, QLD
Serious Nil As the rear cabin door was closed, the airstairs were removed
from the aircraft. A ground crew member, closing the door at
the time, fell through the gap between the airstairs and the
aircraft, and was seriously injured.
09-Apr Yakovlev Yak-52 Albury Aerodrome,
NSW
Serious Nil The aircrafts engine stopped soon after startup. The pilot left
the cockpit to swing the propeller but left the magnetos on.
As the pilot touched the propeller, the engine started and the
propeller struck the pilot on the right hand, the right arm and
the right leg. The pilot was seriously injured.
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11-Apr Grob G-115B Paraeld Aerodrome,
SA
Nil Serious The aircraft bounced and oated on touchdown. The pilot
increased power and retracted the aps for a go-around, but the
aircraft banked to the left and impacted the runway. The aircraft
slid off the runway to the left and came to rest on a taxiway.
12-Apr Piper PA-25-235/A1
Pawnee
Benalla Aerodrome,
VIC
Minor Serious During the landing roll, the aircrafts left main landing gear tyre
burst. The left wing tip and propeller struck the ground, and the
aircraft ipped, sustaining serious damage.
14-Apr Piper PA-31-350
Chieftain
Dalby (ALA), QLD Nil Serious After selecting landing gear down, the left main landing gear
would not extend. The pilot diverted the aircraft to Oakey where a
manual gear extension also failed. After orbiting to burn fuel, the
pilot conducted a wheels-up landing.
15-Apr Gippsland (GA-8)
Aeronautics Airvan
Cape Barren Island
(ALA), TAS
Nil Serious While taxiing for departure in windy conditions, the pilot lost
control of the aircraft which ipped over.
16-Apr Piper PA-18-150
Super Cub
Maroochydore/
Sunshine Coast
Aerodrome, 153 M
22Km, QLD
Minor Serious During banner towing, the aircrafts engine failed and the pilot
conducted a forced landing onto a beach. During the landing roll,
the aircraft nosed over at the waterline.
20-Apr Robinson R44 II
Raven
Edenhope (ALA), 220
T 27Km, VIC
Fatal Serious It was reported that the helicopter struck powerlines and collided
with the ground. The pilot sustained fatal injuries. The investigation
is continuing.
22-Apr Bell 206B Jetranger Wynyard Aerodrome,
191 M 30Km, TAS
Nil Serious After takeoff, the helicopter was turned downwind and lost
tail rotor authority. The helicopter descended from 30 ft AGL
and landed heavily. The tail boom was broken and the skids
sustained damage.
23-Apr Robinson R22 El Questro (ALA), NNE
M 70Km, WA
Nil Serious During mustering, and while hovering above water, the tail rotor
lost effectiveness and the helicopter impacted the water right
side down. The helicopter was destroyed.
01-May Cessna 182R Skylane Hayes Creek (ALA),
SW M 9Km (Douglas
Station), NT
Minor Serious During takeoff from a station road, the aircraft did not accelerate
normally due to the left wheel dragging in long grass. After
becoming airborne, the aircraft began veering left uncontrollably.
The pilot landed the aircraft but was unable to stop the aircraft
before it struck trees.
02-May Amateur-built Hornet
STOL
Normanton
Aerodrome, NE M
50Km, QLD
Minor Serious As the aircraft climbed through 250 ft after takeoff, the aircraft
encountered windshear and lost airspeed. The pilot turned right
to return for landing, but the aircraft stalled and hit the ground.
The two occupants suffered minor injuries.
03-May Bell 47G-3B1 Rolleston (ALA), 180
M 2Km, QLD
Minor Serious As the helicopter climbed through 150 ft AGL at 40 kts, the pilot
felt a bounce, lowered the collective then heard a loud bang.
The engine began racing, so the pilot reduced power and carried
out a forced landing. The helicopter landed heavily and the main
rotor severed the tailboom.
04-May Cessna 172RG
Cutlass
Rockhampton
Aerodrome, W M
65Km, QLD
Nil Serious The aircraft touched down half-way along the runway strip,
over-ran it and collided with a barbed wire fence, resulting in
serious damage.
05-May Robinson R22 Beta Halls Creek
Aerodrome, N M
50Km, WA
Fatal Serious It was reported that two helicopters collided while mustering.
The investigation is continuing.
07-May Beech 58 Baron near Garden Point
Aerodrome, NT
Nil Serious When the landing gear was selected down, it failed to extend.
The pilot subsequently diverted to Darwin and conducted a
wheels-up landing.
07-May Cessna 210N
Centurion
Groote Eylandt
Aerodrome, 225 M
9Km, NT
Nil Serious During the approach to runway 10, the aircrafts engine failed and
the pilot force-landed on mud ats.
14-May Cessna 172R
Skyhawk
Jandakot Aerodrome,
WA
Nil Serious During the landing on runway 24L, the aircraft bounced three
times before the student pilot took off. After the subsequent
landing, it was found that the propeller had struck the runway
and the nose landing gear tyre had burst.
19-May Cessna R182 Skylane
RG
Canberra Aerodrome,
ACT
Nil Serious While on downwind for runway 12, the nose landing gear wheel
detached from the aircraft. The aircraft landed on the main
landing gear and nose gear strut. The aircrafts propeller struck
the runway and damage was caused to the nose leg forks and
nose gear door.
23-May Piper PA-30 Twin
Comanche
Cessnock (ALA), NSW Nil Serious The pilot did not complete the short nal checks and landed the
aircraft with the landing gear retracted.
29-May Cessna 152 Moorabbin Aerodrome,
VIC
Nil Serious During a touch-and-go landing on runway 13L, the pilot over-
corrected the aircraft after encountering crosswind and the
aircraft ran off the runway, coming to rest in a ditch.
Text courtesy of the Australian Transport Safety Bureau (ATSB). Disclaimer information on accidents is the result of a co-operative 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 ndings by the ATSB. The data do not include sports aviation accidents.
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F:07 3204 1902

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For more information on our services and to find out about us,
please visit our website http://www.leadingedgesafety.com.au
or call Dr Graham Edkins on 0410 522 541
he aviation inndduuusstrryy
ng CASA reqquuuirre emmmennnts: :
about us,
ty.com.au
Then go to CASAs homepage:
Click on education/seminars on the
home page drop-down menu.
Like to attend one of CASAs AvSafety seminars?
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Cozart provides peace of mind
with saliva drug testing.
Cozart has a highly advanced reader which removes user error or
bias through accurate analysis and recording of results. Processing
ve drug classes in only ve minutes, Cozart signicantly reduces
workforce downtime. All tests are fully supervised, decreasing
any chances of tampering and adulteration. Australian police trust
the accuracy and robustness of Cozart and currently use this
technnology across ve states. Cozart is also being utilised by CASA
as part of their random testing program.
For more information, email salivadrugtesting.au@siemens.com or
telephone 1300 368 378.
Cozart saliva drug testing
Innovation for generations.
background at all, Amber says. I think the fact that I knew little in
the rst place about aviation has helped if I had known about the
huge cost and the demands of the study involved, I may have been put
off. The Sir Donald Anderson Award Based on examination results,
the rst prize is $3,000, with the winners of second and third place
receiving $2,000 and $1,000.
Amber has had some extra motivation to do well. My partner Michael
and I have studied together for our exams over the years, so there has
been some healthy competition.
We met when studying to complete a Bachelors Degree in Science
(Aviation) at Edith Cowan University. For the past two years Amber has
worked for Skippers Aviation and Michael as a ight instructor for China
Southern at its ying college in Western Australia. They have both just
accepted positions at China Southern as Metro 23 rst ofcers.
CASA sponsors a number of aviation industry
organisations, and as part of this program,
CASA representatives recently attended the
Australian Women Pilots Association annual
conference in Port Lincoln, South Australia.
Aviation safety advisor for South Australia,
Mal Wardrop, presented a number of AvSafety
seminars to conference participants, and
Tanya Rush presented the CASA-sponsored
Sir Donald Anderson Award for 2009 at the
awards dinner.
This award recognises outstanding academic
achievement in professional aviation studies
by a female trainee pilot, and is named in
honour of the late Sir Donald Anderson, who
made a signicant contribution to aviation in
Australia, Tanya Rush explained.
Winner of the award was Amber Lee Grech.
I actually dont come from an aviation
High- ying
women
Amber accepts her award from
CASAs Tanya Rush
CASA AvSafety Advisor, Mal Wardrop
addresses conference delegates
By Jessica Beange
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In the 35 years leading up to 2003, there was
an average of one mid-air collision per year.
However, since December 2007 there have
been seven mid-air collisions, resulting in nine
fatalities. This is a concerning increase.
The majority of mid-air collisions occurred in the circuit area. Additionally,
there have been a number of near misses at busy aerodromes.
Detailed are some key safety factors and practical recommendations
to assist pilots in avoiding mid-air collisions. This list is not
exhaustive, nor are these recommendations the only factors a pilot
should consider.
Situational awareness
Maintaining situational awareness can save your life
know what is going on around you
predict what could happen.
High cockpit workload is a signicant factor in a pilot losing situational
awareness. High trafc density, radio congestion, instructional ights
and inexperience can increase cockpit workload.
Make sure you:
prepare and plan your ight
prioritise your tasks and remain alert
listen for other radio calls to identify other aircraft positions
consider re-scheduling if trafc density or radio congestion increase
to an uncomfortable level.
You need heightened situational awareness during diverse and
complex circuit operations at busy aerodromes. Infringement of
opposite circuit ight paths during contra circuit operations and
management of different aircraft speeds and performance in the circuit
are especially important factors.
To minimise these risks, you should:
remain clear of the opposite circuit, dont
drift after takeoff and dont overshoot
turning onto nals
maintain an active lookout for trafc in the
other circuit
familiarise yourself with the speed and
performance of other aircraft.
Lookout
The rst and last line of defence
An effective lookout is essentialalways
assume that you are not alone. See and
avoid principles are commonly used, but
have limitations. Alerted see and avoid can
be more effective, but is not always possible.
Most mid-air collisions occur when one aircraft
collides with another from behind, or both
aircraft converge from a similar direction.
You should:
maintain an effective lookout in all
directions, including behind
not become complacent, even if you are
familiar with an aerodrome
increase vigilance in high-risk areas,
including inbound reporting points and in
the circuit area
ensure you sight any preceding aircraft
before turning nals, otherwise consider
going around
be aware of, and manage blind spots as part
of your lookout technique
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use strobes, beacons and landing lights to increase aircraft visibility
turn your transponder on, code 1200, ALT mode.
Radio procedures
Talk is not cheap
Aviate, navigate and communicatetheyre your priority. Effective
communication assists situational awareness.
Incident reports show pilots sometimes do not follow or understand
instructions given by air trafc control (ATC). When ATC gives you an
instruction, you should:
acknowledge ATC in a timely manner
think about what is required and then action the instruction
tell ATC if you do not think you can comply with an instruction
advise ATC if you do not understand an instruction
not be afraid to ask ATC for assistance.
When an aircraft is equipped with dual radios, incorrect selection
of frequencies or transmission mode may create communication
difculties. To avoid these:
always conrm that the frequency, transmit selector and volume
control are set for the radio in use
ensure you have received and understood the ATIS well before the
approach point.
Pilots can become confused when they receive an unexpected instruction
from ATC, or are unable to make a planned radio call. To avoid confusion:
have an alternative plan if you are unable to make your inbound
call to ATC due to frequency congestion
monitor radio communications, and do not transmit during ATC
instruction and responses with other aircraft
make radio calls brief, clear, to the point and use standard phraseology.
GAAP procedures
Every GAAP aerodrome has location-
specic procedures.
Surveys of all general aviation procedures
aerodromes (GAAP) show that some pilots
misunderstand the role of ATC at a GAAP
aerodrome. Remember:
in VMC, the pilot in command must
sight and maintain separation from
other aircraft
comply with ATC instructions, and if
unable to comply advise ATC
advise ATC if sight is lost of other
aircraft.
ATC controls runway operations with
landing and take-off clearances. They
also provide trafc information and/or
sequence instructions.
Often pilots do not have a contingency
plan for frequency congestion.
Common congestion problems occur at
GAAP approach points and on nal
approach. Remember:
if the frequency is congested, have a plan B
consider specic risks at your location
consider re-scheduling if trafc density
or radio congestion increase to an
uncomfortable level.
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T10
Flight Safety editor, Margo Marchbank,
caught up with Dale Elliott recently
in Brisbane when he addressed
Australian Parachute Federation
conference delegates.
Dale Elliott has just achieved an Australian rst. In May 2009, he
became Australias rst paraplegic solo skydiver. And dismiss images
of a wheelchair plummeting earthwards from your mind thats
parked at the drop zone, waiting. Without legs that work, Dale has
engineered an ingenious solution to land safely on his rear.
Its been a long journey to this point. At the recent Australian Parachute
Federation of Australia conference in Brisbane, conference delegates
gave the down-sitting Dale a standing ovation after hearing his story.
He started ying as a year 11 student when he was 16; went solo in
January 1992, and got his PPL about a year later. He joined the army,
attending the school of artillery at Manly, a fantastic experience, and
then took on an apprenticeship as a LAME in 94-95. It was really
tough then to get a job as a pilot, he says, You had to have been ying
for about six to seven years. During his apprenticeship, he continued
to y, dropping skydivers at weekends, and completing his night-VFR
and twin-engine CIR ratings. It was all working out really well.
Achieving this rst began six years ago, when, Dale recounts, he was
a commercial pilot looking to get his hours up before trying for the
airlines. He recalls that time vividly: on 23 December 2002, he was in
an Aero Commander, ying through 8,000ft, and through the window
in the roof, he could see the stars. He remembers thanking these
constellations out loud that night. Im 26 years old; Ive been married
to a wonderful woman for six years; and Ive realised the dream Ive
had ever since I was eight or nine of being a pilot. It doesnt get much
better than this. Three days later, Dale and wife Erika were spending
Christmas with the family at Waikerie in South Australias Riverland,
where he grew up.
On Boxing Day, he went for a spin on his cousins Yamaha R6 motorbike.
Ive ridden bikes on my parents farm since I was eight, but I swerved
to miss a dog, and came off. I wasnt going fast, but I knew something
was wrong when I couldnt feel my legs. That something was damage
to his spinal cord at T10 (the tenth of twelve thoracic vertebrae), which
left him a paraplegic and reliant on a wheelchair. Its also, according to
Dale, the most common break following motorcycle accidents, because
the thoracic and lumbar vertebrae (T10-L2) at the base of the rib cage
are in a region where the spine is most exible, and therefore more
prone to injury. (Quadriplegic injury likewise most commonly occurs in
the region of the cervical vertebrae [C5-C7] of the neck.)
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With typical determination, his stay in rehab in Adelaide was
remarkably short. Its all about taking some control back, he explains,
necessary to counter the feelings of depression and hopelessness
which for many follow spinal cord injury. He was soon back working
for an aircraft charter company in Adelaide in charge of pilots
rosters and schedules. I was one, and now had to manage them, he
explains ruefully. But, determined to set himself more challenges,
Dale decided to resume skydiving. Flying jump planes had been a
way of getting some extra ying hours before his accident, and he
had done 37 jumps before as an able-bod. Solo, as a paraplegic,
was something completely different. With the support of Alan Gray
of Adelaide Tandem Skydiving, Greg Smith of SA Skydiving, and
instructor and photographer, Curtis Morton, Dale set about learning
how to skydive as a paraplegic. There was no manual on this, so we
had to go back to basics, he explains. I managed to track down a
South African guy by the name of Peter Hewitt. Hes also a para and
hes now done about 120 jumps, so hes given some great advice.
Dales T10 paraplegia means that his abdominal core strength
is compromised, and balance is affected - and, both legs are
paralysed. Skydiving conventionally requires all of these abilities, for
What can I do in a matter of minutes to
get my legs up out of the way?
manoeuvrability in the air, and for landing.
Developing his gear has been very much a
process of trial and error. His pants rigging
came about as an answer to the question:
What can I do in a matter of minutes to get my
legs up out of the way? He needs control of his
legs in launching himself out of the plane, and
especially for landing, so that he can pull his
legs up out of the way, and land safely on his
rear. I was an aircraft engineer, and worked
with a lot of breglass, sitting my CASA exams
for composite materials. I also cut my teeth on
gliders at WaikerieI used to go and help with
the glider repairs. Theyre some of the best
breglass repair guys in Australia. All this put
him in good stead for dealing with the unique
situation of jumping with paralysed legs.
The irony of developing his equipment didnt
escape Dale. A month before his rst jump,
he was swathed in a full plaster cast, looking
very much like the seen-after shots of a
disastrous jump. The plaster cast was inspired
by a 70s military movie he tracked down
on YouTube, which showed how to make an
arm cast on the battleeld. The plaster cast
worked perfectly, Dale says, as the mould for
making the breglass braces. These custom-
made breglass braces t into the legs of a
pair of motocross pants, which are further
modied with extra padding to cushion his
rear on landing. The braces keep his legs rigid
when necessary, and the cords on the braces
pull his legs up out of the way for landing. The
Mark 1 braces have scored a few bumps and
crashes and theyre beginning to show some
fatigue cracks so its now on to braces Mark
11. Dale is planning on making these from
5mm polypropylene plastic, working on the
theory that they will be much more exible
and durable. Fellow paraplegic skydiver, Peter
Hewitt, has had a special polypro orthopaedic
pair made, but the $1000 cost of these is a
deterrent. Dales working on making his own: king his own:
This stuff (polypropylene) is great to work e) is great to work
with. All I need is an angle-grinder; a jigsaw; ngle-grinder; a jigsaw;
and a commercial-sized oven. ed oven
27
A TYPICAL JUMP
Dale talks through what happens on a typical jump:
As the aircraft climbs through 11,000ft on the way to
12,000ft, everyone gets up and checks their gear. We
check each others pins (which hold the main and reserve
containers closed); put on our helmets and goggles; and
check altimeters. As we approach our exit point, we open
the door and look out to make sure its all clear and we can
see the drop zone. I then make my way across the oor
to the door and swing my legs out to face the oncoming
70kt wind. I count Out, in, GO! and push off the aircraft
out into the blue sky. I throw my arms and head back and
counteract any slipping by twisting my shoulders around.
I check my altimeter every thousand feet or so, which
means about every ve seconds. I do some turns and
have a play around, and might do a somersault or two.
As I am approaching 3000ft, I track to the left or right of
the aircraft track, so I dont y under another skydiver
who has jumped after me. I deploy my main parachute at
3000ft and quickly check that it is ying straight and level.
I identify the landing area, check the wind drift and then
set myself up to pull up my legs and attach the straps to my
chest. This takes about 30 seconds. After that I have a play
around and do some turns under canopy, and at 1500ft I
will be joining a downwind leg. At 600ft I turn onto nalI
can adjust my rate of descent by using front and rear risers
on the canopy. This increases and decreases the angle of
descent. I can get my landings within a few metres of the
target. Having 2000 ight hours and many more landings
has given me an advantage. The paraplegia has no effect
on my canopy control skills or technique. I just need to
land softly every time to avoid injuries. This means I need
to pick my days to jump.
Fitness is also a big thing for Dale. Preparation for his rst solo attempt
focused on building up strength and improving his circulation. You
need strength to move around the plane, he explains, and then
theres the 10-15kg chute to consider as well. So in the lead-up to the
jump, he was doing 20-30km hand cycle rides, getting his heart rate up
over two to three hours. Mastering these complexities, and coming up
with the means to skydive as a paraplegic is no different, Dale argues,
He also dives with a modied parachute donated by Parachutes
Australia; the harness is adapted to allow for his different body
position. Whereas able-bodied skydivers adopt an arched position to
remain stable in freefall, Dale needs to concentrate more on using his
upper body to deect air and stay in a stable position. His arms are far
more active.
Photo: Curtis Morton
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to when, as a pilot, you rst get in a plane
and look at all the instruments. Youve got to
chunk it, and break it down, taking one thing
at a time.
Dales also a sit-down stand-up comic, who
has braved hecklers at various comedy
venues; and a motivational speaker. Following
his appearance at the Brisbane conference, he
ies to New Zealand in late June. Hes excited
by that prospect, because two NZ companies
have offered to sponsor his equipment:
NZ Aerosports are providing a new Icarus
Sare2 canopy; and Deepseed are making
a customised jump suit. The braces tted to
external leg pockets in the new suit will give
much more exibility in preparing for a jump.
Hell talk to employees of both companies
about his skydiving journey.
Then theres the future challenge planned
for 2012. He gures it would make quite a
statement for those with disabilities if he
and fellow para skydiver Peter Hewitt were
to skydive into the stadium for the opening
of the 2012 London Paralympic Games.
He gures it would make quite a statement
for those with disabilities if he and fellow
para skydiver Peter Hewitt were to skydive
into the stadium for the opening of the 2012
London Paralympic Games.
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From his contact with the UK Parachute
Association, hes found that they dont have
any paraplegic skydivers, so he and Peter are
planning on putting a proposal to the Games
opening committee when its convened by
the London organisers later this year. Peter
and I have to get together and get to know
each others style and fall rates in the sky,
and well need demonstration licences,
which require strict examination and landing
accuracy skills.
As Flight Safety went to press, Dale gained his
A licence, and is now a qualied skydiver.
According to CEO of the Australian Parachute
Federation, Susan Bostock, Dales nailed
it (his solo certication). Its quite mind-
boggling, she says. Its difcult enough for
able-bodied skydivers. The it Susan refers to
is the accuracy required for solo certication
to achieve this, skydivers must land within 25
metres of the target in the drop zone on 10 occasions. Some people
who become paraplegics lock themselves away, and become recluses,
but Dales different. He just says, This is the card Ive been dealt, and
makes the most of it.
Recently, CASA has been working closely with parachute bodies such as the
APF, on a range of safety procedures including cloud jumping procedures
manuals, and aircraft operation and maintenance issues. In September-
Octobers Flight Safety, we take a closer look at these developments.
For more information
u
The Australian Parachute Federation (APF) website.
The APF is the organisation which controls skydiving
and parachuting at nearly all the civilian operations in
Australia.
www.saspc.asn.au South Australian Sport Parachute Club
www.daleelliott.com Dales website
www.scia.org.au Spinal Cord Injuries Australia
www.paraquad.org.au Paraplegic & Quadriplegic Association of NSW
He just says, This is the card Ive been
dealt, and makes the most of it.
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Following the above article
which ran in the last issue of
Flight Safety, several readers,
members of the Airtourer
Co-operative Ltd, expressed
concern as to the manner
in which the Victa Airtourer
was represented. Their level
of expertise in this area is
undoubted.
However, this article was designed to increase
general awareness in the aviation community
about fatigue of airframe structures, especially
with respect to aerobatic (those which
experience increased Ghigh G manoeuvring)
aircraft. The lack of recordkeeping was
identied as a major concern in a recent
audit of an operator, sparking the subject
article in Flight Safety Australia as a follow-
up action to provide information to other
operators. The article was deidentied to
protect the privacy of those concerned.
The article was intended to be general
in nature and provide information and
examples of aircraft types with life limitations.
Both constraints on space in the magazine
and reluctance to publish data that may
be seen as an alternate to referring to the
controlled version (source document) of the
limitation were reasons the article does not
contain in-depth specics on any particular type.
The article refers the reader instead to the AMM, TCDS or any applicable
airworthiness directives for details on their types specic limitations.
The details of the Airtourers specic fatigue sites were not spelled out,
but components of the wing and tailplane structure are affected (please
refer to AD/VAT/41 Amendment 1 for details). Comments made
pertained to the wing structure, and not wing failure per se.
The message was to do your homework on the type you are intending
to purchase. The airworthiness of this type may well be updated in the
future, given feedback from industry through the SDR system, accidents
or better knowledge of fatigue sites. Although there was considerable
research done in preparation of this article, it does not pretend to be all
you need to know about any aircraft type. A full and complete statement
on Airtourer fatigue was not the mission here.
One writer referred to the Airtourer SDRs coincidentally appearing in
the same issue, describing them as normal maintenance jobs. The
whole point of the SDR system is to alert other operators to areas they
should consider in normal maintenance. Moreover, it is the registered
operator who is responsible for the maintenance of an aircraft, and for
the keeping of its records. The LAMEs who do the maintenance have
their own responsibilities, but managing the maintenance and record
keeping for someone elses aircraft are not part of them.
The illustration of the dramatised wing failure was an artists
impression, and as such, obviously does not purport to represent a real
occurrence. It did serve to attract attention and provides interest in
the magazine article. The graphic designer used an actual photograph
of another Airtourer on the following page, and believing that the
orientation suited the layout better, reversed this photograph. Given
the pressure of meeting tight deadlines, unfortunately this error was
not picked up until after the magazine had gone to print.
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The illustration of the dramatised wing
failure was an artists impression, and as
such, does not purport to represent a
real occurrence.
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There is also the potential for interfacial bonds for int
between components to fail as the adhesive as
degrades over time. Many composite airframes ny com
in smaller sport and light GA aircraft use bonded t GA air
joints. A structure which contains bonded joints h contain
presents some potential long-term structural g-
durability issues.
Repair of an entirely bonded structure is also
challengingyou cant just unbolt a damaged
panel. The damaged area usually has to be
cut away and replaced, potentially inducing
secondary delamination. Also, determining the
extent of the damage in composites requires
a competent person, usually trained in non-
destructive testing (NDT), to assess the damage.
This is not the case in a metal structure where
the extent of the damage is usually apparent to
anyone, even those without NDT training.
Fatigue is not an issue in all-composite aircraft,
and material strains are low, but in-service skin
repairs, residual strength with hidden damage,
and lightning protection are concerns. Additionally,
there are some regulatory and industry capability
issues which should be considered.
Composite materials are not the new technology they once were.
Many basic sandwich/honeycomb panel composites have been in use
on civilian aircraft for decades and on military aircraft for even longer.
A common perception of the layperson, and even some in the industry,
is that composite materials do not age, or age at a much slower rate
than the equivalent metal structure. While it is true that bre laminate
structures are less susceptible to fatigue than their metal counterparts,
composites have their unique ageing problems.
AN AGEING ALL-COMPOSITE AIRCRAFT?
While many would think all-composite aircraft are immune to
ageing, some issues are beginning to emerge. These include, but are
not limited to:
hidden damage (delamination and disbond);
environmental susceptibility (i.e. trapped moisture freezing and
causing delamination); as well as
UV- and adhesive degradation. Many adhesives were not tested
for long-term durability in service. Many were tested only for
static and peel strength when newly applied, so there are many
unknowns here.
Cracking of ller materials, normally non-structural and in many
cases aesthetic in nature, but in some cases indicating a more
serious structural problem underneath.
Richard Castles, one of CASAs senior airworthiness engineers, with a
special interest in composite materials, looks at ageing and composites.
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COMPOSITE NDT CAPABILITY
The capability of industry NDT practitioners to detect and assess damage to advanced
carbon bre composite structure is emerging as an area which needs to be addressed.
Are there any training or knowledge gaps? Are all industry NDT practitioners up-to-
speed with advanced composite structural inspection, so that they can competently
detect hidden damage to primary and secondary structures?
New structural technologies employed in modern aircraft include carbon bre
wrapped or laminated structure with carbon bre stiffeners; monolithic 3D
composite structures; and extensive structure in which hidden disbonding or
delamination may not be immediately apparent. New equipment and inspection
techniques will be required to inspect this type of advanced structure. Are there
any training requirements which need to be identied? Do local and international
regulatory NDT qualication standards reect the level of expertise required to
inspect primary composite structures?
INDUSTRY REPAIR CAPABILITY
Some maintenance organisations in Australia possess very limited
capability to undertake advanced repairs of composite primary structure.
Current capability is generally conned to standard structural repair
manual (SRM)-based repairs on primarily secondary structure, and
limited to aluminium/Nomex honeycomb panels and simple bonded oneycomb panels and simple bonded
and laminate structures.
Modern composite aircraft contain a signicant portion of monolithic h signicant portion of monolithic
carbon/resin composite structure with integral stiffening, which will
make repairs more complex. Heat control during curing will require
advanced equipment, not just the traditional layup and heat
blanket approach. Major repairs will require advanced autoclave
capability, or advanced in-situ heat blanket repairs.
GROUND HANDLING DAMAGE
The characteristics of the structure of modern composite aircraft
are so different that it is not simply the maintenance technicians
and engineers who may need specialist training. With a
conventional metal structure, any collision between the aircraft
and ground support equipment is immediately apparent - there
will be dings, dents, gouges, scratches, etc.
You can assess the severity of such damage, often simply by
looking at it. However, with a composite structure, even a
severe impact may leave no discernible marks on the outside
of the structure. But it may be a different story insidewith
considerable structural damage: delamination, disbonds,
broken bres, rovings and so on. Research has examined m
the effects of high energy/blunt impact damage scenarios, a
such as those involving ground support equipment.
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SELECTED SERVICE DIFFICULTY REPORTS
1 April 2009 31 May 2009
AIRCRAFT ABOVE 5700KG
Airbus A320232 Horizontal stabiliser FOD.
Ref 510008448
RH horizontal stabiliser FOD. A small 7/32in by 1/4in ring
spanner was found protruding from the inboard end of the
stabiliser forward of the elevator. Spanner was visible from
the ground. Suspect spanner was left behind following last
maintenance. Investigation continuing.
Airbus A320232 MLG lockstay actuator hose swivel
tting ruptured. Ref 510008410
LH main landing gear lockstay actuator hydraulic hose
swivel tting cracked/ruptured. Loss of green system
hydraulic uid.
P/No: 201655144. TSN: 12,116 hours/7,124 cycles.
Airbus A320232 Pilots window cracked.
Ref 510008409
LH aft cockpit window cracked beyond limits. Window
heat computer PNo 416-00318-003 also replaced as a
precaution.
P/No: NP1653133. TSN: 11,317 hours/7,596 cycles.
Airbus A330201 Cabin jet fuel smell. Ref 510008428
Strong smell of jet fuel in cabin following engine start.
Investigation and ground runs could nd no evidence of
fumes. Suspect air conditioning pack ingested exhaust
fumes during engine start.
Airbus A330202 HF system unserviceable.
Ref 510008189
No1 HF system inoperable.
Airbus A330303 Landing gear wheel brake
dragging. Ref 510008179
No5 wheel brake assembly dragging. Investigation found
part of brake stator missing.
P/No: 215782.
Airbus A330303 Water cooling units overheated.
Ref 510008231
Water cooling units inside toilet stowage overheated.
Investigation found dust build-up over time caused clogging
of the cooling ns.
Airbus A380842 Engine cowl latch access panel
missing. Ref 510008362
No2 engine cowl latch access panel partially missing.
Approximately 508mm (20in) of the forward end of the
panel was missing with the rest of the panel delaminated.
Investigation continuing.
P/No: L5412335000600.
Airbus A380842 Rack receptacle socket and printed
circuit card overheat damage. Ref 510008477
Socket 11 of rack receptacle 3223XZ and associated printed
circuit card 3020XZ damaged due to overheating. Hole burnt
in rack buss bar cover. Associated wire 2473-1037-DR10-W
and terminal also heat damaged. Investigation continuing.
P/No: 11532986.
BAC 146100 Engine pylon attachment bracket
cracked. Ref 510008323
No1 engine pylon attachment bracket cracked between
three fasteners at upper attachment ange attaching
bracket to lower wing skin at forward spar.
P/No: HC571H0288000. TSN: 40,340 hours/25,852 cycles.
BAC 146300 Fuel boost pump wire chafed.
Ref 510008479
LH inner fuel boost pump wire 056C chafed and short
circuiting to ground. Wire located between LH rear wing
fuselage fairing disconnect and fuel pump connector 2QG5P.
P/No: 056C. (1 similar occurrence)
BAG JETSTM4101 Flap cable rod end failed.
Ref 510008449
Flap system teleex cable rod end failed due to
suspected binding at clevis pin attachment to ap
position transducer.
P/No: 745284.
Boeing 717200 PSEU faulty. Ref 510008215
Proximity Sense Electronic Unit (PSEU) faulty. PSEU
was on rst ight since tment the previous night.
P/No: 893602. (1 similar occurrence)
Boeing 737376 EGT indicator unserviceable.
Ref 510008296
No2 engine EGT indicator failed.
P/No: WL202EED6. TSN: 4,898 hours. TSO: 4,898
hours. (4 similar occurrences)
Boeing 737376 Fuselage stringers cracked.
Ref 510008227
Fuselage stringers cracked in the following areas:- 1.
BS870 Stringer 23R - crack length 38.1mm (1.5in) 2.
BS880 stringer 24R - crack length 38.1mm (1.5in) 3
BS903 stringer 25R - crack length 33.78mm (1.33in)
Investigation continuing.
(4 similar occurrences)
Boeing 7373YO Nacelle strut mid-spar fuse pin
corroded. Ref 510008208
LH nacelle strut mid-spar outboard fuse pin corroded
on inner surface of the head and in the head radius.
Found during inspection iaw AD/B737/344 (FAA AD
2008-21-03 and Boeing SB 737-54-1044).
P/No: 311A10922.
Boeing 737476 Aileron tab assembly loose.
Ref 510008438
LH aileron tab assembly had excessive free play. Found
during inspection iaw EI 734-27-85R1.
Boeing 737476 Autopilot computer faulty.
Ref 510008458
Autopilot computer faulty.
P/No: 4051600923. TSN: 52,352 hours. TSO: 22,944
hours. (1 similar occurrence)
Boeing 737476 Cabin altitude warning switch
unserviceable. Ref 510008354
Cabin altitude warning switch failed to operate.
P/No: 214C502.
Boeing 737476 Copilots window jammed.
Ref 510008349
First Ofcers No2 window (emergency exit) external
release handle cam would not release the latch.
Investigation found that pin assembly PNo 66-19355-1
located in the internal handle had backed out to a point
that the release cam would not function.
P/No: 5717623096. (1 similar occurrence)
Boeing 737476 Engine fuel spar valve circuit
breaker wire short circuit. Ref 510008403
No1 engine fuel spar valve circuit breaker wire short
circuiting to ground. Short circuit in wire W802-005-20
located between splice SP3276 and splice SP4204.
Investigation continuing.
(1 similar occurrence)
Boeing 737476 Fuselage stringers cracked.
Ref 510008225
Cracks (4off) found in LHS BS 727D-G stringers 22L
and 25L. A further 10 cracks found in the same area.
Manufacturer requested same area on RHS be checked
with cracking found at BS727D and BS727E stringers
S-23R and S-24R. Investigation continuing.
(4 similar occurrences)
Boeing 737476 Leading edge ap sensor target
retaining bolt missing. Ref 510008329
Takeoff conguration warning. Investigation found
No6 leading edge ap sensor target retaining bolt and
nut missing.
Boeing 7377BK FMC failed. Ref 510008451
No2 Flight Management Computer (FMC) failed.
Investigation continuing.
(15 similar occurrences)
Boeing 7377BX Horizontal stabiliser microswitch
failed. Ref 510008453
Horizontal stabiliser position microswitch S132
inoperative.
P/No: 32EN214.
Boeing 7377BX Wing fuel tank water
contamination. Ref 510008357
RH wing fuel tank water contamination.
Investigation continuing.
Boeing 737838 Air conditioning systems relay
smoke/fumes. Ref 510008393
Forward and aft door heaters inoperative. Investigation
found common relay R560 faulty.
P/No: K4DN.
Boeing 737838 Captains window arcing.
Ref 510008348
Captains L2 window exhibited evidence of arcing around
sensing element lead wires.
P/No: 141A481014. (7 similar occurrences)
Boeing 737838 Copilots oxygen mask failed test.
Ref 510008245
First Ofcers oxygen mask Push to Test & Reset fails to
reset after testing.
(1 similar occurrence)
Boeing 737838 Copilots pitot tube blocked.
Ref 510008299
First Ofcers pitot probe blocked.
P/No: 0851HT1. TSN: 74 hours. TSO: 74 hours.
Boeing 737838 Engine auto-throttle servo motor
faulty. Ref 510008229
RH engine auto-throttle system servo motor faulty.
P/No: 305RAA1. TSN: 8,637 hours. TSO: 8,637 hours.
Boeing 737838 Fuel boost pump unserviceable.
Ref 510008294
LH centre fuel tank boost pump unserviceable.
P/No: 609891005. TSN: 1,606 hours. TSO: 1,606 hours.
(6 similar occurrences)
Boeing 737838 Pneumatic systems
pressurisation loss. Ref 510008247
Loss of pressurisation caused by dual bleed air
problem and exacerbated by a slow outow valve.
Investigation continuing.
(3 similar occurrences)
Boeing 737838 VSCU faulty. Ref 510008241
Video System control Unit (VSCU) shut down with
associated smoke and smells. Investigation continuing.
P/No: RDAV300705. TSN: 22,622 hours. TSO: 258 hours.
Boeing 73786N APU failed to start. Ref 510008266
APU failed to start in ight. Investigation continuing.
TSN: 11,542 hours/13,990 cycles. (5 similar occurrences)
Boeing 7378FE Rudder feel and sensing unit spring
broken. Ref 510008347
Rudder feel and sensing unit inner spring broken.
P/No: 65579006. (1 similar occurrence)
Boeing 7378FE Wing fuel tank access panel
anchor nut cracked. Ref 510008367
Wing fuel tank access panel 632FB anchor nut cap
cracked. Fuel leaking from panel. I nvestigation continuing.
Boeing 747438 Airspeed (standby) indicator hose
distorted. Ref 510008240
Standby airspeed indicator static quick disconnect hose
kinked. Investigation found standby altimeter and standby
airspeed indicator static hoses crossed at T tting in
instrument panel. Investigation continuing.
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Boeing 747438 Cargo area panels incorrectly
tted. Ref 510008288
Bulk cargo area panels incorrectly tted and panels
on oor. Investigation showed both vac blower panels
and paper work (print date 12thMarch) on oor plus
rear cargo zipper panel undone. Investigation revealed
the toilet waste vacuum blower lter change had been
carried out. Suspect panel tment task card missing from
maintenance package. Investigation continuing.
Boeing 747438 Centre fuel tank indicating system
wire chafed. Ref 510008443
Centre fuel tank indicating system wire chafed and short
circuiting on connector. Investigation continuing.
Boeing 747438 Coffee maker sparking.
Ref 510008440
Sparks and popping sounds from coffee maker.
Crew member received a mild electric shock.
Investigation continuing.
P/No: HFE9520D01.
Boeing 747438 Electrical power systems circuit
breaker tripped. Ref 510008281
Circuit breaker K1 on P6-1 tripped. Numerous messages
generated. Coffee spill on centre console. Centre CDU
inoperative. Investigation continuing.
Boeing 747438 Passenger oxygen cylinder shutoff
valve in closed position. Ref 510008250
No11 passenger oxygen cylinder shutoff valve in closed
position with lockwire intact. Investigation continuing.
(1 similar occurrence)
Boeing 747438 Wing centre tank leaking fuel.
Ref 510008429
Fuel leaking from centre wing fuel tank at Stn 1190.
Boeing 7474H6 Over-wing escape rope not
attached to structure. Ref 510008238
Over-wing escape rope located above attendants seat MED
No3 RH not attached to structure. Investigation continuing.
P/No: 65B5400514.
Boeing 767336 Autopilots disengaged.
Ref 510008191
LH and RH autopilots disengaged. Investigation continuing.
Boeing 767336 Engine shut-down after start.
Ref 510008226
RH engine shut down after start. R FUEL SPAR
VAL, R ENG SHUTDOWN and R ENG LP PUMP
messages displayed. Investigation continuing.
Boeing 767336 Fuel cross-feed valve faulty.
Ref 510008279
Fuel cross-feed valve faulty. Investigation continuing.
P/No: 125334D.
Boeing 767338ER ACARS printer overheated -
smoke. Ref 510008235
ACARS printer overheated with smoke emitted and
circuit breaker tripped.
(1 similar occurrence)
Boeing 767338ER Aileron lockout mechanism
bearing seized. Ref 510008275
LH aileron remained fully up during control check.
Investigation found a seized bearing in the LH outboard
aileron lockout mechanism. Investigation continuing.
Boeing 767338ER Aircraft fuel tank quantity
indicating system wiring failed bonding check.
Ref 510008356
LH main fuel tank quantity indicating system wiring
failed bonding check. RH auxiliary tank indicating
system wiring also failed bonding check. Investigation
found the high resistance was caused by corrosion
on the wiring shield on both looms. Found during
inspection iaw AD/B767/242.
Boeing 767338ER Aircraft rapid
depressurisation. Ref 510008452
Rapid decompression on descent. Oxygen masks
deployed. Investigation continuing.
Boeing 767338ER Video projector faulty
smoke/fumes in cabin/galley. Ref 510008325
Forward video projector inoperative. Smoke/fumes in
forward cabin and galley. Investigation continuing.
P/No: 7001117001.
Bombardier DHC8315 Aileron splitter quadrant
control cable keeper missing. Ref 510008305
Lower aileron splitter quadrant control cable keeper
missing. Cable keeper found in mechanics tool box.
Investigation continuing.
TSN: 18,438 hours/21,822 cycles.
Bombardier DHC8402 Air conditioning system
oil smell. Ref 510008411
Oil smell through bleed air system causing headaches
and nausea. Investigation could nd no denitive
cause for the smells. Defect not conrmed.
(7 similar occurrences)
Bombardier DHC8315 Copilots front
windscreen cracked. Ref 510008389
First Ofcers front windscreen cracked. Crack length
approximately 600mm (23.6in).
(3 similar occurrences)
Bombardier DHC8315 NLG oleo strut outer
cylinder cracked. Ref 510008303 (photo below)
Nose landing gear shock strut outer cylinder cracked.
TSN: 12,517 hours/13,969 cycles.
Bombardier DHC8402 FCEU wiring loom to
rudder control unit pressure switch chafed.
Ref 510008173 (photo below)
Wiring loom located between Flight Control
Electronic Unit (FCEU) and rudder control unit pressure
switch had chafed insulation causing a short to earth.
Nil evidence of electrical burning.
Bombardier DHC8402 NLG door safety pin
support tting distorted. Ref 510008268
Nose landing gear door safety pin support tting
deformed preventing full engagement of the safety pin.
TSN: 7,104 hours/8,187 cycles.
Embraer EMB120 MLG door hinge bearing
loose. Ref 510008214
LH main landing gear outboard door aft hinge bearing
loose in hinge arm preventing gear door opening
sequence valve from activating.
Embraer ERJ170100 Landing gear brake
housing cracked. Ref 510008293
No4 brake assembly housing cracked and leaking.
Loss of hydraulic uid.
P/No: 900005831PR.
Embraer ERJ190100 Landing gear systems hose
failed. Ref 510008470
RH outboard exible hydraulic brake line failed at
quick disconnect to hose join.
P/No: 2000A0529K01.
Fokker F27MK50 Nacelle fuel adaptor
corroded. Ref 510008394
Fuel adaptor located in lower RH nacelle severely
corroded. Found following removal of fuel pipe
between adaptor and fuel re shutoff valve.
P/No: F8423024001.
Fokker F28MK0100 Hydraulic reservoir T
tting cracked. Ref 510008310
Hydraulic reservoir T tting cracked and leaking.
P/No: MS21912D10.
AIRCRAFT BELOW 5700KG
B&B Aviation 8KCAB Aircraft door hinge failed.
Ref 510008378
Door top hinge failed causing the door to come into
the cockpit and jam the controls and strike the pilot.
The door is constructed of breglass reinforced with
wood. Wood was straight grained but should have
been ply. Aircraft was engaged in aerobatics when
the door failed.
Beech 200 Landing gear torque knee cracked.
Ref 510008326
Main landing gear torque knee cracked from holed
drilled through web.
P/No: 1018100327.
Beech 58 Alternators (bvoth) failed.
Ref 510008363
LH and RH alternators failed during takeoff. Circuit
breakers tripped. System then operated normally
when circuit breakers were reset. Voltage regulators
operating within limits but were adjusted to ensure
better voltage regulation.
Beech 58 Wing structure spar corroded.
Ref 510008427
LH wing upper main spar corroded beyond limits.
Found following discovery of small paint deformity.
TSN: 11,064 hours. (4 similar occurrences)
Beech 76 Landing gear A frame cracked.
Ref 510008346
RH and LH main landing gear A frames PNo 105-
810023-67 and PNo 105-810023-68 cracked in support
attachment bracket for hydraulic actuator connection
as referred to in SB2361. Found during inspection iaw
AD/Beech76/18 Amdt1.
P/No: 10581002367. TSN: 11,771 hours.
(1 similar occurrence)
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Beech B200C Landing gear downlock hook
cracked. Ref 510008312
RH main landing gear downlock hook cracked and broken.
P/No: 508103385. TSO: 2,664 hours/4,170
cycles/4,170 landings/52 months.
Beech E33A Aircraft vertical stabiliser rear
spar support fractured. Ref 510008359
Vertical stabiliser rear spar support PNo 33-640000-97
located at Stn 7.218 fractured. Found during boroscope
inspection iaw AD/B33/36 Amdt2.
P/No: 3364000097. TSN: 5,018 hours.
(1 similar occurrence)
Cessna 182K Elevator torque tubes corroded.
Ref 510008207
During re-skinning of LH and RH elevators due to hail
damage, both elevator torque tubes were found to be
severely corroded.
P/No: 07341107. TSN: 7,975 hours.
Cessna 207A Alternator faulty. Ref 510008271
Alternator faulty. Loose stator in housing caused
interference with rotor causing breakage of the front
housing and belt separation. See also SDR510008270
for similar defect.
P/No: DOFF1030BR. TSO: 5 hours.
(1 similar occurrence)
Cessna 310R Landing gear idler bellcrank
broken. Ref 510008313 (photo below)
RH main landing gear idler bellcrank broken.
P/No: 08411066. TSN: 14,698 hours/25,710 landings.
(2 similar occurrences)
Cessna 404 Cabin heating fan failed.
Ref 510008262
Cabin heating system fan failed. Investigation found
that the permanent magnets in the motor housing
had dislodged due to bonding failure and jammed
the armature.
P/No: 722043SN00672.
Cessna 404 Wing tip fuel tank leaking.
Ref 510008430
LH and RH wing tip fuel tank sealant deteriorated and fuel
leaking. Suspect sealant reacted with fuel to become soft.
P/No: PR1422.
Diamond DA40 Engine mount frame to fuselage
attachment bolt corroded. Ref 510008239
Engine mount frame to fuselage attachment bolt
corroded. Suspect bolt is unapproved part as the bolt
supplied/installed at initial assembly of aircraft at
manufacture does not conform with the approved
data stated in the Diamond MM and IPC.
P/No: LN9037M10X80. TSN: 697 hours.
Fletcher FU24Airpts Rudder leading edge skin
cracked. Ref 510008339
Rudder leading edge skin cracked through
approximately 50%.
P/No: 242402. TSN: 10,545 hours.
Gippsland GA8 Fuel drain manifold corroded.
Ref 510008198 (photo below)
Fuel drain manifold for cargo pod installation
badly corroded.
P/No: GA828205221. TSN: 3,397 hours.
Navion Rangemaster MLG door hinges
incorrect part. Ref 510008368 (photo below)
LH and RH main landing gear door hinges incorrect
part. Hinges were common house-hold door hinges.
Doors misaligned.
Pilatus PC12 Crew door inner handle failed.
Ref 510008369
Crew door inner handle fractured approximately half
way in area where handle is recessed.
P/No: 5521012187. TSN: 6,878 hours/9,138 cycles.
(1 similar occurrence)
Pilatus PC12 MLG brake seized. Ref 510008445
RH main landing gear brake rotor cracked through
causing brake to seize.
P/No: 30244. TSN: 5,322 hours. TSO: 2,274
hours/2,019 cycles.
Piper PA32R300 Stabilator control cable
frayed. Ref 510008364
Stabilator control cable frayed and corroded around
seized pulley.
P/No: 6270137.
Seabird SB7LSeeker Carburettor heat
buttery spindle bearing hole worn/elongated.
Ref 510008375 (photo below)
Carburettor heat buttery spindle PNo 1587160-03-
04 wore through spindle bearing allowing spindle to
contact the edge of the carburettor heat box.
Continued vibration and fretting wore through the
shaft until failure.
TSN: 225 hours/18 months.
Swearingen SA227AC Flap and walking beam
distorted bearings damaged. Ref 510008185
LH ap and walking beam distorted and bearings
damaged. Caused by incorrect tment of RH ap
hydraulic lines which caused RH ap to extend when LH
ap retracted during functional testing of ap system.
Vulcan P68C Flap control wiring loom
short circuited on engine control quadrant.
Ref 510008387
Wiring loom located above engine control quadrant
chafed and short circuiting on quadrant. Wire was for ap
control. Suspect loom poorly secured at manufacture.
TSN: 238 hours.
ROTORCRAFT
Bell 206B Main rotor gearbox sun gear
damaged. Ref 510008424 (photo below)
Main rotor transmission sun gear tooth damaged.
Metal contamination of transmission.
P/No: 206040662101. TSO: 2,415 hours. (1 similar
occurrence)
Eurocopter AS332L Aircraft structure
corroded. Ref 510008385
Extensive corrosion throughout aircraft structure
particularly in underoor tub section.
Eurocopter AS332L Main rotor gearbox
transmission metal contamination.
Ref 510008269
Main transmission chip detector metal contamination.
P/No: 332A32100703P. TSO: 2,975 hours/460
landings. (4 similar occurrences)
Eurocopter AS350BA Hydraulic system
contaminated. Ref 510008331
During hydraulic failure exercise, the hydraulic system
would not come back on line. Investigation could nd no
fault with any hydraulic components. The hydraulic uid
was then drained and found to be milky. The hydraulic
tank ller neck conical screen was also found to contain
a considerable amount of water. The most likely cause of
this incident is aircraft washing along with the fact the
hydraulic uid level and colour cannot be easily inspected
due to the hydraulic reservoir type (ie opaque plastic).
TSN: 5,640 hours.
Eurocopter AS365N Tail rotor pitch change
spider cracked. Ref 510008342
Tail rotor pitch change spider cracked.
P/No: 360A33107003SN237. TSN: 35 hours/46
landings. (3 similar occurrences)
Eurocopter SA365C1 Transmission cowl
separated. Ref 510008408
RH side transmission cowl opened and separated
from aircraft. Investigation continuing.
P/No: 365A24100503. TSN: 12,555 hours.
MDHC 369E Main rotor blade delaminated.
Ref 510008206
Main rotor blade stainless steel leading edge
strip debonding on underside of blade. Length of
delamination approximately 50.8mm (2in) located on
the inboard end.
P/No: 500P2100105. TSN: 258 hours/280 cycles.
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MDHC 369E Main rotor head blade pin broken.
Ref 510008431 (photo below)
Following removal of main rotor blades during
scheduled inspection, one blade retaining pin was
found to be broken in two.
P/No: 369A10045. TSN: 6,855 hours/41 months.
Robinson R22BETA Horizontal stabiliser
cracked. Ref 510008272
Horizontal stabiliser cracked. Stabiliser had been
removed from another aircraft due to severe cracking.
P/No: A0441.
Robinson R44 Engine mufer collapsed.
Ref 510008457
Mufer assembly collapsed at tailpipe junction.
Further investigation found hose to rewall collapsed
and duct PNo A623-1 melted.
P/No: C16932. TSN: 792 hours.
(10 similar occurrences)
Robinson R44 Engine starter switch broken.
Ref 510008264
Collective mounted engine start switch intermittent
in operation. When removed the switch fell apart.
P/No: B2805. TSN: 693 hours. (1 similar occurrence)
Robinson R44 Main rotor blade corroded.
Ref 510008417 (photo below)
Main rotor blade corroded between back of D spar
and balance weight housing. Found following blade tip
removal. Further investigation found corrosion on the
bottom skin which caused skin to debond. Area of debond
approximately 12.7mm by 9.525mm (0.5in by 0.375in).
P/No: C0162. TSN: 597 hours. (4 similar occurrences)
Schweizer 269C Landing gear skid damper cap
cracked. Ref 510008236 (photo below)
LH landing gear skid damper cap assembly cracked.
P/No: 269A3170. TSN: 211 hours.
PISTON ENGINES
Continental GTSIO520M Engine cylinder
cracked. Ref 510008405
RH engine No6 cylinder cracked between fuel nozzle
and top spark plug hole.
P/No: 655474. TSO: 192 hours. (3 similar occurrences)
Lycoming LO360A1G6 Engine starter motor
burnt out. Ref 510008220
RH engine starter motor burnt out. Suspect internal
short circuit due to twisted rear housing and bent bolt.
P/No: 149NLR. TSN: 4 hours. (4 similar occurrences)
Lycoming O235L2C Engine cylinder partially
separated. Ref 510008327
No4 cylinder head cracked and partially separated
from barrel. Crack extended through exhaust valve
seat and extended for approximately half of the
cylinder circumference.
P/No: SL1032A21P. TSO: 1,598 hours/78 months.
Lycoming O360A1A Engine starter motor
broken. Ref 510008232 (photo below)
Engine starter motor rear housing broken. Suspect
rear housing twisted and brush assembly caught on
commutator.
P/No: 149NL. TSN: 25 hours. (6 similar occurrences)
PWA R985SB3 Engine bearing failed.
Ref 510008476
Internal failure of engine. Bronze bearing failure.
TURBINE ENGINES
GE CF680E1 Engine lost thrust message.
Ref 510008228
Engine lost thrust message. Investigation continuing
(1 similar occurrence)
GE CF680E1 Thrust reverser clevis pin missing.
Ref 510008432
LH engine thrust reverser LH actuator lower clevis pin
and locking tab missing. Damage to sleeve/cascade
vane and actuator. Clevis pin retainer missing from
top actuator. Mid actuator clevis pin retainer loose
and not safety wired. Investigation continuing.
P/No: D52B150211.
GE CFM563C Engine turbine blade damaged.
Ref 510008278
Engine parameter shift and loss of EGT margin.
Boroscope inspection found the High Pressure Turbine
(HPT) had signicant leading edge and trailing edge
damage to approximately 15 blades. First stage Low
Pressure Turbine (LPT) blades had major leading edge
damage. Fourth stage LPT blades (2off) had major
impact damage on the trailing edge. Engine changed.
Investigation continuing.
P/No: CFM563C1. (2 similar occurrences)
GE CFM567B Engine VSV bushing worn.
Ref 510008277
Engine Variable Stator Vane (VSV) bushing worn
allowing VSV inner shroud to contact third stage
High Pressure Compressor (HPC) blade causing
excessive wear. Found during inspection iaw EI
N37-72-081R3.
TSN: 24,610 hours. TSO: 24,610 hours.
GE CT79B Engine oil smell in cockpit.
Ref 510008267
Oil smell in cockpit. Smell isolated to RH bleed air
system. RH engine inspected with slight oil staining
on inside of intake duct. Axis A cover o-ring seal
leaking. Nil odour for approximately 11 hours until
fumes reappeared. Investigation continuing.
Lycoming LTS101750B1 N2 governor drive
spline broken. Ref 510008416
N2 governor faulty. Investigation found the drive
spline broken into three pieces. The spool bearing had
failed and there was internal contamination in the
governor drive body assembly.
P/No: 43012120425491021. TSN: 1,992 hours. TSO:
1,992 hours. (1 similar occurrence)
PWA PW118B HMU faulty. Ref 510008388
RH engine Hydro-mechanical Unit (HMU) faulty due to
low motive ow output. Investigation continuing.
P/No: 7863908L27. (4 similar occurrences)
PWA PW530A Bellows at P3 bleed air pipe
ange cracked. Ref 510008180
Bellows located at P3 bleed air pipe ange cracked
and broken.
P/No: 31J181901. TSN: 4,136 hours/4,453
cycles/4,453 landings.
Rolls Royce TRENT97284 Fuel injector nozzle
bolt sheared. Ref 510008221
No4 engine No1 fuel nozzle ange bolt sheared.
Investigation continuing.
P/No: AS48821.
Turbomeca MAKILA1A FCU unserviceable.
Ref 510008315
No2 engine fuel control unit unserviceable.
Investigation continuing.
P/No: 0164168410. TSN: 11,111 hours. TSO: 1,275
hours/557cycles/21 months. (2 similar occurrences)
PROPELLERS
Hartzell HCB4MP3A Propeller counterweight
slug bolts AD requirement. Ref 510008441
Propeller counterweight slug bolts affected by AD
2009-10-14 and Hartzell Alert SB-61-313 Rev2.
P/No: B338614H.
MTV MTV6AC187 Propeller pitch control valve
failed. Ref 510008174
RH engine surged then failed. Investigation found a
failed propeller pitch control valve which caused the
propeller to feather and stop the engine. Investigation
continuing.
(2 similar occurrences)
Peske AS1730 Propeller blade holed.
Ref 510008177
Propeller blade leading edge holed in area approximately
100mm (4in) outboard of spinner. Investigation found a
void or inclusion in area underneath the hole. Cracking
also evident along leading edge on both sides of the hole
for approximately 60mm (2.36in).
COMPONENTS
Rolls Royce turbine disc cracked.
Ref 510008224
Low pressure turbine second stage disc cracked in
rtree areas. Investigation continuing.
P/No: UL29026M.
Note: Occurrence figures based on data received
over the past five years.
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NINE easy steps to lodge your SDR online NINE easy steps to lodge your SDR online
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Go to the CASA website: www.casa.gov.au
1
Go to the QUICK LINKS Information about: drop-
down menu on the right of the home page, and select
Service Difculty Reportsits the last option in
the list which appears when you click on the drop-
down menu. This takes you directly to the SDR page.
2
To get started, click on the underlined words SDR
and SUP online form which are at the top of the
Service Difculty Reports page.
3
Select SDR type from the drop down box, the form
will refresh with the applicable sections open for
you to complete.
Required information is marked with an asterisk. Fill
in any other pertinent information by opening the
applicable section and entering details.
Tip for composing your description
So that you dont waste time on the web, and
give yourself time to research and compose your
description, you can create a temporary MS Word
document, enter your description and then copy/
paste to the SDR description box.
This can be done before you select SDR and SUP
Online Form.
Note: The form description box has a maximum character
limit of 4000 characters - approximately 56 lines. You can
include additional information as an attachment.
4
The occurrence and causal factor elds are not
required data, but lling in one or more of these will
help us to assess your report.
5
Selection of defect report type:
Initial notication of defect (additional information can
be provided at a later date, i.e. follow-up report), or
Follow-up notication (with additional investigation
results).
Note: If Follow-up is selected, a tick box eld will
appear titled, Follow-up report from an earlier defect
notication. Click and enter the defect receipt number
of your initial report.
6
Click Submit: you will be prompted if any of the
required elds are not complete, i.e. the applicable
eld(s) will be coloured and/or a red text message
will be displayed
7
You will be given a receipt number and the opportunity to
attach photos, movies or other supporting documents.
(You can make multiple attachments, but the size of each
must not exceed 2Mb. Files in excess of 2MB can be
emailed to sdr@casa.gov.au)
Note: Record your receipt number, date of occurrence
and submitters name for future reference.
8
Finish procedure or submit another defect - there are
three options to continue data entry:
return to a cleared input screen,
return to the input screen with your previously entered
data retained, or
enter a receipt number, including the defect reports
date of occurrence and submitters name, exactly as
shown for that defect reports receipt number.
9
If you need further information please refer to the help page, simply click
on the SDR help link at the top right of the SDR page.
!
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4 June 2009
Part 39-105 - Lighter Than Air
There are no amendments to Part 39-105 - Lighter
than Air this issue
Part 39-105 - Rotorcraft
Brantly B-2 Series Helicopters
AD/B-2/5 - Tail Cone Reinforcement - CANCELLED
AD/B-2/7 - Main Rotor Blade Dampers - Installation -
CANCELLED
AD/B-2/8 - Tail Cone Reinforcement - CANCELLED
AD/B-2/9 - Main Transmission Mount - Reinforcement
- CANCELLED
AD/B-2/10 - Rotor Blade Hinge - Modication -
CANCELLED
AD/B-2/11 - Tail Rotor Blade Retaining Nut - Safetying
- CANCELLED
AD/B-2/24 - Rudder Control Post Upper Attachment -
Modication - CANCELLED
AD/B-2/27 - Tail Rotor Blades Strike Indicators -
Installation - CANCELLED
Eurocopter AS 332 (Super Puma) Series
Helicopters
AD/S-PUMA/84 - Main Gear Box Epicyclic Reduction
Gear Module - CANCELLED
AD/S-PUMA/85 Amdt 1 - Main Rotor Drive - Epicyclic
Reduction Gear Module
Eurocopter AS 355 (Twin Ecureuil) Series
Helicopters
AD/AS 355/60 Amdt 5 - Tail Rotor Blade Trailing Edge
Eurocopter BK 117 Series Helicopters
AD/GBK 117/23 - Time Limits / Maintenance Checks -
Airworthiness Limitations
Eurocopter BO 105 Series Helicopters
AD/BO 105/27 - Cyclic-Stick Locking Device
Eurocopter EC 135 Series Helicopters
AD/EC 135/22 - External Mounted Hoist System
Eurocopter EC 225 Series Helicopters
AD/EC 225/11 - Main Gear Box Epicyclic Reduction Gear
Module - CANCELLED
AD/EC 225/12 Amdt 1 - Main Rotor Drive - Epicyclic
Reduction Gear Module
McDonnell Douglas (Hughes) and Kawasaki 369
Series Helicopters
AD/HU 369/4 - Main Rotor Locknut and Retaining Ring -
Modication - CANCELLED
AD/HU 369/6 - NAS 1291 - 4 Nuts Used in Specic
Applications Inspection - CANCELLED
AD/HU 369/7 Amdt 1 - Oil Cooler Blow System -
Modication - CANCELLED
AD/HU 369/24 - Tail Rotor Drive Shaft Damper -
Inspection - CANCELLED
AD/HU 369/25 - Longitudinal Cyclic Friction Guide Link -
Modication - CANCELLED
AD/HU 369/26 - Main Rotor Pitch Link Bolts and Nuts -
Inspection - CANCELLED
AD/HU 369/30 - Main Rotor Pitch Control Rod -
Replacement - CANCELLED
AD/HU 369/32 - Seat Belt Assemblies - Inspection and
Replacement - CANCELLED
AD/HU 369/33 Amdt 1 - Fuselage Structure, Forward
Section - Modication - CANCELLED
AD/HU 369/36 - Flexible Hose Assembly - Replacement
- CANCELLED
AD/HU 369/39 - Tail Rotor Control Bellcrank Supports -
Inspection and Modication - CANCELLED
AD/HU 369/40 - Tail Rotor Fork Hinge Nut - Replacement
- CANCELLED
AD/HU 369/42 - Collective Torque Tube and Bungee
Support Bracket - Inspection - CANCELLED
AD/HU 369/44 Amdt 1- Collective Torque Tube and
Bungee Support Brackets - Inspection - CANCELLED
AD/HU 369/45 - Tail Rotor Swashplate Bearing Locknut -
Increase in Torque - CANCELLED
AD/HU 369/50 - Main Rotor Hub Strap Pack Retention
Bolts and Bushings - Inspection and Replacement -
CANCELLED
AD/HU 369/52 - Attachment Hardware for Sta-Strap
Securing Electric Wiring to Boom Fairing at Sta 138.50 -
Inspection - CANCELLED
AD/HU 369/57 Amdt 2 - Collective Stick Support Bracket
Reinforcement Strap - Installation - CANCELLED
AD/HU 369/59 Amdt 1 - Main Transmission Oil Lines -
CANCELLED
AD/HU 369/63 - Landing Gear Struts and Feet -
Inspection - CANCELLED
AD/HU 369/64 - Tail Rotor Bellcrank - CANCELLED
AD/HU 369/65 - Fargo Auxiliary Fuel Tanks - CANCELLED
AD/HU 369/66 - Eon Corp. Seat Belt Assemblies -
CANCELLED
AD/HU 369/73 - Tail Rotor Fork Bolt - CANCELLED
AD/HU 369/74 - Particle Separator Filter Bypass Door
Latch - CANCELLED
AD/HU 369/79 - Tail Rotor Transmission Output Shaft
Duplex Bearings - CANCELLED
Robinson R44 Series Helicopters
AD/R44/1 - Cooling Fan - CANCELLED
Schweizer (Hughes) 269 Series Helicopters
AD/HU 269/72 - Idler Pulley Support Bracket - Inspection
- CANCELLED
Part 39-105 - Below 5700kg
Aerospatiale (Socata) TBM 700 Series
Aeroplanes
AD/TBM 700/52 - Oxygen - Pilot Operatin Handbook
Aerostar (Piper/Ted Smith) 600 and 700 Series
Aeroplanes
AD/TSA-600/1 Amdt 1 - Pilot Seat Back-Rest Attach
Bolt - Inspection and Replacement - CANCELLED
AD/TSA-600/5 - Centre Fuel Tank Fuel Probe Gasket -
Replacement - CANCELLED
AD/TSA-600/6 - Aileron Outboard Hinge Bolt -
Inspection - CANCELLED
AD/TSA-600/7 Amdt 16 - Nose Landing Gear Drag
Brace Trunnion and Actuator Fasteners - Inspection -
CANCELLED
AD/TSA-600/9 - Alternator Field Circuit Protection -
Modication - CANCELLED
AD/TSA-600/10 - Pilot and Passenger Seat Cushion
Diaphragm - Inspection and Modication - CANCELLED
AD/TSA-600/11 - Seat to Track Retaining Clips -
Inspection and Modication - CANCELLED
AD/TSA-600/14 - Wing Tank Fuel Sumps - Inspection
and Modication - CANCELLED
AD/TSA-600/15 - Outboard Aileron Hinge Bolt
Installation - Inspection and Modication - CANCELLED
AD/TSA-600/18 - Main Landing Gear Clamshell - Door
Placard - Replacement - CANCELLED
AD/TSA-600/24 - Nose Landing Gear Support Structure
- Inspection and Modication - CANCELLED
AD/TSA-600/25 Amdt 2 - Aft Horizontal/Vertical
Stabiliser Attach Fitting - Inspection
AD/TSA-600/29 - Wing Tank Fuel Line - Inspection -
CANCELLED
AD/TSA-600/34 - Hydraulic System Internal Leak
Check - CANCELLED
AD/TSA-600/37 - Lower Wing Skin and Spar Caps -
CANCELLED
AD/TSA-600/40 Amdt 1 - Nacelle Fuel and Oil Pressure
Hoses - CANCELLED
AD/TSA-600/42 Amdt 1 - Rear Spar Corrosion -
CANCELLED
AD/TSA-600/44 - Flap Actuator Attachment Brackets
- CANCELLED
Airtractor AT-300, 400 and 500 Series Aeroplanes
AD/AT/27 Amdt 2 - Wing Lower Spar Cap
Dornier 228 Series Aeroplanes
AD/DO 228/10 Amdt 1 - Fuselage Frame 19
Fairchild (Swearingen) SA226 and SA227 Series
Aeroplanes
AD/SWSA226/1 - Frame Splices - Inspection -
CANCELLED
AD/SWSA226/5 - Wing Centre Section Improved
Venting - Modication - CANCELLED
AD/SWSA226/6 - Trim Tab Actuator Rods - Inspection
- CANCELLED
AD/SWSA226/7 - Fuel Line and Heat Shroud -
Inspection - CANCELLED
AD/SWSA226/9 - Main Landing Gear Uplock Roller -
Inspection and Modication - CANCELLED
AD/SWSA226/10 - Engine Windmilling Limits Placard -
Installation - CANCELLED
AD/SWSA226/11 - Rudder - Inspection - CANCELLED
AD/SWSA226/12 - Rudder Bellcranks - Inspection -
CANCELLED
AD/SWSA226/13 - Aileron Tab - Inspection and
Modication - CANCELLED
AD/SWSA226/14 - Aileron Control System -
Modication - CANCELLED
AD/SWSA226/15 - Main Landing Gear Door Hinge
Angles - Inspection and Replacement - CANCELLED
AD/SWSA226/16 - Aileron Balance Weight Attachment
Bolts - Inspection - CANCELLED
AD/SWSA226/18 - Stabiliser Trim Disconnect Controls
- Modication - CANCELLED
AD/SWSA226/22 Amdt 1 - Elevator Quadrant -
Inspection - CANCELLED
AD/SWSA226/27 - Wing Main Spar - Inspection for
Manufacturing Defects - CANCELLED
AD/SWSA226/31 - Aileron Control Cable Installation -
Inspection - CANCELLED
AD/SWSA226/33 - Elevator Mass Balance Weights -
Inspection - CANCELLED
AD/SWSA226/35 - Aileron Static Rebalance -
Incorporation - CANCELLED
AD/SWSA226/39 - Main Landing Gear Door Actuating
Mechanism - Modication - CANCELLED
AD/SWSA226/48 - Swivel Reading Lights - Inspection/
Modication - CANCELLED
AD/SWSA226/49 Amdt 1 - Fuel Vent Line and
Electrical Wire Bundle Support Clamps - Installation -
CANCELLED
AD/SWSA226/50 Amdt 1 - Aileron Control Cables -
CANCELLED
AD/SWSA226/51 Amdt 1 - Fuel Booster Pump Wiring
Harness - CANCELLED
AD/SWSA226/54 - Placard - Use of Reverse Thrust -
CANCELLED
Gulfstream (Grumman American/ American
Aviation) AA-1 Series Aeroplanes
AD/AA-1/2 - Alternator Field Protection - Modication
- CANCELLED
AD/AA-1/3 - Placards and Fuel Tank Cap Chains -
Installation - CANCELLED
AD/AA-1/4 - Fuel Tank Contents Manometer Vent Lines
- Modication - CANCELLED
APPROVED AIRWORTHINESS DIRECTIVES
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AD/AA-1/5 - Carburettor - Inspection - CANCELLED
AD/AA-1/6 - Control Surface Bearing Support -
Inspection - CANCELLED
AD/AA-1/8 - Fuel Quantity Indicator - Modication -
CANCELLED
AD/AA-1/11 - Fuel Pressure Lines - Inspection -
CANCELLED
AD/AA-1/12 - Fuel Tank Vent Lines and Fuel Contents
Gauge Lines - Modication - CANCELLED
AD/AA-1/15 - Centre Spar Console - Inspection and
Modication - CANCELLED
AD/AA-1/18 - Glove Box - Modication - CANCELLED
Gulfstream (Grumman American/ American
Aviation) AA-5 Series Aeroplanes
AD/AA-5/2 - Front Seat - Modication - CANCELLED
AD/AA-5/3 - Fuel Tank Vent Lines - Modication -
CANCELLED
AD/AA-5/4 - Aileron - Additional Drain Holes -
CANCELLED
AD/AA-5/5 - Elevator Trim Tab Hinge - Inspection -
CANCELLED
AD/AA-5/6 - Fuel Tank Vent Lines - Modication -
CANCELLED
AD/AA-5/11 - Centre Spar Console - Inspection and
Modication - CANCELLED
AD/AA-5/12 - Flap Surfaces - Inspection - CANCELLED
AD/AA-5/14 - Spar/Skin Spacer - Inspection and
Removal - CANCELLED
AD/AA-5/15 - Fuel Line - Inspection - CANCELLED
AD/AA-5/18 - Circuit Protection Separation -
Modication - CANCELLED
AD/AA-5/21 - Glove Box - Modication - CANCELLED
AD/AA-5/22 - Aileron Torque Tube - Inspection and
Modication - CANCELLED
AD/AA-5/25 - Elevator Drain Holes - Inspection and
Modication - CANCELLED
Gulfstream (Grumman American) GA-7 Series
Aeroplanes
AD/GA-7/5 - Propeller Control Ball Joint - Replacement
- CANCELLED
Liberty Aerospace XL Series Aeroplanes
AD/XL/1 - Mufer Cracking
Pilatus PC-12 Series Aeroplanes
AD/PC-12/32 Amdt 1 - Nose Landing Gear Drag Link
AD/PC-12/58 - Air Data Attitude & Heading Reference
System
Piper PA-42 (Cheyenne III) Series Aeroplanes
AD/PA-42/5 - Major Structural Fatigue Limitations -
CANCELLED
Piper PA-44 (Seminole) Series Aeroplanes
AD/PA-44/15 - Wing and Carry-Through Structure -
CANCELLED
Piper PA-46 (Malibu) Series Aeroplanes
AD/PA-46/35 - Current Limiters
SIAI Marchetti S205 and S208 Series Aeroplanes
AD/SM-205/13 - Engine Operating Limitation -
Installation of Placard and Modication of Tacho
Marking - CANCELLED
SIAI Marchetti FN-333 (Riviera) Series Aeroplanes
AD/FN-333/2 - Fuel Solenoid Valve Relocation - Flexible
Hose Installation - CANCELLED
AD/FN-333/3 - Inlet Manifold Rear Drain - Modication -
CANCELLED
Stephens Akro Series Aeroplanes
AD/AKRO/1 Amdt 1 - Airspeed Restriction - CANCELLED
Part 39-105 - Above 5700kg
Airbus Industrie A330 Series Aeroplanes
AD/A330/17 Amdt 3 - Type A Passenger/Crew Door
Slide Rafts and Type 1 Emergency Door Slides
AD/A330/67 Amdt 1 - Keel Beam Fastener Holes at
Frame 40 - inspection
AD/A330/69 Amdt 1 - Fuel Tanks Modications
AD/A330/88 Amdt 1 - Intermediate Pressure Turbine
Overspeed Protection
AD/A330/101 - Cable Loom 9R Routing
AD/A330/102 - Door 2 Hat Rack Electrical Connectors
Beechcraft 400 Series Aeroplanes
AD/BEECH 400/14 Amdt 1 - Flightcrew Seats
Boeing 717 Series Aeroplanes
AD/B717/32 - Auxiliary Hydraulic Pump
Electrical Wiring
Boeing 727 Series Aeroplanes
AD/B727/218 - Upper and Lower Fuselage Skin
Lap Joints
Boeing 737 Series Aeroplanes
AD/B737/235 Amdt 1 - Fuselage Skin Area at the
Dorsal Fin Assembly
Boeing 767 Series Aeroplanes
AD/B767/250 - Lower Wing Skin
AD/B767/251 - Aft Pressure Bulkhead
British Aerospace BAe 125 Series Aeroplanes
AD/HS 125/183 - Cockpit Ventilation and Avionics
Cooling System Blower Motor
Dornier 328 Series Aeroplanes
AD/DO 328/73 - Flight Compartment Door
Locking Device
Part 39-106 - Piston Engines
De Havilland Piston Engines
AD/DHE/1 - Accessory Drive Shaft - Modication to
Provide Weak Neck - CANCELLED
AD/DHE/3 - Propeller Oil Transfer System -
Modication - CANCELLED
AD/DHE/4 - Supercharger Drive System - Modication
- CANCELLED
AD/DHE/5 - Sun Gear Distance Piece - Modication
- CANCELLED
AD/DHE/6 - Connecting Rod Securing Nuts -
Modication - CANCELLED
AD/DHE/7 - Throttle Bell Crank Pivot Stud -
Modication - CANCELLED
AD/DHE/8 - Gudgeon Pin - Replacement - CANCELLED
AD/DHE/9 - Engine Speed - Restriction - CANCELLED
AD/DHE/17 - Carburettor - Inspection - CANCELLED
AD/DHE/21 - Minimum Modication Standard at
Major Reconditioning - CANCELLED
AD/DHE/22 - Minimum Modication Standard at
Major Reconditioning - CANCELLED
AD/DHE/23 - Minimum Modication Standard at
Major Reconditioning - CANCELLED
AD/DHE/24 - Minimum Modication Standard at
Major Reconditioning - CANCELLED
AD/DHE/25 - Minimum Modication Standard at
Major Reconditioning - CANCELLED
Teledyne Continental Motors Piston Engines
AD/CON/58 - Challenger Engineering Chrome Plated
Cylinder Barrels - CANCELLED
AD/CON/73 - Unapproved Camshaft Repairs -
CANCELLED
Part 39-106 - Turbine Engines
AlliedSignal (Lycoming) Turbine Engines -
ALF502 and LF507 Series
AD/ALF/21 - High Pressure Compressor Discs
Allison Turbine Engines - 250 Series
AD/AL 250/2 - Compressor Front Bearing Thrust
Washer and Spring - Replacement - CANCELLED
AD/AL 250/3 - Oil Filter By-Pass Valve Poppet Guide -
Replacement - CANCELLED
AD/AL 250/6 Amdt 1 - Power Turbine Governor -
Modication - CANCELLED
AD/AL 250/14 - Compressor Wheels, Glass Bead
Peening - CANCELLED
AD/AL 250/16 - Ceco Fuel Control and Governor
External Plug and Lever - Replacement - CANCELLED
AD/AL 250/18 - Compressor Bleed Valve Orice -
Installation - CANCELLED
AD/AL 250/20 Amdt 1 - Fuel Pump Drive Shaft -
Inspection - CANCELLED
AD/AL 250/21 - Ceco F.C.U. Throttle Shaft and
Governor Quadrant and Shaft Assembly - Inspection
- CANCELLED
AD/AL 250/30 - Fuel System - Fuel Pump to Control
and Fuel Control to Pump By-Pass Tube Clamps -
Replacement - CANCELLED
AD/AL 250/31 - Fuel System - Check Valve Assembly -
Installation - CANCELLED
AD/AL 250/33 - Fourth Stage Compressor Wheel -
Retirement - CANCELLED
AD/AL 250/45 - Power Turbine Inner and Outer
Coupling Shaft - Replacement - CANCELLED
AD/AL 250/50 Amdt 1 - N2 Overspeed Control
Assembly - Addition of Lockwashers to Ground
Jumper Lead - CANCELLED
AD/AL 250/55 Amdt 3 - Gas Producer Rotor Assembly
- Tie Bolt P/N 6843388, 6876991 and 6889320 -
CANCELLED
AD/AL 250/62 Amdt 1 - Fourth Stage Nozzle
Assembly - Replacement - CANCELLED
AD/AL 250/67 Amdt 1 - Increased Labyrinth Seal
Clearance Second Stage Turbine Nozzle - CANCELLED
AD/AL 250/69 - Installation of Internal Energy
Absorbing Ring - CANCELLED
AD/AL 250/70 - No. 8 Bearing Scavenge Line Air/Oil
Separator - CANCELLED
General Electric Turbine Engines - CF6 Series
AD/CF6/74 - High Pressure Compressor Spool Shaft
Stage 14 Disc
AD/CF6/75 - High Pressure Turbine Rotor Stage 1 Disc
AD/CF6/76 - High Pressure Turbine Stage 1 Rotor Discs
General Electric Turbine Engines - CF34 Series
AD/CF34/17 - High Pressure Seal
Rolls Royce (Allison) Turbine Engines - AE 3007
Series
AD/AE 3007/6 Amdt 2 - High Pressure Turbine Stage
2 Wheels
Rolls Royce Turbine Engines - RB211 Series
AD/RB211/39 - High Pressure Compressor Rotor Discs
and Rotor Shafts
Part 39-107 - Equipment
Flight Management Systems
AD/FMS/3 Amdt 1 - Honeywell NZ-2000 and IC-800
Navigation Computers
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5ervice DifhcuIty Pepcrts
or contact your local CASA Airworthiness Inspector [freepost]
Service Difculty Reports, Reply Paid 2005, CASA, Canberra, ACT 2601
Online: www. casa.gov.au/airworth/sdr
TO REPORT URGENT DEFECTS
CALL: 131 757 FAX: 02 217 1920
Mandatory
compliance with
state-of-design ADs
From 1st October 2009, changes to CASR Part 39 mean CASA will
no longer issue Australian ADs mirroring state-of-design airworthiness
directives (ADs). All registered operators must ensure their aircraft
complies with state-of-design ADs applicable to their aircraft and
equipment. For example, if you own a Cessna which is designed in
the United States, you must comply with all applicable ADs issued by
their Federal Aviation Administration. This also applies to ADs for the
engine and propeller, both designed in the USA.
If the aircraft model was on the Australian Civil Aircraft Register before
1 October 2009, the registered operator must comply with state-of-
design ADs issued on or after 1 October 2009.
If the aircraft model was not on the Australian Civil Aircraft Register
before 1 October 2009, the registered operator must comply with all state-
of-design ADs issued for the aircraft prior to and after the 1 October 2009.
Of course, operators still have to comply with all relevant
Australian ADs.
State-of-design ADs can be obtained from the CASA website or the
National Airworthiness Authority (NAA) website. On the CASA
website, the aircraft model and equipment list will contain any existing
Australian ADs and the state-of-design ADs. If a National Airworthiness
Authority issues a state-of-design AD which varies the requirements of
the Australian AD; CASA will either cancel or amend the Australian
AD. As CASA is still responsible for the continuing airworthiness of
the Australian eet, CASA may issue an Australian AD at any time to
address an unsafe condition.
If you prefer to obtain state-of-design ADs
directly from the National Airworthiness
Authority, you must establish the applicable
NAA.
CASA will only mail, email or fax emergency
ADs to registered operators but will still
provide a bi-weekly subscriber email service
for routine ADs. As CASA will no longer
rewrite state-of-design ADs and issue them as
Australian ADs, there will be no hard copy AD
books or AD amendment service after issue
12 2009.
An alternative means of compliance (AMOC)
against a state-of-design AD approved by the
National Airworthiness Authority will now be
accepted by CASA.
More information
Advisory circular AC 39-01(3) Airworthiness
Directives is available on the CASA website:
W: www.casa.gov.au
E. airworthiness.directives@casa.gov.au
P. 131 757
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C
arbon and
alum
inium
/titanium

are d
is
sim
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m
a
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ls, and
as such, corrosion
can occur in these
in
terface areas, so
w
e need to change
the m
in
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e
t tha
t
corrosion only occurs
in and be
tw
een
d
iffe
re
n
t m
e
ta
ls
.
. . . Continued from page 32
To summarise:
Signicant damage can occur without visible surface indications.
Damage cannot be allowed to grow to degrade strength below design
ultimate. Residual strength is the criterion, NOT damage growth rate.
Damage must be detectable BEFORE residual strength falls below design
ultimate. This is damage tolerance.
LIGHTNING DAMAGE
The higher resistance of composites when compared to a traditional
metallic structure means that when a lightning strike occurs, more
heating of the composite matrix will occur, resulting in more instances
of melting or charring of the matrix resin. Repairs are likely to be
more complex. As with ground blunt impact damage, not all lightning
damage is easily detectable from the outside of the aircraft.
CORROSION PREVENTION AND CONTROL
You shouldnt assume corrosion prevention and control is not necessary
just because there is a high composite content in the aircraft. The
interface between carbon components and titanium/aluminium parts
and fasteners is the very place where dissimilar materials corrosion can
occur. Carbon and aluminium/titanium are dissimilar materials, and as
such, corrosion can occur in these interface areas, so we need to change
the mindset that corrosion only occurs in and between different metals.
REPAIRS OUTSIDE STRUCTURAL REPAIR MANUAL
LIMITS
There may be a need to assist industry engineers to acquire the
requisite knowledge to assess and provide repair schemes for damage
repair outside structural repair manual (SRM) limits. It is worthwhile
therefore to ask questions such as:
Are there any training or knowledge gaps?
Are engineers up-to-speed with advanced composite structures, so that
they can condently and competently approve and perform a repair
outside SRM limits? Many are highly competent, but some may require
assistance. Generally, large manufacturers will provide comprehensive
formal training, but what about smaller manufacturers?
IN SUMMARY
These are some of the maintenance challenges to be faced as our all-
composite aircraft age, but being forewarned is being forearmed. If c
we can anticipate the training and capability requirements in advance, w
then we will be better placed to implement strategies to deal with the tth
unique nature of modern composite aircraft. un
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Pilot M
ichael Ralphs graphic retelling of an all-too-common VFR occurrence.
On 29 July 2007, a Piper W
arrior own by a VFR pilot, with three people on
board, entered cloud without an autopilot. Against the odds they survived.
Michael (C182 pilot): I organised a weekend yaway for our aero club
from Moorabbin to Echuca for the Winter Blues Festival. Our party
included my wife Merryn and I, and two friends John and Sandra, in a
Cessna 182; and Dave, his wife Molly, and Kate (revalidating a lapsed VFR
licence), in the Piper. Sundays weather for our departure from Echuca
was low cloud and drizzle. I was one of the last to depart, after thanking
our hosts and performing thorough pre-ight checks on the C182.
Dave (Warrior pilot): Molly sat in the back and Kate sat beside me to
get some experience. We took off after lunch, intending to return to
Moorabbin via the Kilmore Gap, and found scattered, scrappy clouds
at 900 AMSL. We pressed on but conditions worsened, even though S
others had made it through. I didnt like the conditions and returned to others had made
Echuca, landing at 2:00pm. I decided to put some more fuel into my
tanks, having used about half an hours worth in the aborted attempt to
y home and in case we had to divert on our next attempt. y home
Moorabbin
Bendigo
Echuca
Shepparton
Kilmore
Ballarat
Melbourne
Mangalore
0 50km
30m
Waranga
Basin
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Michael: Seeing Dave taxi over to the bowser
prompted me to do the same. As it turned out,
I didnt need to, but Daves precaution was a
major factor in their survival.
Dave: Michael and I decided we would stay
overnight in Echuca. We began tying the
aircraft down for the night. A local pilot said
that it was OK at Ballarat and Bendigo, and
after my rst attempt to y towards Mangalore
with a 600 AGL cloud-base, 1,200 at Bendigo
seemed attractive.
Michael: It was clear at Moorabbin, with scattered clouds at 5,000.
Dave wanted to y via Bendigo and approach Melbourne from the
west. Since there was a stratus layer over Victoria north of the Great
Dividing Range I thought that the cloud-base would be the same
height AMSL at Bendigo as at the Kilmore Gap, but the ground would
be higher to the west; we should y through the Gap. We agreed that
we would y in company and assess the situation in the air. Plan
A would see us head south for the Kilmore Gap, Plan B would see
us head for Bendigo, and Plan C would see us land back at Echuca
and stay overnight after all. The C182 is faster than the Warrior, so I
would have to slow down.
: John: I thought we had agreed to try for
go rst. Bendig
el: Michae No! Im convinced that we were
going to try for the Gap. However, since we going to
didnt state which frequency we would have didnt st
our conference on CTAF, area or company our confe
and Dave took off before we were ready, I nd Dav
concede that we did not plan very well. Dave ede th
started up and taxied away while we were still started up an
loading and pre- ighting our plane. ing and p
We lifted off at 4:00pm and climbed to 850 o
AMSL. Ten minutes into the ight I heard Dave MSL. Ten m
faintly calling me on the radio. I responded tly calling
twice but he didnt call again. Presuming he was did
ahead of us on the same track, I didnt see an
urgent need to establish radio contact. Entering
the Kilmore Gap I called Melbourne Radar to Radar to
request ight-following. Although the overcast ough the overcast
made the scene rather gloomy, we tran ed transited
the Gap safely through to Kilmore and ew more and ew e to Kilmore and g
back to Moorabbin. bb b r b
We taxied to our parking bay and shut down. We taxied to our to
climbed out another pilot, Ken, emerged As we climbe As b ut b tt o d s we climbed out
from Ops and called me over. Have you heard from om Ops and called m
from Dave? he asked. John rang Kate ten minutes ago, from ? he asked. Jo
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why? I replied. Weve just heard from Melbourne Radar that they
have own into cloud and requested assistance, Ken said. No more
has been heard from them so Melbourne Radar called Ops to ask
about the planes equipment and the pilots qualications.
We knew the implications: researchers at the University of Illinois
tested 20 non-instrument-rated pilots in simulators to see how long
they could y on instruments after losing visual references outside
of the cockpit. Time intervals ranged from 20 to 480 seconds. The
average time interval before they lost control was 178 seconds not
quite three minutes.
I rang Daves mobile: it went to voicemail. I rang Kates mobile: it
went to voicemail. For the next thirty minutes, I thought Dave had
conrmed these statistics.
Merryn: Ive never seen Michael look like that haunted is how Id
describe it.
Michael: Sick with worry, I helped the others secure the C182, and
then we entered the Ops building. The instructors on duty were
subdued. The club president asked me for any information. People
were clustered around the radio. Then we heard Melbourne Centre
talking with Dave, who was now on top of the cloud at 10,500 AMSL.
He was alive, but still in trouble. I couldnt stand; I sat on the carpet
beside the radio and prayed silently.
Dave: We left without Michael because his aircraft was 30 knots faster,
so he should have been able to catch up. Molly was anxious about
ying in this weather and I was concerned that last light was a few
minutes prior to 6:00pm. Also, the weather at Bendigo might worsen
if we delayed, so I planned a track to the west of Bendigo and Ballarat.
There were patches of low cloud and we cruised between 1,100 and
1,300 AMSL from Echuca to the west of Bendigo.
Kate: I guess we were about 20 minutes into the ight when I started
feeling uneasy.
Dave: I called Michael, but did not receive a response. The conditions
were worsening, but it seemed to be brighter further west. About
ten miles south of Bendigo I could see showers rolling through so
I turned north, asking Kate to set the ADF to track to the Bendigo
B. As we progressed, the cloud base seemed to be lowering. In NDB. As we progres
ndsight, I can see that the ground was rising beneath us and as I hindsight, I can see that the g d was rising ben
tried to maintain my ground clearance I was
inadvertently climbing towards the cloud. I
decided to try to land at Bendigo.
Kate: The GPS suddenly began warning us of
terrain ahead. There were no obstacles - we
must be really low. My chest started to feel
tight. As I pored over the map I noted a large
hill to the south of Bendigo; it was at least
1,000ft above our current altitude! Where
was Bendigo? I couldnt see it on the GPS.
Dave: As we approached Bendigo again
there were showers passing through, but we
could see the town. I couldnt reverse course
without entering cloud. I began circling, only
a few hundred feet above hilly, tree-covered
ground, looking for a break to duck through.
We were in trouble.
I contacted Melbourne Centre and advised
them that I needed help as cloud was
beginning to surround us. With visibility
worsening, I made the decision to level my
wings and climb away from the terrain,
knowing that this would take us into cloud.
It was the hardest decision of my life, but I
believed that staying where we were, with
showers obscuring our visibility in such close
proximity to the ground, was perilous.
Mike (ATC): A call came from a VFR pilot
requesting assistance. I asked him to stand
by while I dealt with another ight. When I
returned to him he was already in cloud. My
heart pounded as I turned to my supervisor,
Ive got an emergency.
Kate: The disorientation as we entered the
cloud was overwhelming, and I felt the
aircraft lurching as Dave fought to o keep
control. I thought of my two young ng
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MLB CTR: Are you instrument-rated?
Dave: Negative.
MLB CTR: Keep your wings level and trust your instruments. Are you
night-rated?
Dave: Negative.
MLB CTR: Do you have an auto-pilot?
Dave: Negative.
MLB CTR: How many POB?
Dave: Three people.
MLB CTR: What is your fuel status?
Dave: Fuel is OK. About four hours endurance.
Thank God I had taken on more fuel in Echuca. Prior to refuelling we
had only enough for the 75-minute ight plus 45 minutes in reserve.
Our ight was to last two and a half hours.
Mike: We have a checklist for handling a VFR into IMC emergency. I
enlisted Dennis to take over all other trafc in my sector to another
frequency and my supervisor contacted AusSAR who scrambled an
emergency helicopter. I called Susie over to assist because she has a
private pilots licence. She began to examine the WAC chart to check
the lowest safe altitude.
Dennis (ATC): That day was one of the worst Ive had in my 15 years as
an ATC. I thought I was going to witness a crash. It was a classic nightmare
situation for a VFR pilot, one which has ended more than a few lives. n for a VFR pilot, one which has e
boys, blissfully ignorant of my predicament.
My heart ached at the thought that I would
never see them again.
Molly: I knew we were in trouble when I heard
Dave swear: he never swears! I didnt want
to see the end coming, but I didnt scream
or cry because I knew that Dave needed to
concentrate. I thought of the new will which I
had neglected to sign the previous day.
Dave: When we entered the clouds I became
immediately disoriented as I chased the
needles. For a moment I thought wed had
it. I knew the statistics, but was grimly
determined not to validate them. Everything
they tell you about ying into cloud is true.
My senses were totally confused. The nose
is too high. Put the stick forward. Turn the
carby heat off. Retract the aps in stages.
I began monitoring the ASI, AH, VSI and
DG. Once I stabilised the climb I radioed
the controller again. As I recall, the ensuing
conversation with Melbourne Centre went
something like this:
MLB CTR: Are you in cloud?
DDave: ti Afrmative.

When we entered the clouds I became immediately disoriented as I
chased the needles. . . Everything they tell you about ying into cloud is
true. My senses were totally confused. The nose is too high. Put the stick forward.
Turn the carby heat off. Retract the aps in stages.

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The controller was impressive: so calm
, so reassuring. It
seemed like he was guiding Dave on a walk in the park. At last
we heard Dave call the controller: W
ere clear! We can
see the ground!
Flying into cloud without instruments (or without knowing how to
use them) is incredibly dangerous. Its almost inevitable youll lose
control of the aircraft within a few minutes and crash, as without
visual reference to the horizon you cant tell if the aircraft is turning
or ying with level wings. If movements are gentle they dont register
with your senses - a wing could be gradually dropping and you dont
realise until its too late. Or you do realise, over-correct and lose
control that way.
Kate: I gazed out of the window at the whiteness. It hurt my eyes.
Whilst our deaths no longer appeared to be imminent, we were a long
way from safety. As we climbed through the clouds, we had periodic
contact with the ATC who was conrming our position and trying to
establish when we broke through. I wished that he would talk more
often. His calm voice made me feel less alone. Finally, we emerged
into clear air at about 5,000. Whilst we could now see, it was of little
comfort. There was solid cloud above and below our little aircraft.
Michael (C182): Climbing from 1,000 to 5,000 at 500 feet per minute
would take eight minutes considerably more than 178 seconds.
Mike (ATC): Another controller entered a ight data record into the
Eurocat system with a discrete code so I could maintain the correct
identication of the aircrafts radar paint even if he temporarily
dropped off and returned to radar. Eventually the pilot, sounding
surprisingly calm, reported that he was on top of the cloud. calm, r
ve: Dave: Were into clear air. We
Mike: M Good. Can you see any holes? Andy had found out that the
rcraft was a Warrior and part of a y-away. He contacted the aero rcraft was a aircraft
ather more information about the plane, the people on board club to gather
and their ying experience. He had also obtained reports that there aaand their ying exp
were breaks in the cloud at Bridgewater which is 15nm NW of ere wwere breaks in the clo
Bendigo. I discussed this with the pilot and he decided to BBendigo. I discussed th s with the pilot and
track that w track that way. at way.
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Dave: I asked whether we could be vectored towards the coast and
descend over Port Phillip Bay.
Mike: He reported that he couldnt nd any breaks in the cloud. I
suggested that I provide radar vectors to Ballarat, and then further
south toward the coast where we hoped the cloud would clear. We
then planned to turn him east across the bay to Moorabbin.
Dave: Melbourne Centre asked how I felt about descending through
cloud, but I really didnt have a choice. They suggested getting us
overhead the aireld at Mangalore and making descending orbits,
turning through the cloud. I rejected the option: No - no turns! I felt
that I would have a much more controllable descent with my wings
level and descending at 500 feet per minute. The controller agreed
and suggested Shepparton. That was better because I am familiar
with that aireld and getting there wouldnt involve turns in cloud.
We couldnt take up the heading we were given for Shepparton at
the level we were at without entering cloud again, so we found a hole
and climbed above the next layer of cloud. We were on top by 9,500
AMSL, although as we tracked towards Shepparton the cloud tops
rose and we had to climb to 10,500 to stay clear. The little Warrior
didnt climb as well at that altitude as it does at sea level; the climb
took ages.
Kate: The enormity of what was happening hit me when I heard that
passenger jets were being asked to look for holes in the cloud for us,
anywhere between Sydney and Melbourne. Dave pointed our aircraft
into the opening in the cloud and we climbed steadily. At one point
we re-entered the cloud and he had to descend and reverse course
to get us out. We passed 7,500, 8,000, 9,000 I was screaming
inside: How much longer? We were nally clear at 9,500.
Dave: The controller calculated that we should commence our
descent immediately. We re-entered the cloud (the second-hardest
decision of my life) and I tried to keep the wings level, monitoring
the air speed and rate of descent. A couple of times I was asked to
turn to the right as we had started a slight left-hand turn. ATC again
reminded us of the fast-disappearing daylight. I would have loved to s of the fas
increase RPM and descend more quickly, but I didnt want to risk ncrease RPM and
getting out of control. getting out of contro
Mike: i The pilot wanted to descend straight ahead at 500
m, which meant he was now top of descent. Next fpm, which me f descent. Next
call he was on descent and back in cloud.
Within a few seconds the radar paint began
a slow left turn. I let him know, and he
straightened up but he was now tracking to
the west of Shepparton. I decided not to say
too much and just let him keep it level.
Michael (C182): They were just about to
commence their descent when Ops patched
into the frequency and discovered that
Dave, Molly and Kate were still alive so
far. We listened to the conversation as they
descended. Whilst the controller couldnt
see Daves instruments, he could see their
projected track changing 40
o
~ 50
o
to the
left and warn them: Youre turning. Lift your
left wing.
The controller was impressive: so calm, so
reassuring. It seemed like he was guiding
Dave on a walk in the park. At last we heard
Dave call the controller: Were clear! We
can see the ground!
I felt like crying with relief.
Dave: We broke through the cloud near
Waranga Basin at about 2,800 AMSL. I
descended to about 2,000, but there were
still cloud patches, so I continued the descent
to 1,500. We had about ten minutes to run
to Shepparton, and it was already quite dark
with all that cloud above us. Melbourne
Centre advised that the wind was 050
o
magnetic, so I replied I would y a straight-in
approach to runway 36. Id only get one go
and then it would be pitch-black.
Mike (ATC): The pilot reported: I can
see the ground! The relief for us was
overwhelming. He was flying through the
scud at the base of the cloud. I looked at the he c
map to assist him identify his surroundings, map e dentify his surroundings
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By asking for help, I
had ATC looking out
for me. All I had to do was
y the plane and go
where I was told.
and then gave him the distance and direction
to the aerodrome.
Dave: We approached the aireld, and I
advised Melbourne Centre that I was lined up
on nal. The controller asked me to advise
when we were safely on the ground, and
the emergency helicopter would relay the
message. It was so dark I could hardly see the
instrument panel. I didnt know how to turn
on the panel lights.
Michael (C182 pilot): We were listening: Hes
in the circuit on nal theyve landed. We
began clapping softly and exhaling long sighs.
We were too drained to cheer.
Mike (ATC): Within a few moments, I heard
the happiest SAR cancellation of my career.
Dave: We landed safely and taxied off the
runway at about 5:50pm local time. End of
ylight was ve minutes later, ofcially, daylight was ve minutes
ut with the heavy overcast it was but with the heavy overcast
already pretty dark. dy pretty dark.
Kate: I dont know how, but Dave managed a textbook landing, and
we taxied gratefully to the club house. My legs almost collapsed as
we alighted, and I wanted to kiss the ground. The relief as we entered
the building was too much to contain for Molly and me. We cried and
hugged as Dave moved the aircraft to the visitor parking area.
Dave: ATC had been in touch with the Shepparton Aero Club. They
asked me to call ATC who admitted: We were very worried about
you! They werent the only ones!
Dennis: Huge sighs of relief all around, believe me. Airservices
provided counselling for all of us the next day. I needed a bit of a break
myself as once Id wound down; I was quite emotional when Id had
time to think about it. I was pretty close to tears - its not every day
you fear for someones life for an extended period and cant do a whole
lot about it.
Michael: (C182): Any inconsistencies between my version, Daves version,
Kates version and those of Dennis and Mike are as a result of what happens
when people recount their personal memories of a shared event. After two
and a half hours of nightmare ying, Im just glad that Dave is here to
argue the ner points. Id like to express my heartfelt thanks to Mike, Susie
and Dennis for their guardianship of my friends.
Dave: By asking for help, I had ATC looking out for me. All I had to do
was y the plane and go where I was told. Their alerting me to the start
of my graveyard spirals before I lost control was incredibly valuable.
Michael: Back at home, I felt very unsettled when I uploaded the
weekends photographs from my camera and looked at the picture of
the three of them smiling at me on Saturday. That photo could have
been on the front pages that week.
Dennis: Ive been involved in other emergencies, but this one has
affected me most. I guess because it took an hour and a half; there
was danger the whole time; and we had input. Something we said or
did could have inuenced whether the pilot lived or died.
In situations like this the nal call belongs to the pilot - we cant y the
plane for them, even if we are pilots, which Im not. Even if it has a . Even
successful outcome it doesnt stop me feeling very responsible for what esponsible for
happened. Could I have done more or better? The point is to learn from o point is to learn from
the experience.
Reprinted with permission from rinted with permission from Australian Flying g ying ng who rst published ub u s rs ho who rst published
the story in Jan/Feb 20 t story in Jan/Feb 2008.
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EVER HAD A
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Executive Director's Message
The ATSB is releasing a
publication titled Past Present
Future. It is the story of
the ATSB, and the earlier
organisations that came
together to form the Bureau. The
publications release celebrates
the 10-year anniversary of the
formation of the ATSB on 1 July
2009.
I am proud to have been the
Executive Director of the ATSB since its creation, helping
to maintain and improve transport safety in Australia and
internationally.
In the aviation sector, the ATSB team has worked
to improve safety through investigations that have
included: an Avgas fuel investigation, which inuenced
international fuel processing and standards; the
internationally recognised investigation into the Ansett
Boeing 767 aircraft that were grounded due to missed
maintenance inspections; and a Robinson R22 helicopter
investigation, which led to directives on the life limits of
an R22s main rotor blades.
The ATSB also conducted the investigation into the
tragic accident at Lockhart River in Queensland on 7 May
2005 in which all 15 people on-board the Fairchild Metro
23 aircraft died. The investigation into Australias worst
civil aviation disaster since 1968 has resulted in greater
regulatory attention being given to the regional aviation
sector.
Pioneering work to develop analysis models culminated
in the ATSB publication Analysis, Causality and Proof in
Safety Investigations. The ATSB analysis model ensures
that human and organisational factors are examined
in the interests of improving safety systems. ATSB
research also makes sure the bigger picture is taken
account of by identifying important safety trends.
Within the region, the ATSBs participation in the Garuda
Indonesia Boeing 737 fatal accident at Yogyakarta
airport was the inception of the Indonesian Transport
Safety Assistance Package (ITSAP). Under ITSAP,
Australian transport safety professionals are working
closely with their Indonesian counterparts in an effort to
build additional capacity to meet the challenges facing
Indonesia.
If you would like to learn more about the history of
accident investigation in Australia, you can download a
copy of Past Present Future from the ATSBs website at e
<www.atsb.gov.au>

Kym Bills, Executive Director
The Australian
I
n December 2007, the ATSB released a research report that examined
immediately reportable matters (IRMs) (otherwise known as accidents
and serious incidents) involving regular public transport (RPT) opera-
tions. Te purpose of this report was to inform the aviation community
of any important safety trends, and to provide the travelling public with
a better appreciation of the types of occurrences that are reported to the
ATSB.
To present a complete picture of air transport operations, which
encompasses both RPT and charter operations, the ATSB has conducted a
follow-on study that reviews IRMs in charter operations for the period
1 January 2001 to 31 December 2006.
Similar to the previous report, a subset of generally more serious IRMs
were reviewed including: accidents; violations of controlled airspace
(VCA); breakdowns of separation (BOS) and airproxes; fre, smoke,
explosions or fumes; crew injury or incapacitation; fuel exhaustion; and
uncontained engine failures. Charter fying activity, measured as fying
hours and number of charter operators, was also reviewed.
Te study found that the charter industry appears to be in a period of
transition with some sectors of the industry expanding while others
have contracted. Overall activity initially declined followed by higher
activity from 2004 to 2006. Despite this increase, the number of hours
fown in 2006, the latest year reviewed, was not as high as the historical
peak in charter hours observed in 1999. Te number of charter operators
decreased in 2005 and 2006, so fewer operators have conducted more of
the hours fown in those years.
Total IRMs reported and the individual IRM categories examined were
generally stable across the period 2001 to 2006, with the exception
of accidents. Te rate of accidents involving charter aircraf dropped
signifcantly between 2001 and 2006, while at the same time the rate
of reported incidents increased. Te most common type of accident
experienced in charter operations was wheels-up landings, either due to
mechanical problems with the landing gear or due to crew operation of
the landing gear. Te more severe occurrence types involved collisions,
loss of control of the aircraf, and loss of power from the engine.
Occurrences involving fre, smoke or fumes and airspace related
occurrences such as VCA and BOS/airprox remained stable with no
statistically signifcant increase in the rate. Te number of occurrences
involving fuel exhaustion was small and, consequently, variable between
years. Te other IRM categories; crew injury/incapacitation and
uncontained engine failures, were rare.
Tis review provided encouraging data on the charter accident rate,
emphasised the stability of the rate of airspace related occurrences, and
the rarity of uncontained engine failures and crew incapacitation in
charter operations.
ATSB Research and Analysis Report AR-2007-057
Reporting trends in charter
operations
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Aviation Safety Investigator
O
n 2 September 2008, at about
0845 EST, while climbing through
fight level (FL) 250, en route from
Brisbane, Qld to Honiara, Solomon
Islands, a regular fare-paying passenger-
carrying Embraer RJ 190-100 LR aircraf,
registered VH-SXK, sustained a fuel leak
from both main wing tanks. Te fight
crew reported that, as they few through
moderate turbulence, they were notifed
by the cabin crew (the aircraf had two
fight crew, three cabin crew
and 40 passengers) that vapour
was streaming from both wing
tanks. Te pilot in command
walked back to check and
confrmed that fuel was stream-
ing at a high rate from both
wings.
Te fight crew notifed air
traf c control that they had
a problem and requested and
received a clearance to return
to Brisbane Airport. During the return
to the airport, the aircraf reached a
maximum level of FL370, with fuel still
leaking. Te cabin crew reported that
the fuel venting/leakage momentarily
stopped about 8 minutes later, but then
resumed on descent into Brisbane, when
the aircraf faps were extended at about
4,000 f above mean sea level.
Afer landing at Brisbane Airport,
aerodrome rescue and fre fghting crews
inspected the aircraf and reported no
fuel leakage.
Te operator downloaded the data from
the aircrafs fight data recorders and
provided it to the ATSB for analysis.
Te data documented that, just prior to
the occurrence, the aircraf was passing
through FL250 at 290 KIAS when it
encountered turbulence. Te turbulence
recorded values ranged from 0.6 to 1.4
positive absolute g, a range of about
0.8 g, which lasted for about two and a
half minutes.
Te data also confrmed that the
maximum computed airspeed was
299.75 KIAS, momentarily decreasing to
270 KIAS before returning to 290 KIAS.
Vertical speed varied from -1,232 to
4,880 f/min, with associated variations
in pitch angle.
Te data confrmed the fuel disparity
between fuel burn and fuel removed from
the fuel tanks, with a diference of around
680 kg (1,500 lbs). Te operator reported
that the aircraf departed with 12,800 kg
of fuel and that afer landing and taxiing,
9,600 kg remained, with a total of 600 kg
lost due to the venting/leakage.
Te venting/leakage was determined to
be the result of a design issue related to
maintaining positive air pressure in the
fuel surge tanks in the aircrafs wings.
Te fuel vapours noted by the cabin
crew during the climb were the result of
venting/leaking from the wing fuel surge
tanks and eventually from the NACA
inlet. Te fuel leakage noted by the cabin
crew during the approach to land at
Brisbane Airport was likely the result
of residual fuel released during the fap
extension.
In 2007, the aircraf manufacturer
had identifed the problem (following
a similar occurrence on a similarly
designed model aircraf). An operational
bulletin was issued recommending
aircraf operating procedures to
mitigate the likelihood of a fuel
leak. However, the operator did
not have access to the bulletin
using the aircraf manufacturers
electronic on-line document
system.
Although the operator was
unaware of the problem, on
this occasion the aircraf was
being operated generally within
the recommended operating
parameters when the fuel leakage
occurred. Te turbulence sustained by
the aircraf during climb out, along with
a momentary airspeed increase and
the large variations in vertical speed,
probably contributed to the fuel leakage.
Te aircraf manufacturer has developed
a new foat vent valve design to eliminate
the problem. Te design change has been
introduced into newly manufactured
aircraf and a service bulletin with
recommendations to replace the current
foat vent valve with a redesigned valve
will be issued in 2009.
ATSB Aviation Occurrence Investigation
AO-2008-060
Fuel system event
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Investigation briefs
Engine in-ight shutdown
Occurrence 200704288
On 13 July 2007 at about 1420 Western
Standard Time, a Boeing Company 717-
200 aircraf, registered VH-NXK, was
being operated on a scheduled passenger
service from Newman, WA to Perth when
the right engine failed during the climb to
cruise. Te fight crew disconnected the
autopilot, actioned the Engine Fire/Severe
Damage checklist, and commenced
descent to fight level 140. Te fight crew
broadcast a PAN to air trafc services.
Te aircraf returned to Newman
Aerodrome and landed safely.
Te operators maintenance organisation
carried out an internal inspection of
the failed engine and found that all of
the blades on the high pressure turbine
stage-1 disc were sheared of.
Te engine was removed from the aircraf
for shipment to the engine manufacturer
for investigation and repair. A serviceable
engine was ftted and the aircraf was
returned to service.
A subsequent investigation by the engine
manufacturer revealed that a high
pressure turbine stage 1 (HPT1) blade
had separated from the blade disc below
the blade platform. Te manufacturer
identifed that the failure was due to
low-cycle fatigue, causing the remaining
HPT1 blades to separate from the disc.
Tat led to the subsequent engine in-fight
shutdown. Te mechanism of the failure
was similar to previous engine failures
that had occurred since November 2003.
At the time of the incident, the aircraf
operator was engaged in a programme
to replace all of the life improvement
package 3 standard HPT1 blades in their
feet of engines with a new HPT1 blade.
Navigation event
Occurrence 200703484
On 31 May 2007, the pilot of a Beech
Aircraf Corp. Super King Air, registered
VH-XCB, was conducting an Area
Navigation (RNAV) Global Navigation
Satellite System (GNSS) non-precision
approach (NPA) at Ballarat, Vic. in
instrument meteorological conditions
(IMC) as part of a check fight for renewal
of a command instrument rating. While
conducting the approach, the check pilot
visually determined that the aircraf was
displaced outside the permitted lateral
tolerances of the published fnal approach
track. Te pilots primary fight display
showed that the aircraf was within
permitted tolerances. Tere were no
associated messages or alerts.
An examination of the aircrafs
navigation equipment by an avionics
technician found the installation was not
approved for the procedure. A technical
problem prevented the equipment from
meeting approval standards.
Although some documentation of the
navigation receivers installation was
incomplete and there were unanswered
questions about the approval and
operational status of the installed
navigation equipment, the signifcant
safety issue concerned operation under
the instrument fight rules (IFR),
during which RNAV (GNSS) NPAs were
frequently fown. Te aircraf had been
fown by many professional pilots who
believed that the aircraf was approved
for RNAV (GNSS) NPAs and who had
neither ascertained the operational
status of the navigation equipment
installed from the aircrafs fight manual
supplement (FMS), nor attempted to
resolve the reason for at least one previous
unexplained tracking error while
fying an RNAV (GNSS) NPA in visual
meteorological conditions.
Te operator of the aircraf annotated the
aircrafs maintenance release to refect
that the Global Positioning System (GPS)
was not approved for use in the conduct
of RNAV (GNSS) NPAs.
Ditching event
Occurrence 200802048
On 3 April 2008, a Piper PA-32-300
Cherokee Six aircraf, registered
VH-ZMP, took of from Brampton Island,
Qld for a charter fight to Mackay, with a
pilot and four passengers on board. Tis
was the sixth fight since the aircraf had
been refuelled. When climbing through
approximately 400 f, the engine surged
and lost power. Te pilot turned the
aircraf lef approximately 30 degrees
to face into the wind and to be parallel
with the wave tops on the sea below and
ditched the aircraf between Brampton
Island and Carlisle Island.
Te aircraf decelerated rapidly and came
to rest, foating in an upright position
for about 1 minute. All of the occupants
evacuated and were later recovered by a
rescue helicopter. Te engine power loss
was consistent with fuel starvation. Tere
had been insufcient time to resume
power by selecting reserve fuel from such
a low altitude before ditching.
Te aircraf had an inner fuel tank and
an outer fuel tank in each wing. Each fuel
tank independently fed a fuel selector. Te
operators fuel management policy was
to use the tip tanks for fight fuel and to
use the main tanks for 60 litres of reserve
fuel. Both tip tanks were flled at Mackay
for fight fuel as a standard procedure and
fuel selection was alternated between the
tip tanks for each fight.
Following the event, the aircraf operator
amended the aircraf fuel management
procedures to require a minimum of
30 L of fuel in the selected fuel tank for
any take of.
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Fuel system event
Occurrence 200705014
On 13 August 2007, a Boeing 737-700
aircraf, registered VH-VBR, was operating
on a scheduled fight from Brisbane
to Hamilton Island, Qld. On reaching
cruise altitude, the fight crew became
aware of a fuel imbalance situation due
to fuel loss from the number-2 (right)
engine. At 1311 Eastern Standard
Time and approximately 148 km SE of
Rockhampton, Qld, the crew conducted
an in-fight shut down of the right engine.
Te aircraf was subsequently diverted
to Rockhampton where a single-engine
approach and landing was completed
without further incident.
A subsequent examination of the
number-2 engine revealed that fuel was
leaking from the main fuel return pipe
where it connected into the oil/fuel heat
exchanger. Te pipe connection was of
fanged plate design, held in position by
four bolts tightened into threaded inserts
on the oil/fuel heat exchanger body. Te
threaded inserts had failed, pulling free
of the heat exchanger body.
Bolt tightening sequence showing thread stripping and
insert migration into the gasket
As a result of a number of in-service
failures of the fuel return pipes, the
oil/fuel heat exchangers were subject
to several modifcation requirements
including the replacement of the threaded
inserts with key locked inserts. Te
ftment of the key lock inserts resulted in
a higher torque value for the fuel return
pipe attachment bolts.
Te investigation found that the failure
of the inserts was the result of over
tightening that had occurred during
previous maintenance. Te oil/fuel heat
exchanger had not been subjected to the
key lock insert modifcation.
As a result of this occurrence, the aircraf
operator notifed the maintenance
provider of the incident and received
assurance that their process, procedures
and oversight were adequate to prevent a
recurrence.
In-ight engine failure
Occurrence 200704598
On 25 July 2007, a twin engine Cessna
441 (Conquest II) aircraf carrying
three passengers was being operated on
a scheduled passenger fight from Port
Augusta to Adelaide, SA. At 1035 Central
Standard Time, while cruising at fight
level 210, the aircrafs right engine failed
suddenly approximately 23 km north of
Ardrossan, SA.
When the failed Garrett TPE331-8
turboprop engine was removed from the
aircraf and subsequently disassembled,
it was revealed that the compressor
bearing at the front end of the engine
had catastrophically failed. Tat bearing
provided both axial and lateral support
for the turbine section. Once that
support was lost, the engines rotating
turbine section shifed forward under
the infuence of thrust loads, resulting in
rotor-to-case contact and rapid engine
failure.
Te compressor bearing had been
installed as a new item into the engine
at the time of the last major overhaul.
It had subsequently accumulated some
1,295 hours of service prior to the
failure. Te ATSB examination found
that the inner and outer races, and the
bearing balls, had spalled from rolling
contact fatigue. In addition to the
spalling damage, considerable levels of
residual magnetism were found within
the compressor bearing as well as other
engine components. Te presence of
residual magnetism provided strong
evidence that direct electrical current
had passed through the engine sometime
during service.
Te aircraf had been inspected two
months prior to the engine failure for
a suspected lightning strike. Despite
the operator not fnding any evidence
of lightning strike at that time,
magnetisation of the engine components
as found during the ATSB examination
was indicative that the aircraf had
indeed been struck. Te passage of such
electrical currents from a lightning strike
creates undetected electrical damage
that manifests itself through localised
welding and pitting of bearing surfaces.
Over time this then develops into spalling
of the bearing, which creates vibration,
overheating, and ultimate bearing
failure.
Wirestrike
Occurrence 200807955
On 25 December 2008, at about 0845
Eastern Daylight-saving Time, a Cessna
Aircraf Company 172M aircraf,
registered VH-ROO, struck a powerline
that was located on a property at
Kernot, 25 km north-west of Leongatha
Aerodrome, Vic.
Te aircraf impacted the ground about
100 m from the powerline and caught fre.
Te pilot, who was the sole occupant, was
fatally injured.
Te pilot was conducting a private fight
from his property (located approximately
3 km from the accident site) to Tyabb
airport and then proceeded to overfy the
property at Kernot. Information from a
number of witnesses suggested that the
pilot had a history of low fying.
Examination of the wreckage did not
identify any mechanical defects that
would have afected the safe operation of
the aircraf. Evidence from a number of
sources suggested that the pilot was aware
of the location of the powerline and was
familiar with the area.
Tere was no operational reason, such as
adverse weather, or for takeof or landing
for the pilot to be below 500 feet above
ground level at the time of the accident.
Based on reports of the pilots previous
low fying it was likely that the pilot
made a deliberate decision to overfy
the property at a very low level on this
occasion.
Te investigation concluded that the pilot
overfew a property at Kernot at very low
level and did not see powerlines that were
located about 600 m from the house in
sufcient time to avoid a wirestrike. Afer
breaking the powerlines, the aircraf
impacted the ground and caught fre.
Tis accident reinforces the inherently
hazardous nature of low-level fying.
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Australias voluntary condential aviation reporting scheme
REPCON briefs
REPCON is established under the Air
Navigation (Confdential Reporting)
Regulations 2007 and allows any person
who has an aviation safety concern to
report it to the ATSB confdentially.
Unless permission is provided by the
person that personal information is
about, the personal information will
not be disclosed. Only de-identifed
information will be used for safety action.
To avoid doubt, the following matters are
not reportable safety concerns and are not
guaranteed confdentiality:
(a) matters showing a serious and
imminent threat to a persons health
or life
(b) acts of unlawful interference with an
aircraf
(c) industrial relations matters
(d) conduct that may constitute a
serious crime.
Note 1: REPCON is not an alternative
to complying with reporting obligations
under the Transport Safety Investigation
Regulations 2003 (see www.atsb.gov.au).
Note 2: Submission of a report known
by the reporter to be false or misleading
is an ofence under section 137.1 of the
Criminal Code.
If you wish to obtain advice or further
information, please call REPCON on
1800 020 505.
Introduction of a new headset
R200800102
Report narrative:
Te reporter expressed safety concerns
about the introduction of a new headset
into one of the operators aircraf types
and listed a number of safety issues with
the new headsets as compared to the
previous headsets.
Te safety issues listed included: an
electrical buzzing noise in the headset
that was very distracting; reduced
situational awareness and loss of audible
cues in the fight deck and surrounds; and
headaches with prolonged use resulting in
a reduced ability to concentrate.
Te reporter also indicated that below
10,000 feet, crew have been instructed
to use only one ear cup of the headset
resulting in: speech from the other
crew members being very dif cult to
understand; disorienting audio cues;
frequently missed or misinterpreted
radio calls from ATC; and muf ed EICAS
(Engine Indicating and Crew Alerting
System) warnings.
REPCON comment:
REPCON supplied the operator with
the de-identifed report. Te operator
advised that the new headset was chosen
over the old headset due to the superior
noise attenuation qualities, as well as
some defciencies in the old headset when
used with the crew oxygen mask and
goggles. Te new headset provides Active
Noise Reduction (ANR) via the battery
pack. Part of the program involves re-
wiring the aircraf such that the aircraf
electrical system will supply power to the
ANR facility. Given that the re-wiring
program would take at least 18 months,
the battery pack arrangement is used as
a stop-gap until the re-wiring program is
completed.
Unfortunately, the battery pack also
creates interference that amplifes the
electronic noise normally heard at a low
level when using ANR headsets. Tis
is unavoidable in any ANR headset.
Te degree of amplifcation is variable
across the feet. One aircraf is currently
modifed to power the ANR facility and
uses this headset with no additional
background hum and all reports have
been very positive.
In relation to the specifc issues raised in
the REPCON report:
Te operator claims that the impact of
the background hum and associated
headaches on individuals is very
subjective. Some Flight Crews have
refused to fy with the headset due to the
hum, whereas other Flight Crews have
refused to operate the very same aircraf
until the headsets were re-installed. Te
operator added that it could not make
comment on individual circumstances
and impacts except that this type of
headset is quite diferent to what has been
used for the previous two decades.
Te potential reduction in situation
awareness and audible cues are known
characteristics of all ANR headsets, not
just the one provided. With the inboard
ear uncovered (as was the procedure with
the previous headset) the covered ear
should allow clearer audio reception. Te
beneft of ANR headsets is in eliminating
extraneous noise and making voice
and radio interpretation clearer - the
major impact on most Flight Crews is
the reduction in radio reception volume
required for the same (if not better) audio
quality.
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EICAS warnings have been tested in the
aircraf and simulator with no adverse
impact noted - this is a certifcation
issue for Regulators if a headset were to
degrade aural warnings. Tis is especially
so in an aircraf where aural warnings
are provided through area speakers as
opposed to headset piping. Further, the
physics of the use of ANR headsets can
show that aural warning perception
remains unchanged with commensurate
changes in noise attenuation in both the
ambient and aural warning output. Te
headset has the manufacturer and FAA
TSO (Technical Standard Order) approval
for use on the aircraf type referred to
in the REPCON report. Te latter is
important, in that the manufacturer or
FAA can limit aircraf applicability if they
so desire.
REPCON supplied CASA with the
de-identifed report and a version of
the operators response. CASA had
noted an issue with the headsets during
operational surveillance of the operator.
CASA noted that the problem will be
fxed when the headsets are hard-wired
to the aircraf power system. CASA
will continue to liaise with the operator
regarding the proposed timeframe to
complete the modifcation.
IFR operations using a VFR only
approved GPS
R200800114
Report narrative:
Te reporter expressed safety concerns
about the operator conducting IFR
operations using a VFR only approved
GPS unit as the primary means of
navigation. Te reporter believes that
direct routing, SIDS and STARS are ofen
accepted when ATC make a request to
deviate from the fight plan and that ATC
must be aware that the aircraf does not
have an approved GPS for that request as
it would be on the fight plan information.
REPCON comment:
REPCON provided Airservices with the
de-identifed report. Airservices provided
the following response:
From an ATC point of view, if it is an
IFR fight, it would be processed as such
and controllers should check the feld 18
remarks in the fight plan for GPS. What
is not clear is how a controller would
know the GPS unit is only approved for
VFR use. In the Aeronautical Information
Publication (AIP), section ENR 1.10-14
does not show that permutation.
REPCON supplied CASA with the
de-identifed report and a version of
Airservices response. CASA advised
that they support Airservices position.
It is a pilot responsibility to indicate
accurately the navigation capability on
the fight plan and advise capability in
fight if given clearance requirements
that cannot be complied with. CASA has
published and continues to publish pilot
guidance material on requirements for
IFR navigation utilising GPS. CASA is
following up the issue with the operator
concerned.
Emergency exit brieng
R2008000106
Report narrative:
Te reporter expressed safety concerns
that no briefng was given by cabin
crew to passengers seated next to the
emergency exit doors on how to operate
those doors.
REPCON comment:
REPCON supplied the operator with
the de-identifed report. Te operator
advised that the crew indicated that the
fight had been delayed and subsequently
was behind schedule and the exit row
passengers were briefed during the initial
cabin pre-fight procedures. However, two
passengers boarded very late and were
seated in the emergency exit rows. Tis
was not realised until afer takeof and
the seat belt sign had been turned of.
REPCON supplied CASA with the de-
identifed report and a version of the
operators response. CASA advised that
they will address this matter as part of its
operational surveillance and ensure that
it forms part of the operators internal
audit schedule.
REPCON reports received
Total 2007 117
Total 2008 121
First Quarter 2009 41
What happens to my report?
For Your Information issued
Total 2007 58
Total 2008 99
First Quarter 2009 42
Alert Bulletins issued
Total 2007 1
Total 2008 12
First Quarter 2009 0
Who is reporting to REPCON?
#
Aircraft maintenance personnel 29%
Air Trafc controller 4%
Cabin crew 2%
Facilities maintenance personnel
/ground crew 1%
Flight crew 32%
Passengers 6%
Others* 26%
# 29 Jan 2007 to 30 April 2009
* examples include residents, property owners, general
public
How can I report to REPCON?
On line: ATSB website at <www.atsb.gov.au>
Telephone: 1800 020 505
by email : repcon@atsb.gov.au
by facsimile: 02 6274 6461
by mail : Freepost 600,
PO Box 600, Civic Square ACT 2608
For further information on REPCON, please
visit our website <www.atsb.gov.au> or call
REPCON on: 1800 020 505.
58
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THEE ACCIDENT
The regional routes own by Brisbane-based Queensland Ai A rlines were pros os sspe pe pp ri r ng by e
As usual, the service from Brisbane to Coffs Harbour via Coo ola laaang ng ng ng gattta ta ta ta and Casino and
Thursday, 10 March 11949 was to o be own by one of the co coomp m anys s Lo Lockheed 18 Lo ooode
Lodestar VH-BAG carried a crew o of f th th thre re re ree: e: e: e: cccc ccapppptain, rst ofcer an aa d ight h a aaattendant.
from Brisbanes Archereld airp por ooo t at 7.45a aaam, VH-BAGs southbound ight wa was s norma
way, and it landed at Coffs Harbour at 9.20am. The day was ne and clear, with h a a a lig
fr from o the east.
Af A te err r th th th the e eso so southbound passengers alighted, the oil company agent refuelled the eLo Lo Lo Lockk ck ckhe he he he h ed eee . Th
was ttedd w wit ith h fo four wing tanks installed inboard of the engines on either side, and nd 100 gaa
octane avgas wass pum mmpe p d into the two forward tanks, almost topping n them up. Ei Eigh ght p
boarded the aircraft, and d th thei e r luggage loaded into the roomy nose compartment.
The Lodestar took off at 9.550a 0am, landing at Casino 35 minutes later. Threee p
disembarked, and another six, all l bo bo b oked e to Brisbane, joined the ight. AAga g in the heir lug
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At 11.15, , wh wh wh h when en en eee the Lodestar had be be beeen en en en on the ground for less sss th th th th than an an an a a aaa
qu qu quarter of an ho hh ur, the engines were sta aart rt rt rted ed ed ed, aan aa d the ma m chin ne e ee ta ta ta a taxi xi xied ed ed ed e
away to the e western end of the east-west str tr tr trip ip ip ip. . Th The airc rc r ra raaaaft ft ft ft t dd ddid id id id nn nnot ot ot ot ot
appear to o pause near the threshold, but began its ta ta ta take ke ke keof of of off f ff in i to t the he he he eeeeas aas ast ttt
almosttt iiiimmediately.
Beco ccc ming airborne about half way along the strip, it con nti ti inu nu nu nued tooo o
y close to the ground as it accelerated. Then, as the underccar aaa riagggge e
retracted, it began to climb. The angle of climb appeared norm rm rmmal al al al
at rst, but within seconds, those watching from the terminal w wwer er e e eee
abbergasted to see the Lodestar nosing up into an impossibly ssste te eeep ep ep ep
climb. What the hells the matter with him? the airline driver c cri ri ri ried ed ed ed
out in alarm.
With the engines still at take-off power, the climb co co cont nt nt ntin in in i ued to s ste t ep epppen nn
as the aircraft gained height. Some watching ng ng ng ng gg ttt tho ho ho ho hhh ught it wo w uld go ove ve v r r
on its back, but when abnormally y n nnnos os os os os oo eee- eeee up at between 200 and d 300 00
feet, its starboard wing dropp pp pp pped ed ed edd aaaannnd the machine lost height. The wing g
was picked up as the L LLLod od od od dees estar hesitated slightly. Then the port wing g
dropped steepl pl pl ply y y y an an an andddd the machine entered a curving descent to the
left ft, , gr g ad ad ad adua ua ua ua u ll ll ll llyy assuming a more level attitude as it did so o oo at low speeeeed ed dd. .
Re Re eega ga ga gain iin ining a at attitude still well above the ground, it drop pppe pe p d al almo mo ost st st st
verticallly into a swampy area between the airstrip and the beach ch ch chh, , , hi hi hh tt tin in n i g g g
the e ground heavily on its belly and exploded into ames, thick kk bl bl bl blaac a k
smoke billowing skywards as re engulfed the wing gs s and d fuselage gg .
Deeply shocked, the groundsman and a aaage ge gents staff grabb bed re
lo oad ad ded into the nose compart tment. At 10.35
the aircraft took off again and after r a further
25 minutes, arrived over Coo oolang gggat at at at a ta ta ta ta.
Coolangatta aerodr dd om om mme then was on the site
of the hhee pp ppre re rr sent airport neaar the township of
Bilinga, but consisted only of three relatively
short unpaved strips cut fro r m the surrounding
coastal scrub. Two of th t em were on the
approximate alignments sss of todays runwayys, s,
with the third interseeeecting strip (todayy ay ay a
taxiway) running in aan easterly dire re ect c ion
towards the beach.
Overying gg, th the ee Lo LLo Lo LL de de de de d star made a left-hand
ci ircuit and touched down smoothly into the
eaast. Taxiing ahead to the strip intersection,
it tur u ned left and continu ued to the north-
western end of what is todays Runway 32,
shutting down in front oof Queensland Airlines
small airport term rminal. The occupants
disembarked, fou ou ou uuuur rr of the passengers leaving
the aircraft.
Fo FF r th the e rema m ining leg ba ba ba back ck ck ck tto o o o Ar Ar Ar Ar AA ccch chereld,
another 11 passse se seeng nger er e s s joiiiined ed ed ed the ight,
making a total of f 18 18 18 18. TTThey inclu uuude de de dedd d d d th ttt e chief
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mechanis is is ismm indica ca caate te te ted a setting gggg of of of of f aaabo bout three divisions nose-upa
ty ty typica cal l sett t ing for land nd nd ndin in in ing. g. gg. g. g Ex Ex Ex Exaaamination of the victims showed that all
had di d ed instant nt tly ly ly ly i iiin n n n the im mmmpa pa pp ct.
VH VV -BAG AG AG AGs s s s u uuupp weight when it it ttoo oo oo ook kkk off was slightly less than the
ma ma ma maxi xi xi ximmmum, and the loading gures u usee seed d d by Queen ensl s an and d Airlines and in
th th h the passenger waybill revealed only mi mino no oor r rr di dd screpancies. IIt t wa wa wa was s s s li li li li like ke ke ke ke ely ly ly ly
th th th that VH-BAGs weight at take-off would have e be beeen en en en under t the hee he maximum
pe erm rm rr issible 16,800 pounds.
CCCCENTTRRE OF GRAVVVVIIIITTTTYYYY
VH VVV -BBAGs Certi t ca ca caa c te te te te t of Airworthiness (CofA) specied that its cent ntre re re re
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Becaus us sse e e e th ttt e disposition of the passengers
in the cab abb abin in in in wwwas a uncertain, investigators
calculated the m mmmos ooo t favourable and most
adverse combinations ns ss, , , , us usin ing the weights of
all items making up the loadd. Th T ese indicated
that VH-BAGs centre of gravity on beginning
takeoff would have been at bes st t 41 41.88 per
cent MAC, and at worst 42.4 per cent M MMMAC.
But when the undercarriage retracted, thes ese e
would have increased ttto 43.4 per cent and d
43.9 per cent MAC respectively -- betw wee e n 4. 44 4
per cent and 4.9 per cent MAC tail lll-h -h -h -heavy.
STEEP CLIIIIMMMMMMMBBBBB
Th TTT e Lo Loooode de de de de dessssstars tendency to climb steeply
af af af affte te te terr liftoff had been noticed on a number
of occasions, particularly when the loading
was tail-heavy. The companys operations
supervisor recalled an insta anc n e with a captain
under training. The Lodest sttar a had a f ful u l l
complement of passengers, and ddd he he hh told the
pilot he was checking that about 10 000 di di dd visions
of nose-down trim wa as s ne ne n cessary for ta ta take kk off
with 15 degrees of ap.
The pi pi pi pi pp lo lo lo lot tttt under training however, wound on
on oooo ly about six divisions of nose-down trim,
an an a d the supervisor decided to allow the trainee
to lea earn rn the lesssso sss n for himself. The ground
run was normal, the airspeed increasing to
110mph without difculty holding the aircraft
down. But when the trainee allowed tthe he he
aircraft to lift off, ,, and climb at this speed, he
was startled at the force necesssary to hold
Queenland d Airli li li iines
nes
ne nes
ne ne ne nes
ne e nne
L L
ockheed Lode destar V VH-B
H-B
H
B
H-B
H-BAG undergoing
servicing at Br risb isb is s
ane
ane
an n
s Archer
her e eld Airport. .
VH VV BAG s Certica ccc te of Airworthiness (CofA) specied that its cent ntre ree iness (CofA) speci
of gra r vi v ty ty ty ty y m mmmust lie between 28.5 per cent and 39 per cent of the wings s ween 28.5 per cent and 39 per cent of the
me me me mean ann aerodynamic c chord (MA MMM C) (i.e. between those percentages of mic chord (MA MMM C) (i.e. between those percentages
th hhhe e aver e age distance from the leading edge of the wing to its trailing stance from the leading edge of the wing to its trailing
ed ed ddgee). For calculating the centre of gravity, the Department provided a alculating the centre of gravity, the Department provided a
lo lo lo load ad ad ad cccchart with the CofA, with load sheets to use with the he chart. with the CofA, with load sheets to use with the he chart.
AAA AA Depa pa pa part rt rt rtme me me ment nn al aeronautical engineer determining VH-BA BAG G G s s s s ac ac ac acctu tu tu tu tu ual me me me ment nn al aeronautical engineer determining VH- AAG G G s s s s ac ac ac acctu tu tu tu tu ual
ce ce entre re of gr grrav av av avit it it ity y y y at the time of takeoff uncovered som om mme di d smaying gr grrav av av avit it it ity y y y at the time of takeoff uncovered s e di d smaying
in i cons sis is is s i te ttt nc cie ie ie es. T TThe he he he ll loa oad chart contained a number of errors, resulting enc cie ie ie es. T TThe he he he ll loa oad chart contained a number of errors, resulting
fr fr fr from oom om m dd ddis i crepanciiies b bbet et et etwe wwe ween en e Lockheed 18 11 data supplied by the RAAF repanciiies b bbet et et etwe wwe ween en e Lockheed data supplied by the RAAF
(o (o (o (on n n n nn wh wh wh wh hic ic ic ic i h th the De De De Depa part rrr ment nt t hhhhad ad aa based the chart), and original gures th the De De De Depa part rrr ment nt t hhhhad ad aa based the chart), and original gures
ob ob ob obta ta ta tain ined edd ed ed f fro ro oomm m m th th th the e U. UUU S. CAA. Th Th Th The e ee pa passenger seats were also 25mm omm m m th th th the e U. UUU S. CAA. Th Th Th The e ee pa passenger seats were also 25mm
fu fu fu u fu furt rt rt rt rthe he he he hherr r r r ap ap ap ap apar ar ar arrtt tt th th than aaa indicated on th he e ch char a t, resulting in a signicant th th han aaa indicated on th he e ch char a t, resulting in a signicant
re re re e re r ar ar ar arwa wa wa wa ard rd rd rd mmm mmov ov ov ovem em em em e en en eent of the hhh centre of gravi vity ty w wwit ith all seats occupied. nnt of the hhh centre of gravi vity ty w wwit ith all seats occupied.
Th Th Thhhe e e e e ch ch ch chhar ar ar ar a tttt on on on on only ly ly ly lyy ppppro ro rr vi vvv de ddd d for the aircrafts unde de derc rcarriage down d for the aircrafts unde dd arriage down
co co cooooond nd nd nnd n it it it i io io io ooon, n, n, n, n yyyy yet et et ett rrrret et et et e ra ra ra ra ract ct ct c in in in ing g th the undercarriage moved the ce cent ntre of gravity of gravity
fu fu fu fu u fu furt rt rt r he he he hheer rrrr re re reee rr aaar ar arwa wwa wa wa w rd rd rd rd rd...
was startled at the force necessary to hold
th th th the ee control column forward. The captai in to t ld told
him m to to tt apply more nose-down tr trim im m, and the and the
aircraft t the h n climbeed d d d no nnn rmally. From the From the
load sheet ffffor or or or tttthii his ight it was determined s determined
thatt, , , , wi ww th th t the uund nd dercarriage retracted, the th the ercarriage retracted, the
Lodestar a s centre of of ggra r vity was just Lode s centre vity was just behind behind
the stipulated rear limit. the stipulated rear limit.
At the next pilots meeting, tthe he he operations At the next pilots meeting, tthe he he oper
supervisor pointed ed ed edd out the impor rta tanc nce of at supervisor poi ted ed ed edd out the impor rta ta
least 10 divisions of no no no nose se se se-d -d -ddown trim, to oge geeeth th th ther least 10 divisions of no no no nose se se se-d -d -ddown tr
with the necessity to ke ke ke keep ep aall ll ll ll load forwarrd, ddd, with the necessity to ke ke ke keep ep aall
with 16 passengers on board. d. with 16 passengers on boar
About a month before the aacc cc cid id i ent, the About a month befo
companys senior check pilot also expe peeerienced companys senior check pilot also expe peeerienced
a steep climb. The aircraft beca aaame air rrrbo bbb rne a steep climb. The aircraft beca aaame air rrrbo bbb rne
normally after a short run un, but almost normally after a short run un, but almost
P
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im mme m diately began to climb steeply. Even with both han n an nds ds ds s ds, he he h was
unable to force the control column forward. Wh Wh W en the airspee e d had
fallen to 85mph, rather than risk ta aaki ki ki ki k ng ng ng ng o ooone hand off the wheeeel to adjust
the elevator tri im, he rais ii ed d t ttthe hhh aps. This immediately alter eee ed the trim
of the aircrrraf af af ft, tt ttthe h wheel mmoved forward, and the clim im im i b continued
norm mmally. Thinking this inci c dent over, the check pilot t tthought he might
have begun the takeoff with less than 10 d divisions s oof nose-down trim.
Even so, he was certain so some nose-down trim wa wa w s applied.
Asked if he had ever not ot ticed a tendency towa w rds instability in ight,
the e senior check pilot r rec e alled an occasionnn n when, with a full load of
passengers, no luggagee in the nose com mpa pp rtment, and only a light fuel
load, he found it imposs sss ible to trim the he h aircraft to y level. Constantly
hunting long gitudinal al a ly ly ly ly lyyy, , it it it it wwwas as as as uuuunp np np nple le le leas as as assan an an an a t ttt to to to to y yyyy.
Information was soug ught from the U.S. CAA, and from
the Lockheed Aircraft Corporation, on the handlin
charracteristics of the Lodesta tt r aircraft with the centr
of gravity behind the rear a limit. This established tha
the centre of gravity rear limit had been amended
from 40.6 per cent MAC to 39 per cent. From this, thee
investigators conc nc nnc nc clu l ded that VH-BAGs longitudin nnal al al al
instability would reeeeeac ac aa h dangerous prop ppppor or or orti ti ti tion o s at
43.4 per cent t t MA MM C, the p pppro ro ro robable po oosi si si i ss ti ti ti ti t on on on on aat the time
of the accid ddden en en ent. t
LOAD CCCCHHHHAAAARRT
Th Th Th The in investigators now turned their atten enti tion on o to
the grave error in VH-BAGs load distribut ut ttiio ion, n,
and to what extent the companys practices had ad
contributed to it. A clause in the Certicate ooooof ff f
Airworthines ss stated: The aircraft must bbbbbe eeee lo lo lo loaded
in accordance e with the attached lo loo load aad ad chart which
is part of this Certicate. eee Furthermore, the
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The investigators belieevvveeedd
the answer waassss tttthhhheeee sssseeeeetttttttttttttiiiinngggg oooooffff
the
Departmental loa aaad d dd dd sh sh sh s eets for calculating the eets for calculating the
centre of gr gr g aaavity, using index uni its tt derived vity, using index uni its tt derived
from om om om m o t the load chart, stated: Index units MUST oad chart, stated: Index units MUST
be supplied except where an approved loading plied except where an approved loading
procedure or approved loading slide rule is edure or approved loadin slide rule is
in useeee. . BBBut ut because an Air Navigation Order useeee. . BBBut ut because a
covering t thi hi hi his ss s re re re requ q irement had not yet been vering t thi hi hi his ss s re re re requ q ir
written, the pro oce ce ce cedu du du dure rrr was still not mandatory. itten, the pro oce ce ce cedu du du d
The operations supervi vi viisso so or r to told the investigators e operations supe
that although a load charttt www was as as as always carriiied at although a load c
on the aircraft; the pilots were e fa fa fa fami miliar enough the aircraft; the pilots wer liar enough
with thee aircraft to o be ab ab a le to load it bby by b rref eference thee aircraft to o be ab ab a le to load it by by rref eference
to the loa oad shee et t which showed the w wei eigh ght o loa oad shee et t which showed the w wei eigh ght o
passengers, luggage and freight. The senior chec ec s, luggage and freight. The senior chec ec
pilot enlarged on this, explaining that pilots followe pilot enlarged on this, explaining that pilots follow
general rules for loading. The nose compartme gen
was lled rst, the No 2 compartment from t was
m
ng
re
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t

The Lockheeds twin- nned tail assembly survived the re, but shows
downward distortion from the high vertical impact.
d
h h
ee
of of
cck k k cck k k
ed
ent
the
The burnt-out remains of the Lockheed, after it fell almost vertically into
swampy ground.
front next and so on, irrespective of passenger loadd add. Th Th Th Th h The passenger
load was disposed about the main spa pp r, r, llli ling gg the front nt seats rst.
The front fuel tanks were also so so soo l lllle le led rst. The senior ch check pilot said
that the load charrt ttt wa w s never used on regular scheduuules as there was
not suuuf f f cc ccie ie ie ent time. He He believed the general ruleeees s for loading were
adequate, except when n heavy freight was being g g ca c rried.
This was obviously not ot so. In view of the time VVH- HH BAG had been in service,
the variations in load d encountered, the instan ances of rear centre of gravity
instability experienceeeed, and the quite unrem emarkable loading at Coolangatta t
which produced suc ch hh dire consequencees, ss, it seemed likely that VH-BAG had
been own in a dang n erously tail-heavy vy vv condition on numerous occasions.
Why then was theee cre r w w un unab able le ttoo o o cco co correct the powerful nos os o e- e up up up up ttten en en ende dee denc nc nc n yy y y
af after th th th t e e take ke ke k of of fff f ff fffffffrom Coolangatta when others had got away with it?
Did some other factor exacerbate the tail-heavy condition, preventing
the crew from taking acttion to avoid the accident?
Th Th T e e investigators beliieved the answer was the setting of the elevato or r r
tr rrrim. The position of the trim tab cables on the mechani nism smssss sssspo po po pool
sugges ee ted the take k -off could have begun with the eleva vaato to to o tor r r r tr tr tr triim still in
the position on nn to ooo which it was adjusted for the e la la and nd nd ndin in in inggg at Coolangatta.
If this were t ttthe he he he hh case, the crew would ha ha aave ve ve ve had d no hope of applying
sufcient ttt ff fforward dddd ffffor ooo ce on the cont nt ttro ro ro ro r l l ll co colu lumn to prevent the nose rising
st steeply as the machi hii hine ne ne ne acc ccccel el el el eeler er er eerat aat a ed after takeoff. The experiences of
the se s ni ior che eck ck ck ck ppppilot ot tt and nd dd t ttthe he he h operations supervisor showed that, when
taking off wit it th h hh aaaa rrearward c cccen en en entr tr tr tr re ee of gravity and 15 degrees of ap, the
ai a rcraaaaft ft ft ft f eeeexh xh xh xhibited a nose-up tennde de de denc nc nc n y y that wwwas difcult to overcome,
ev ev ev even en en en with some nose-down trim. WWit it th hh h th the trim iina aadv dver erte tent nt tly lyy left in a
nose-up setting, it would be impossible.
Wh Why the crew overlooked such a vital action n re rema ma ma ma aain in in ined unanswered.
Though it was not the companys practice to o us us us us u eee ee any y fo fo orm rm rm rm of check list,
all crew ewwwss ss followed a standardised checking
procedure. TTTThe hhh re ee was evidence that the
captain and traf af af afc c cc manager had quarrelled
immediately before VVVVH- H- HH BA B G taxied away
from the terminal, but any b bea earing this might
have had on the oversight remained a matter
of conjecture.
THE RECOMMENDATIONS
The investigators report conclu ude ded d wi i with
two principa p l recommmendation nnnns: s: s
That all airlines b be ee subject to periodic
checking bbbbbby y y yyy DDDepartmental ofcers to
ensu su uuure re re re re r thhat no company practice was
c c c c ontrary to the interests of safety.
That responsibilities for the safe loading
of aircraft, and the procedures to be
followed, be dened i in n Air Navigation n
Orders and promulgated w wwithout delay ay.
Their report made no mention oof f ff th th hhe ee loose
system of cockpit checking n that cont nt nttri r buted
to this tragedy. But tthi hiiis, s with other disa aast st ss ers
overseas res sssul ul ul ulti ti ing from the neglect of vital al al al
pre- e ta ta ta a ta ake kke ke-off actions in modern complex
aircraft f , would eventually point the way
fo fo for r the e adoption of tighter, more positive
systems based on some form of written
check list.
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Undercarriage down, the Lockheed prepares to land. Note the extended wing aps.
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Payments
Usually, you will need to pay the DAMEs
account after your appointment.
If you wish to pay the CASA fee at the end of
your appointment, you can do so by completing
a payment form (attached to the medical
form, or available from your DAME).
The DAME will send this form to CASA with your
medical report. Remember: we cant process
your medical until the CASA fee is received.
IF YOURE RENEWING YOUR
MEDICAL
How to avoid delays when doing your renewal
for medical certication.
Visit your DAME early. You can have your
examination up to 28-days prior to the
expiry date for your medical certicate.
Restriction 1 RENEW BY CASA ONLY.
Arrange any specialist reports before you
visit your DAME. You can have any tests
required, or visit your specialist up to three
months before your certicate expires.
Left it a bit late? The DAME may re-validate
your medical for up to two (2) months
from the expiry date if he considers you
are t to y. This re-validation can only be
for two months and only if you do not have
the restriction RENEW BY CASA ONLY.
Take an express post envelope for postal
and ask the DAME to use this to post the
medical forms to CASA.
WHERE DO I START?
Obtain an aviation reference number (ARN), if you dont already
have one. This is your unique number, and identies you when you
do business with CASA. You can download the ARN application
(Form 1162) from the CASA website. When you send in the form,
make sure you send the appropriate identication documents with
your application.
Once you have your ARN, you should book an appointment with a
designated aviation medical examiner (DAME).
Locate a DAME in your areasimply use the Quick Links Information
about Aviation medicals on the CASA website homepage, and then
go to Search for a medical examiner on the Aviation medicals page.
Make the DAME your GP
That way, your regular treating doctor - your GP - will be on top of
any change in your medical condition. This will help you full the
CASR 67.265 requirement to notify changes in medical condition, and
suitability to return to ying.
When you book your appointment ensure you inform the receptionist
that you are booking for a CASA aviation medical examination.
Ask for information on any additional testing needed for the class of
licence that you are applying for: class 1, 2 or 3.
In most cases, you can save time in the medical certication process
by having any additional tests prior to your DAME appointment. The
practice staff will be able to assist you with any referrals or information
you may require.
What to take to your appointment see ow chart opposite.
The DAME will conduct your medical examination. If you havent yet
had the additional testing, the DAME will refer you for these. Remember,
your medical will not be processed until we receive results from all
required tests. The DAME is responsible for sending your medical and
all test results to CASA.
?
?
?
Con used
out the process
??
n used u
dical certicat
??
out the process out the proces
???
di
d
e
d
???
A
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65
Medical certicate enquiries
Once the original or renewal medical and all required reports are s
received by CASA, the following processing times can be expected:

For a standard class 1, class 2 or class 3 medical 7 days

Any medical (class 1, 2 or 3) requiring review by a CASA

assessor 21 days

Any medical (class 1, 2 or 3) considered to be a complex case

Up to 60 days
You can enquire about the status of your medical application by
phoning 1300 737 032, or email avmed@casa.gov.au
Make sure you know your age requirements.
Pay the $75 CASA processing fee.
The payment form is included on the
medical examination forms, ask your DAME
for this page to include payment with the
medical. Alternatively you can fax the form
to CASA on 02 6217 1640, or pay by phoning
1300 737 032
If you wish to send the payment direct to
CASA by post it can be sent to:
Civil Aviation Safety Authority
Aviation Medicine
PO Box 1544
Canberra ACT 2601
The payment form (162) can also be found on
the CASA web site, under Forms.
To save delays in processing of the payment
please ensure that all details are included,
especially name of applicant, ARN, credit
card number, expiry date and signature.
Other possible delays.
Sometimes it may be necessary to seek further
information in order to accurately assess the
medical. In this case a letter may be sent to
your DAME; with a copy to you; asking that
the information is sent to CASA.
Some applications may also require review by
our panel of doctors before a decision can be
made about issuing the medical certicate.
The medical review panel meets regularly
and every attempt is made to complete this
process within 28 days from receipt of all the
required relevant information.
If you have any questions regarding your
medical certication, or about any of these
processes, please contact Aviation Medicine on
1300 737 032 or at avmed@casa.gov.au.
You want to apply for an initial or renewal
medical certicate
Do you have an ARN?
NO
Find a DAME & book appointment.
Ask for details on additional testing.
Have these tests before the appointment
if possible it will save time in the
certication process.
Attend DAME appointment
taking your:

ARN

Photo ID

Test results

Credit card details for CASA payment
Payment for DAME
CASA fee payment
Do you have a credit card?
Has the DAME requested any further tests?
If yes, have these done as soon as possible
as your medical will not be processed until
CASA receives all your test results.
Mail a cheque
or money
order (with
your ARN
written on the
back of it) to:
Aviation
Medicine
CASA
GPO Box 1544,
Canberra ACT
2601
Your medical
will not be
processed
without
payment.
NO
YES
YES
YES
Complete the credit card payment form. Your
DAME will enclose this with your medical and
will send it to CASA.
Apply for an
ARN before
applying
for medical
certication
You can have your
examination up to
28-days prior to
the expiry date for your
medical certi cate.
me
day
ir
o
66 66
FFFFFFFFLLLLLYYYYIINNNGGG OOOOPSS
AVQUIZ
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1. You are tracking VFR by day to a towered aerodrome at an
assigned level and, with 8nm to run, you are cleared to make a
visual approach. This means that you may leave the previously
assigned level and descend
(a) to circuit height a at any time.
(b) to circuit heigh hhht at any time as long as the aerodrome is
in sight.
(c) below the lowest safe altitude only when the aircraft is
within 3nm of the aerodrome and the aerodrome is in sight.
(d) to an altitude not below that permissible for VFR ight
(CAR157) until within 5nm from the aerodrome.
2. A VFR aircraft may be authorised to make a visual approach
when at a distance from the aerodrome of up to
(a) 3nm.
(b) 5nm.
(c) 10nm.
(d) 30nm.
3. Satellites identify the new 406/121.5 MHz ELTs/PLBs by means
of the unique transmitted code which is registered against a
particular aircraft. This code is referred to as
(a) the UNI and consists of 15 digits.
(b) the UNI and consists of 10 digits.
(c) the serial number, and has at least 10 digits.
(d) the serial number or UNI, and has 15 digits.
4. The above ELTs may be registered online or the aircraft details
may be changed at www.
(a) casa.gov.au
(b) airservicesaustralia.com
(c) beacons.amsa.gov.au
(d) amsa.gov.au
5. In a METAR for place A, the gures quoted immediately before
the QNH read 9/8, and at place B they read 10/8. This means
that, at place A, the dry bulb is 9C and the
(a) dew point is 8C and fog is closer to forming at A than B.
(b) w wet bulb is 8C and fog is closer to forming at A than B.
(c) dew point is 8C and fog is closer to forming at B than A.
(d) wet bulb is 8C and fog is closer to forming at B than A.
6. In class G airspace, the minimum visibility for a helicopter,
provided certain conditions are complied w dddddd ith, is
(a) 700m
(b) 800m
(c) 1000m
(d) 3000m
7. Unless requested by the pilot, a take-off clearance will not be
issued to a helicopter when the tail-wind component exceeds
(a) 3kt.
(b) 4kt.
(c) 5kt.
(d) 8kt.
8. At altitudes between A050 and A100, the range of a VOR, for
planning purposes, unless otherwise published in ERSA, is
(a) 60nm.
(b) 90nm.
(c) 120nm.
(d) 150nm.
9. If a single-engine aircraft is in cruise with the wings level, and
it is noticed that the aircraft is yawing to the left, the skid ball
(a) may be either side depending on the direction of f
propeller rotation.
(b) will not indicate unbalanced ight.
(c) will be displaced to the right.
(d) will be displaced to the left.
10. A TAF for a location in the EST time zone includes the
following: TEMPO 0710/0714 2000 SHSN This forecasts,
between the times indicated,
(a) showers and snow of expected duration 30 to 60 minutes.
(b) showers of snow of expected duration 30 to 60 minutes.
(c) showers and snow of expected duration less than 30 minutes.
(d) showers of snow of expected duration less than 30 minutes.
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MAINTENANCE
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1. Operational tests of 406 ELTs should be limited to
(a) 5 secs maximum and preferably w y ithin 5 m mminutes either side
of the hour.
(b) 5 secs maximum, and preferably within h the rst 5 mins of
the hour, and only after notifying AusSAR.
(c) 10 secs maximum and there is no preference as to times.
(d) 10 secs maximum and no AusSar notication is required.
2. An articial horizon with 360 degrees of roll freedom has
(a) a third gimbal pivoted fore and aft.
(b) a third gimbal pivoted laterally.
(c) the outer gimbal pivoted at the rear only.
(d) the outer gimbal pivoted at the front only.
3. The purpose of the dump valve in a pressurised aircraft is to
(a) equalise cabin pressure with the ambient pressure.
(b) modulate the outow to control cabin altitude.
(c) increase cabin inow to rapidly raise the cabin altitude.
(d) increase cabin outow to rapidly raise the cabin altitude.
4. A A coo c ling system that uses the evaporation of a liquid to
absorb heat is termed
(a) an air cycle machine.
(b) a vapour cycle machine.
(c) an evaporative cooler.
(d (d) a thermal expansion valve.
5. 5 In a vapour cycle refrigeration system, the low side refers to
the portion of the system
(a (a) betwween the compressor an a d the condenser, and is at a
lower pressure than the compressor inlet.
(b (b) b ) between the condenser and the thermal ex xxxpansion valve,
and n is at a lower pressure than the compressor inlet.
(c) between the evaporator and the compressor in which the
pressure may be either above or below ambient.
(d) between the evaporator and the compressor in which the
pressure is always below ambient.
6. With regard to a wing, washout refers to
(a) a reduction in incidence from the root to the tip.
(b) an increase in incidence from the root to the tip.
(c) an increase in camber from the root to the tip.
(d) a decrease in camber from the root to the tip.
7. On a rudder operated by a servo tab, application of right rudder
from the e cockpit will move the servo tab to the
(a) left relative to the rudder.
(b) right relative to the rudder.
(c) right relative to the rudder and left relative to the trim tab.
(d) left relative to the rudder and right relative to the trim tab.
8. A thermocouple-type re detection system relies for operation on
(a) a change in current in a circuit powered by the aircraft
electrical system.
(b) a change in resistance in a circuit powered by the aircraft
electrical system.
(c) a change of resistance in a circuit independent of the
aircraft electrical system.
(d) a small current generated independently of the aircraft
electrical system.
9. In a simple independent hydraulic braking system, the fa ailure
of the return spring in one of the two master cylinders
(a) will result in uneven braking on one side.
(b) will result in brake failure.
(c) may result in the brakes grabbing.
(d) may result in the brakes dragging.
10. On a twin spool jet engine the
(a) low-pressure compressor drives the high-pressure turbine.
(b) low-pressure compressor is driven by the high-pressure
turbine.
(c) high-pressure compressor is driven by the low-pressure
turbine.
(d) high-pressure compressor is driven by the high-pressure
turbine.
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IIFFRR OOPPERATIONS
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Rad Radio o nav na igation aid - positive xes
Refer e to ERC 1/2 (dated 4.6.09). For each of the following questions,
ass s ume the aircraft you are ying is equipped with:
2 VORs
1 DME
1 slaved ADF (ADF 1)
1 xed card ADF (ADF 2) )
1. If you are tracking along W 293 between Bendigo (BDG) and
Mildura (MIA) at A080 by day, which of the following would x
the position Prost?
(a) - MIA VORs with 314 TO centred
- ADF 1 (on MIA) 314 TO
- ADF 2 (on SWH) 104 R
- DME (MIA) 98 (ignoring slant distance).
(b) - MIA VORs agged
- ADF 1 (o n MIA) 314 TO
- ADF 2 (on SWH) 104 R
- DME (MIA) agged
(c) - MIA VORs agged
- ADF 1 (on MIA) 014 R
- ADF 2 (on BDG) 194 R
- DME (MIA) 98
(d) - MIA (VORs) agged
- ADF 1 (on MIA) 014 R
- ADF 2 (on SWH) 104 R
- DME (MIA) agged
2. You are southbound along H119 between Swan Hill (SWH) and
Canty at A100, HDG 130 m. Which of the following would x the
position of Canty?
(a) - VOR 1 (on MIA) with 129 FROM centred
- VOR 2 (on MNG) 270 FROM centred
- ADF 1 (on SWH) 318 TO
- ADF 2 (on MNG) 320 R
- DME (on ML 52) (ignoring slant)
(b) - VOR 1 (on ML) with 339 TO centred
- VOR 2 (on MNG) with 270 TO centred
- ADF 1 (on BOL) 158 TO
- ADF 2 (on MNG) 320 R
- DME (ML) 52 (ignoring slant)
(c) - VOR 1 (on ML) with 159 TO centred
- VOR 2 (on MNG) with 090 TO centred
- ADF 1 (on BOL) 158 TO
- ADF 2 (on MNG) 320 R
- DME (ML) 52 (ignoring slant)
3. You are overhead Balranald (YBRN) at A 060 on a HDG of 340m.
Which of the following would provide this x?
(a) - VORs (on NY N A) 030 FROM centred
- ADF 1 (on SWH) 172 TO
- ADF 2 (on SWH) 192 R
(b)- VORs (on NYA) 210 TO centred
- ADF 1 (on SWH) 172 TO
- ADF 2 (on SWH) 168 R
(c)- VOR 1 (on NYA) 030 FROM centred
- VOR 2 (on NYA) 210 TO centred
- AD A F 1 (on SWH) 172 TO
- ADF 2 (on SWH) 192 R
(d) These nav. aids cannot be used for a positive x.
4. You are overhead the aerodrome at Temora (YTEM). C Coul o d the
NDBs at West Wyalong (WWL) and Cootamundra (CTM) be
used to x this position, and why?
(a) Yes, since you are within range of both these NDBs (50nm
and 35nm respectively).
(b) No, because the angle between the track lines is less than
45 degrees.
(c) No, becausse you must be within 30nm of each of the NDBs
(irrespective of actual range) to x position.
(d) Both (b) and (c) are correct.
5. You are tracking from Wonthaggi (WON) to Latrobe Valley
(LTV) at 5000 (Note that this is a non-published track). What is
the lowest altitude to which you may descend in IMC, and how
is this determined?
(a) The LSALT that you have calculated for the route being
own - 3100.
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(b) The grid LSALT for the route being own - 3900.
(c) The MSA - 3000 - for LTV based on a positive x from East
Sale (ESL) TACAN (paired 113.5) and LTV NDB.
(d) The MSA - 3000 - for LTV based on a positive x from
Melbourne (ML) DME and LTV NDB.
6. Refer to ERC 1. Which of the following choices would be a
positive x to establish Jacka (south of CWS VOR/NDB)? You
are maintaining 5000, HDG 170 m.
(a) CWS VOR 160 FROM ADF 1 (CWS) 340 TO ADF 2 (CWS) 170 R.
(b) CWS VOR 160 FROM ADF 1 (WON) 032 TO ADF 2 (WON) 222 R.
(c) WON VOR 211 FROM ADF 1 (CWS) 160 TO ADF 2 (CWS) 190 R.
(d) CWS VOR 160 TO Melbourne DME 70.
(e) Both (b) and (d) are corr oo ect.
7. Your position is overhead Wonthaggi (WON) VOR at 4000
tracking toward Cowes (CWS) for the Phillip Island (YPID)
NDB-approach. What is the lowest altitude to which you may yyy
descend in IMC enroute to CWS?
(a) MSA of 2100.
(b) LSALT of 2300.
(c) Approach commencement altitude of 2000. 000
(d) Maintain hemisphere altitude of 4000 until overhead CWS.
8. You are tracking from CWS along W 495 toward Waren at
6000. HDG is currently 350m. Which of the following would
indicate Waren?
(a) - VOR 1 (CWS) 357 FROM centred
- VOR 2 (WON) 319 FROM centred
- ADF 1 (PLE) 320 TO
- ADF 2 (MB) 267 R
- DME (ML) 31 (ignoring slant)
(b) - VOR 1 (CWS) 357 FROM centred
- VOR 2 (ML) 122 FROM centred
- ADF 1 (PLE) 320 TO
- ADF 2 (MB) 281 R
- DME (ML) 31 (ignoring slant)
(c) - VOR 1 and 2 (CWS) 357 FROM centred
- ADF 1 (MB) 271 TO
- ADF 2 (WON) 135 R
- DME (ML) 30 (ignoring slant).
(d) - VOR 1 (WON) 319 FROM centred
- VOR 2 (ML) 302 TO centred
- ADF 1 (CWS) 177 TO
- ADF 2 (MB) 267 R
- DME (ML) 30 (ignoring slant)
9. You are tracking along V376 at 6000 between Melbourne (ML)
VOR and Raven. Your destination is Bendigo (YBDG). What is
the lowest altitude to which you may descend in IMC enroute?
(a) The LSALT initially of 4500, and 4000 once past Raven.
(b) The grid LSALT of 4700 to Raven, then 4000.
(c) The MSA for BDG of 4000 based only on VOR (ML) 314
FROM centred and DME (ML) of 36 (ignoring slant).
(d) The MSA for BDG of 4000 based on VOR 1 (314) FROM centred,
DME (ML) 36 or crossing Mangalore (MNG) VOR 2 radial 234.
10. You are overhead Melbourne (ML) DME at 8000 on YMML QNH.
What will the DME read? (To the nearest decimal)
(a) 0.0 DME
(b) 1.3 DME
(c)1.2 DME
(d) 1.4 DME
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Key
CASA events
Other organisations events
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Date Event Venue Organiser & More info
July
8 July Ju AvSafety Seminar fety Av ina Toowoomba T oo Darling Downs Aero Club Aer Darl ow b
www.casa.gov.au
8 July July AvSafety Seminar AvSa eminar y Mildura ldura Mildura Aero Club ra Aero C
www.casa.gov.au
8 July July AvSafety Seminar i AvSafety Se Geraldton era d Geraldton Aero Club n Aero Club Geraldt
www.casa.gov.au
14 July 14 July AvSafety Seminar AvSafety eminar Esperance E perance Esperance Aero Club Espe ance Aero Club
www.casa.gov.au
14 July 14 July AvSafety Seminar minar AvSafety Se Warracknabeal War acknabeal Yarriambiack Function Room Room biack Function Yarriam
www.casa.gov.au
15 July 15 July AvSafety Semina AvSafety Seminar Cessnock Cessnock Venue to be conrmed Venu to be conrmed
www.casa.gov.au
15 July 5 July AvSafety Seminar i AvSafety Se Alice Springs Alice Springs Alice Springs Aero Club b rings Aero Clu Alice Sp
www.casa.gov.au
Aug
5 August Aug AvSafety Seminar AvS inar ety Narrabri N bri Narrabri Aero Club Aero ub ar
www.casa.gov.au
5 August ust AvSafety Seminar afety Se Temora Temora Aero Club Club Temora
www.casa.gov.au
5 August 5 Augu AvSafety Seminar AvSa eminar Kalgoorlie lgoorlie Kalgoorlie Boulder Aero Club K orlie Boul Aero Club
www.casa.gov.au
6 August 6 August AvSafety Seminar minar AvSafety Se Gunnedah Gun edah unnedah Aero Club ah Aero Club Gunned
www.casa.gov.au
6 August 6 August AvSafety Semina AvSafety eminar Forbes Forbes Forbes Aero Club Forbes Aero Club
www.casa.gov.au
11 August 11 August AvSafety Seminar minar AvSafety Se Yarra Valle Yarra Valley Yarra Valley Aero Club lley Aero Club Yarra V
www.casa.gov.au
18 August 18 August AvSafety Seminar AvSafety eminar Cairns irn Cairns Aero Club C s Aero Clu
www.casa.gov.au
Sep
30 Sep September-2 p Septem
October October
RAAA Convention (30th (30t AA Conve
anniversary of RAAA & 10th of RAAA & 10t anniversary
anniversary of the convention) conv versa an the n)
Hyatt Regency ency
Coolum, Sunshine Coo um, Sunshine
Coast, QLD C , Q
Regional Aviation Association of Australia on of Aus tion Ass Regiona
www.raaa.com.au
September September Greener Skies 20 Greener S es 2009 Hong Kon Hong Kong Venue/dates to be conrm Venue/dates to be conrmed
www.orientaviation.com/greenerskies08
Oct
6-8 October tob 8 Safeskies Conference ce skie S fe Hyatt Hotel Canberra l Ca H a Biennial conference- details closer to s clo eren Bie co e o
the time m
Nov
2-5 November 5 No 62nd annual International Air 62nd al Interna A
Safety Seminar (IASS) S SS) ty S
Kerry Centre Hotel, rry Centr l
Beijing, China B na
Flight Safety Foundation Safety Fo ti
http://www.ightsafety.org/seminars.html
Please note: AvSafety Seminar calendar subject to change, please conrm date Please no e: AvSafety Seminar calendar subject to change, please conrm date
and venue with your regional AvSafety Advisor an h yo AvS sor ty reg enu
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QUIZ ANSWERS
For pilots and aircraft owners.
IInn tthhiiss mmoonntthhss iissssuuee::
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Australian Pilot
m.au Web: www.aopa.com.au
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FLYING OPS
1. (d) ENR1.1 para. 11.6.4
and 11.6.5; (c) is the
requirement at
night.
2. (d) ENR 1.1 para. 11.6.1.
3. (a) AMSA website
4. (c) amsa.gov.au has links
to beacons.amsa.gov.au
5. (a) the closer the dry
bulb to the dew point (the
spread), the more likely
fog is to form.
6. (b) ENR 1.2 table 2.6.
7. (c) ENR 1.1 para. 82.3.4.
8. (b) GEN 1.5 para. 2.2.
9. (d) with wings level in
these circumstances,
yaw indicates unbalanced
ight.
10. (b) GEN 3.5 para. 12.22.3.
MAINTENANCE
1. (b) GEN 3.6 para. 8.4.
2. (c)
3. (a)
4. (b)
5. (c)
6. (a) to promote stalling
near the wing root rst.
7. (a)
8. (d)
9. (d)
10. (d)
IFR OPS
1. (b) The planning range for
VHF at A080 is 90nm.
2. (c)
3. (d) The minimum angle for
a positive x is 45 degrees
4. (d) AIP ENR 1.1 - 36, PARA
19.5.1
5. (c)
6. (e) At 5000 you are still
within range of the ML
DME. AIP GEN 1.5 - 6
PARA 2.2b
7. (a) Station passage WON
is a positive x within
25nm of CWS - known
distance of 19nm.
8. (b)
9. (d) 36 DME ML or crossing
MNG 234 radial is a 25nm
BDG x
10. (c) 8000 - 412 (DME ELEV)
= 7588 6080 = 1.2
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INSIDE NEXT ISSUE
essential aviation reading
ightsafety
You are invited to participate in an Aviation Safety
Management Research Project survey.
This survey seeks input from aviation industry
personnel, from all areas, to provide an analysis
of Australian aviation incident reporting.
To access the survey, please go to
www.amba.hobson.net.au The University
guarantees anonymity of participants.
The survey results will be published in a research
project report submitted in partial fullment of the
requirements for the award of an MBA - Aviation
Management.
For more information:
email c.hobson@student.rmit.edu.au
INCIDENT REPORT SURVEY
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Ground safety - part 2 of our series

Helicopter safety - EMS

Flight Safety talks to Tony Kern about error
management
And more readers' 'Close Calls'
Fuel - on. Master - on. Throttle - set. Brake - set.
Call Clear Prop and start up.
Sound familiar? Every time we go flying we all go
through this routine, or variations of it depending on
what we are flying, but there are two words in the
routine which are almost always said as an aside:
Clear Prop.
The intention is obviously to tell people in the vicinity
of your aircraft to keep clear of the propeller. We are
all aware, or should be, of the serious injuries that
can result from contact with a spinning propeller.
The story is told of a pilot who called Clear Prop only
to see a quizzical face appear from under the spinner
who declared that indeed the propeller did seem to
be clear! Maybe just a story, but it does illustrate the
need to use words that are effective in
communicating ones intentions.
It has long been my contention that Clear Prop is a
meaningless phrase, often spoken in a hurry, and
often without any emphasis or clarity. My habit is to
adopt the military phraseology of Stand Clear, Start-
ing. These words clearly indicate your intentions and
requirements. There is no ambiguity.
In addition to the choice of words, it is important to
ensure that they are called out clearly and loudly;
mumbling into the windshield is not good enough!
It is easy to become complacent and merely go
through the motions. Start up in the early morning
when nobody else is around, or in a parking area on
a farm strip somewhere in the bush makes the idea
of calling Clear Prop seems ridiculous, but it is in
these situations that concentration on adhering to
procedures helps to reinforce good habits.
The ramp or parking area at any airfield, even those
that seem to have even the most modest activity, is
an inherently dangerous place. It is inevitable that
other people, be they pilots or visitors, can and will
be in the vicinity of your aircraft. The dangers
increase markedly at such events as NATFLY where
the flight line can be extensive and crowded. In such
situations particular care is required to ensure you
have clearly and loudly signalled your intentions to
start up.
If there are curious people inspecting your pride and
joy as you conduct your pre-flight checks and walk-
around, it is a good idea to tell them that you will be
starting the engine shortly and to keep well out of
the way. And preferably, to move to a position where
they remain visible to you from the cockpit. Safety
on the ground is as important as in the air.
Being aware of your surroundings on the ground, as
well as in the air, and being able to clearly announce
ones intentions so that others can remain clear of
you demonstrates good airmanship. I would urge all
pilots to commence every flight by calling loudly and
clearly:
STAND CLEAR, STARTING!
Martin Hodgson
Senior Underwriter - Aviation
Good people to be with.
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Brisbane Ph: (07) 3031 8588 Adelaide Ph: (08) 8202 2200
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Safe. Secure. Strong.
They are the foundations of a business partnership you can rely on.
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AFS Licence No 239545