92

May–June 2013
It's getting real | flight simulation comes of age
Patching the wings of time | keeping classic types safely in the air
 04 12
ARTICLES
04 It's getting real 20 In the wash-up
Flight simulation has never had more The do's and don'ts of aircraft washing
potential to enhance aviation safety
22 Patching the wings of time
12 Snakes on a plane Keeping classic types safely in the air
Safety and the beastly aspects
28 Changes to the Australian
of aviation
sigmet format
14 Impact at sunrise What's new in the world of aviation
An old sensory trap leads to the death weather?
of 103 people

AIRWORTHINESS
36 What goes around
Keep your helicopter hovering
40 Service difficulty reports

Cover photo: © British Airways

 CONTENTS
Issue 92 | May–June 2013

14 22
REGULARS
62 Av Quiz 88 ATC Notes
62 Flying ops News from Airservices Australia
65 Maintenance 90 Accident reports
68 IFR operations 90 International accidents
93 Australian accidents
72 Close calls
72 Frying tonight 96 Flight bytes
76 Icing in the USA 100 Calendar
78 Complacency can kill Upcoming aviation events
80 ATSB supplement 102 Product review
News from the Australian 102 Coming next issue
Transport Safety Bureau
ARTICLES
04 It's getting real
12 Snakes on a plane
14 Impact at sunrise
20 In the wash-up
22 Patching the wings of time
28 Changes to the Australian
sigmet format
04 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Flight simulation

E T
IITT’’SS GGETT T
I I
N NGG RREEAALL::
T S
S IIMM U
U L
L A
A T
F
FL L IIGGHHT

The best proof that flight simulation works is found not on Earth, but
on the surface of the Moon, where the Apollo 11 excursion module
Eagle still sits. In July 1969, Neil Armstrong landed the Eagle, by hand,
after being forced to take over from its autopilot. He was flying a craft
that no one had ever flown before, to a
As it blurs the line between place no human had ever been – and
actual and synthetic he got it right the first time. During the
experience, flight simulation unprecedented descent fellow astronaut
is developing its potential to Buzz Aldrin commented: ‘you can feel it
in here when it throttles down. Better than
enhance aviation safety. the (stationary) simulator.’
Forty-four years later, the state of the art in flight simulation allows
pilots flying the F-35 Lightning II to make their first flight in the $100
million military jet their first solo flight – there is no two-seat version
of the F-35.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 05

OFF AAGGEE
N C
C O
O M
M EES
S O
I
ATI N
T O O

Instead, pilots build their confidence and competence in a 360-degree field-

of-view flight simulator. The F-35 simulator, (one of five at Eglin air force base
in Florida, USA, was breathlessly described by the local newspaper as ‘a
30-foot globe resembling a giant golf ball.’ Its capabilities are such that even
experienced jet pilots forget that they are still on the ground.
Air transport is already following this model: ‘Endorsement training on a
[Boeing] 737 or [Airbus] A320 level D full flight simulator now allows a first
officer’s first flight on type to be on a passenger-carrying flight – that’s how
good modern simulators are’, says CASA simulator specialist Quentin Fuller.
At the same time, another revolution in simulator technology is occurring at the
opposite end of the cost spectrum, where it may bring even more widespread
training and safety benefits.
And aviation regulators around the world are taking a more sophisticated
approach to simulation, with the adoption of a new International Civil Aviation
Organization classification system.

Simulated history: the state of play

Flight simulators have been around for almost as long as the aircraft they
represent. The Antoinette Trainer, of 1909, consisted of dummy controls,
a sawn-in-half barrel as fuselage, a universal joint and levers, with which
ground- based operators could simulate the unsteady progress of the primitive
06 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Flight simulation

Antoinette monoplane. Twenty-five years later a young

Edwin Link would make his fortune with an instrument
flight trainer that the US Army Air Corps snapped up
in the wake of the disastrous crash rate following its
assignation to fly air mail routes.
Link trainers became a part of mainstream aviation
training during World War II when 10,000 of them were
built. They provided a cheap and safe way
of teaching what pilot training guru Wolfgang
Langewiesche called the ‘fierce and monkish art’
of instrument flying to half a million military pilots.
Although cheaper than aircraft, simulators
were big-ticket items. Link charged the Air
Corps $US3500 each for his first batch of six
‘If you have a solid foundation in trainers, a considerable sum in 1934. The four
attitude flying, the transition to flying Boeing Stratocruiser simulators that Curtiss-
a simulator or on instruments is Wright delivered to United Airlines in 1954 cost
$US3 million.
that much easier, but if you have
taught yourself performance flying Perhaps when future aviation historians write
you’ll chase the numbers forever.’ about flight simulation they will note the debut
of Microsoft Flight Simulator in 1982, or the
first Sony PlayStation in 1994. Computers and microelectronics have made
realistic simulation possible for very little cost, and introduced the concept to
basic flying schools all over the world.
The other development made possible by low-cost electronics is affordable
visual simulation. Analogue simulators such as the Link were IFR training
devices, as there was no way to reproduce the view from the cockpit with mid-
20th century technology.
Modern low-cost computer-based simulators can now offer wrap-around
projection systems with fields of view of 220 degrees horizontally and 70 degrees
vertically. These allow student pilots to practise visual manoeuvres on the ground.
The latest simulator designs can test students in taxi, take-off, circuits, VFR cross
country, turns around a point and landing.

Photos: 1909 training rig for the Antoinette aircraft, Wikipedia

 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 07
CASA’s head of flying standards, Roger Weeks, is enthusiastic about the potential
of flight simulators, although he concedes that the unofficial home-computer
sector of flight simulation can create its own problems.
‘One thing that has become noticeable in general aviation is new students turning
up at a flying school having become quite proficient in Microsoft Flight Simulator
or some other home computer sim,’ he says.
One of the difficulties associated with self–teaching on
this technology is that, without realising it, they become
performance pilots. They try to fly by performance,
rather than by attitude. The cautionary note is that
attitude flying (power plus attitude equals performance)
is always the correct means of controlling an aircraft.
‘If you have a solid foundation in attitude flying, the
transition to flying a simulator or on instruments is
that much easier, but if you have taught yourself
performance flying you’ll chase the numbers forever.’
Photo: Stratofreighter flight simulator, Wikimedia
Out of tragedy: Mandatory simulator use
In 2009, CASA began a project investigating making flight simulators mandatory
for some aspects of pilot training. By February 2010, industry consultation
had established there was widespread support, tempered by a desire to have
a graduated approach based on aircraft size and the number of simulators
available. The following month the issue was accorded a terrible prominence
when an Embraer EMB-120 Brasilia crashed in Darwin while simulating engine
failure, killing both pilots.
Under the new requirements conversion command training for pilots, as well
as training and checking for pilots working for an air operator required to have
training and checking organisation approval, must be carried out in a simulator
in clearly defined circumstances.
Where training is being carried out for a multi-engine aeroplane with between
10 and 19 seats it must be conducted in an appropriate simulator, if one is
available in Australia. For training for aircraft with more than 20 passenger seats
the training must be done in a simulator if one is available in Australia, or in a
recognised foreign state.
08 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Flight simulation

The same requirement applies to aeroplanes with

a maximum take-off weight of more than 8618kg.
The simulator provisions also apply to relevant
helicopter operations.
These changes took effect on April 1 2013.
Weeks says the benefits of simulation go beyond
simple operational safety. ‘Simulator training’s
immediate effect is to address the safety issues
associated with an individual training flight. But,
more importantly, the broader benefit is that you
can be more thorough and go into emergency
and abnormal procedures in more depth in a
simulator than you would safely be able to in an
actual aircraft’, he says.
‘The quality of the training that a simulator is
‘The quality of the training that a
able to provide to prepare pilots for a worst-case
simulator is able to provide to prepare scenario is much better than in an actual aircraft.
pilots for a worst-case scenario is
‘So long as the simulator is of the appropriate
much better than in an actual aircraft. fidelity, the positive transfer of learning from the
box into the actual aircraft is very strong. All the academic research and practical
experience shows that.
‘I think when we go forward 10 years and look back to 1 April 2013 the industry will
say “that was a good move.’’ ’

High-Level Requirements for ICAO Standard FSTD

Type I Type II Type III

PPL, MPL1, CPL (All T) IR (T) Class Rating (T)

Cockpit
Class, enclosed Generic, open Class, enclosed
and structure
Instruments
Flat panel and overlay
and panels
Non sim area Open
Visual display 200 x 40 direct 45 x 30 flat screen 200 x 40 direct
Motion None
Flt & Flt ctrl Class rep Generic Class rep
Aircraft systems Aircraft representative (required procedures)
Air Traffic Control None Background chatter None
Legend
Specific Representive Generic
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 09
Hyper-reality in seven steps: ICAO’s new simulator
classifications
ICAO 9625 (Manual of Criteria for the Qualification of Flight Simulation Training
Abbreviations:
Devices) may not be the most arresting title but the document to which it
refers is potentially very significant for flight simulation and, by extension, ATPL Airline transport
pilot licence
aviation safety in general.
CPL Commercial pilot licence
The third edition of ICAO 9625 was produced in 2009 (with a volume in 2012
CQ Continuing qualification
for helicopters) after four years of effort by an international working group
IO Initial operator
led by the British-based Royal Aeronautical Society. It hammered out a
seven-stage classification of flight simulators and training devices, with the MPL Multi-crew pilot licence
most basic devices as Type I, and top-of-the-line, full-motion, type-specific, (Phase 1, Core flying
skills; Phase 2, Basic;
dynamic environment simulators as Type VII. (See table below) Aviation Phase 3, Intermediate;
regulators around the world, including CASA, have agreed to adopt this Phase 4, Advanced)
classification. PPL Private pilot licence

‘One of our current limitations is the classification we have traditionally had Re Take-off and landing
for instrument training devices. It is almost a one size fits all,’ says CASA recency

head of flying standards Roger Weeks. ‘One of the positives of moving to RL Recurrent licence training
the ICAO classification is that there are seven recognised levels of flight and checking
training devices. RO Recurrent operator
training and checking
‘As we introduce the ICAO standard it will encourage operators, particularly T Training
in general aviation, to invest in more sophisticated flight training devices.
TP Training to proficiency
‘We’re talking about devices that are still generic – they don’t use test flight TR Type rating training and
data like a licensed simulator – but these days they do have very good checking
visuals. Some even have motion. Under the old system these were given the
same credit as a desktop-based device with a computer screen, a yoke and
a couple of pedals on the floor.’

Type IV Type V Type VII Type VII

TR, ATPL IO, RO, RL TR, ATPL MPL4 RE,
MPL2 (T+TP) MPL3 (T+TP)
(All T) RO, RL IO, CQ (TP)
Aircraft replica, Aircraft replica,
Class, enclosed Class, enclosed
enclosed enclosed
Hi quality flat panel High quality flat panel
+Full 3D replication
and overlay and overlay
Enclosed Enclosed
45 x 30 Flat screen 200 x 40 direct 200 x 40 collimated 200 x 40 collimated
None Reduced 6 DOF Full 6 DOF
Generic Aircraft specific Class rep Aircraft specific
Specific (All proc.) Class rep Specific (all proc.)
+ Dynamic automated + Dynamic ATC
Background chatter Background chatter
environment environment
10 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Flight simulation

‘Those lower-level devices won’t get the

licensing credits in the future, but the
higher-end devices will be given them.
Weeks says the level of licensing credit
given will be linked to the fidelity of the
device. ‘We want to encourage operators to
invest in upgraded devices.’
‘It sounds like a paradox but one of the
ways we will be doing that is by saying no.
The virtual future: Let me explain: If an operator comes to us
CASA’s Flight Simulation and wants upgrade credit on an existing
low-fidelity device, the answer is likely to
Operational Plan 2012-14 be no. Any upgrade in credit will require an
CASA followed on from the mandatory upgrade in the performance of the device.
simulator training changes with a plan that lays ‘We have a number of devices in Australia
out its policy on flight simulation and training. that were grandfathered across. If one of
At the heart of the Flight Simulation Operational those devices went out of approval, for
Plan 2012-14 are six proposed developments: whatever reason, and the operator asked
1. Adoption of the classification framework CASA to reapprove it, it wouldn’t get the
contained in (ICAO) Document (Doc) 9625 same credit. The policy is to encourage the
for fixed wing and rotary wing simulators use of new technology.
as a means of enhancing international ‘The reality is that the cost of increased
harmonisation fidelity is coming down, and there are
2. Mandating the use of simulators for certain operators that are already investing in
types of aircraft for the training and checking fidelity beyond that required by legislation.
of certain high-risk emergency procedures Their view is that the training outcome is
enhanced by better fidelity.’
3. Amending Part 60 of the Civil Aviation
Safety Regulations (CASR) 1998 to provide Fuller says the cost advantages of
coverage of all flight simulation devices simulation are multiplied for larger aircraft.
‘When you look at the cost of an aeroplane,
4. Improving oversight of organisations and its hourly costs, a $14 million simulator
involved in flight simulator training via the doesn’t seem so expensive. And that’s
introduction of CASR Part 142 even before you consider potential training-
related damage. What would one hard
5. Encouraging the aviation industry, including
landing in an A380 cost?’
the flying training sector, to increase the use
of flight simulation devices with appropriate
fidelity
6. Encouraging extant simulator operators
to invest in adequate maintenance and
upgrading of their devices to ensure that the
devices remain an appropriate platform for
training and checking
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 11
Nightmare scenario: Europe’s SUPRA project
The crash of Air France Flight 447 in 2009 raised some disturbing questions about
how pilots deal with rare, sudden and confusing emergencies on the flight deck.
The European Union responded with the SUPRA project. SUPRA stands for
Simulation of Upset Recovery in Aviation. Its brief was to investigate the simulator
requirements necessary for upset recovery training.
SUPRA, which ran from 2009-2012, worked to develop better mathematical
models of aircraft behaviour beyond the normal flight envelope, and it validated
them in the mother of all simulators – Desdemona.
Built by Austrian simulator specialist AMST Systemtechnik for the Royal Dutch
Air Force, Desdemona, which stands for disorientation demonstrator (in Dutch)
can subject its pilots to a continual 3g. It does this by combining a gimballed
platform, free to face in any direction, with an 8m horizontal sledge mount that
also spins and has 2m of vertical movement.
The results of subjecting pilots to actual g-forces were
enlightening. ‘For example, we discovered that if you
have a pilot who has little or no actual experience
of feeling g-forces in a real aircraft, that pilot will be
overwhelmed by g-forces when he first feels them. So
if you give a pilot the task to pull 2g, it will probably be
too conservative, and he'll only pull 1.5g, which could be
insufficient for recovery in a dangerous situation’, said
the coordinator of the SUPRA project, Eric Groen.

Further information: Photo: Desdemona flight simulator

CASA Flight Simulation Operational Plan 2012-14

www.casa.gov.au/WCMSWR/_assets/main/aoc/training/download/fso_
plan2012_14.pdf
CASA notice of final rule making: mandatory flight simulator training
www.casa.gov.au/wcmswr/_assets/main/newrules/ops/download/nfrm-1007os.pdf
 12 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Animals in the air

Snakes on a plane: beyond Hollywood

Stephanie Painter investigates the safety implications of reptilian aviation,
and other beastly aspects of flying

It was supposed to be a routine flight from (Thankfully, unlike in the Twilight Zone episode,
Cairns to Port Moresby, but for one unsuspecting it was not a gremlin intent on bringing down
passenger it might well have had parallels with the plane.)
‘Nightmare at 20,000 Feet’, a 1963 episode of
American cult television series The Twilight Zone. Pilots and crew closely monitored the snake and
the plane landed safely. The snake was not as
About 20 minutes into the January flight aboard lucky, the 215-knot slipstream having thrashed
QF191, the female passenger alerted crew to an it against the side of the plane, spraying blood
unwelcome creature on the aircraft’s wing. across the engine.
Fellow passengers scoffed, dismissing her claim. Its misadventure serves as a reminder to be
But, as they would soon find out, she was correct. vigilant in guarding aircraft from unwelcome
passengers — snakes, birds, rodents and other
Entwined between the engine pylon and flap was insidious creatures that manage to weasel their
a three-metre scrub python, the longest species way into any nook or cranny.
of snake in Australia.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 13
CASA safety systems inspector Bruce Reilly ‘For example, some manufacturers advise
has heard all sorts of tales during his career in that only pitot covers are fitted for short-term
aircraft maintenance for major airlines and small parking, whereas more work is involved for
GA operators. long-term aircraft storage, as all orifices need to
be covered.’
‘I’ve heard of a rat running riot on a plane.
They caught it, which was good because if it After more than two decades in aircraft
had got into the guts of the aircraft it could have maintenance, CASA’s Northern Territory
cost a fortune’, he said. aviation safety advisor Peter Ball has firsthand
knowledge of the hazards that can ensue when
‘Their urine and droppings can cause corrosion, aircraft are left unprotected.
and they can gnaw through electrical cables.
‘Last year, a local charter pilot I know was
‘The damage might not be noticed straight mid-flight in a Beechcraft Baron when a snake
away but it can put the aircraft in very poked its head out of the control panel — it
serious danger and also be very was chasing a tree frog that had sought refuge
expensive to repair.’ under the front passenger seat’, Ball says.
Reilly said it was common for snakes, ‘So in this instance, there were two stowaways
birds and wasps to find their way into — one a lot less welcome than the other.
aircraft.
‘Smaller aircraft can be subject to that sort of
‘It’s a great little place from their occurrence, but wasp and bird nests are more
perspective — a ready-made, common.’
cosy home where they can
nest’, he said. While big commercial aircraft do not usually
stay still long enough to have such issues, he
‘It can happen so easily, especially has seen some infested with mice, rats and
when aircraft are parked out in the cockroaches.
middle of the grass for a long period
of time or they are operating in rugged ‘Not only can animals and pests eat through
jungle or outback areas, as helicopters electrical cable insulation, but they could
often do.’ become jammed in critical areas’, he says.
While the spaces around landing gears are Ball emphasises the need for aircraft to be
particularly difficult to block off, a range of fitted with covers when not in use — especially
covers are available. These not only protect the pitot covers to protect critical flight instruments
aircraft from unwanted invaders, but also help from insects and their nest-building activities.
combat dust and rust. (A wasp nest in a pitot tube was suspected of
being involved in the crash of Birgenair Flight
‘The main thing it comes down to is good 301 in 1996. The Boeing 757 crashed after the
maintenance practices and ensuring that pilots were confused by inconsistent airspeed
whenever you park or store an aircraft, you do readings.)
the basics of putting on the purpose-made pitot
covers and engine blanks’, he said. ‘Sometimes people leave an aircraft window or
door open and all manner of things can wander
‘All aircraft will have some form of maintenance in. This might result in a nasty surprise while
instructions regarding what you should do if airborne.’
you are parking or storing them for particular
periods of time.
14 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Impact at sunrise

sunrise
IMPACT AT

Click here to watch on youtube © Dutch Safety Board

 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 15

The beginning of the end was Almost, because one procedure had
almost exactly like the final been carried out wrongly, whether
minutes of tens of thousands from distraction, poor training or a
of other flights on Airbus moment of fuzzy-headedness we will
A330s since 1994. With the never know. It is likely that the man
engines at flight idle the who made the mistake didn’t know
background sounds were either, for the electronic record
occasional radio calls, the recovered later from the desert
murmur of slipstream around floor showed no sign of realisation
the flight deck windows on his part. Yet his was not the final
and the languid, butler-like mistake that killed all but one of
tones of the radio altimeter the 104 people on board Afriqiyah
announcing ‘one-thousand’, Airways flight 771. Instead the pilots
and later ‘hundred above' of this highly advanced aeroplane
as the flight approached fell victim to one of the oldest killers
minimum descent altitude. known to aviation.
16 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Impact at sunrise

Flight 771 originated from Johannesburg, South Africa, and

was uneventful until its disastrous landing, handling the hot
and high take-off at OR Tambo International Airport with no
problems. Its destination was Tripoli International Airport, Libya,
from where the majority of its passengers, including 71 Dutch
citizens, were to take connecting flights.
About 0400 Universal Coordinated Time or 0600 local time the
flight was on final approach to Tripoli’s Runway 09. According
to the METAR forecast issued at 0350 UCT, winds were
variable at one knot, there was 6000 metres visibility and no
significant clouds below 5000 feet. It was about ten minutes
before sunrise, which, at that time of year in Libya, was often
accompanied by ground fog.
Without any emergency call the Airbus hit the ground 900
metres short of Runway 09, within the perimeter of the airfield.
It was doing 260 knots and had a downward speed of 4400
feet per minute.
Flight 771 was the second fatal crash of an A330 in 12 months,
following the loss of Air France 447 in June 2009. This caused
a frisson of concern amongst operators and regulators around
the world about the prospect, however remote, that a type
that had operated without killing a passenger for 16 years
was developing a fatal flaw. At the time of the crash there
were about 690 A330s in service. However, a preliminary
investigation ruled out fuel exhaustion and found no evidence
of technical malfunction before the accident.

© Sergey Kustov
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 17

The final minutes

The world went on flying and Libya descended
into civil war. During the chaos that Tripoli ATC directed the aircraft to land from the
accompanied the fall of the country’s dictator, west, into the soon-to-rise sun (glints of which
Colonel Gadhafi, the normal functions of would have been visible over the horizon from
government ceased. It was not until February the cockpit) on Runway 09. Unlike its reciprocal,
2013 that the Libyan Civil Aviation Authority Runway 27, this runway was only equipped
was able to issue a report. for non-precision approaches, that is, without
vertical guidance. For an advanced aircraft such
The final investigation found no technical as the A330 this is not the throwback to yank-
issues, apart from a minor issue of stickiness and-bank hand-flying that it may seem.
(delay in returning to the off position) in the
captain’s side autopilot disconnect and side There are three routine ways to fly a non-
stick priority buttons, both of which had been precision approach in an A330: The crew
resolved before the crash, according to the can select the desired track and flight path
aircraft’s technical log. angle (TRK and FPA) manually, using the
autopilot. Alternatively, they can entrust the flight
The aircraft had 2175 flight hours, making it management guidance and envelope computer
factory-fresh by the standards of commercial (FMGEC) to take care of lateral guidance, in NAV
airliners. It was less than a year old and mode, and select vertical guidance themselves
had undergone its most recent A check at using the autopilot’s flight path angle mode.
Lufthansa Technik in Milan eight weeks before
the crash. Thirdly, they can devolve both lateral and vertical
guidance to the FMGEC. Instead of measuring
The crew had considerably more collective the aircraft’s height against a glideslope the
flight hours than their aeroplane, with the pilot FMGEC checks the aircraft’s height and DME-
having 17,016 hours, the first officer, 4216 derived position on approach against a model
hours and the relief pilot 1866 hours. The approach stored in its database. The flight mode
captain and first officer each had 516 hours annunciator shows a prominent ‘FINAL APP’ in
experience on the A330. All three were on the this ‘managed approach’ mode.
flight deck at the time of the crash.
All these modes will fly the aircraft to minimum
descent altitude, at which point a go-around
must be flown if the runway, or its markings,
cannot be seen. As many thousands of routine
flights have shown, all the modes are safe, if
carefully monitored by the crew.
The cockpit voice recorder revealed that the crew
of Flight 771 did not monitor their approach. It
also revealed that five minutes before impact the
captain and first officer had not decided which
approach mode to use. They should have done
so much earlier, during top-of-descent briefing.
18 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Impact at sunrise

From the report:

‘At 03 h 57 min 35 UTC, the Captain asked the co-pilot, who
agreed, to carry out the approach in “Nav approach”….
At 03 h 57 min 51, the Captain called out “Track FPA” and the
co-pilot replied “I will do it [when] establish”.’
Within 15 seconds, the captain had commanded two different
approach modes.
At 03 h 58 min 54 the APPR button was pushed and FINAL APP
lit up on the annunciator. Thirty seconds later the first officer
selected FPA (flight path angle mode), setting a descent angle
of three degrees. Eight seconds later he called ‘Minus three
degrees sir’, to the captain, who at that moment was replying to
a radio call from another aircraft advising of low cloud near the
runway threshold.
In FPA mode the flight path was no longer managed to ensure
reaching the runway, but was a fixed angle. This should have
been done at the final approach fix, a VOR known as Tango
Whisky. The impromptu mode change meant the first officer had
set the angle before passing TW. Consequently, as they passed
TW, they were more than 300 feet too low. Nobody noticed this.
At 620 feet the languid synthetic voice announced ‘Minimums!’,
to which the captain responded ‘continue’. The first officer, who
was pilot flying, seconded the captain’s response.
Six seconds later, the first officer asked the captain whether he
should go around. A further six seconds later, at 280 feet AGL,
a different, altogether more urgent synthetic voice, the terrain
awareness warning system (TAWS) declaimed ‘Too low! Terrain!’
and the captain called ‘go around, go around, go around!’
The first officer selected TOGA (take-off go-around) thrust and
pulled back his side stick. But after four seconds he reversed
his inputs to command nose down. After 21 seconds of this the
TAWS spoke again, with ‘Don’t sink! Too low!, Terrain!’, and ‘Pull
up!’ About this time the captain pressed the side stick priority
button to take over, but he too initially commanded a nose-
down input. At the very end both side sticks were pulled fully
back, indicating that the pilots ‘were aware of the flight path and
ground proximity’.
The crash left a debris field 800 metres long.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 19

Analysis • The deviation resulting in a saving of time

What finally killed everyone on board the flight and a reduction in workload for the crew
except for a nine-year-old Dutch boy who • Possible crew fatigue at the end of the
became the last surviving member of his family overnight flight from Johannesburg.
was an old sensory trap – the somatogravic
‘Overall, the management of tasks during the
illusion.
approach deteriorated very quickly, ’ the report
Without a view from the cockpit a sudden concluded.
forward acceleration during level flight feels very
In 2013, another document came to light that
similar to the nose pitching up. The temptation
analysed the accident differently. It was a letter
to lower the nose is very strong. Somatogravic
from the Dutch Safety Board, which aided the
illusions typically happen during take-off or go-
investigation, commenting on the draft report.
around in IMC. Flight 771 had descended to a
bare patch of desert where they had expected After a respectful opening, the Board went on
to see runway lights, and, as the preceding pilot to anger the Libyan CAA by laying out its own
had warned, there was more low cloud than the conclusions, emphasising the authority gradient
METAR indicated. in the cockpit, the state of Afriqiyah’s safety
culture, to what extent its safety management
There was another factor: the same crew had
system worked, the level of oversight the Libyan
made a similar mistake in descending too early
CAA had established over the airline, and the
on a flight the previous month, and had tripped
role of fatigue in the crash.
the overspeed alarm on go-around. This may
have led the first officer to focus on airspeed In March 2013, Afriqiyah made a public
rather than attitude, the report concluded. statement setting out steps it had taken to
improve safety since the crash. These included
The go-around was made necessary by
enhanced auditing for maintenance, flight data
the crew arriving in the wrong place. This
monitoring, increased flight crew rest periods
happened, the report said, because of poor
beyond the legal requirement, and contracting
crew resource management. There was nothing
foreign pilots to assist in enhancing safety
to indicate that the captain or the reserve pilot
culture.
had monitored the flight path on approach.
Moreover, the crew had gone below MDA, One point had been terribly proven: despite what
despite seeing no sign of the runway. its detractors, and some of its advocates say,
the A330, in spite of all its technology, is not pilot-
It identified four factors that had contributed to
proof.
what it called ‘a typical procedural drift’.
• The routine nature of the return flight to Further information
Tripoli that could lead the crew not to carry
out the checklist in a formalised way Afriqiyah Airways inquiry rules out technical faults
Flight International, 8 June 2010
• The routine nature of this deviation, Afriqiyah Airlines statement march 2013
without any immediate negative impact http://preview.tinyurl.com/cm6hzok
on flight safety
20 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
In the wash-up

information, the AOA protection demonstration

went disastrously wrong and in the last minute of
the flight airspeed went from a low of 40 knots,
Cleanliness may be next to godliness but with a 57-degree pitch-up, to 263 knots about a
be careful when you bring a sponge, a second before impact.
hose or a bottle of cleaning product near
an aircraft. While few general aviation aircraft have AOA
sensors, they all have pitot-static systems for
On 27 November 2008, an Airbus A320-200 airspeed indicators and altimeters. The Birgenair
crashed into the sea off the coast of Perpignan, and AeroPeru crashes of 1996, where Boeing
France, during an airworthiness check flight 757 airliners had their pitot-static systems
before being returned to its owner, Air New blocked by insects and incorrect maintenance,
Zealand. It was destroyed, killing all seven respectively, are grim examples of how even
occupants. high-time airline transport pilots can become
The French Bureau of Inquiry and Analysis fatally disorientated when blockages cause these
report found the accident happened when instruments to send inaccurate, or sometimes
the crew lost control of the aircraft following even contradictory, signals.
an improvised demonstration of the Airbus’s There are also straightforward airframe
renowned angle of attack (AOA) protection. hazards. CASA senior maintenance engineer
The AOA sensors were, literally, frozen. Gus Anderson says two aircraft undercarriage
Before being repainted in Air New Zealand scissor links have failed this year, potentially
colours, the aircraft had been rinsed with fresh due to aircraft washing and lack of lubrication
water using a water jet and without the AOA afterwards. Both were on Piper PA-28 variants.
sensors being masked. Both these processes In one case the scissor link failed on the main
were contrary to the manufacturer’s prescribed wheel of a fixed-wheel model, leading to one of
procedures in the aircraft maintenance manual. the main gear wheels departing in flight, and a
As a result, water got into at least two of the forced landing for the student pilot. In the other
three AOA sensors. There it remained for case, the pilot of a retractable–gear PA-28
three days before the accident flight. The Arrow found the nose gear would not retract.
temperatures encountered in the high-altitude A forced landing followed, after which it was
part of the check flight froze the water and found the scissor link was extensively corroded
jammed the AOA sensors. This prevented and had failed.
them from sending angle of attack information
to the flight control computers. Without this
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 21

CASA’s airworthiness bulletin AWB 02-019,

Issue 1, of February 2007, addresses aircraft
washing. Washing aircraft after flight to Anderson says unapproved domestic or
remove contaminants such as dirt and salt automotive cleaners can contain ingredients
‘is commendable and a good practice’, the hazardous to aircraft. These could be solvents
bulletin says. The problem occurs when ‘failure that destroy rubber, caustic agents (as found
to re-lubricate bearings, hinges and bushes in commercial truck wash solutions) and even
afterwards can lead to excessive wear and salt, which, ironically, is one of the corrosive
corrosion’. substances cleaning aims to remove.

AWB 02-019 was written after defect reports Finally, pressure cleaners have no place in
had been received concerning roller bearings washing aircraft. ‘These units produce point
and ball bearings on undercarriages, control pressures of 1400psi, or more, which makes it
surfaces and other components. ‘Some too easy for water to penetrate into bearings and
of the defects reported indicated that after past seals, and possibly even through riveted
undercarriages were washed the bearings were joints,’ he says. The alternative is hand washing
not re-lubricated and a combination of corrosion with an approved aircraft cleaning product and
and excessive wear led to failures and stiffening a soft brush or cloth. ‘It’s much harder work, but
of the scissor arms and oleo struts. In other is less damaging to the aircraft, which makes
instances, rod end bearings were found to have it safer.’
failed before they normally would, due to a lack
of lubrication after continual washing of the Further information
aircraft.’ Bureau of Inquiry and Analysis for Civil Aviation
Use of unapproved cleaning agents was another Safety (BEA) report:
problem. ‘There have been reports of corrosion ‘Accident on approach to Perpignan’
and failures of hinges in various external www.bea.aero/docspa/2008/d-la081127.en/pdf/
positions on aircraft as a result of washed-out d-la081127.en.pdf
lubricants and the use of unapproved cleaning
agents,’ AWB 02-019 says. www.bea.aero/fr/enquetes/perpignan/
animation.d-axla.1024x768.xvid.avi
The bulletin recommends that operators
and maintainers recognise the problems CASA AWB 02-19 Aircraft Washing
associated with excessive cleaning, or the use www.casa.gov.au/wcmswr/_assets/main/
of unapproved cleaning agents. airworth/awb/02/019.pdf

‘The use of non-approved cleaning agents

should cease,’ it says. ‘These agents can
damage seals, rubber components and
surfaces, leading to corrosion and possible
component failures.’
22 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Warbirds

PATCHING THE
WINGS OF TIME
The warbird movement has been dealing with
ageing aircraft issues for decades. Along the
way, its operators have learned a few things
about how to keep classic types in the air.
If there’s one thing that unites incurable aeronautical romantics with the rest of
humanity it’s the sight and sound of a Spitfire.
The curve of the elliptical wing, the noble baritone of
the Rolls-Royce Merlin, the stirring associations
with sacrifice and freedom: all good
reasons to go to Temora, in NSW, to see
the two flying Spitfires in Australia.
What’s not so obvious is that
there’s another, practical,
reason to be grateful for the
Spitfire, and the warbird
movement at large. In
the 21st century, both
are directly relevant to
the mass of non-heroic
general aviation. The
knowledge, tricks and
hard-won lessons that
keep Spitfires in the
sky are relevant to any
operator of an ageing
aircraft.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 23

LESSON 1 CHEAP TO BUY CAN MEAN COSTLY TO FLY

Aviation classifieds are full of temptation, in the form of aircraft that cost little more
than a prestige car but offer abilities no automobile can match. If only it were that
simple – and cheap. Temora Aviation Museum chief engineer Andrew Bishop says
the same temptations haunt the warbird market, where jet trainers are, on first
glance, attractively inexpensive. Let the buyer beware that purchase price is no
more than a cover charge for admission to an expensive club, he says.
‘The purchase price reflects ongoing maintenance costs. You especially see it
with warbird jets. It’s like a ticket to the movies. That’s the cheap part, but when
you buy the choc-top and the popcorn, that’s where it stings you.’
The chief executive of the Temora Aviation Museum, Kenny Love, says long-
running civil types such as the Beechcraft Baron illustrate the ageing aircraft
dilemma well. ‘It’s still in production and, currently, costs around a million dollars.
You can get one made in the 1970s for $180,000 or $200,000. Although that
sounds like quite a bargain, what you have to remember is that the spare parts
schedules are set around that million-dollar price point. You’re going to be paying
a higher labour rate but you’re maintaining an older aeroplane.
All else being equal, the newer the aeroplane you can buy the better, says Love.
24 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Warbirds

LESSON 2 ANYTHING IS POSSIBLE – FOR A PRICE

For warbirds that represent the struggles of an entire country, cost is not the obstacle it
might be for an individual owner.
Senior engineering officer for the British Royal Air Force’s Battle of Britain Memorial
Flight, Warrant Officer Kev Ball, says its aircraft are priceless artefacts of significance to
the Royal Air Force and the nation.
That is the sort of provenance that opens purse strings. The BBMF operates a unique
variant of the Lancaster bomber, the only one of the more than 7000 made to have had
its main spars replaced.
It was no small job. In 1996/97 the wing centre section forward and rear, upper and lower
spars were replaced, together with those making up the outer wing forward upper and
lower and rear lower sections. In 2004/05 the fins were stripped and re-sparred and it is
planned that in 2015/16 the tailplane spars will be replaced.
‘With current fatigue consumption rates it is not envisaged that the wing spars will need
replacing until approximately 2028’, Ball says.

LESSON 3 SOME GROW OLD GRACEFULLY

Aeroplanes are like people. Although all need maintenance as they grow older, some are
high-maintenance by temperament, and some are easy-going low-maintenance types.
Two near-contemporary jets based at Temora illustrate the contrast. The museum’s
Gloster Meteor is a robust simple aircraft with no ‘magic metal’ advanced alloys in its
airframe, engines or systems. Its single-stage centrifugal flow Rolls-Royce Derwent
turbojets are inefficient but low stressed – they can be fitted with wire inlet screens to
prevent foreign object damage.
In contrast, the Meteor’s near contemporary, the CA-27 Avon Sabre (on loan to Temora
from the RAAF Museum) is a more demanding aircraft to keep airworthy. The Avon,
powered by a Rolls-Royce Avon turbojet, is an ‘orphan’ aircraft. Only 112 were made,
compared with 9748 Sabres powered by the significantly less-powerful General Electric
J47 engine. It has limited documentation, in comparison with the mainstream Sabre
and significant differences in airframe construction. Its sub-systems are complex by
comparison with the Meteor’s. The active support of the RAAF Museum, as a connection
to the original operator, is essential to keep the Sabre airworthy.
Bishop and Love say the general lesson for civil aircraft operators is to know your aircraft:
research any proposed buy, or analyse what you already own. Simple, popular, and
widely supported are the words that tick boxes here.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 25

LESSON 4 AIRCRAFT SHOULD ACT THEIR AGE

‘We do make concessions in that we now operate aircraft in quite a small area of
their designed flight envelope’, says Kev Ball. All aircraft in the BBMF have limits
on flying hours, G-loads, engine boost and all-up weight.
For fighters the normal acceleration limits for a display are within the range of
+1 to +3.5G with a never exceed limit of 0 to +4G, while the Lancaster is limited
to +1 to 1.5G normal, with a never exceed of 0 to +1.8G.
“These limits are significantly lower than those which would be experienced during
the aircraft’s normal operating life cycles,” Ball says.
‘With regard to engine boost, the Lancaster’s current release to service normal
operating limit is +9PSI, with a never exceed +18, and the Spitfire +7 with a
never exceed +12. Originally boost pressures of up to +18PSI would have been
allowed as a matter of course.’
‘For the Lancaster we rarely fly with more than 1000 gallons (4540 litres) of fuel on
board (2154 gallons / 9782 litres is the capacity) with a general guideline that we
fly with the lowest weight possible while allowing for enough fuel to conduct the
planned task with a suitable reserve.’
Other life-extending practices include starting the engine and taking off as soon
as possible to avoid overheating, particularly on the heat-prone Mk II and V
Spitfires, pre-oiling the engines prior to start to reduce wear and operating
the undercarriage on the Lancaster only in straight and level flight, in order to
reduce stresses.
BBMF flying hours are limited to about 200 hours for the Spitfires, 180 for the
Dakota, 120 for the Hurricanes and 100 for the Lancaster.
Temora hours are lower again. Their Spitfires log about 10 hours each every
year, made up of about 30 flights each. Small aircraft, such as the Ryan, which
rarely flies away from its home airport, may only do six or seven hours a year.
The highest utilisation is the museum’s Lockeed Hudson bomber, which logs up
to 20 hours.
26 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Warbirds

LESSON 5 TECHNOLOGY IS YOUR AIRCRAFT’S FRIEND

‘As aircraft get older you have to be more proactive’, says Bishop. ‘We need to
change our focus to the parts of the aeroplane that we can’t see.’
The Temora Spitfires use Australian-made Perkins flight data recorders that hour-
by- hour build up a picture of engine, systems and airframe use and condition.
The Perkins boxes pay for themselves by giving advance warning of problems,
Bishop says.
‘It gives us great trend monitoring because it’s factual. We can say “two years
ago on a similar flight these were the figures we were seeing”.’
Temora’s Spitfires have been retrofitted with modern full-flow oil filtration, which
Merlins fitted to Spitfires never had. ‘We also use SOAP (spectrographic oil
analysis program) analysis of the oil,’ Bishop says. ‘It can show us whether we’re
starting to see metal (in the oil) and what type of metal it is, moisture content and
whether it’s becoming acidic. We can catch things in the early stages.’
Non-destructive testing is a major part of Temora’s airworthiness regime, and
includes fluorescent dye penetrant testing done in house, and and X-ray and
eddy current inspections that are contracted out.
‘As metals age surface corrosion is not your only enemy, says Bishop.
‘We’re starting to find intergranular corrosion which is not always evident
to the naked eye.
Technologies change, you need to embrace them and use everything that
can help.’
However, there is also an important place for an old-fashioned technology –
paper and ink. Warrant Officer Ball says the BBMF archives all its airworthiness
paperwork. ‘Records have been kept that in some cases go back to the
war years.’ Likewise, Temora maintains an extensive library of maintenance
documents, including manuals, pilot’s operating handbooks, and course notes.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 27

LESSON 6 REMEMBER, YOU’RE NOT ALONE

‘Our library is a global one,’ says Bishop. ‘We share it with the rest of the warbird
community and they share theirs with us.
‘All this information has been around for the past 70-odd years but today we’re
seeing it being gathered up, scanned, put on CD-ROM, accessible on the internet
and shared across the world.
‘If we want to talk to BBMF about maintenance on their Spitfires we can do that.
They are the equivalent of a workshop next door. Smartphones for sending
pictures are a very useful tool. They give us the ability to say “have you got this
part?” or “have you seen this?”’
The internet has other uses. ‘We are under the warbird, experimental and limited
category and are able to use more in the way of salvaged parts without history
– so, buying parts from eBay happens,’ says Bishop. (This, of course, is not an
option for general aviation aircraft).
‘Obviously, they go through very stringent inspection and test criteria before
fitment. Not all measure up – life is full of disappointments in the old airplane
world.’

LESSON 7 IT’S NOT ROCKET SCIENCE

Kenny Love says that the basic concepts of maintaining an ageing aircraft are
simple, but need to be consistently applied.
‘You need to know your airplane; you need to know it back to front. On a deeper
level you, or your engineering company, need to understand what the aircraft is
made of – what the materials are, what their life span is.
‘You need to be in tune with other operators. Look out there and see what other
problems people are finding.
The last word should perhaps go to the designer of the Spitfire, R. J. Mitchell, who,
long before the aircraft became an icon, told test pilot Jeffrey Quill: “If anybody
ever tells you anything about an aeroplane that is so bloody complicated you can't
understand it, take it from me: it's all balls”.’
28 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
SIGMET changes

CHANGES TO THE
AUSTRALIAN SIGMET FORMAT
The Bureau of Meteorology will be introducing changes to its SIGMET format
at 0000 UTC on 30 May 2013. Most of these changes are being made to align
the Bureau’s SIGMET service with the International Civil Aviation Organization's
(ICAO) specifications. These changes will simplify both the entering of SIGMETs
into flight planning systems, and the training of international pilots.

Changes will be made to the:

i. description of vertical extent for levels at and below 10,000 feet
ii. format of the SIGMET sequence number
iii. format of the last line of the SIGMET.
Additionally, the Bureau will issue a single SIGMET per weather event, per Flight Information Region
(FIR), rather than the current practice whereby SIGMETS are issued per meteorological watch region
by the office responsible for that region. This current practice can result in more than one SIGMET
being current for one event in an FIR.

VERTICAL EXTENT
Australian SIGMETs currently give vertical extent in hundreds of feet using:
i. the letter A (altitude) for levels up to and including 10,000 feet (e.g. A100)
ii. the letters FL (flight level) for levels above 10,000 feet (e.g. FL110).
From 30 May 2013, vertical extent will be given in:
i. feet for levels below 10,000 feet (e.g. 9000FT)
ii. hundreds of feet for levels at and above 10,000 feet (e.g. FL100).
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 29

Only FL will be used when describing a phenomenon that extends over the transition level
(10,000 feet), as shown in the following example:
YMMM SIGMET C01 VALID 130200/130600 YPDM-
YMMM MELBOURNE FIR SEV TURB FCST WI YIDK - YWLA - YHKT - KALUG FL080/150 STNR NC
RMK: ME NEW
(Note that the first point of a polygon is not repeated when describing the horizontal extent of an event.)

SEQUENCE NUMBER GROUP

Australian SIGMETs currently use a four-character sequence number group consisting of a two-
letter location designator followed by a two-digit number, e.g. the sequence number group AD01
describes the first SIGMET issued by the Bureau’s Adelaide meteorological watch office on the given
UTC day. Two systems of location designators are currently used, one for low-level phenomena and
another for high-level phenomena.
From 30 May 2013, a new three-character sequence number will be introduced and a two-letter
location designator will be provided in the last line of the SIGMET.
The position in the SIGMET message of the new sequence number will remain the same (the third
group in the first line). However, the format will change to ANN, where:
i. A will be a single alpha character that will be assigned to the SIGMET event (e.g. severe icing)
and will be used for any subsequent SIGMETs issued for that event within the FIR. There will not
be two Australian SIGMETS current with the same sequence alpha character, even if they refer
to the same event that is occurring across the two FIRs, i.e. if the event is straddling the YBBB\
YMMM boundary, the two respective SIGMETs will have different letters for the same event.
30 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
SIGMET changes

The first event for the day (after 0001 UTC) will be given the first unassigned alpha character, e.g.
A, the second event B, and so on through to Z. Any event (within the day) after Z will be given the
first unassigned character (from a previously cancelled SIGMET).
ii. NN will be a two-digit number providing a sequential count of the number of SIGMETs issued for
the event within the FIR since the last 0001 UTC.
When a SIGMET persists into the following UTC day, its letter character will remain the same, but
the sequential count will be reset to 01, as shown in the following examples:
YMMM SIGMET D02 VALID 122230/130230 YMHF-
YMMM MELBOURNE FIR SEV TURB FCST WI S4015 E14430 - S4015 E14830 - S4400 E 14830 -
S4400 E14500 FL120/160 STNR NC
RMK: ME REV D01 121830/122230
YMMM SIGMET D01 VALID 130230/130630 YMHF-
YMMM MELBOURNE FIR SEV TURB FCST WI S4015 E14420 - S4015 E14830 - S4400 E 14830 -
S4400 E14500 FL120/160 STNR NC
RMK: ME REV D02 122230/130230

LAST LINE OF SIGMET

The Bureau provides information additional to the ICAO specification in the last line of the SIGMET,
to assist users in processing the message. An example of the current format is STS: REV SIGMET
BN05 202000/210000.
From 23 August 2012, the format of this line will be changed to RMK: LocationDesignator Status
Reference, as shown in the following example:
YMMM SIGMET C02 VALID 101200/101600 YSRF-
YMMM MELBOURNE FIR SEV TURB FCST WI YSWG – YCBB – YTRE – YMCO SFC/FL120 MOV N
20KT WKN
RMK: ME REV C01 100800/101200 SEE ALSO YBBB D02
RMK (remark) is used to indicate that the information that follows is not part of the ICAO
specification and will be removed prior to international distribution of the SIGMET (as is the case
with TAF and METAR/SPECI)
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 31

LocationDesignator (e.g. ME) provides a quick reference on the location of the phenomenon.
Two systems of location designators are currently used, one for low-level phenomena and another
for high-level phenomena. From 30 May 2013, only one system of location designators will be
used, as shown in the map above:
MW: will be used for events in the Melbourne FIR to the west of 130E
ME: will be used for events in the Melbourne FIR east of 130E
MM: will be used for events in the Melbourne FIR that cross 130E
BN: will be used for events in the Brisbane FIR north of 30S
BS: will be used for events in the Brisbane FIR south of 30S
BB: will be used for events in the Brisbane FIR that cross 30S.
Status information (e.g. REV C01 100800/101200) is provided using the following terminology:
a. NEW (e.g. RMK: MW NEW) to indicate either that the SIGMET is for a new phenomenon in the
FIR, or is a SIGMET being issued to correct a previously issued SIGMET that was in error (and
has been cancelled).
b. REV (e.g. RMK: MW REV B01 100100/100500) is used to indicate that the SIGMET reviews
(supersedes) an existing SIGMET (either NEW or REV) within the FIR. REV is followed by the
sequence number and validity of the SIGMET being reviewed.
c. CNL (e.g. RMK: MW CNL B01) is used when a SIGMET is being cancelled. CNL is followed by
the sequence number of the SIGMET being cancelled.
A reference (e.g. SEE ALSO YBBB D01) will be included when there is a SIGMET current for the
same event in the adjoining Australian FIR (i.e. when the weather event straddles the YMMM\YBBB
boundary), e.g. RMK: ME REV C01 100800/101200 SEE ALSO YBBB D01
The following examples show the new format (with the changes given in red). The first SIGMET is
for a turbulence event that is initially confined to the Brisbane FIR (YBBB). The second and third
SIGMETs are subsequently issued because the extent of the turbulence is expected to move
south and straddle the YBBB/YMMM boundary. The fourth and fifth SIGMETs cancel C02 and D01
because the intensity of the turbulence has weakened and hence no longer requires a SIGMET.
 32 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
SIGMET changes

YBBB SIGMET C01 VALID 100800/101200 YBRF-

YBBB BRISBANE FIR SEV TURB FCST WI YMNY – YJAK – YEUO – YTHY
SFC/9000FT MOV S 15KT NC
RMK: BN NEW
YBBB SIGMET C02 VALID 101200/101600 YBRF-
YBBB BRISBANE FIR SEV TURB FCST WI YARY – YTIB – YWAG – YEMG
2000/9000FT MOV S 15KT WKN
RMK: BN REV C01 100800/101200 SEE ALSO YMMM D01
YMMM SIGMET D01 VALID 101200/101600 YSRF-
YMMM MELBOURNE FIR SEV TURB FCST WI YARY – YTIB – YWAG - YEMG
FL020/100 MOV S 15KT WKN
RMK: ME NEW SEE ALSO YBBB C02
YBBB SIGMET C03 VALID 101500/101600 YBRF-
YBBB BRISBANE FIR CNL SIGMET C02 101200/101600
RMK: BN CNL C02
YMMM SIGMET D02 VALID 101500/101600 YSRF-
YMMM MELBOURNE FIR CNL SIGMET D01 101200/101600
RMK: ME CNL D01
Note that when a SIGMET event straddles the YBBB\YMMM FIR boundary, the alpha characters in the
sequence number groups will be different (C for YBBB, and D for YMMM in the examples above), but
the description of the horizontal extent will be the same.
These SIGMET format changes are summarised in the table following.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 33
Current From 30 May 2013
Describing vertical extent
A (altitude) for levels up to and including FT (feet) for levels below 10,000 feet,
10 000 feet, e.g. A100 e.g. 9000FT
FL (flight level) for levels above 10,000 feet, FL for levels at and above 10,000 feet,
e.g. FL110 e.g. FL100
Note: when the vertical extent crosses the transition level, only FL is used e.g. FL020/110
Sequence number
Four characters consisting of a two-letter Three characters consisting of a
location designator followed by a two-digit single-letter event designator followed
number e.g. SY01 by a two-digit number, e.g. C01
Last line of SIGMET
e.g. STS: REV SIGMET SY01 191900/200100 e.g. RMK: BS REV A01 191900/200100

In addition to these format changes, from 30 May 2013 there will only be a single SIGMET current
for a weather event per FIR. This compares with the current practice, whereby each of the Bureau’s
meteorological watch offices issues SIGMETs only for their region of responsibility, often resulting in
multiple SIGMETs being current within an FIR for one weather event.
Under the new procedures, when a weather phenomenon straddles the boundaries of adjoining
meteorological watch offices, the offices will collaborate so that only a single SIGMET per FIR will
be current for the event. However, note that when a phenomenon straddles the YBBB\YMMM FIR
boundary, there will be a SIGMET current in each FIR for the event.

SIGMET COVERAGE
The Bureau issues low-level (below FL185) SIGMETs for thunderstorms, turbulence, icing, mountain
waves, duststorms and sandstorms for the shaded area given in the diagram below.
SIGMETs for high-level (at and above FL185) turbulence and icing are issued for the Brisbane FIR
and the Melbourne FIR to 50S. SIGMETs for tropical cyclones and volcanic ash are issued for the
whole of the Brisbane and Melbourne FIRs.
AIRWORTHINESS
36 What goes around
40 Service difficulty reports
36 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Helicopter underspeeds

WHAT GOES
AROUND…
What will you do when you’re low,
slow and the horn goes off?
Helicopters can hover, but never forget that they can also
stall. Low rotor rpm, leading to full or partial blade stall is a
persistent destroyer of helicopters, particularly light piston-
engine types. It also kills pilots.
Every helicopter pilot knows the theory: The helicopter’s rotor
blades are wings, like those on an aircraft. Flying a helicopter
consists of managing the lift generated by those wings
by controlling their angle of attack with the collective pitch
control, and converting some of that lift into thrust with the
cyclic pitch control. Then there’s the ‘small’ matter of using
the tail rotor to keep the aircraft balanced and pointing in the
right direction, and the added annoyance that every control
input affects every other control input.
The lift the blades generate depends on how fast they go
round, and what angle of attack they are pitched at. Like any
wing, if the blades are pitched to too great an angle of attack
they will stall and stop generating lift. That’s why rotor rpm
is vital.
There are four signs of low rotor rpm:
1. Increase in vibration as stall buffet commences over the
rotor blades
2. Shaking in the cyclic from blade stall buffet
3. Decrease in engine noise as the rotor blades slow down
4. The telltale warning light and aural alert.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 37

Hot, high and heavy

Low rotor rpm, which in the popular Robinson R22 means
when rotor rpm drops below 97 per cent (the normal
operating range is 101-104 per cent), is associated with three
helicopter operating conditions: hot, high and heavy.
Hot and high are interchangeable, as the concept of density
altitude illustrates. High ambient temperatures diminish air
density, as does altitude. In hot and high conditions the
engine has less power and the air has slightly less lift. The
helicopter has less performance, and flies as though carrying
an invisible, but very large passenger.
In these conditions rotor rpm drop can happen with the
engine operating as it was designed to. It can also happen in
any atmospheric state if the engine partly or fully fails.
‘It’s all about recognition’, says CASA’s Cairns-based
helicopter flying operations inspector Col Webb.
‘On the Robinson R22 you’ve got to get the collective down
within 1.8 seconds of an engine failure. If not, the helicopter
glides like a typewriter.’

Recovery from low rotor rpm is a matter of:

a. lowering the collective to reduce the rotor blade
angle of attack
b. adding engine power
c. pulling back slightly on the cyclic, as required,
so that airflow past the helicopter can energise
the rotor blades, as it does in an autorotation.
There’s another factor in the helicopter’s complex flight
equation. Forward speed is an additional source of energy
that can be converted into rotor speed should the worst
happen. Webb puts it more simply. ‘Movement is life’,
he says.
‘If you hover over a 60-foot gum tree, as I’ve seen some pilots
do, and you have an engine failure you’ll end up among the
branches. If you have any airspeed, even 20 knots, you have
a chance of making it to a bit of paddock.’
38 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Helicopter underspeeds

How low do you go? The training dilemma

Low rotor RPM conditions are inherently difficult to train for,
Webb acknowledges, because simulating them accurately is
a dangerous exercise in itself.
‘If you fly an R22, even with two people on board, in Victoria
in winter it climbs like a homesick angel. The same aircraft in
Kununurra in January is a very different proposition. You’ll be
pulling the collective up around your ears to do things you
could do in Melbourne by flexing your fingers.
‘And I doubt that any flying school in the south is going to risk
its aircraft by loading them up to near maximum weight just
to add realism to autorotation or governor failure training. It
might make it realistic but it probably wouldn’t be safe.’
Robinson’s R22 Pilot’s Operating Handbook is further
testimony to the difficulty and danger of training for low rpm.
'Surprise throttle chops can be deadly', says one safety notice
in the handbook. ‘The student may freeze on the controls,
push the wrong pedal, raise instead of lower the collective,
or just do nothing. The instructor must be prepared to handle
any unexpected student reaction.’
Another safety notice, titled 'Fatal accidents caused by low
rpm rotor stall', says: ‘No matter what causes the low rotor
rpm, the pilot must first roll on throttle and lower the collective
‘No matter what causes simultaneously to recover rpm before investigating the
the low rotor rpm, the pilot problem. It must be a conditioned reflex.’
must first roll on throttle Still another safety notice reminds operators that: ‘Practice
and lower the collective autorotations continue to be a primary cause of accidents in
simultaneously to recover the R22 and R44. Each year many helicopters are destroyed
rpm before investigating practising for the engine failure that very rarely occurs.’
the problem. It must be a
Heliwork WA’s senior base pilot Howard James says that
conditioned reflex.’ while many budding mustering pilots in northern Australia
are aware of the dangers of low rotor rpm, there is a gulf of
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 39

understanding between that and familiarity. ‘Awareness is not

preparedness,’ he says. However he agrees low rotor rpm is
a difficult condition to safely demonstrate in a low-inertia rotor
helicopter such as an R22.
‘It’s a very different matter when you’re down close to the
trees – you have to react quickly and correctly.’
‘I’d say nine out of ten low hours pilots arriving here would
lower the collective without increasing the throttle in that
situation – and that means they’d keep going down to the
ground without recovering the lost rotor rpm.’
Another factor for consideration is when a new pilot gets
into a low level/low rotor rpm situation and facing disaster
in the face. ‘They tend to ‘‘choke” the throttle and not let the
governor do its job of increasing/restoring lost rotor rpm’,
James says.
‘In this situation I have always instructed pilots to override
the governor to full throttle, at the same time as lowering the
collective to save the situation. Then they should have a good
hard look at why they have got themselves into that situation
and change their flying technique to prevent a repetition.’
The other seasonal rotor rpm trap is the second round of
aerial mustering, which in northern Australia begins in August
and can run into the hotter months of October and November.
By the end of the second round a dangerous combination ‘That’s why we have turn-
forms. Pilots are susceptible to long-term fatigue and aircraft of-the-weather as a factor
performance is substantially less than at the start of the in our briefings as the
season. season goes on,’ he
‘That’s why we have turn-of-the-weather as a factor in our says. It and fatigue are a
briefings as the season goes on,’ he says. It and fatigue are a combination to be wary of.’
combination to be wary of.’
40 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Service difficulty reports

From 21 March 2013 Airbus A330-203 Crew seat belt bolt separated.
Note: Similar occurrence figures not included in this edition SDR 510016520
First officer's seat belt LH side attachment bolt
ABOVE 5700kg and nut separated and the seat belt fell off.
Airbus A320-232 APU leaking. SDR 510016466 Investigation continuing.
Strong smell noticed in cockpit and cabin. Oil leak Airbus A330-203 Flight control warning system
detected on APU generator terminal block and oil suspect faulty. SDR 510016486
scavenge line. P/No: 38007081. Low-speed rejected take-off warning. Suspect faulty
TSN: 5,442 hours/4,634 cycles. computer. Investigation could not fault system.
Airbus A320-232 CIDS incorrect part. Airbus A330-203 Hydraulic O-ring deteriorated.
SDR 510016366 SDR 510016372
Cabin intercommunication data system (CIDS) Hydraulic system pressure module servo control
director incorrect part. pressure line O-ring seal deteriorated and leaking.
P/No: Z014H0000231B was found installed, but Loss of hydraulic fluid. P/No: NAS161212.
P/No: Z064H000131A is correct.
Airbus A330-243 Hydraulic check valve faulty.
Airbus A320-232 Landing gear door hinge SDR 510016461
cracked. SDR 510016625 Blue and green hydraulic system high-pressure check
LH main landing gear door forward hinge fitting on valves had signs of rotation when inspected iaw
keel beam cracked. Crack length approximately 20mm AD 2012-0244R1. (Two similar defects)
(0.78in). Found during NDT inspection iaw SB A320-53-
Airbus A380-842 Passenger seat lock faulty.
1196 (AD 2012-0118). P/No: D5337062220400.
SDR 510016396
Airbus A320-232 Fuselage skin damaged. First class passenger seats (2off) had incorrectly
SDR 510016358 functioning 16G locks. P/No: 3AAM1095501.
Fuselage skin had a dent and crack forward of the (One similar defect)
R2 door. Dent approximately 89mm 3.5in) long and
ATR722-12A AC inverter u/s. SDR 510016447
3.174mm (0.12in) deep. Crack in dent approximately
No. 2 static inverter unserviceable. P/No: 1002010202173.
14mm (0.55in) long. Initial investigation suspects
TSN: 513 hours/472 cycles. TSO: 513 hours/472 cycles.
impact by ground vehicle/equipment following most
recent flight. Investigation continuing. ATR722-12A Attitude and direction data system
terminal block u/s. SDR 510016660
Airbus A320-232 Humidity control system filter
attitude heading SDRerence system (AHRS) failure.
odour. SDR 510016513
Investigation found terminal block 810VT 39 pin not
Intermittent bad odour (chemical/cleaning) from demister
locking. P/No: NSA937901MA2202.
filter. P/No: 425A2005.
TSN: 1159 hours/860 cycles/7 months.
Airbus A320-232 Hydraulic pump unserviceable.
ATR722-12A Audio integrating system RCAU u/s.
SDR 510016553
SDR 510016341
Electrical hydraulic pump (blue system) unserviceable.
remote control audio unit (RCAU) unserviceable.
Hydraulic fluid leaking from breather. P/No: 974540.
P/No: CAU2583AC01.
Airbus A320-232 Wing cover plate separated. TSN: 726 hours/534 landings/5 months.
SDR 510016561
ATR722-12A Crew seat spring broken.
Main fuel tank pump cover plate on the underside of
SDR 510016515
the LH wing separated during flight, causing damage
Pilot's seat forward/aft locking control lever spring
to wing root fairing. P/No: D2825023020000.
broken. Investigation continuing.
Airbus A321-231 TCAS computer u/s. P/No: 1A5270016. TSN: 3149 hours/3015 cycles.
SDR 510016417
ATR722-12A Landing gear position switch u/s.
Traffic collision avoidance system (TCAS) computer
SDR 510016613
unserviceable. Investigation continuing.
LH and RH main landing gear weight on wheels
P/No: 9400300001. TSN: 1931 hours/961 cycles.
proximity switches 50GB and 54GB faulty.
Airbus A330-202 AC generation system contactor Suspect water contamination. P/No: DHE1148.
suspect faulty. SDR 510016614 TSN: 58 hours/24 cycles.
Essential bus not feeding from AC bus 1. Suspect
BAe 146-100 APU odour. SDR 510016630
faulty contactor 3XC. Investigation continuing.
Momentary oil smell in cockpit. Investigation found
P/No: NSA936501TA1004.
no definitive cause for the smell but the APU sump oil
Airbus A330-202 Wing cover missing. level was higher than normal.
SDR 510016562
LH wing No. 2 moveable flap track fairing cover missing.
P/No: F5757416300000.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 41
BAe 146-300 Flight compartment windshield Beech 1900D Fuselage skin panel corroded.
cracked. SDR 510016395 SDR 510016569
Captain's ‘A’ windshield outer pane cracked in Lower fuselage skin panel corroded and de-bonded
many places. No evidence of impact damage. in area of stringers 13R, 14R and 15R between FS 563
P/No: NP1701015. to FS 423.25. P/No: 1294300653.
Beech 1900C Trailing edge flap bolts corroded.
SDR 510016490
LH trailing edge flap hinge bracket attachment bolts
corroded. P/No: NAS66033.
Beech 1900C Vertical stabiliser angle corroded.
SDR 510016558
Vertical stabiliser T angle and centre rudder hinge
corroded. Minor corrosion on hinge, and deep
corrosion pitting on T angle. P/No: 10164001419.
(One other similar defect)
Beech 1900C Wing skin cracked. SDR 510016507
LH and RH wing collector tank access cut-outs cracked.

Beech 1900D Fuselage gusset cracked.

SDR 510016571
Gusset at FS 303.25 on RH side lower fuselage cracked.
Beech 1900C Wing rib cracked. SDR 510016604 P/No: 114430002204.
LH and RH wing ribs P/Nos.: 114-1200305 and 114-
1200307 cracked in lower aft area. Photograph. Beech 1900D Fuselage gusset cracked.
TSN: 31,086 hours/39,184 cycles. SDR 510016564
Gusset at FS 288.00 on RH side centre fuselage
Beech 1900D Elevator hinge corroded. cracked. P/No: 1294300794.
SDR 510016576
RH outboard elevator attachment hinge had deep
corrosion pitting. Other hinges had minor corrosion.
P/No: 101-6200111.
Beech 1900D Fuselage frame cracked.
SDR 510016563
RH upper fuselage frame at FS 183.29 cracked.
P/No: 12942004019.
Beech 1900D Fuselage frame cracked.
SDR 510016565
Fuselage frame at FS 288.00 RH side cracked.
P/No: 1294300557.
Beech 1900D Fuselage intercostal cracked.
SDR 510016568
Intercostal at top edge of cargo door frame at
FS 498.25 cracked. P/No: 12944004471.
42 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Service difficulty reports

Beech 1900D Fuselage gusset cracked. Boeing 737-7BK Elevator control system
SDR 510016566 contaminated. SDR 510016588
Gusset at FS 348.25 on LH side centre fuselage cracked. Elevator control system RH flexi line water contamination.
P/No: 1294300793. Line located behind elevator pitot tube.
Beech 1900D Fuselage gusset cracked. Boeing 737-838 Data loader overheated.
SDR 510016567 SDR 510016451
Gusset at FS 348.25 on RH side centre fuselage Data loader overheated and failed when navigation data
cracked. P/No: 1294300793. load attempted. Investigation found the cover very hot
Beech 1900D Landing gear actuator cracked. and shroud assembly melted. Electrical burning smell
SDR 510016609 also evident. Investigation continuing. P/No: 223530001.
LH main landing gear actuator attachment lug cracked. Boeing 737-838 Spoiler cable corroded and frayed.
Found during inspection iaw MSB 32-3870. SDR 510016523
P/No: 11438004115. TSO: 8839 Hours/12,054 Cycles. LH wing spoiler control cables WSB1-L2 and WSB2-L2
Beech 1900D Landing gear actuator cracked. corroded and frayed. Investigation continuing.
SDR 510016610 P/No: BACC2C3D03552EG.
Nose landing gear actuator cracked on end cap. Boeing 737-838 Flight compartment window u/s.
P/No: 11238002223. SDR 510016370
Beech 1900D Seat track cracked. SDR 510016570 First officer's No. 2 sliding window emergency release
LH forward seat track cracked. P/No: 114430074141. mechanism failed to release window, preventing it from
opening. Investigation found internal handle release
Beech 1900D Wing skin corroded. SDR 510016572 trigger actuating but window failed to move because of
LH wing trailing edge skin and stringer corroded and lack of lubrication of the handle.
de-bonded between WS 123.98 and WS 171.29.
P/No: 118-1100151. Boeing 737-838 Fuel cross feed valve failed.
SDR 510016448
Beech 300 Vertical stabiliser rivets loose. Fuel cross feed valve suspect faulty. Investigation
SDR 510016621 could not duplicate the fault but valve actuator
Vertical stabiliser canted bulkhead at Stn. 437.274 had changed as a precaution.
a row of loose/working rivets across angle connecting
fuselage upper skin to upper bulkhead. Suspect Boeing 737-838 Pressure regulator/outflow
rivets had not expanded sufficiently to provide secure valve suspect faulty. SDR 510016379
attachment. Pressurisation system difficult to control. Suspect
caused by faulty positive pressure relief valve (PPRV).
Boeing 717-200 Engine TGT indicating system Investigation continuing. P/No: 7207376.
harness suspect faulty. SDR 510016383
LH engine turbine gas temperature (TGT) harness Boeing 737-838 Window wiring wire broken.
suspect faulty. Investigation found no definitive fault SDR 510016449
but due to the intermittent nature of the fault the harness RH window overheat sensor wire burnt. Investigation
was replaced. P/No: CA22400. also found wiring to terminal block TB5014 incorrectly
installed. Investigation continuing. P/No: W2004550320.
Boeing 717-200 Hydraulic pump failed.
SDR 510016403 Boeing 737-8BK Cabin temp controller u/s.
RH engine-driven hydraulic pump failed. Investigation SDR 510016493
found drive shaft sheared. Light metal contamination Aircon system zone temperature controller unserviceable.
of system. Case drain filter had heavy metal P/No: 6228145. TSN: 19,213 hours/8152 cycles.
contamination. P/No: 66180. Boeing 737-8BK Passenger door lock pin sheared.
TSN: 29,904 hours/21,813 cycles. SDR 510016512
Boeing 737-476 Elevator tab control rod loose. L1 door failed to fully open. Investigation found the upper
SDR 510016374 hinge lock pin retainer screw sheared and the washers
LH elevator inboard tab control rod forward jam nut jamming the hinge. P/No: 141A60761.
loose and threads on adjustment bushing worn. Boeing 737-8FE APU duct cracked. SDR 510016472
Boeing 737-476 Fuselage door frame cracked. Two bolts found in the forward end of APU access door.
SDR 510016378 Investigation found the bolts (P/No: MS955708) were from
Stn 348.2 door frame cracked in area adjacent to the load compressor discharge duct outlet flange. The
lower inboard door stop attachment hole. Found during duct was bent away from the attachment point allowing
inspection iaw EI 734-053-0246R1. the seal (P/No: S8990-153) to be displaced. Investigation
also found a crack in the compressor plenum housing in
Boeing 737-476 Galley oven u/s SDR 510016487 excess of 25.4mm (1in). TSN: 23,201 hours/27,626 cycles.
Oven C425 emitting smoke and making a popping
sound. P/No: GENM2585015.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 43
Boeing 737-8FE Artificial horizon u/s. Boeing 737-8Q8 Aileron tab actuator failed.
SDR 510016440 SDR 510016404
Standby artificial horizon unserviceable. Aileron trim actuator failed. Control wheel continues
P/No: H341BWM. TSN: 21,137 Hours/14,854 to roll for a short period after trim switch release.
Cycles/14,854 Landings/81 Months. TSO: 3098 P/No: R15048. TSN: 32,126 hours/18,606 cycles.
Hours/1927 cycles/1927 landings/13 months. Boeing 737-8Q8 APU oil system pipe broken.
Boeing 737-8FE Brake antiskid valve faulty. SDR 510016518
SDR 510016655 APU rear bearing oil scavenge pipe broken at aft
RH brake anti-skid valve resistance out of tolerance. flareless fitting. P/No: 38818271.
Resistance measured at 260 ohms. Boeing 737-8Q8 Hydraulic hose loose and leaking.
P/No: 39353. TSN: 31,886 hours/18,264 cycles. SDR 510016405
Boeing 737-8FE Cabin aircon suspect faulty. Hydraulic hose B-nut loose and leaking on No. 2 brake
SDR 510016401 assembly quick disconnect hose. Nut connects hose to
RH aircon pack suspect faulty. Investigation could find no elbow P/No: BACE21BR0606P. Investigation also found
definitive fault but a pack wash was carried out as Nos. 1 and 2 wheels and brakes contaminated with
a precaution. hydraulic fluid. P/No: AS154A04EE0320B.
Boeing 737-8FE Drag control system cable broken. Boeing 747-438 Air distribution system duct
SDR 510016355 damaged. SDR 510016422
LH wing spoiler cable WSB2 broken at pulley just outside LH and RH trim air diffuser ducts (TADD) ducting
engine aft pylon. Cable failed at 62 lbs tension (nominal damaged. Found during inspection iaw EI 74421108R02
is 80 lbs tension). Cables being rigged at the time. and EI 74421107R2.
P/No: BACC2C3004062FG. Boeing 747-438 Air distribution system filter
Boeing 737-8FE Fire detection system inoperative. contaminated. SDR 510016519
SDR 510016643 Burning smell and white particles contaminated
APU fire detection system inoperative. Found during test. upper deck. Investigation found recirculation filters
TSN: 5858 hours/7732 cycles. had disintegrated after becoming wet. Filter debris
Boeing 737-8FE Hydraulic fitting loose and leaking. passed through recirculation fans and check valve,
SDR 510016380 causing check valve flapper to fail and fan blade tips
No. 5 flight spoiler hydraulic return line T-piece loose to disintegrate. Investigation continuing.
and leaking. Investigation found the fitting loose by Boeing 747-438 Hydraulic hose ruptured.
approximately three quarters of a turn. SDR 510016345
Boeing 737-8FE Oxygen wiring short circuit. Body landing gear steering system hydraulic hose
SDR 510016602 located in LH wing gear well ruptured. Loss of
Passenger oxygen light illuminated in flight. Suspect No. 1 hydraulic system fluid. P/No: AS11508K0306.
short circuit on wire at pin 6 of connector D440 (oxygen Boeing 747-438 Pressure outflow valve filter
panel). Fault could not be reproduced and aircraft disintegrated. SDR 510016438
declared serviceable. Burning smell in cockpit and cabin accompanied by
Boeing 737-8FE Pneumatic distribution system lint/cotton type material blowing from sidewall vents.
smoke/fumes. SDR 510016534 Smell and lint stopped when recirculating fans turned off.
Fumes evident in cabin and cockpit. Investigation could Investigation found LH lower aft recirculation
find no definitive cause for the defect but the No. 2 filter disintegrated and LH lower recirculation check
engine had been subject to a borescope inspection valve damaged. LH lower recirculation fan changed
during overnight maintenance and it is suspected as a precaution.
that excess lubricant might have been applied to the Boeing 747-438 Waste disposal system drain
borescope access plugs and eventually entered the mast blocked. SDR 510016484
bleed system. Water leaking into aft galley. Investigation found
Boeing 737-8FE Pneumatic distribution sense blocked drain mast.
line cracked. SDR 510016533 Boeing 767-336 Drag control actuator cracked
No. 1 engine bleed air system low duct pressure. and leaking. SDR 510016416
Investigation found sense line from bar to precooler No. 6 spoiler actuator housing cracked and leaking.
control valve cracked in one area and sheared in another. Loss of hydraulic fluid. P/No: 252T13013.
P/No: 332A235014. Boeing 767-336 Anti-ice system odour.
Boeing 737-8KG Exterior light lens missing. SDR 510016392
SDR 510016364 Oily smell in cockpit and forward cabin shortly after
Lower anti-collision light lens lower half missing. engine anti-ice selected. Investigation could find
P/No: 3182431. no definitive cause for the smell and it has not
reoccurred since.
44 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Service difficulty reports

Boeing 767-338ER Air conditioning system noisy. Bombardier DHC8202 Engine oil pressure
SDR 510016398 transducer u/s. SDR 510016354
Moderately loud noise and vibration in floor area No. 1 engine oil pressure transducer unserviceable.
around rows 28 to 32, mainly on RH side of aircraft. P/No: APT761000100DW. TSN: 7346 hours.
Investigation continuing. Bombardier DHC8202 Engine oil wiring connector
Boeing 767-338ER APU u/s. SDR 510016573 faulty. SDR 510016552
Cabin began to fill with smoke. APU shut down LH engine oil pressure gauge wiring connector to
and aircraft evacuated. APU fire bottle discharged. transducer faulty.
Investigation continuing. P/No: 380029812. TSN: 55,709 Bombardier DHC8311 Engine TSCU u/s.
Hours. TSO: 5,748 hours. SDR 510016557
Boeing 777-3ZGER Emergency lighting power No. 2 engine torque signal condition unit
supply u/s. SDR 510016481 (TSCU) unserviceable. Autofeather failed to arm.
Emergency lighting battery pack unserviceable. P/No: 30005000048.
Connectors separated from battery pack and stuck Bombardier DHC8315 Ditching dam uncommanded
on power supply and battery wiring melted and fused. activate. SDR 510016516
Investigation continuing. P/No: D71702001. LH emergency exit ditching dam deployed in flight.
TSN: 18,930 hours/1,569 cycles. Inflatable dam, hose and fitting torn away and dam
cover assembly and ditching dam adapter damaged.
Investigation found the gas bottle and burst disc
intact, indicating system pressure was not the cause
of the deployment.
Bombardier DHC8402 Hydraulic pipe cracked and
leaking. SDR 510016517
Total loss of No. 2 hydraulic system fluid. Investigation
found rigid hydraulic pipe located in area of RH aft
wing root had cracked and separated. Engine-driven
hydraulic pump and power transfer unit (PTU) changed
due to run time exceedance without fluid. System filters
also changed. P/No: 82920592001.
TSN: 16,437 hours/15,674 cycles.

Boeing 777-3ZGER Smoke detector u/s.

SDR 510016607
No. 3 crew bunk smoke detector unserviceable.
Smoke detector could not be faulted on ground but
was replaced anyway as false warnings had happened
before. Suspect intermittent fault. P/No: PU90471WR3.
TSN: 19,177 hours/1589 cycles.
Bombardier CL604 Fuel quantity probe u/s.
SDR 510016601
Fuel system imbalance during take-off. Investigation
found a ‘slight film’, possibly water, inside the No. 6
probe and a small amount of ‘black growth’ on the wires
and terminals connecting the probe. Suspect bacterial
growth. Probe found to be serviceable after cleaning.
Bombardier DHC8102 PSEU u/s. SDR 510016543
Weight on wheels (WOW) caution light on take-off.
Investigation found a faulty card in the proximity sense
electronic unit (PSEU) and the RH inboard proximity
switch was faulty.
Bombardier DHC8202 Cabin aircycle machine
seized. SDR 510016645
Aircycle machine (ACM) seized. Minimal oil in unit.
P/No: 7829018.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 45
Cessna 750 Tail cone corroded. SDR 510016349 Embraer EMB120 Trailing edge flap actuator
Tail cone upper forward skin corroded between suspect faulty. SDR 510016436
FS 466.00 and FS 489.50. RH wing trailing edge flap actuator suspect faulty.
Cessna 750 Fuselage skin corroded. Investigation continuing. P/No: 3203001007.
SDR 510016350 Embraer EMB120 Wing cover plate missing.
Fuselage skin corroded in area beneath TCAS antenna SDR 510016596
at FS 205. RH wing pressure SDRuelling access panel separated
Cessna 750 Horizontal stabiliser spar corroded. during flight. P/No: 12042723011.
SDR 510016347 Embraer ERJ170100 Hydraulic pump leaking.
LH horizontal stabiliser aft upper spar corroded at SS 39. SDR 510016479
Cessna 750 Pylon skin corroded. SDR 510016346 LH engine-driven hydraulic pump leaking.
LH and RH engine pylon skins corroded. Investigation continuing. P/No: 5116404.
Cessna 750 Wing skin corroded. SDR 510016348 Embraer ERJ170100 Hydraulic fitting cracked
LH lower wing skin corroded in area of flap attachment and leaking. SDR 510016434
at CWS 268.05 Hydraulic fitting in area of No. 4 multifunction spoiler
cracked and leaking. P/No: AS1008D0806.
Cessna 750 Wing skin corroded. SDR 510016351
LH and RH wing lower skins corroded at access Embraer ERJ190100 Aileron control system nut
openings. binding. SDR 510016336
RH aileron fuselage sector upper quadrant assembly
Embraer EMB120 Aileron seal u/s. SDR 510016634 sleeve nut lockwire broken. Nut migrated outwards and
LH aileron sealing canvas unserviceable. Seal preventing fouled on upper quadrant bellcrank.
full operation of the aileron. P/No: 12008131007.
Embraer ERJ190100 Airconditioning smoke/fumes.
Embraer EMB120 Landing gear wire broken. SDR 510016495
SDR 510016537 Electrical burning smell in cockpit. Investigation could
Landing gear wire broken between connector P1548 find no definitive cause for the smell and it could not
and transition. Wiring conduit full of corrosion. be duplicated.
Embraer ERJ190100 Air conditioning check valve
u/s. SDR 510016418
RH air conditioning system check valve unserviceable.
Investigation found flapper hinge pin had not been
installed correctly and was partially adrift.
P/No: 10012522. TSN: 2576 hours/1671 cycles.

Embraer EMB120 Powerplant wiring worn

and damaged. SDR 510016442
Engine starter wire worn through and shorting on
nacelle structure.

Embraer ERJ190100 APU bleed air valve failed.

SDR 510016439
APU anti-surge valve failed. P/No: 4952897.
TSN: 2435 hours/1,617 cycles/1617 landings/24 months.
TSO: 2435 hours/1617 cycles/1617 landings/24 months.
Embraer ERJ190100 Control column sensor faulty.
SDR 510016656
Copilot's outboard control column position sensor faulty,
causing controls to feel notchy, with a flat spot in the
neutral position. P/No: 4259001001.
46 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Service difficulty reports

Embraer ERJ190100 Data recorder module u/s. Fokker F28MK0100 Brake pack worn and damaged.
SDR 510016496 SDR 510016522
No. 3 generic I/O module unserviceable, giving No.1 brake pack worn unevenly. Investigation found the
erroneous error messages. P/No: 70253651901. heat pack assembly jammed, with four bolts sheared
TSN: 9236 hours/5690 cycles. on the brake pack end plate. P/No: 50118093.
Embraer ERJ190100 Flight compartment windshield TSN: 7276 hours/5962 cycles.
cracked. SDR 510016586 Fokker F28MK0100 MFDU suspect faulty.
LH windshield interlayer cracking and delaminating. SDR 510016639
P/No: NP18730113. TSN: 120 hours/75 cycles. Flap asymmetry message during descent.
Embraer ERJ190100 Flight control PACE u/s. Suspect multi-function display unit (MFDU) faulty.
SDR 510016646 Investigation continuing.
Primary actuator control electronic (PACE) unserviceable. Fokker F28MK0100 Drag control rod damaged.
P/No: 7028273822. TSN: 12,577 hours/8665 cycles. SDR 510016386
Embraer ERJ190100 Hydraulic restrictor valve RH No. 5 lift dumper horizontal rod to bellcrank
cracked and leaking. SDR 510016471 attachment bolt incorrectly fitted. Bolt, nut and split
Hydraulic restrictor valve on the hydraulic system pin caused damage to control rod.
emergency extension selector valve cracked and leaking. Fokker F28MK0100 Flight director system
P/No: 19071270901. computer suspect faulty. SDR 510016508
Momentary GND/FLT warnings. Flight warning
computer, radio altimeter antenna and ground flight
relays suspect faulty. Investigation continuing.
Fokker F28MK0100 Landing gear actuator eye
bolt cracked. SDR 510016511
Main landing gear eye bolt cracked in threaded area.
Found using magnetic particle inspection. Crack length
approximately 12mm (0.47in).
P/No: 415183. TSO: 14,742 hours. (One similar defect)
Fokker F28MK0100 Main landing gear bearing
cracked. SDR 510016425
LH and RH main landing gear upper bearings
cracked. Found during fluorescent penetrant inspection.
P/No: 412061. TSO: 14,742 hours.
Embraer ERJ190100 Slat position command sensor
unit u/s. SDR 510016554
RH outboard flap skew sensor faulty. P/No: 1716282A.
Embraer ERJ190100 Outside air temperature probe
u/s. SDR 510016644
No. 1 true air temperature (TAT) probe unserviceable.
TSN: 12,577 hours/8665 cycles.
Embraer ERJ190100 Pneumatic precooler cracked.
SDR 510016420
No.1 bleed air precooler core cracked. P/No: 10027932.
TSN: 13,665 hours/9110 cycles.
Embraer ERJ190100 PRSOV suspect faulty.
SDR 510016648
LH bleed air high-pressure regulating and shut-off valve Fokker F28MK0100 Passenger seat bolt dislodged.
(HPPRSOV) suspect mismatch with nacelle pressure- SDR 510016369
regulating shutoff valve (NAPRSOV). P/No: 10012463. Passenger seat row 11B pivot bolt moved from
TSN: 2057 hours/1273 cycles. (One similar defect) secured position, causing seat to recline into emergency
exit pathway.
Fokker F28MK0100 AC power relay unserviceable.
SDR 510016641 Fokker F28MK0100 Pressure outflow valve
Electrical Power Centre (EPC) relay P/No: DRH181 contaminated. SDR 510016548
unserviceable due to loose contact B2 inside relay. Aircraft pressurisation loss. Cabin controllers unable to
Found during inspection iaw SBF100-24-043. maintain cabin pressure. Investigation found secondary
outflow valve had a stray piece of insulation lodged under
the valve seat which allowed the valve to leak. Foreign
object removed and the valve operated normally.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 47
Fokker F28MK0100 Trailing edge flap connector Lear 45 Pneumatic system clamp loose and leaking.
contaminated with water. SDR 510016344 SDR 510016532
Trailing edge flaps faulty. Investigation found trailing edge LH bleed air leak. Investigation found clamp loose and
flap No. 3 synchro connector contaminated with water leaking. During rectification, the leak detector loop was
and Nos. 2 and 3 synchro out of adjustment. found resting inside the minimum distance from the
Fokker F28MK0100 Trailing edge flap connector clamp and was adjusted accordingly.
low resistance. SDR 510016509 Saab SF340A Hydraulic swivel u/s. SDR 510016482
Trailing edge flap LH inner flap synchro connector RH main landing gear drag brace hydraulic swivel failed.
P3568B had low insulation resistance at pin C. Loss of hydraulic fluid. Initial investigation suspects
Investigation found faulty solder sleeve on wires fatigue failure of the swivel. P/No: L38710SA.
AWB0130-C5. P/No: P3568B. Saab SF340B Flight compartment windshield
Fokker F28MK0100 Trailing edge flap system cracked. SDR 510016362
suspect faulty. SDR 510016424 LH cockpit windshield cracked. Windshield found to be
Pilot reported flap asymmetry during landing. very hot around cracked area, followed by warning lights.
Investigation could not duplicate the fault and flaps have P/No: 7256100703.
operated correctly since.
Fokker F28MK0100 Trailing edge flap relay
suspect faulty. SDR 510016549
Flap asymmetry indication. Investigation could find no
definitive cause for the defect but test relay K0744A
changed as a precaution. Investigation also found
inboard, centre and outer flap synchronisers all required
readjustment. P/No: FKA610AY4.
Fokker F28MK070 Autopilot system u/s.
SDR 510016638
Autopilot system suspect faulty. System made an
uncommanded thrust reduction when co-pilot's autopilot
activated. Investigation continuing.
Fokker F28MK070 Elevator control cable broken.
SDR 510016583
Unusual noise when control lock engaged. Investigation
found the elevator gust lock cable broken in the area
of the wheel well vertical cable run. No evidence of Saab SF340B Fuel wiring conduit worn and
rubbing evident and the pulleys functioned correctly. damaged. SDR 510016375
Investigation continuing. P/No: D75057419. Wing fuel tank refuel valve electrical conduits
P/Nos. 7228308563REV3 and 7228308564REVA both
Israel 1124 Communications power supply excessively worn in area hidden by grommets P/No
incorrect part. SDR 510016453 11190. Grommets installed as part of Mod 1981/SB340-
Radio transceiver power supply had three incorrect 28-011. Conduit 7228308-564REVA also found to have
capacitors. Investigation also found chassis fuel inside it. Found during modifications iaw SB340-
P/No: 6358627001 had an incorrect locking device on 28-026. P/No: 7228308563REV3.
shaft instead of the correct retainer clip.
P/No: 6414325002.

Saab SF340B Horizontal stabiliser bearing u/s.

SDR 510016475
RH elevator trim tab inboard bearing housing collapsed.
P/No: SA614A1503.
48 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Service difficulty reports

Saab SF340B Pneumatic duct delaminated. Beech 58 Nose landing gear collapsed.
SDR 510016359 SDR 510016521
RH rubber duct between wing and fuselage delaminated Nose landing gear collapsed during landing.
and leaking. Duct delaminated at clamp between Investigation continuing.
the rubber and metal ducts. Area of delamination Beech 58 Wing spar corroded. SDR 510016373
approximately 3.81mm (1.5in). P/No: G20030TRIAL. LH and RH wing spars had areas of Level 1 corrosion.
TSN: 292 hours/303 cycles. Found during inspection iaw AWB57-008. Corrosion
Ayres S2RG10 Fuselage longeron cracked. found in the following areas: RH wing spar at Stn 113.172,
SDR 510016525 Stn 108281, Stn 94.094 and Stn 83.547 LH wing spar at
Upper longeron cracked. TSN: 5733 hours. Stn108.281, Stn 94.094 and Stn 31.750
Beech 200 Flight compartment windshield failed. TSN: 7604 hours.
SDR 510016529 Beech 76 Elevator tab trim chain FOD.
Pilot's windshield failed during cruise. SDR 510016547
Unable to reach full elevator nose down trim.
BELOW 5700kg Investigation found FOD in LH elevator trim jack chain.
Beech 200 Horizontal stabiliser spar cap corroded. Beech 76 Landing gear retract/extension
SDR 510016454 system faulty. SDR 510016384
LH horizontal stabiliser rear spar lower spar cap had Landing gear transit light flickered intermittently then
exfoliation corrosion in areas between HSS 15 and stayed on when landing gear selected down, and the
HSS 18. Maximum thickness reduction of approximately circuit breaker popped and would not reset. Emergency
0.812mm (0.032in). at HSS 16.5. P/No: 1016200144. gear extension carried out. Following landing, hydraulic
TSN: 13,742 Hours/16,774 landings/2801 months. fluid found in the wheel well and on the LH flap lower
surface. Investigation found the following defects: 1.
power pack motor P/No: HYH5001 burnt out; 2. LH main
landing gear actuator P/No 1053840023 fixed end cap
leaking due to being only hand tight; 3. actuator end
cap O-ring rolled and split for approximately two thirds
of its circumference.
Britten-Norman BN2A20 Emergency exit dislodged.
SDR 510016361
RH emergency exit moved from closed position.
Exit did not come completely out of the recess and was
able to be temporarily refitted for the rest of the flight.
Investigation could find no definitive reason for the exit to
move and it is suspected outside interference might have
been involved.
Britten-Norman BN2A20 Power lever rod end failed.
SDR 510016385
LH engine throttle control rod end failed in threaded area.
(three similar defects)

Beech 200 Wing attach nut incorrect part.

SDR 510016545
During wing bolt replacement it was found that the nuts
supplied with wing bolt replacement kit (P/No: 10140831)
were the incorrect part and failed before reaching
desired torque. Investigation found some kits had been Cessna 152 Elevator tab actuator worn.
supplied with incorrect nuts. P/No: 132797LF1612. SDR 510016394
(One other similar defect) Trim jack actuator worn beyond limits. P/No: 12600741.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 49
Cessna 152 Fuselage floor panel cracked. Cessna 182P Rudder attach fitting corroded.
SDR 510016627 SDR 510016337
Cabin floor cracked in two areas under aft end of Rudder upper attachment fitting separated and
centre seat rails. Crack lengths approximately 50.8mm badly corroded.
(2in). Found during inspection iaw SID 53-47-01.
One crack had an illegal repair attempt.
P/No: 04102381. TSN: 6759 hours/408 months.

Cessna 152 Fuselage bracket cracked.

SDR 510016393
Fuselage bracket cracked. Found during SID 55-11-02.
P/No: 04320049. TSN: 6765 hours.
Cessna 152 Main landing gear support loose.
SDR 510016626
Main landing gear support hi-lock pins (3off)
loose. Found during inspection iaw SID 32-13-02.
P/No: 04412092. TSN: 6759 hours/408 months.
Cessna 152 Rudder torque tube cracked.
SDR 510016619 Cessna 208B Main landing gear strut incorrect
Rudder pedal torque tubes P/Nos: 0411526-1 and part. SDR 510016400
0411526-2 cracked. Found using dye penetrant Incorrect main landing gear legs and centre springs
inspection iaw Cessna SID 27-20-01 and AD/C150/39. fitted. Parts were for a Cessna 208, not a 208B.
P/No: 04115261. TSN: 6759 hours/408 months. P/No: 2641013200.
Cessna 152 Rudder spar cracked. SDR 510016628 Cessna 340 Landing gear position switch
Rudder spar cracked in area below upper hinge point. intermittent. SDR 510016642
Found during inspection iaw SID 55-41-01. LH main landing gear downlock switch intermittent
P/No: 04330109. TSN: 6759 hours/408 months. in operation. P/No: 1SE13.
Cessna 172R Trailing edge flap control cable Cessna 404 Engine tacho generator u/s.
corroded. SDR 510016577 SDR 510016651
Trailing edge flap cables P/Nos.: 0510105-193 (2off) Engine tacho generator incorrectly fitted to mounting
and 0510105-194 had corrosion pitting at the cable ends. pad causing bevel gear teeth to be loaded up and
P/No: 05101 (2off). TSN: 10,685 hours. eventually shear off. Investigation found square drive
diameters on tachometers could vary by up to
0.2032mm (0.008in), causing different assembly loads.
P/No: 22A667. TSO: 3 hours.
50 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Service difficulty reports

Cessna 404 Flight control link broken. Gulfstream 500S Wing attach fitting cracked.
SDR 510016526 SDR 510016415
Link assembly snapped. Limited information provided. Wing to fuselage attachment fitting cracked.
P/No: 086170046. TSN: 14,098 hours/13,495 cycles. Found during inspection iaw AD/AC/93.
Cessna 404 Landing gear blowdown bottle empty. P/No: WINGSTA24. TSN: 31,833 hours.
SDR 510016652 Kavanagh E240 Balloon load frame cracked.
Landing gear emergency blowdown bottle empty. SDR 510016492
Investigation found the valve was cracked, allowing bottle Balloon burner load frame cracked.
to discharge. Suspect shuttle valve also sticking.
P/No: 99101543. TSN: 4561 hours/720 months.
TSO: 444 hours/13 months.
Cessna 441 Hydraulic line u/s. SDR 510016389
Landing gear hydraulic pressure line failed during
landing gear blowdown test. Investigation found line
was corroded in area beneath air conditioning duct.
P/No: 571702227. TSN: 11,897 hours/11,277 cycles.

Mitsubishi MU2B20 Wing skin corroded.

SDR 510016636
Wing lower skin inner surface contained intergranular
corrosion in numerous areas. Corrosion was found
to be beyond limits and was full skin thickness
(0.060in - 1.524mm) in some areas. Wing corroded
Cessna 441 Wing spar disbonded. SDR 510016608 beyond repair. P/No: 017A11021.
Wing rear spar disbonded in area between WS 34.25 Pilatus PC12 Cabin pressure sensor failed.
WS 82.3. Found during inspection iaw AD/ C400/103. SDR 510016585
P/No: 572216525. TSN: 23,754 Hours/19,307 Cycles. Environmental control system (ECS) duct temperature
Cessna A150M Stabiliser attach bracket cracked. sensor/switch unserviceable.
SDR 510016599 P/No: 9738132122. TSN: 15,149 hours/11,916 cycles.
Horizontal stabiliser rear attachment bracket cracked Pilatus PC12 Hydraulic pressure switch
in two places on lower aft edge. unserviceable. SDR 510016541
P/No: 043200410. TSN: 4887 hours Hydraulic system high-pressure switch unserviceable.
Cessna T303 Elevator trim tab cracked. P/No: 9738114306. TSN: 8113 hours/10,671 cycles.
SDR 510016589 Pilatus PC12 Hydraulic relay sticking.
RH elevator trim tab lower skin cracked in area of control SDR 510016616
arm attachment. P/No: 25340171. TSN: 8511 hours. Hydraulic power pack relay stuck in engaged
Embraer EMB500 Tyre FOD. SDR 510016595 position, causing hydraulic system to continually cycle.
RH main landing gear tyre destroyed by FOD on runway. P/No: 9740926112.
FO (a broken brake adjuster housing from a large aircraft) Pilatus PC12 Pitot tube failed. SDR 510016612
cut a 31.75mm (1.25in) hole through all plys of th tyre. Discrepancy in air speed indications. Investigation found
P/No: 215K261. TSN: 26 hours/31 landings. pitot system plastic tube damaged adjacent to marker in
Grob G115B Emergency locator beacon strap LH wing adjacent to inboard side of aileron. Plastic tubing
deteriorated. SDR 510016593 appeared to be cut/scored. P/No: 9179505004.
ELB Velcro strap deteriorated due to exposure to sunlight Piper PA28151 Main landing gear bolt sheared.
while sitting on rear parcel shelf. SDR 510016407
P/No: S182051201. TSN: 2201 hours. RH main landing gear lower torque link attachment bolt
sheared and fell out. Lower section of landing gear and
wheel separated from aircraft. Bolt sheared in area where
the bolt thread met the shank. P/No: 400165AN522.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 51
Piper PA28R201 Nose landing gear bolt sheared. Piper PA34220T Rudder torque tube cracked.
SDR 510016429 SDR 510016441
Nose landing gear torque link bolt sheared and seized in Rudder torque tube cracked.
torque link bushings due to corrosion/lack of lubrication. P/No: 9621200. TSN: 3631 hours/384 months.
Torque link half. P/No: 20735-05 also found to be cracked Piper PA42 Engine mount rusted. SDR 510016450
at the bushing. LH and RH engine aft engine mount frames corroded
(rusted). Rust caused holes in the mounts. Suspect rust
started internally and worked through to the exterior.
P/No: 7019029. TSN: 7799 hours/7031 cycles.

Piper PA44180 Hydraulic power pack failed.

SDR 510016458
Hydraulic power pack motor brushes stuck,
preventing motor from running pump.
P/No: HYC5005. TSN: 9007 hours.
Swearingen SA22AC Hydraulic pipe worn and
damaged. SDR 510016539
Hydraulic pipe worn and holed. Loss of hydraulic fluid.
Pipe located in RH wing behind spar.

Swearingen SA227DC Aileron chain worn and

damaged. SDR 5100216542
Aileron control column chain partially seized.
Investigation found link roller damaged/cracked.
photograph. P/No: 2771026001. TSN: 18,862
hours/14,122 cycles.
Swearingen SA227DC Directional gyro u/s.
SDR 510016524
RH directional gyro unserviceable. P/No: 6226136002.
TSO: 703 hours/647 cycles.
52 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Service difficulty reports

Swearingen SA227DC Wing attach fittings cracked. COMPONENT

SDR 510016427 Evacuation slide CO2 cylinder leaking.
LH and RH wing spar fittings P/Nos: 27-22121-011, SDR 510015571
27-22135-006 and 27-22136-006 cracked. Found Escape slide CO2 cylinder leaking. Suspect green fitting
during eddy current inspection iaw SB CC7-53-006 attaching pressure head to cylinder defective. P/No:
and ultrasonic inspection iaw SB CC7-53-006 and D17862107. TSN: 23,690 hours/20,009 Landings/137
AD 2012-18-01. P/No: 2722121011. months. TSO: 2 months. (Three similar defects)
TSN: 29,113 hours/35,211 cycles.
Propeller blades loose. SDR 510016014
Propeller blades abnormally loose in hub.
Investigation continuing. P/No: HCC3YR2UF.
TSO: 2225 hours/36 months.
Engine make/model unknown.Tappet body spalled.
SDR 510015987
Severe spalling on tappet bodies. Camshaft lobes worn
severely. P/No: 72877. TSN: 1292 hours.
PISTON
Continental IO520M Engine adapter cracked and
Swearingen SA227DC Landing gear solenoid leaking. SDR 510016506
valve faulty. SDR 510016480 LH engine oil pump cover/tacho drive adapter cracked
Landing gear hydraulic solenoid valve faulty. and leaking. P/No: 631056A1. TSN: 1000 hours.
Investigation continuing. P/No: 246006. Lycoming IO540AE1A5 Engine exhaust collector
TSO: 5692 hours/3501 cycles. cracked. SDR 510016387
Swearingen SA227DC Power lever cable u/s. Exhaust muffler RH collector cracked and bulging at
SDR 510016582 connection. P/No: C1696. TSN: 870 hours.
LH power lever forward teleflex cable binding then Lycoming IO540AE1A5 Magneto u/s.
seizing. P/No: 3219012123. SDR 510016423
Swearingen SA227DC Wheel bearing u/s. RH magneto unserviceable. See SDR510016421
SDR 510016426 for associated defect.
RH outboard main wheel bearing inner race seized on P/No: 10600646201. TSN: 1 033 hours.
axle. Tyre deflated. Investigation found four of six wheel Lycoming IO540AE1A5 Engine manifold cracked.
tie bolts loose. Investigation continuing to determine SDR 510016353
sequence of events and initial failure mode. Engine intake manifold cracked in two places at weld.
TSO: 204 hours/134 cycles. P/No: D7301. TSN: 572 hours.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 53
Lycoming IO540AE1A5 Engine manifold cracked. Lycoming LTIO540J2BD Engine fuel distribution
SDR 510016663 pipe cracked. SDR 510016587
Engine intake manifold cracked in several places. RH engine fuel nozzle air supply line cracked and broken
P/No: D7301. under attachment clamp. Evidence of weld repair in area.
P/No: 75332. TSO: 502 hours.

Lycoming O320H2AD Magneto gasket suspect

Lycoming IO540K1A5 Engine piston ring faulty. SDR 510016444
unserviceable. SDR 510016649 Magneto gasket P/No: LW12681 suspect thinned/
Nos. 4 and 5 pistons had broken oil control rings. deteriorated, allowing magneto to rotate to the retarded
Ring lands also damaged. Piston pin bores also worn position. Clamp P/No: 66M19385 found to be torqued
by up to 0.254mm (0.010in). P/No: 14H21950. correctly but magneto could still be turned by hand.
TSN: 2013 hours. TSN: 230 hours.
Lycoming O360A1G6 Engine power section
tappet body worn. SDR 510016445
Metal contamination of engine oil filter. Suspect caused
by worn tappets. Investigation continuing.
P/No: 15B26064.
Lycoming O360A3A Engine camshaft worn.
SDR 510016413
No. 4 cylinder camshaft lobe worn. Metal contamination
of oil system. P/No: LW18837. TSO: 1180 hours.
Lycoming O360J2A Engine exhaust valve u/s.
SDR 510016635
No. 1 cylinder exhaust valve cracked, with a piece of
the valve missing. TSO: 466 hours.
Lycoming O540F1B5 Engine nut missing.
SDR 510016631
Engine low on power. Initial investigation found metal
contamination of the oil filter. Further investigation
found the idler gear support nut missing, with one
camshaft gear tooth broken. Suspect nut came loose
and caused the additional damage. Lockwire pieces
found in the sump. P/No: O540F1B5.
TSN: 4,00 hours. TSO: 123 hours.
54 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Service difficulty reports

Lycoming TIGO541E1A Engine piston worn and Lycoming TIO540A2C Magneto u/s. SDR 510016485
damaged. SDR 510016650 LH engine LH magneto failed. Seized drive shaft and
Metal contamination of oil filter. Investigation found piston metal contamination inside housing. P/No: 103492901.
skirts contacting crankshaft. Further investigation found TSN: 393 hours.
the piston skirts were longer and different. Unknown model Engine crankcase cracked.
P/No: LW10545. TSO: 263 hours. SDR 510016371
Engine crankcase cracked at No. 2 cylinder top
LH stud. Crack length approximately 25.4mm (1in).
P/No: LW11036. TSO: 1456 hours.
PROPELLERS
Hartzell HCB4MP3C Propeller hub leaking.
SDR 510016501
Oil leaking from area of RH propeller hub. Suspect
internal damage to piston or seal. Investigation
continuing. TSN: 4527 hours. TSO: 340 hours.
McCauley 2D34C9 Propeller spinner incorrect fit.
SDR 510016432
Propeller spinner and forward spinner bulkhead missing.
Aft spinner bulkhead the incorrect part for this aircraft,
Lycoming TIO540A2C Exhaust turbocharger which had been received for painting by maintenance
contamination-metal. SDR 510016647 organisation. P/No: 1699600115.
Engine failed to produce boost at altitude. Investigation
found ferrous swarf in the turbine exhaust housing. MTV MTV6AC187 Propeller governor u/s.
P/No: 4066109020. TSO: 554 hours. SDR 510016550
RH propeller constant speed unit (governor) base
defective. Found during inspection iaw MT-propeller
SB.27. TSN: 345 hours.
MTV MTV6AC187 Propeller governor u/s.
SDR 510016551
LH propeller constant speed unit (governor)
base defective. Found during inspection iaw
MT-propellerSB.27. TSN: 345 hours.
Rotol R3754123F21 Propeller wiring harness
worn and damaged. SDR 510016530
RH propeller autocoarsen solenoid earth wire open
circuit. Investigation found wire KF606-20 worn in area
behind plug 162VP-J7. Caused by contact with wire
Lycoming TIO540A2C Fuel control unit (FCU) u/s. HE-662-1201 (plug 16 VP-J9). Wiring harness damaged.
SDR 510016390
RH engine FCU unserviceable. Small amount of fuel
residue in the air diaphragm. P/No: 252416315.
TSO: 319 hours.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 55
ROTORCRAFT Bell 206B3 Fuselage corroded. SDR 510016594
Agusta Westland AW139 Fire detector failed. Investigation during strip-down found extensive
SDR 510016470 corrosion and delamination/disbonding beyond limits
No. 1 engine fire detector failed during flight. in many components including LH and RH upper
Suspect internal failure. P/No: 636013450170C10M. longerons; LH and RH passenger seat, fuselage
TSN: 2,508 hours. outer tub, passenger seat back rest. TSN: 13,772
hours/14,840 cycles.

Agusta Westland AW139 Main rotor gearbox

bearing faulty. SDR 510016469
Main rotor gearbox magnetic chip detector illuminated
during flight. IMetal particles on chip detector. Lab
examination confirmed the particles to be bearing
material. P/No: 3G6320A00135. TSN: 543 hours.

Bell 206B3 Tail rotor gearbox cracked and leaking.

SDR 510016431
Tail rotor gearbox case cracked and leaking in area
around the forward LH mount boss. Investigation
also found rear bulkhead fitting P/No: 206-030-446-001F
cracked. P/No: 206040425127131135. TSO: 1841 hours.
Bell 412 Engine work deck delaminated.
Bell 206B3 Main rotor transmission isolation SDR 510016467
mount faulty. SDR 510016611 LH engine work deck delaminated. P/No: 205030280127.
Main transmission isolation mount unserviceable. TSN: 5,185 hours.
Drive shaft contacted mount top plate during start-
up. Replacement (new) isolation mount similarly
unserviceable and the drive shaft again contacted the
mount top plate. Suspect replacement mount defective
from new. P/No: LB9130111SNLK10432.
56 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Service difficulty reports

Bell 412 Main rotor combining gearbox Eurocopter AS332L Nose landing gear (NLG) u/s.
contamination-metal. SDR 510016662 SDR 510016408
Combining gearbox metal contamination with small NLG strut lost oil pressure. Lower plug (attachment bolt)
slivers found on chip detector plug. Chips within failed, allowing loss of oil and gas from strut.
limits and aircraft returned to service after cleaning. P/No: C239437. TSN: 10,822 hours.
P/No: 311718001. TSN: 5,340 hours. TSO: 257 hours.
Bell 412 Main rotor mast seal leaking.
SDR 510016592
Main rotor mast seal leaking. Suspect seal defective.
Seal is a recently released type.
P/No: 412340001101. TSN: 2 hours.
Bell 412 Marker beacon receiver contamination-
water. SDR 510016357
Marker beacon receiver water contamination from
torrential rain associated with cyclone. Smoke and fumes
in cockpit. P/No: 066104400. TSN: 6953 hours.
Bell 429 Fuselage air scoop damaged.
SDR 510016410
LH top transmission cowl starter/generator intake
scoop cracked, with a section missing.
P/No: 429061202101.
Bell 429 Main rotor swashplate fitting u/s.
SDR 510016412
Swashplate grease fittings unserviceable. Following
regreasing, the ball in the fitting did not reseat. Ball and
spring nut in the fittings had separated and entered the
swashplate area. Bell information letter (Gen-03-88)
indicates fittings P/No: NAS51614 are defective.
TSN: 254 hours.
Bell 429 Crew door bolt suspect faulty.
SDR 510016658
LH crew door release mechanism handle release striker
bolt loose. The bolt was re-torqued but once again
loosened when the external handle was operated.
P/No: 31741. TSN: 297 hours. TSO: 297 hours.
Eurocopter AS332L Main rotor transmission Eurocopter AS350BA Throttle u/s. SDR 510016633
contamination-metal. SDR 510016581 Loss of throttle control on pilot's collective stick. Throttle
Main transmission chip detector contaminated with gimbal joint/rod assembly P/Nos. 350A27320800 and
a large number of ferrous chips. Gearbox removed 350A273208-01 broken. (See SDR 510009307 for similar
for further investigation and overhaul. defect). TSN: 3347 hours.
P/No: 332A32100703X. TSN: 6196 hours.
Eurocopter AS365N Fuel boost pump u/s.
TSO: 85 hours.
SDR 510016381
No. 1 fuel boost pump failed.
P/No: P9416606. TSO: 677 hours.
Eurocopter AS365N Tail rotor control link u/s.
SDR 510016376
Yaw system force link failed preventing disengagement
of the autopilot yaw system during manual input.
P/No: 365A27376106.
Kawasaki BK117B2 Main rotor blade cracked.
SDR 510016443
Main rotor blades (4off) cracked chordwise in metal
erosion strips on blade leading edge. P/No: 117150071.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 57
Kawasaki BK117B2 Tail rotor drive shaft bearing Robinson R22 Beta Engine air intake filter cracked.
u/s. SDR 510016540 SDR 510016497
Tail rotor long driveshaft forward bearing unserviceable. Engine air filter cracked. P/No: A7711. TSN: 100 hours.
Bearing missing the mounting rubber and appeared
to have contacted the drive shaft. Rubber sleeve had
disintegrated on the forward flange, allowing it to move
rearwards. Bearing also appeared partially seized.
P/No: BB1B649781B. TSN: 1847 hours/40 months.

Robinson R44 Engine collector cracked.

SDR 510016387
Exhaust muffler RH collector cracked and bulging at
connection. P/No: C1696. TSN: 870 hours.
Robinson R44 Engine tachometer u/s.
SDR 510016421
Dual tachometer (engine/rotor) unserviceable.
P/No: C7923. TSN: 1032 hours.
Robinson R44 Manifold pressure sense line worn.
SDR 510016399
Manifold pressure sense line worn through at
RH engine mount attachment. Engine mount
attachment screw lockwire rubbing on sense line.
P/No: C7401. TSN: 281 hours.
Robinson R66 Engine/transmission clutch leaking.
SDR 510016600
Engine to transmission clutch/freewheel assembly
leaking P/No: F0181. TSN: 367 hours/515 cycles.
Sikorsky S76A Hydraulic hose failed.
SDR 510016591
Nose landing gear up hydraulic hose burst.
Loss of hydraulic fluid. P/No: SS48CT3A132000.
Kawasaki BK117B2 Vertical stabiliser plate cracked.
SDR 510016504 Sikorsky S76A EFIS symbol generator
RH horizontal stabiliser end plate (vertical fin) cracked. contamination-water. SDR 510016580
P/No: 11730641. First officer's electronic flight instrument system
(EFIS) screens flickered and went blank. EFIS symbol
generator contaminated with water due to operations in
heavy rain. P/No: 7011672708. TSN: 4505 hours.
Sikorsky S76A Main rotor gearbox liner suspect
faulty. SDR 510016342
Main transmission jet bore liner suspect faulty. Liner
found to be protruding by approximately 0.762mm
(0.030in). Investigation found a longer liner had been
fitted, but was still correctly seated. Found during
inspection iaw SB 76-66-50. TS-065-2B had also
been incorporated. TSN: 13,395 hours. TSO: 1 hour
(One other similar defect)
58 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Service difficulty reports

Sikorsky S76C Central display u/s. SDR 510016339 PWA PT6T3D Fuel control unit (FCU) contaminated.
Remote data acquisition unit (RDAU) unserviceable. SDR 510016514
P/No: 7645001098109SN2100. TSN: 546 hours. No. 1 engine fuel control unit (FCU) suspect faulty due
TSO: 546 hours. to nil response to throttle. Investigation found a piece of
O-ring in P3 orifice. P/No: 324488310. TSN: 2424 hours.
TURBINE ENGINE TSO: 299 hours.
Allison 250C20B Engine fuel tube cracked.
SDR 510016459
Engine fuel tube cracked under ferrule and leaking.
P/No: 6875632D. TSN: 3754 hours.
GE CFM567B HMU u/s. SDR 510016494
No. 2 engine hydromechanical unit (HMU) unserviceable.
P/No: 1853M56P14. TSN: 17,308 hours/10,238 cycles.
Lycoming ALF5071F Turbine engine compressor
seal leaking. SDR 510016465
Oil smell noticed in cabin. Boroscope of No. 3 engine
found oil wetness at the inlet to the high-pressure
compressor. Suspect No. 1 bearing oil seal leaking.
Investigation continuing. P/No: 231308401.
PWA PT6A41 Turbine engine contamination-metal. PWA PW118A Turbine engine oil system hose burst.
SDR 510016430 SDR 510016365
RH engine chip detector indication. Investigation found LH engine oil cooler hose burst. Loss of engine oil.
metal on detector and in oil filter. Engine removed for Evidence of rubbing, with braiding worn and broken.
further investigation. P/No: PT6A41. P/No: 1593731.
PWA PT6A42 FCU suspect faulty. SDR 510016623
LH engine experienced an uncommanded acceleration
which reached the torque limiter setting. Suspect faulty
fuel control unit (FCU). Investigation continuing.
P/No: 324476814.
PWA PT6A60A Turbine engine reduction gear
O-ring incorrect part. SDR 510016503
Engine reduction gearbox leaking. Investigation found
an incorrect seal between the thrust bearing cover and
No. 7 bearing. Seal was P/No AS3209159, but the
correct part number is AS3209252.
TSN: 4899 hours. TSO: 990 hours.
PWA PT6A60A Turbine blade cracked.
SDR 510016502 PWA PW118A Turbine engine oil system hose
Engine compressor turbine blades cracked at blade leaking. SDR 510016363
tips. Investigation also found evidence of minor tip LH engine oil return hose leaking. Hose had been
rub on the shroud segments. P/No: 312111101. rubbing - hose braiding worn. P/No: 12036021001.
TSO: 1,790 hours/2,706 cycles.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 59
PWA PW118A Turbine damaged. SDR 510016605 Turbomeca Arriel 2B Fuel controlling system
LH engine oil pressure low, followed by engine failure. pipe broken. SDR 510016352
Initial investigation found turbine extensively damaged. Engine P3 labyrinth pipe broken. P/No: 0292687310.
No. 6/7 bearing housing failed. No. 6/7 bearing oil supply
pipe and transfer tube failed. Investigation continuing.
PWA PW123E Fuel heater u/s. SDR 510016489
RH engine fuel heater unserviceable. Fuel temperature
rose above 57 degrees C.
P/No: WA19888. TSN: 18,523 hours/19,647 cycles.
PWA PW123 Turbine engine leaking.
SDR 510016435
RH engine shut down, with numerous caution indications.
Passenger reported oil streaming from engine. Initial
investigation found oil all over the engine from a broken Turbomeca Arriel 2B Turbine engine reduction
oil feed line. Further investigation found metal on the gear seal incorrect fit. SDR 510016499
gearbox chip detector and no drive between the starter Engine output shaft magnetic seal incorrectly fitted,
and gearbox. Suspect failed tower shaft or gears. with the carbon surface facing away from the machined
Investigation continuing. surface and causing oil leakage. P/No: 9560137520.
PWC PW127M Turbine engine power loss. TSN: 2667 hours/2939 cycles/3678 landings.
SDR 510016360 Turbomeca Arriel 2S Turbine engine leaking.
No. 1 engine momentary loss of power (2 seconds) SDR 510016620
before returning to normal. Investigation could find No. 1 engine oil leak. Oil coming from the area of
no definitive cause for the defect and aircraft was Nos. 3 and 4 module bolt split joint and liaison tube.
returned to service. Investigation continuing. P/No: 0292005450.
Rolls-Royce TAY65015 Engine oil filter TSN: 1740 Hours. TSO: 1740 hours.
contamination-metal. SDR 510016437 Turbomeca Arriel 2S Turbine engine leaking.
Metal contamination of No.2 engine oil filter. SDR 510016340
High speed gearbox oil return chip detector No. 1 engine fire warning. Excessive oil leaking
also contaminated. Engine removed for from module 3/4 flange area. No evidence of fire.
further investigation. Investigation continuing. P/No: 0292025170.
Turbomeca Arriel 1C Turbine engine turbine TSN: 3487 hours. TSO: 574 hours.
blades u/s. SDR 510016377
No. 1 engine first stage gas generator turbine
blades unserviceable. Investigation could find no
record of any temperature, pressure, overspeed or
environmental abnormalities and washes had
been carried out iaw manufacturer’s data.
P/No: 70BM035620. TSN: 4591 hours/8129 cycles.
TSO: 1598 hours/3487 cycles.

TO REPORT URGENT DEFECTS

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

Online: www.casa.gov.au/airworth/sdr/
REGULARS
62 Quiz
72 Frying tonight
76 Icing in the USA
78 Complacency can kill
80 ATSB
88 Airservices
90 Accidents
96 Flight bytes
100 Calendar
102 Product review
102 Coming next issue
62 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Av quiz

FLYING OPS
1. At an altitude of 5000 feet, the theoretical VHF range of a ground station at an
elevation of 1000 feet is approximately:
a) 88 kilometres.
b) 68 kilometres.
c) 88 nautical miles.
d) 68 nautical miles.

2. Flight levels are:

a) pressure heights.
b) density heights.
c) pressure heights corrected for pressure deviations from ISA.
d) density heights corrected for temperature deviations from ISA.

3. When chocking an aircraft (particularly a tailwheel type) with only two

chocks, and considering the effect of wind:
a) one should be placed in front of the upwind wheel and the other behind the
downwind wheel.
b) one should be placed behind the upwind wheel and the other in front of the
downwind wheel.
c) both should be placed in front of the main wheels.
d) they should be placed at the front and the back of the tail wheel.

4. EOBT means:
a) estimated out and back time.
b) elapsed out and back time.
c) estimated off block time.
d) estimated on board time.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 63
5. When ‘sailing’ downwind tail first in a float plane, the water rudders:
a) supplement the main rudder and should be left extended for improved control.
b) supplement the main rudder and should be retracted to avoid over control.
c) oppose the main rudder and should be left extended for stability.
d) oppose the main rudder and should be retracted.

6. Wheelbarrowing is a term used to describe, during landing, the:

a) transferring of weight to the nose wheel by attempting to push the aeroplane onto
the ground.
b) ground contact with the main wheels first.
c) ground contact with the tail wheel first.
d) tendency of tailwheel aeroplanes to run off the runway.

7. Tailwheel aircraft are directionally unstable:

a) in the air because of the loss of stabilising effect from the nose wheel.
b) on the ground because the forward fuselage tends to blanket the fin.
c) on the ground because the main wheels are positioned forward of the centre of gravity.
d) on the ground because the main wheels are positioned aft of the centre of gravity.

Photo: Civil Aviation Safety Authority

64 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Av quiz

8. In considering a transponder for use with an ADS-B installation the appropriate

technical standard order (TSO) would be:
a) TSO-C166.
b) TSO-C166 with UAT capability.
c) TSO-C146.
d) TSO-C196.

9. The best power-off glide speed corresponds to the:

a) best lift-drag ratio and increases with decreasing weight.
b) best lift-drag ratio and reduces with decreasing weight.
c) lowest induced drag and increases with decreasing weight.
d) lowest induced drag and reduces with decreasing weight.

10. The positional accuracy of primary radar:

a) decreases with range due to the influence of the ionosphere.
b) increases with range due to the energy of the reflected return signal.
c) decreases with range due to the divergence angle of the transmitted beam.
d) increases with range due to the divergence angle of the transmitted beam.

Photo: Civil Aviation Safety Authority

Flying ops answers

1(c) an approximate formula is 1.4 times the square root of the differences in height in feet. 2(a) 3(b) to have maximum resistance to
weathercocking. 4 (c) introduced with the November 2012 NAIPS changes. 5(d) 6(b) is the correct way to land. Answer a) – wheelbarrowing is a
common cause of accidents. 7(c) Answer b) – can, in some instances, cause control difficulty. 8(a) 9(b) 10(c)
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 65

MAINTENANCE
1. In the absence of any manufacturer’s instructions, one method for preparing
the interior of empty rubber bag fuel tanks that have contained Avgas is to:
a) liberally coat the inside of the bag with a 50-50 mixture of fuel and engine oil.
b) dry the inside with compressed air.
c) use engine-preserving oil to coat both sides of the bag.
d) fill the bag with fuel.

2. If the lead from the starting vibrator to the retard magneto points in a piston
engine ignition system is shorted to the outer shielding braid:
a) the magneto will only operate in the running mode.
b) the magneto will not operate in any mode.
c) the magneto will only operate in the starting mode.
d) the starting spark will be advanced and kick back may occur.

3. An antenna-tuning unit associated with an HF radio installation:

a electrically matches the transmitter and feed line to the antenna and must be
readjusted if the frequency is changed.
b) electrically matches the transmitter and feed line to the antenna and, once
correctly adjusted, the settings are correct for all frequencies.
c) fine tunes the receiver.
d) fine tunes the transmitter.

4. With respect to the effect of fuel on aircraft composite structures:

a) Avgas as well as Mogas may dissolve the structure, in particular the laminates.
b) Avgas as well as Mogas may dissolve the structure, in particular the foam filler.
c) Avgas does not pose a risk because it does not contain toluene.
d) Mogas does not pose a risk because it does not contain toluene.
66 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Av quiz

5. A magnetic particle inspection (MPI) during which a DC

current is passed through the part is termed:
a) longitudinal magnetisation and is used for detecting cracking in a
circumferential direction.
b) longitudinal magnetisation and is used for detecting cracking in a
longitudinal direction.
c) circular magnetisation and is used for detecting cracking in a
circumferential direction.
d) circular magnetisation and is used for detecting cracking in a
longitudinal direction.

6. In a dynafocal engine mount system:

a) each mount has an opposing mount on an opposite radius.
b) the mounts are at the same radius from the crankshaft.
c) the extended lines of the stress axes of the mounts are radial to the
crankshaft or main-shaft.
d) the extended lines of the stress axes of each mount meet at or near
the centre of gravity of the engine.

7. An existing GNSS receiver is suitable for use with a proposed ADS-B

installation providing it:
a) meets either TSO C145 revision A or later, TSO 146 revision A or later, or
TSO 196.
b) has integrity monitoring.
c) is an IFR-approved type.
d) has mode C and mode S capability and extended squitter.

8. In Australia, a transponder used in an ADS-B installation must:

a) be certified to TSO C146 revision A or later.
b) be certified to TSO C145 revision A or later.
c) not have an active UAT capability.
d) have both 1090 MHz and UAT capability.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 67
9. ATA Chapter 57-40 refers to:
a) fuselage skins.
b) wing skins.
c) wing attach fittings.
d) stabiliser attach fittings.

10. Standard hardware part number NAF213790 refers to a:

a) corner anchor nut.
b) check nut.
c) nut for electrical use.
d) brass manifold nut.

Photo: Civil Aviation Safety Authority

Maintenance answers
1(a) from an old CAA Airworthiness Advisory Circular. 2(b) 3(a) 4(b) 5(d) in circular magnetisation, the flux direction is circumferentially around
the part. 6(d) 7(a) Because additional validity or monitoring outputs are required to the transponder, not all existing IFR GNSS receivers are
suitable for use with an ADS-B installation. See AC21-45(1). 8(c) the UAT frequency spectrum is not available in Australia, so UAT must not be used.
9(c) 10(d)
68 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Av quiz

IFR OPERATIONS
The following questions relate to a typical general aviation piston twin-engine aircraft.
The engines are normally aspirated wing mounted, as distinct from centre line thrust,
and are clockwise rotating when viewed from the pilot’s seat.

1. Which of the following best describes the definition of minimum control

speed (Vmc)?:
a) It is the lowest true airspeed (TAS) at which directional control can be maintained
by the use of rudder in an asymmetric flight condition.
b) It is the lowest indicated airspeed (IAS) at which directional control can be maintained
by the use of rudder in an asymmetric flight condition.
c) It is the lowest IAS at which all control surfaces (rudder, ailerons, and elevators/
stabilator) will be effective in maintaining control of the aircraft in any flight situation,
whether symmetric or asymmetric.
d) It is the lowest IAS at which all control surfaces will be effective in maintaining control
of the aircraft in an asymmetric flight situation.

2. Which of the following best shows the flight conditions in which Vmc
is determined?
a) The aircraft is at MTOW with a forward CG. It is factored for sea level (ISA) with the
failed (critical) engine’s propeller windmilling. Rudder trim has been applied to ease
rudder control input from the pilot, with up to 5 degrees angle of bank towards the
‘live’ engine permitted.
b) The aircraft is at MTOW with an aft CG. It is factored for sea level (ISA) for maximum
performance from the aircraft and to further assist performance, the failed engine’s
propeller is feathered. Rudder trim is applied and up to 5 degrees angle of bank
is permitted.
c) The aircraft is at MTOW (aft CG) and factored for sea level (ISA) and the failed (critical)
engine’s propeller is windmilling. No rudder trim is applied and up to 5 degrees angle
of bank is permitted.
d) The aircraft is at MTOW (aft CG) factored for sea level (ISA), with the ‘live’ engine
developing full power and the failed (critical) engine’s propeller windmilling. No rudder
trim is applied, and up to 5 degrees bank angle towards the ‘live’ engine is permitted.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 69
3. What is the purpose of applying up to 5 degrees angle of bank toward the ‘live’
engine in an asymmetric condition?
a) Rudder control input alone is reduced
b) Aircraft performance (climb, cruise, descent) alone is improved
c) Both rudder control input is reduced and aircraft performance improved
d) The aileron application prevents a slip towards the failed engine, thus keeping
the aircraft balanced
e) Both c) and d) are correct

4. Which of the following is the correct definition of take-off safety speed (Vtos)?
a) It is the minimum speed at which control of the aircraft will be ensured on take-off and
climb, taking into account turbulence and sudden complete engine failure. It is 1.1 x Vmc
for light multi- engine aircraft.
b) It is the speed that ensures control of the aircraft under existing conditions, including
turbulence and sudden complete engine failure. It is 1.2 x Vs1 (Stall speed in the
configuration being considered).
c) It is the speed that ensures both control and continued climb performance on
the aircraft under existing conditions, including turbulence and sudden complete
engine failure.
d) It is the speed that ensures control of the aircraft under existing conditions, including
turbulence and sudden complete engine failure. It is 1.3 x Vso or 1.23 Vs1

Photo: Civil Aviation Safety Authority

70 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Av quiz

Photo: iStockphoto

5. What does Vyse represent?

a) It is the best single-engine angle of climb speed, shown typically as a blue line on the ASI.
b) It is the best single-engine rate of climb speed, shown typically as a red line on the ASI.
c) It is the best single-engine rate of climb speed, shown typically as a blue line on the ASI.
d) It is the lowest speed at which an intentional simulated engine failure should be
introduced during training.

6. What effect will a weight reduction have on both the best single-engine rate of
climb speed and climb performance?
a Vyse will reduce, but rate of climb will increase.
b) Both Vyse and rate of climb will increase.
c) Both Vyse and rate of climb will decrease.
d) Vyse will increase, but rate of climb will decrease.

7. Which of the following best describes the definition of critical engine, and which
engine would that be on our subject aircraft?
a) It is the engine fitted with an auxillary service such as a hydraulic pump for raising and
lowering of undercarriage and flaps. Thus, if that engine fails, it will create the additional
problem of having to hand pump the gear and flaps. It could be either engine on our
subject aircraft, depending on which one has the pump.
b) It is the engine that if it fails will create the greatest yaw rate towards the failed engine.
It is the right engine on our subject aircraft.
c) It is the engine that if it fails will create the least yaw rate towards the failed engine.
It is the left engine on our subject aircraft.
d) It is the engine that if it fails will create the greatest yaw rate towards the failed engine.
It is the left engine on our subject aircraft
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 71
8. What is ‘asymmetric blade effect’ and on which engine of our subject aircraft
will this effect be the greatest?
a) It is the displaced thrust towards the upgoing propeller blades, and thus has the
greatest effect on the operative left engine.
b) It is the displaced thrust towards the downgoing propeller blades, and thus has the
greatest effect on the operative left engine.
c) It is the displaced thrust towards the downgoing propeller blades, and thus has the
greatest effect on the operative right engine.
d) It is the displaced thrust towards the upgoing propeller blades, and thus has the
greatest effect on the operative right engine

9. Which of the following are further considerations in determining the severity

of yaw following an engine failure?
a) Torque effect
b) Slipstream effect
c) Gyroscopic effect
d) All of the above

10. If the aircraft was to be fitted with counter-rotating engines and propellers,
this is considered to be ‘beneficial’ as distinct from ‘conventional’ rotation.
Which of the following correctly lists the effects that are altered to achieve
this advantage?
a) Asymmetric blade, torque, slipstream and gyroscopic effects
b) Asymmetric blade, torque and slipstream effects
c) Torque, slipstream and gyroscopic effects
d) Asymmetric blade effect only

IFR answers
1(a) Normally shown on the ASI as a red line. 2(d) Essentially in defining Vmc, the conditions are mainly ‘worst-case scenario’ (with the
exception of the 5-degree bank angle). Remember also that SL is worst-case since power output on the normally aspirated engine is greatest
down here; that is, greatest yaw. 3(e) The 5-degree roll creates a secondary effect, yaw, opposite to the failed engine, so rudder can be relaxed
somewhat. Because the aircraft is now directly into the airflow (balanced) there is less airframe (keel surface) drag. Also note, no more than
5-degree bank, otherwise detrimental aileron drag develops. Remember too, that the balance ball will show ‘½ ball out’ to the live engine side.
4(b) Answer a) was a consideration years ago. Answer c) it is not a continued performance speed, just control. Answer d) Vat (at threshold)
is determined for approach to land. 5(c) A tip: If you ever have trouble remembering that ‘Y’ is for rate, and ‘X’ is for angle, just ask yourself:
‘Which letter, Y or X, has more angles in it?’ The answer is ‘X’ Answer d) – This abbreviation is Vsse 6(a) At a lower weight, less lift will be
required, but remember that the best CL (lift coefficient – angle of attack) is still desired, so the only other variable in our lift formula is speed
– less weight, less lift, less speed. Note that on the typical light twins, the change is negligible, so if only one blue line is given in the POH
use it for all weights. 7(d) Answer a) is a common misconception. Yes it will create problems all of its own, but it has nothing to do with the
critical engine – this is a purely aerodynamic consideration. 8(c) This is the key factor in determining the critical engine – that is, a much longer
moment arm from the downgoing blades of the still-operating right engine to the CG – more yaw to the left when this one fails. Also known
as P (propeller) factor. 9(d) In each of these effects, the worst-case scenario is the failure of the left engine. So, in a sense they are a ‘support
cast’ to the asymmetric blade effect. 10(a) With this inward rotation of each engine, all the forces are of equal amount and are, in effect, mirror
images of the other side, so the critical engine is eliminated.
72 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Frying tonight

Name withheld by request

There are some situations in flying that really energise your

thinking. Think of engine failure. Think of weather conditions
deteriorating below minimums. And, as I recently discovered, the
smell of something burning just moments after take-off.
The morning’s solo flight from Griffith to my home base in
Canberra promised to be routine. The met briefing was for a light
westerly tailwind and a mid-level cloud base well above the LSALT.
No worries there.
There was a local NOTAM ‘'Bird hazard exists due
to locust plague’.'
‘OK’, I thought, ‘I need to look out for the birds’.

As I walked out to the Arrow, a local ag pilot drove up. He was

getting ready for a day of spraying as the farmers had been taking
a hammering from the swarming insects.
‘What’s it like flying around the locusts?’ I asked.
‘Need to stay above the big swarms,’ he advised, ‘but keep an
eye on the oil temp, as the little buggers can plug up your oil
cooler.’ Good bit of local knowledge, I thought.
With the flight plan in the system and pre-flight completed, it
was time to fly. At the holding point, I went through my checklist.
An instructor once told me that a checklist is always a work in
progress. Mine has grown from the original (BUMFISH) to a
current two-page incarnation that would make a NASA mission
controller proud.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 73

The section on engine failure on take-off I usually recite out loud: BUMFISH checklist
Fly the plane (maintain 90 kt) on downwind

B
Find the field (options restricted to 30 degrees left or right)
Brakes test
Figure out the approach (straight ahead)
Fix or isolate the problem (time permitting)
Phone a friend (call ATC)
Undercarriage down
U
Fuel and electrics shutdown Mixture rich
M
F
Flee the aircraft (take the EPIRB and grab bag, two door latches
to open, exit, and move upwind) Fuel selector both

So far, no passengers have asked to deplane after my monologue,

but it has raised a few eyebrows.
Instruments normal
I
With the checklist complete, it was time to taxi out. There was the
occasional locust on the runway, but what could the odd insect
Switches and lights on
S
do to an aircraft, I asked myself.
A lot, as I was about to find out.
Hatches and
harnesses secure H
The ground roll was routine. A quick instrument check as the
plane accelerated showed all was normal. Rotate at 60kt, gear
up and trim for 90kt – so far so good. Passing through 300ft AGL,
I noticed a burning smell. Slight at first, but rapidly becoming
more intense.
My first reaction was disbelief. (Others would later call this my
moment of denial.) Then the adrenalin kicked in. The plane
was flying OK, but obviously I had a problem. Most likely a fire,
but where?
Should I do an immediate landing straight ahead (as per my
engine failure rehearsal)? It has been drilled into all of us never to
turn back if there is an engine failure. But the instrument readings
were all normal. The engine sounded okay and felt strong.
74 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Frying tonight

Would a better option be an immediate turn back to the aerodrome

and a precautionary landing? A precautionary landing that
would require an unrehearsed low-level circuit at an unfamiliar
aerodrome. What if the engine stopped on the way back? Would
the extra minute or two in the air create a truly flaming Arrow?
Obstacles? Traffic? My focus was starting to narrow ...
It was time to stop dithering and start doing.
A rapid return to the aerodrome and a precautionary landing
seemed the best option.
During my last flight review, Ben, my examiner, had gone through a
new CASA learning module that reviewed the effect of distractions
on aviation safety. Plenty to distract me here, I thought.
‘Just fly the plane.’ my inner voices kept reminding me.
‘And remember to get the gear down.’

‘Well, that was your culprit.

A locust. They don’t smell real flash
when they are cooking.’

Time to phone a friend. A quick call to Melbourne Centre to advise

them of the change of plan. The controller’s response was brief.
‘What’s the nature of your problem?’
‘Something’s burning.’
‘Copy,’ he replied, ‘Report operations normal in five minutes. Out.’
What followed was a very tight circuit, a normal (wheels down)
landing, an Ops Normal call to Centre ... and then a few extremely
deep breaths.
Going over the aircraft revealed nothing out of the ordinary – no oil
or fuel leaks, no visible smoke or scorch marks around the engine.
It was time to call Rob, my LAME.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 75
He directed me to the cabin air intake on the engine cowling,
where ram air is directed over the exhaust system.
‘Can you see a bit of soot on the exhaust manifold? About 2cm
long?’ he asked.
‘Yes’
‘Well, that was your culprit. A locust. They don’t smell real flash
when they are cooking.’ (Rob’s a country boy.)
The flight back to Canberra was far less eventful.
Thinking back, I realised that while I had rehearsed for a complete
engine failure after take-off, I had no mental script for the
possibility of a return and precautionary landing. The issues of
circuit direction, local obstacles, built-up areas, conflicting traffic
and a compressed time for landing checks could all have been
reviewed on the ground beforehand.
A new section on precautionary landings now graces my (ever-
expanding) pre take-off checklist.
I also understood the hidden benefit of notifying Centre when
things are not going well. Obviously there was little that the
controller could do for me in the cockpit. But a few calm words
and knowing that ‘The System’ was swinging into action was
hugely reassuring. Sometimes that is all that is needed to prevent
a difficult situation becoming something worse.
I now know that a 30gm insect can compromise the safety of a
1200kg aircraft, and I am also pretty certain that locusts will not
be featuring on a Master Chef menu any time soon.

EVER HAD A CLOSE CALL?

Write to us about an aviation incident or
accident that you have been involved in.
If we publish your story, you will receive
$500. Articles should be between 450 and
1,400 words. Submit your close call by
emailing [email protected]
76 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Icing in the USA

Icing in the USA

Name withheld by request

A few years ago, while living in the south- I glanced out to see a light dusting of white on
eastern United States, I decided it was time the exposed tyre. Not much, and his seemingly
for an instrument rating. I had about 250 hours unconcerned attitude gave me little reason
total from flying in Australia and the USA and for alarm. Did not have far to go, after all. We
thought the new rating would make me a more continued on the approach. I was eager for us
proficient, safer pilot. It was one of my first to get to the inbound turn. I asked him what
instructional flight shooting approaches, early was happening with the ice, not wanting to
in winter, but the weather was looking doubtful. take my eyes off the instruments to look out of
There was always the chance of ice and snow the window. I was informed that ice was now
in that region. The possibility of some actual IFR accumulating on the leading edge. No longer
practice was very exciting, but after checking just a dusting; the ice was now building up at
the conditions before leaving for the airport I had an alarming rate. The instructor was still just
every expectation of having to settle for ground sitting there, offering no suggestions when I
instruction. The instructor and I went through asked for updates. It seemed he was happy
the preflight briefing together. There were icing enough for us to fly about and see just how
conditions for sure, but above our altitude and much ice a Cessna 172 could carry. We knew
to the east. No PIREPs available that were of the flat terrain well and cloud base was less
much help to us. The CFII seemed confident than 1500 feet below, giving us close to 2000
we were good to go and I thought we would be feet AGL in visual conditions. I brought up the
only doing a couple of approaches to our own possibility of descending out of the cloud but
runway anyway. It was a well-lit 5000' strip at the his response was that we could not deviate from
un-towered field, with a class C airport close by our ATC instructions. By then the windshield,
as an alternative. The workload for me, being leading edges and wheels had a good covering
an instrument student, was always high. This and it was still building up. I was not sure we
time was even more intense, being well aware were going to make it at that point and it was
that this was the real deal. No foggles needed, clear there was no help coming from the right-
no clear blue sky for the CFII's enjoyment. I hand seat. I told him we needed to descend
had us westbound towards the IAF ‘EROVE’ straight away and, calling ATC, said we were
at 4000 feet. At the IAF we would turn inbound descending out of the cloud due to ice. They
for runway 18. I had not done a GPS approach acknowledged and I increased my rate of
before and was just getting comfortable with descent to get clear of the clouds. I noticed the
the too-good-to-be-true simplicity of it when airspeed dropping. I added more power. Still
the instructor commented, ‘We're picking up more ice accumulating on the leading edge.
some ice’, in a matter-of-fact sort of way. He was Speed still dropping. Now at full power and
looking out of his window at the wheel. ‘Ice’ was the ASI indicating close to stall speed. Intense
not a word I wanted to hear in the air. concern, but no reply to my comments on our
power/speed situation. Finally, some input from
the instructor, ‘Did you put on the pitot heat?’
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 77

Hell, no! How did I forget that? Of course the

reason was being caught up with the ice, and
flying on instruments I had overlooked solutions
Lessons learned
to our predicament. Carb heat was on; I added
pitot heat and windshield defrost. At the same 1. Know your aircraft and the systems.
time I remembered the GPS with its ground I could have made better use of the GPS.
speed glaring at me. It showed a much more
comfortable number than the ASI but still, not 2. Remain calm. Better to think through the
very impressive for the amount of power I was solutions than be overly focused on the
using. With the pitot heat on, the ASI came alive. problem. With two pilots on board, one
The windshield defroster was doing its best but could be going through checklists while
the windshield remained totally covered with the other flies.
ice. We broke out of the cloud and finally the 3. Choose your instructor with care. I later
windshield began to clear, with sheets of ice found out that the CFII had a bad
breaking off, giving a clear view ahead. My relief reputation around the field. We should
was short lived though. The leading edge ice never have been flying IFR that afternoon.
was hanging on. The big question on my mind
was the new stall speed of our now-modified 4. Be well prepared. I was new to IFR,
C172 wing. In the pattern for a conventional but that did not excuse me from taking
VFR approach, some of the leading edge ice responsibility and knowing everything
was breaking off, but a lot remained. I informed I could.
the instructor that I would come in hot, at least
5. Treat every flight as though life depends
100 knots then 90 on late final, landing with
on doing it right – because it just may.
partial flaps. I had no idea how much speed
I will never know how close we came to
we really needed. I kept the speed up and the
disaster that day, but it forever changed
turns to base and final shallow and balanced.
my outlook. It made me question more,
The objective of sure but precise flying seemed
no matter how experienced the instructor.
to matter so much more on that approach. The
The experience also taught me to not
landing itself was uneventful; flare, float and
lower my own standards, no matter what
wait for it to settle. One of my better ones, with
those around me considered as over-
the intense concentration I gave it. I have never
cautious or unnecessary preparation.
been so happy to get on the ground.
After parking and getting out, still somewhat
shaky, I spent an interesting few minutes
pulling strips of ice almost a metre long off the
leading edge.
78 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Complacency can kill

I was rostered to take over from the other pilot at

lunchtime the very next day, with three joy flights
to conduct in the afternoon. Each flight followed
a similar profile; a short transit to the training
area before flying a basic aerobatic sequence
consisting of loops, slow rolls, barrel rolls and
stall turns. I did feel a little uncomfortable with
Name withheld by request my lack of familiarity with the aircraft. As a full-
time pilot I had logged many hours flying one
Many years ago I was over the moon
type and was used to knowing my aircraft and
to be offered casual weekend work its systems inside out. However, I knew that if
flying joy flights in an aerobatic, I took things slowly and regularly referred to
radial-engine warbird. I had just the checklist I would be OK. The pneumatic air
moved into a new management role system and metric gauges were unfamiliar to
with a large operator but I missed me at first but the simplicity of the aircraft meant
the line flying. I was really looking that I was soon able to dispense with
forward to being paid to roar about the checklist.
and turn upside down – a complete The pilot I was taking over from told me that
contrast to my previous flying role. he had refuelled the aircraft so I should have
enough fuel to finish the day without needing
It had been many years since I had used my to refuel again. The endurance was specified
aerobatic endorsement and I had never flown as just under two hours. Take-off to
this type of aircraft before, but a check flight with landing was almost exactly
the chief pilot quickly quelled any reservations. 20 minutes plus taxi time, so
My aerobatics were surprisingly tidy. The I calculated that my three
aircraft was designed as a training aircraft for flights would leave me with
communist-bloc pilots and was a delight to fly. sufficient reserves. The fuel
The fun of rediscovering my aerobatic skills gauges, like most in
reminded me why I had pursued a this category of aircraft,
career as a pilot. were virtually useless.
It was a beautiful day for
flying; clear and cold. The first
two passengers left the hangar
with ear-to-ear grins and empty
sick bags. The final flight ended with the
sun low in the sky and we were treated
to a beautiful orange and pink sunset as we
pitched into the circuit with the canopy cracked
open to let the bracing slipstream wash over
us. After taxiing back the long way to let a large
multi-engine aircraft depart, we shut down in
front of the hangar as the customer’s husband
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 79

and young children filmed from How could I have been stupid enough to put my
the tarmac. It was the passenger’s passengers and myself in that situation?
birthday and her husband had bought
the flight for his wife as a present. I On reflection, I identified a number of
helped her out of the cockpit, another errors that contributed to my very
satisfied customer, and congratulated myself narrow escape. I realised that I had
on a job well done. I was proud of my flying failed to lean the mixture after take-
and pleased that my efforts to make off and consequently my fuel burn
sure the passengers enjoyed their was much higher than predicted. If I
flights had paid off. The only downside had been more familiar with the aircraft I could
was that I had not had any break have been cued by the sight of the mixture
between flights. As each passenger lever being in an abnormal position during the
unstrapped, I barely had enough time transit to and from the training area. Dispensing
to do a quick walk around before with the checklist was irresponsible, particularly
greeting the next passenger and as I was apprehensive about my lack of
beginning the process again. experience with the aircraft type. Furthermore,
I had not visually confirmed the fuel level prior
I spend half an hour cleaning oil to accepting the aircraft from the other pilot, or
off of the cowl and fuselage whilst even once during the afternoon – a schoolboy
admiring the robust profile of the error. Did the other pilot say he had refuelled
old warbird. Just before pushing the before, or after, his last morning flight? His
aircraft inside the hangar for the night, casual assurance that I would have enough fuel
I ordered fuel so that the oncoming pilot for the rest of the flights would have been of
would not need to refuel before the next little comfort to us as we ditched on our return
flight. I knew the refueller quite well and to the airport. Just a simple glance inside the
we chatted amiably as he set about filling tanks between flights would have been enough
the tanks. As he completed the paperwork, to recognise the need for more fuel, but I had
he made some comment about thinking the allowed time pressures to distract me from the
tanks were smaller than they were. I thought most basic safety and airmanship checks.
nothing of it at the time but after I pushed the
aircraft into the hangar, his comment began to The primary factor though was my complacency.
bother me. I checked the docket and saw that I had convinced myself that flying a relatively
he had pumped about 120 litres into the aircraft. simple aircraft on joy flights would be an easy
I felt myself go white as I realised that I had task and I failed to take the appropriate amount
used every drop of the usable fuel! It was sheer of care. The memory of the happy family
dumb luck that had allowed me to taxi back welcoming their mother after her birthday flight
to the hangar without the engine failing due to and the thought that I had nearly brought about
fuel starvation. I was even more horrified when I her demise haunted me for weeks, but it was all
recalled my track back to the aerodrome - over that I needed to remind me that complacency is
a large cold lake. I was horrified. a potential killer.

As a professional pilot I had never even

come close to running out of fuel – that
was the domain of cowboy operators and
low-timers wasn’t it?
 Lending a hand overseas
When a Fokker 100 jet crashed in Myanmar late last year, tragically
killing two and injuring more than 30 people, Myanmar authorities
were keen to discover what happened to prevent a similar accident
from happening again. To assist with technical aspects of their
investigation, Myanmar investigators asked the ATSB to lend a hand.
ATSB’s assistance involved our investigators downloading and
decoding data from the aircraft’s flight data recorder and the cockpit
voice recorder (commonly known as ‘black boxes’) at our facilities
in Canberra. The valuable information retrieved by the ATSB is now
being used by Myanmar investigators in their ongoing investigation.
The Myanmar accident I’m extremely proud of the capabilities
is one in a number and skills of our Australian investigators
of investigations and the high regard with which they’re
where the ATSB has held overseas.
provided support to our
regional neighbours. Under international protocols and Australian
Government policy, we’ve assisted many countries—including New
Zealand, Papua New Guinea, Indonesia, and several other Pacific
Island countries—with their investigations.
And it’s not just aviation accidents where we’ve lent a hand.
Following last year’s tragic sinking of the passenger ferry Rabaul
Martin Dolan Queen in PNG, the PNG government requested the ATSB’s
Chief Commissioner assistance with the on-site investigation. In response, we sent
two senior investigators to work with local authorities over several
months. The PNG Commission of Inquiry has released a report
outlining proposals to prevent an occurrence of a similar tragedy.
24 Hours
The ATSB has established an international reputation for conducting
1800 020 616
high-quality transport safety investigations. And it’s because of this
Web
reputation that countries are continuing to seek our expertise.
www.atsb.gov.au
Twitter Of course this is a two-way street. Singapore, Indonesia and New
@ATSBinfo Zealand among others have supported our investigations, as have
Email our North American and European colleagues. We are grateful for
[email protected] their help.
ATSB.gov.au

The easy way to find

the ATSB’s active
investigations
The ATSB’s website
now has a Google maps
application that pinpoints all
active ATSB investigations
around the world. The
system uses latitude and
longitude coordinates
to display markers for
aviation, rail and marine
occurrences. Clicking on
a marker will reveal the
reference number and
details. A click on the
reference number links
to the investigation page
with full details of the
occurrence and progress
so far.
This feature will make it
much easier to find information on our active investigations.
A search-by-locality function allows you to search for
occurrences in a particular area. For example, by entering
‘Perth, WA’ into the search field, you can see all the ongoing
investigations in the Perth region. The map page also links to
a list of current investigations.
We are continually improving our website to make information
more accessible to our stakeholders and the general public.
Prepare to live

The ATSB’s Avoidable Accidents booklet series tells the

stories of pilots whose simple mistakes have resulted in
serious, and sometimes deadly, consequences.

Covering fuel management, low-level flying, partial power loss,

flying in poor weather, wirestrikes and flying experience, each
publication can help pilots avoid these types of accidents.

Avoidable Accident Series

Avoidable Accidents No. 4 Avoidable Accidents No. 6

Avoidable Accidents No. 2 Avoidable Accidents No. 3 Avoidable Accidents No. 5
Avoidable Accidents No. 1
Managing partial power loss after Accidents involving pilots in Starved and exhausted: Experience won’t always save you
Wirestrikes involving known wires:
Low-level flying A manageable aerial agriculture hazard takeoff in single-engine aircraft Instrument Meteorological Fuel management aviation accidents Pilot experience is not always a protection
Conditions against an accident

Research Research Research Research Research Research

AR-2009-041 AR-2011-028 AR-2010-055 AR-2011-050 AR-2011-112 AR-2012-035

Order your free copies now from [email protected]

or phone 1800 020 616
 Challenging assumptions on
pilot experience
A new booklet recently released by the ATSB dispels
the myth that experience will always protect pilots
from an accident.
The booklet Experience won’t always save you: Pilot
experience is not always a protection against an
accident, is the latest release in the ATSB’s well-
received Avoidable Accidents series.
“There’s a reverence for those who have been flying
a long time,” said Dr Stuart Godley, the manager
of the ATSB’s Research Investigations and Data
Analysis team. “We like to believe that they’ve got
the right stuff, that they know themselves and their
aircraft, and they can draw on their wisdom to
keep themselves safe. There are many famous
accidents where it appears that pilot experience
has made all the difference.”
“However, a closer analysis of these accidents
suggests that things other than experience have
always also played a significant part in saving the
day,” continued Dr Godley, “but they tend not to
be emphasised in anecdotes and media.” On the
other hand, fatal outcomes can and do happen to
very experienced pilots, leading to questions of
how could such a thing happen to someone with
so much flying behind them.”
In creating this booklet, the ATSB has drawn
on its investigation archives of 20 years to find
case studies that illustrate how a fatal accident
can happen to anyone, even those who have
been flying for years. These examples cover a
range of operations and aircraft types, and each
one analyses the accident, breaking down the
decisions and factors that contributed to the final,
fatal result.
“These were experienced pilots Cont...
who knew their business.”
 “The issues examined are
something that all pilots need to
think about and take into account.”

“These were experienced pilots who knew their business,”

said Dr Godley, “but it wasn’t enough to keep them safe.”
In some of these occurrences, very experienced pilots were
undertaking flying that involved much higher risk. It turned
out that their flying experience alone was unable to help
them avoid disaster. Other accidents involved experienced
pilots who may have allowed factors other than their
experience to influence their actions. In other examples, the
pilot’s vast experience may have even led to decisions that,
in hindsight, were associated with more risk than necessary.
As with all the Avoidable Accidents booklets, Experience
won’t always save you is available for free. “The book can be
downloaded from the ATSB website or we’re happy to mail
free copies to anyone who would like them,” said Dr Godley.
“We’ve had excellent feedback on these publications—
they’re a useful resource to anyone involved in flying, but
we feel that this newest booklet is especially important. The
issues that it examines are something that all pilots need to
think about and take into account.”
Please send requests for copies of the booklet via email to
[email protected]
Warning to Bombardier pilots
Until modifications are made to DHC-8 aircraft, pilots and operators of
DHC-8-100, -200 and -300 series aircraft need to take steps to minimise
the possibility of propeller overspeed due to ground beta selection in
flight. This warning comes as a result of an ATSB investigation into an
incident near Weipa, Queensland.
On 6 December 2011, a The aircraft manufacturer has
Bombardier DHC-8-315 advised that it will release
aircraft was on descent a Service Bulletin.
to Weipa Airport. The first
officer’s hand was on the power levers, which were in the flight idle
position. When the aircraft encountered turbulence, the first officer
inadvertently lifted one or both of the flight idle gate release triggers
and moved the power levers below the flight idle gate. While the power
levers were in the ground beta range, both propeller speeds increased
uncontrollably by over 300 revolutions per minute. Realising the situation,
the first officer immediately moved the power levers back above the flight
idle gate and the propellers returned to the normal rpm.
The ATSB found that many DHC-8-100, -200 and -300 series aircraft did
not have a means of preventing inadvertent or intentional movement of
power levers below the flight idle gate in flight, or a means to prevent
such movement, resulting in a loss of propeller speed control. This design
limitation has been associated with several safety occurrences.
The ATSB also concluded that the beta warning horn had sounded;
however, the pilots were not acutely aware of what it meant due to a lack
of previous exposure to the sound.
The aircraft manufacturer has advised that it will be releasing a Service
Bulletin modification to rectify the propeller speed control issue.
That bulletin will be mandated by an Airworthiness Directive from the
airworthiness authority of the State of Design (Canada) to ensure that the
bulletin is incorporated into all the aircraft affected by the design issue
worldwide, including in Australia. The aircraft operator has also introduced
a series of actions to reduce the risk of such occurrences. The ATSB has
released an extract from the cockpit voice recorder with the beta warning
horn and the audible rise in propeller speed, to all Australian operators of
the aircraft type. The audio file is also available on the ATSB website.
More details of the investigation, along with the findings,
can be found in the investigation report AO-2012-005.
 REPCON BRiEFS

Australia’s voluntary confidential aviation reporting scheme How can i report to REPCON?
Online:
REPCON allows any person who has an aviation safety concern to report it to the ATSB confidentially.
www.atsb.gov.au/voluntary.aspx
All personal information regarding any individual (either the reporter or any person referred to in the
Telephone: 1800 020 505
report) remains strictly confidential, unless permission is given by the subject of the information. Email: [email protected]
The goals of the scheme are to increase awareness of safety concerns and to encourage safety Mail: Freepost 600
action by those best placed to respond. PO Box 600, Civic Square ACT 2608

VFR Coastal route Victor 1 Procedures published in ERSA have been

devised to allow pilots in this area to comply
The reporter expressed a safety concern with all normal class G airspace procedures.
regarding the separation between aircraft Introduction of a northbound route 1 NM further
in the Victor 1 light aircraft lane. The out to sea may cause difficulty with aircraft
reporter had recently been involved in an operators’ ability to comply with engine failure
incident where his aircraft had conflicted requirements.
with another aircraft flying in the opposite Introduction of extra reporting points may
direction within the Victor 1 lane. enhance pilot situational awareness but, in
contrast to the expectation of the reporter, may
The reporter has made two suggestions to
actually increase frequency congestion.
improve separation in the lane:
• that the Victor 1 northbound route should ATSB comment:
be moved 1 NM further out to sea to After further consultation, CASA suggested that
create a better horizontal separation the reporter might wish to attend the next NSW
Regional Airspace and Procedures Advisory
between opposite-direction aircraft. Committee (RAPAC) meeting to present their
• that two further mandatory en-route ideas to the committee. While the reporter
declined this offer, a representative from the
reporting points be established for either ATSB’s REPCON area did attend.
northbound or southbound aircraft.
The committee agreed that operating in a
This would create a better situational
see-and-avoid environment can be rendered
awareness for flight crews, while limiting much safer when pilots are alerted by radio
congestion on the frequency. broadcasts, especially in a confined area such
as the Victor 1 lane.
CASA response:
As there is already a lengthy and detailed
There is insufficient detail in the REPCON to list of instructions in ERSA, the committee
understand the nature or cause of the specific considered that adding to these could be
event referred to by the reporter. Without such counterproductive. The committee agreed that
information, CASA does not have any basis the CASA Aviation Safety Advisor would prepare
to determine if specific Victor 1 procedures an education campaign to be used during future
CASA Safety Forums.
contributed in any way to the event. Pilot non-
compliance with Victor 1 or Visual Flight Rules For further information on these issues please
(VFR) procedures may also have contributed to refer to the ATSB website:
the incident mentioned in the REPCON. Limitations of the See-and-Avoid Principle.

VFR Coastal Route Victor 1 is in class G

airspace and is restricted to operations by
day and in Visual Meteorological Conditions.
 REPCON BRiEFSary

Attempted use of an iLS flight, including NOTAMs, SNOWTAMs,

that had been NOTAMed runway conditions, temperature/
pressure reports, upper wind and airport
unserviceable meteorological forecasts. The information
The reporter expressed a safety concern above is intended to be used to ensure
that a high capacity aircraft had conducted safe operations i.e. including a safe take-off,
a standard arrival route (STAR) and departure, en-route, landing, taxi and parking.
was turning onto finals and asked the 3. Prior to descent and not later than the
controller if they were cleared for a commencement of an approach, the Pilot
Runway 03 instrument landing system Flying (PF), shall brief on a number of
(ILS) approach, even though the ILS had operational requirements.
been NOTAMed as unserviceable, the 4. The Pilot Not Flying/Pilot Monitoring is
automatic terminal information service required to add to the briefing the relevant
(ATIS) confirmed that the ILS was performance data applicable for the approach
unserviceable and the controllers had and also the remaining fuel/time before
already verbally confirmed with the crew initiating diversion.
that the ILS was unserviceable. 5. On FMS-equipped aircraft, crew are expected
to cross check the data inserted, particularly
The reporter questions which approach when lateral navigation is expected to be
had been briefed, checked and entered used for arrival/approach.
into the flight management computer
In the interest of safety we will be sharing the
(FMC) if the crew did not understand that
REPCON Aviation Safety Confidential Reporting
the ILS was unserviceable.
Scheme with our flight crew. We will also
Operator’s response: be reminding our pilots to be more diligent
with regards to operational procedures and
We have checked the company’s NOTAMs and
NOTAMs.
acknowledged that there was a notice informing
the pilots that the ILS was unserviceable. CASA comment:
We understand the confidentiality involved. Due to the de-identified nature of the report
Since we have limited information about the CASA is unable to examine the matter further.
incident and personal information identifying an CASA is satisfied with the operator’s response.
individual has been removed, it is difficult for us
ATSB comment:
to provide accurate feedback. Nevertheless, the
following are our comments: This report serves as a reminder to flight crew
of the importance of ongoing vigilance at all
1. During pre-flights, our company requires stages of flight, from pre-flight planning through
the Captain to strictly observe and meet to arrival at destination, and of the need to
the requirements concerning routes and the assimilate and assess operational information
airport. during the conduct of flight.

2. During pre-flight, the Captain is required

to obtain available aeronautical and
meteorological information pertinent to his
ATC notes

Flight notification –
the importance of getting it right
Since the introduction of ICAO Amendment 1 to flight planning requirements
and the upgrade of NAIPS to NAIPS Internet Service in November 2012,
Airservices has noticed some common errors with the submission of
flight notifications.

I
naccurate information in the flight Two major issues that have been noticed
notification can result in unnecessary are the relationship between some entries
delays, increased workload and in fields 10 and 18 and incorrect entries in
application of incorrect separation standards. field 18.
It is particularly important to file accurate Field 18 indicators (eg NAV/) are often
data in the following fields: free text, so strict adherence to formats
described in AIP is necessary.
ƒ 10a – Communication, Navigation &
Approach Aid Equipment & Capabilities
ƒ 10b – Surveillance Equipment &
Capabilities
ƒ 18 – Other Information (particularly
indicators STS, PBN & NAV)
Approved users of GNSS require the following entries depending on your authorisations.
Navigation capability Field 10a Field 18
Night VFR area navigation GZ NAV/GPSRNAV or NAV/RNP2 GPSRNAV
IFR area navigation (enroute) GZ NAV/GPSRNAV or NAV/RNP2 GPSRNAV
RNAV GNSS Non-precision GR PBN/S1 or PBN/S2 as appropriate
approach (Note that this must be entered in addition to
GPSRNAV where applicable)
IFR area navigation enroute GRZ NAV/GPSRNAV or NAV/RNP2 GPSRNAV
and Non-Precision approach Plus
(RNAV GNSS NPA) PBN/S1 or PBN/S2 as appropriate
RNP approach LNAV GR PBN/S1 or PBN/S2 as appropriate
Inertial RNAV systems IR PBN/B1 or PBN/B5 as appropriate
IZ NAV/AUSEP

Note: RNP2 does not yet have a PBN code therefore must be included as other in field
10a Z and NAV/RNP2 GPSRNAV.
Common errors received in Item 18 Other Information – NAV/.
Incorrect Entry Should be Explanation
NAV/GPS RNAV NAV/GPSRNAV ATM system does not recognise the space
between GPS and RNAV
NAV/GPSNPA PBN/S1 or S2 Non-precision approach capability is described by
S1 or S2
NAV/ADSB /B1 (or similar) ADSB capability should be filed in Field 10b
NAV/NONRVSM STS/NONRVSM One of the 12 defined reasons for special handling
and must be in STS/
NAV/RNP5 PBN/** RNP5 is not a recognised approval
NAV/INS RNAV PBN/** **An RNAV or RNP capability should be filed as a
PBN/ capability (e.g. PBN/B5) except RNP2 (see
note above)
NAV/RNP10 PBN/A1 An RNP 10 capability should be filed as PBN/A1
NAV/GPS Field 10a G GNSS capability (which includes GPS) should be
filed in Field 10a
In some cases, NAIPS Internet Service will give an indication of incorrect entries (eg. PBN
errors), however it will not flag the errors described above. Pilots are encouraged to check
the content of their flight notification entries against AIP requirements.
AIP defines what should be filed in fields 10a/b and 18 (AIP ENR 1.10)
Further information is available on CASA’s website or by emailing [email protected]
90 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
International accidents

International accidents/incidents 31 December 2012 – 8 March 2013

Date 31 December Description
Aircraft BA 3101Jetstream 31 Passenger aircraft (first flight 1987) sustained substantial damage
Location San Pedro Sula Airport, when it veered off the runway after landing and came to rest in a
Honduras ditch. One of the pilots suffered minor injuries.

Fatalities 0
Damage Substantial
Date 4 January Description
Aircraft BN -2A-27 Islander Passenger aircraft (first flight 1968) with six people on board lost
Location Between Los Roques and contact with ATC about seven minutes after take-off. Radar showed
Caracas, Venezuela the aircraft continuing to climb to an altitude of 5400 feet, at a speed
of 120 knots, then rapidly lose altitude and speed. The aircraft has
Fatalities 6 not yet been located but luggage and wreckage that might have
Damage Missing been from it have been found along the coast of the island
of Curacao.
Date 15 January Description
Aircraft Cessna 208B Super Cargo aircraft (first flight 1994) crashed into woodland shortly after
Cargomaster take-off, killing its pilot. Weather overcast and freezing.
Location 2.5km W of Pellston
Airport, MI, USA
Fatalities 1
Damage Written off
Date 23 January Description
Aircraft DHC-6 Twin Otter 300 Aircraft (first flight 1979) reported overdue on a flight from the South
Location Queen Alexandra Range, Pole to Terra Nova Bay in solid cloud cover, high winds and heavy
Antarctica snow. The emergency locator beacon was activated at about 22.00
and a search aircraft circled over the site for about five hours, but
Fatalities 3 the crew was unable to see through the thick cloud. Searchers finally
Damage Destroyed made visual contact with the crash site late on January 25 and said
that it appeared to be ‘not survivable’.
Date 29 January Description
Aircraft CL-600-2B19 CRJ-200ER Aircraft (first flight 2000) came down on approach in freezing fog,
Location 4km NE of Almaty Airport, killing everyone on board.
Kazakhstan
Fatalities 21
Damage Destroyed
Date 2 February Description
Aircraft ATR 72-212A Aircraft (first flight 1997) lost altitude shortly before touchdown,
Location Roma-Fiumicino Airport, landed heavily on its nose gear, bounced three times, and came
Italy to rest in the grass beside the runway. Four people injured, two of
them seriously. There were strong cross winds, with gusts of up to
Fatalities 0 41kt, and wind shear had been reported about 15 minutes before the
Damage Substantial aircraft landed.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 91
Date 6 February Description
Aircraft Airbus A320-211 Airbus (first flight 1990) nose gear collapsed on landing in gusty and
Location Tunis-Carthage Airport, rainy conditions.
Tunisia
Fatalities 0
Damage Substantial
Date 7 February Description
Aircraft Antonov 2R Biplane (first flight 1979) struck snowy terrain during a domestic flight.
Location Knyazhin, Ukraine The RH wings collapsed, the fuselage was badly damaged and the
pilot was injured.
Fatalities 0
Damage Substantial
Date 9 February Description
Aircraft Beechcraft 1900C IFR clearance cancelled at 9000ft and the aircraft (first flight 1986)
Location Blue River Airport, BC, continued on a VFR approach. Directional control was lost and the
Canada aircraft skidded sideways, left the runway and ran nose first into a
large snow bank.
Fatalities 0
Damage Substantial
Date 11 February Description
Aircraft CASA CN-235 Transport plane (first flight 1992) crashed into forested sloping terrain
Location 4km S Monrovia on approach to the airport, killing all on board.
International Airport, Liberia
Fatalities 11
Damage Destroyed
Date 13 February Description
Aircraft Antonov 24RV Charter plane (first flight 1973) carrying football fans crashed on
Location 2km W Donetsk Airport, approach in heavy fog. There is some confusion about the number of
Ukraine people on board but five passengers were reportedly killed.

Fatalities 5
Damage Destroyed
Date 20 February Description
Aircraft Beechcraft 390 Premier IA Corporate jet (first flight 2007) destroyed in a landing accident.
Location Thomson-McDuffie Airport, The captain and co-pilot survived but the five passengers were killed.
GA, USA The pilot apparently aborted the approach and the plane continued
along the runway at a low altitude before hitting an unlit concrete pole
Fatalities 5 and power line about 59 feet AGL, severing the outboard section of
Damage Destroyed the left wing. The aircraft continued for over 400m before crashing
into trees, losing its engines and bursting into flames.
92 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
International accidents

Date 4 March Description

Aircraft Raytheon 390 Premier I Aircraft (first flight 2007) crashed into a field and caught fire after
Location 1km SE Annemasse ‘contacting’ a house immediately after take-off. Only one of the three
Airport, France people on board survived.

Fatalities 2
Damage Destroyed
Date 4 March Description
Aircraft Fokker 50 Passenger aircraft (first flight 1992) reportedly came down in a
Location Goma Airport, Congo residential area as it was preparing to land in poor weather. Of the ten
people on board (three passengers, six crew and a loadmaster) only
Fatalities 7 the three passengers survived.
Damage Written off
Date 6 March Description
Aircraft Beech B200 King Air Aircraft (first flight 1999) chartered to transport employees to a mining
Location Pias Airport, Peru site crashed into a wooded hillside en route, killing all on board.

Fatalities 9
Damage Destroyed
Date 8 March Description
Aircraft Beechcraft 1900C-1 Cargo plane (first flight 1988) destroyed after it crashed into the
Location 32km NE Dillingham Muklung Hills. The crew had asked ATC for permission to enter a
Airport, Alaska, USA holding pattern at the IAF while they asked for a runway conditions
report, but radar contact was then lost and the wreckage was not
Fatalities 2 located until the following day.
Damage Destroyed

International accidents
Compiled from information supplied by the Aviation Safety Network (see www.aviation-safety.net/database/)
and reproduced with permission. While every effort is made to ensure accuracy, neither the Aviation Safety
Network nor Flight Safety Australia make any representations about its accuracy, as information is based on
preliminary reports only. For further information refer to final reports of the relevant official aircraft accident
investigation organisation. Information on injuries is not always available.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 93
Australian accidents/incidents 7 February – 25 March 2013
Date 7 February Description
Aircraft Eurocopter AS.350B2 The helicopter collided with terrain. The pilot sustained
Location Hobart Aerodrome, 252.5° M minor injuries and the helicopter was substantially damaged.
31km, TAS Investigation continuing.

Injury Minor
Damage Substantial
Date 9 February Description
Aircraft Cessna 150F The pilot rejected the take-off due to insufficient
Location Mittagong (ALA), 219 degrees M take-off distance and the aircraft collided with a tree.
21km, NSW Investigation continuing.

Injury Nil
Damage Substantial
Date 9 February Description
Aircraft Alexander Schleicher The aircraft landed hard resulting in substantial damage.
Segelflugzeugbau ASK-21
Location near Balaklava (ALA), SA
Injury Nil
Damage Substantial
Date 15 February Description
Aircraft Eurocopter MBB-BK 117 B-2 During cruise, the crew received abnormal hydraulic
Location Port Pirie Aerodrome, SSE M indications. The helicopter then pitched violently upwards
28km, SA and rolled over. The crew recovered to normal flight
conditions and returned to Port Pirie. No one was
Injury Nil injured but the helicopter was substantially damaged.
Damage Minor Investigation continuing.
Date 17 February Description
Aircraft Enstrom 480B During aerial agriculture operations, the helicopter struck
Location Leongatha Aerodrome, N M 19km, a powerline and the pilot made a precautionary landing.
VIC Investigation continuing.

Injury Nil
Damage Substantial
Date 19 February Description
Aircraft Ayres S2R-T34 During aerial agriculture operations, the aircraft struck
Location Condobolin Aerodrome, 128 a powerline and subsequently crashed. The aircraft
degrees T 7km, NSW was substantially damaged but the pilot was uninjured.
Investigation continuing.
Injury Nil
Damage Substantial
94 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Australian accidents

Date 23 February Description

Aircraft Robinson R44 During aerial spraying, the helicopter struck a wire.
Location Ballarat Aerodrome, E M 18km, The pilot lost control of the aircraft and landed heavily.
VIC The helicopter was substantially damaged and the pilot
suffered minor injuries. Investigation continuing.
Injury Minor
Damage Substantial
Date 8 March Description
Aircraft Jabiru J430 During the initial climb, the engine failed and the
Location Tyabb (ALA), E M 4km, VIC pilot conducted a forced landing in mud flats.
Investigation continuing.
Injury Nil
Damage Substantial
Date 9 March Description
Aircraft Grob - Burkhaart Flugzeugbau As a Cessna 150 aircraft touched down, a Grob G103 glider,
Twin Astir on approach to the same runway, collided with the upper
Location Tocumwal Aerodrome, VIC surface of it. The Grob sustained substantial damage and the
Cessna minor damage. Investigation continuing.
Injury Nil
Damage Substantial
Date 15 March Description
Aircraft Grob - Burkhaart Flugzeugbau During circuit training, the pilot lost control of the aircraft and
G-115C2 it collided with the ground, sustaining substantial damage.
Location Jandakot Aerodrome, WA Investigation continuing.

Injury Nil
Damage Substantial
Date 17 March Description
Aircraft Amateur-Built Vans RV-8A During initial climb, the pilot lost control of the aircraft and
Location Rainbow Beach (ALA), QLD it crashed.

Injury Minor
Damage Substantial
Date 17 March Description
Aircraft Amateur-Built Spitfire Mk XXVI The aircraft was participating in an airshow when it collided
Location Parafield Aerodrome, 020 degrees with terrain, fatally injuring its pilot. Investigation continuing.
M 1km, SA
Injury Fatal
Damage Destroyed
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 95
Date 21 March Description
Aircraft Robinson R44 A Robinson R44 helicopter, registered VH-HWQ, was being
Location Wollongong Aerodrome, 10 operated on a private flight from Bankstown to Bulli Tops,
degrees M 30km, NSW NSW. On board were the pilot and three adult passengers.
While in the process of landing at a function centre at Bulli
Injury Fatal Tops, the helicopter collided with terrain and burst into flames,
Damage Destroyed fatally injuring all four occupants. The ATSB has deployed a
team of four investigators and the investigation is continuing.
Date 24 March Description
Aircraft Mooney M20J The pilot commenced a missed approach due to birds near
Location Hedlow (ALA), QLD the runway. One bird was struck and the aircraft subsequently
collided with a bull. The occupants were uninjured but the
Injury Nil aircraft was substantially damaged. Investigation continuing.
Damage Substantial
Date 25 March Description
Aircraft Cessna T210N Soon after take-off, the aircraft collided with terrain. Its two
Location Roma Aerodrome, NW M 2km, occupants were fatally injured and the aircraft was destroyed.
QLD Investigation continuing.

Injury Fatal
Damage Destroyed

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

Register hits record information on our external web site, and around
2002 stopped selling both the books and
The Australian Civil Aircraft Register reached
the disks.
a significant milestone this month, with the
15,000th aircraft registration recorded. ‘Registration marks are very important to many
members of the aviation industry. We regularly
Registration of Australian aircraft began in
publish a list of available marks and people
July 1919 when the International Commission
are also able to reserve a particular mark for a
for Air Navigation allocated civil aircraft
12-month period.
registration prefixes to each member nation.
British Commonwealth countries were ‘The bigger airlines such as Qantas and
allocated the letter 'G' with the next one or Virgin tend to reserve blocks of registration marks,
two letters indicating the countries within the so a certain model of aircraft can have
Commonwealth, with Australia allocated 'G-AU'. consecutive marks.
Australian Certificate of Registration No.1 was ‘We also allocate the marks starting with VH-G to
issued on 28 June 1921 for an Avro 504K aircraft the Gliding Federation of Australia, which registers
registered G-AUBA. gliders and motor-gliders on CASA's behalf.
From January 1929, Australian aircraft began ‘The aircraft in the register include fixed-wing
displaying 'VH' as a prefix to the registration aircraft, helicopters, gliders and balloons, with
mark. The first machine to be registered under about 50 new registrations being processed
the new system was a Gipsy Moth that bore the each month.’
marking VH-UKF.
The register increased gradually after World War Safer skies
II, reaching 1000 aircraft in the late 1950s and
10,000 in the early 1990s. It reached 11,000 in Air safety reached a new high last year, with a
the late 1990s, 12,000 in 2003, 13,000 in 2008 new low for accidents involving Western-built
and 14,000 in 2010. jets, the International Air Transport Association
(IATA) says.
Registrar Pat McLeod says there have been * The overall accident rate fell to one in every
many changes in the aircraft register over five million flights, down 46 per cent from 2011
the years.
* There were 15 fatal airliner accidents, down
‘Obviously, when the register was first from 22 in 2011
introduced in the 1920s there were no * There were 414 air deaths worldwide,
computers, so each registration was recorded compared to 486 in 2011
as a handwritten entry in a book’, says Pat.
* However, the death rate for Western-built jets
‘With the introduction of computers the increased to 0.08 per million passengers from
registration data was captured electronically, 0.07 in 2011
and we have also seen changes within
IATA director general Tony Tyler said, ‘the
CASA with the implementation of new systems
industry’s 2012 record safety performance was
such as LARP, AIRS and the upcoming release
the best in history. Each day approximately
of EAP.
100,000 flights arrive safely at their destination.
‘In the 1990s we had a subscription list and Airlines, airports, air navigation service
used to sell floppy disks holding the entire providers, manufacturers and safety regulators
aircraft register list and also release books work together to ensure that every flight is as
every quarter. In 2000 we began publishing the safe as possible’.
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 97

Photos: The Australian Civil Aircraft Register, CASA

A golden solution for pilots hit by ‘Are we working on a bulletproof vest for the
laser pointers eyes? Yes, that's probably a pretty good analogy
for what we're developing here’, he said.
New gold-plated glasses for pilots could be
a ‘bulletproof vest for the eyes’ against laser Nearly 3500 such ‘laser incidents’ occurred in
pointer attacks. the U.S. last year, and there were 740 recorded
within Australia by the ATSB (for the period
Jayan Thomas, a scientist at The University of 1 January – 31 December 2012).
Central Florida leads a team that has created
gold nanoclusters - more than 200,000 times If the lab work eventually translates into a
smaller than the tip of a pen - that have ‘optical commercial product, it could be a breakthrough
limiting’ qualities. This means that the tiny gold in laser-safe eyewear. Military pilots have
particles can block and extinguish high-energy used gold-tinted laser-safe eyewear for some
laser beams, while allowing harmless visible time, but it is effective only against certain
light to pass through. frequencies of laser beams. It is hope that the
new product will protect against lasers of all
Thomas says his research in gold strengths and wavelengths.
nanotechnology could one day produce ‘laser-
proof’ glasses coated with gold to protect pilots Source: Orlando Sentinel and the ATSB
from being temporarily blinded by a laser shone
from the ground.
98 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Flight bytes

Electronic charts approved Robinson gets the lead out

Australian pilots can now, officially, use maps on Robinson Helicopter Company has announced
an iPad or other similar tablets. On 22 March, that it is working with Lycoming and the FAA to
OzRunways received a CASA approval under have unleaded fuels approved for use in piston
CAR 233 (1)(h) to publish aeronautical maps, engines permitted in its R22 and R44 models.
charts and other aeronautical information and
instructions. This is the first time an approval has CEO Kurt Robinson said that the FAA had
been issued for Australian VFR maps and charts issued a project code and made it a priority,
to be used in tablet application. adding that he hoped to have all the necessary
approvals from engine maker Lycoming in the
OzRunways will provide VFR maps and charts, first half of this year. ‘It’s environmentally the
in addition to AIP, ERSA, DAP and IFR charts, to right thing to do and it bothers me that it hasn’t
the general aviation community via their app for been done.’
electronic flight bags (EFBs).
By mid-year Robinson will also begin installing
CASA released CAAP 233-1 Electronic Flight fuel bladders as standard equipment on R22s.
Bags in November last year. It provides These will decrease that model’s endurance by
information on and guidance in the use of 15 minutes, but not add any weight. ‘I believe
portable EFBs as a replacement for paper in the the additional security is worth the loss of
flight compartment. endurance’, Robinson said.
One note of caution: It is important to remember Source: Aviation International News
that CASA does not approve the iPad or other
similar tablets for use as EFBs. This does
not mean that they are disallowed – you
can use them if you wish – but as mass-
market consumer electronic devices they can
never meet the standards (of demonstrated
performance, and manufacturing transparency)
that approved devices must.
If you fly with an iPad as your EFB you must
ensure that the current editions of the maps
and charts are loaded on the EFB and readily
available at all times. What this means, in effect,
is that you must have a plan for what you would
do if the iPad had a flat battery or failed for any
other reason. This plan could be carrying paper
maps and documents within reach (not in the
luggage hold!), or it could be having a second
iPad within reach. If not, you could be in breach
of CAR 233 (1)(h) – and/or lost.
More information on electronic flight bags is at:
http://www.casa.gov.au/efb
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 99
Happy birthday Safeskies!
Safeskies celebrates 20 years and its 10th
conference this year, which will be held at the
Hotel Realm Canberra on 16 and 17 October.
The conference will bring speakers from the
UK, USA and Europe, and from Boeing, Agusta Director of Aviation Safety, CASA | John F McCormick
and Cranfield University, to discuss the latest Acting Manager Safety Promotion | Margo Marchbank
developments in operational safety. Australasian Acting Editor, Flight Safety Australia | Robert Wilson
speakers will include representatives from Deputy Editor, Flight Safety Australia | Joanna Pagan
Designer, Flight Safety Australia | Fiona Scheidel
government, defence, airlines, general aviation, Contributing designer | Duncan Grant
rotary wing, aero medical, law enforcement,
maintenance and cabin safety, among others. ADVERTISING SALES
Phone 131 757 | Email [email protected]
Attendance costs are deliberately kept low (with
sponsorship by ‘investors in aviation safety’)
CORRESPONDENCE
so that as many people as possible can hear
Flight Safety Australia GPO Box 2005 Canberra ACT 2601
about the latest developments in the field and
Phone 131 757 | Fax 02 6217 1950
have the opportunity to network with operators Email [email protected] | Web www.casa.gov.au/fsa
from other sectors.
The 2013 conference theme is ‘People and CHANGED YOUR ADDRESS
If you have an aviation reference number (ARN)
Technology’, with speakers on issues, including and want to update your contact details, go to
UAVs, rotary wing aircraft developments, pilot www.casa.gov.au/change
training and automation, cabin safety, the latest For address change enquiries, call CASA on 1300 737 032
technology in large passenger jets and a case
study from the Air France flight 447 accident DISTRIBUTION
investigation. This year’s conference will also Bi-monthly to aviation licence holders, cabin crew and
industry personnel in Australia and internationally.
reintroduce question times at the end of each
session.
CONTRIBUTIONS
Safeskies also hosts the Sir Reginald Ansett Stories and photos are welcome. Please discuss your
ideas with editorial staff before submission. Note that CASA
Memorial Lecture and conference dinner at cannot accept responsibility for unsolicited material. All
Parliament House, Canberra, the night before efforts are made to ensure that the correct copyright notice
accompanies each published photograph. If you believe
the conference. The 2013 Ansett lecturer will be any to be in error, please notify us at [email protected]
Raymond Benjamin, Secretary General of ICAO.
© Copyright 2013, Civil Aviation Safety Authority Australia.
For more details visit www.safeskiesaustralia.org
Copyright for the ATSB and ATC supplements rests with
the Australian Transport Safety Bureau and Airservices
Australia respectively—these supplements are written,
edited and designed independently of CASA. All requests
for permission to reproduce any articles should be directed
to FSA editorial (see correspondence details above).

ISSN 1325-5002.
Cover photograph: © British Airways
100 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Calendar

ACT/NEW SOUTH WALES

Bathurst 13 May
Broken Hill 17 Jun
Camden 24 Jun
Cowra 10 Jun
Dubbo 10 Jun
Gunnedah 25 Jun
Mudgee 13 May
Narrabri 25 Jun
2 November Newcastle 13 May
Warbirds Downunder, Temora, NSW Orange 13 May
www.aviationmuseum.com.au/vistor_information/warbirds_ Parkes 10 Jun
downunder_2013/index.html
Port Macquarie 13 May
Aviation Safety Advisers – coming to your area soon! Taree 13 May
For some years CASA has been holding very successful aviation Warnervale 13 May
safety seminars for the wider aviation community. These were
run by CASA aviation safety advisers (ASAs) at all major aviation
VICTORIA
hubs, often in conjunction with local aero clubs or aviation
organisations. Bairnsdale 2 Jun
In 2013 there will be a change of focus from seminars to site Bendigo 21 May
visits by ASAs, who will be visiting organisations to discuss Deniliquin 22 May
the forthcoming aviation regulatory changes. They will travel
throughout Australia and organisations and individuals are Echuca 21 May
welcome to contact their local ASA to arrange an appointment Hamilton 11 Jun
time. The approximate May/June travel schedule for each region Horsham 23 May
is shown below, and other details can be found on the AvSafety
Latrobe Valley 25 Jun
seminars and workshop page at www.casa.gov.au/avsafety
Lethbridge 13 May
ASAs are also available for visits within capital city environs
(within approximately two hours drive of the centre of a MEL Basin 1 May
capital city). MEL Basin 18 Jun
Aero clubs and other aviation organisations are also welcome to Port Campbell 14 Jun
run aviation safety seminars, with ASAs presenting on selected
Portland 12 Jun
topics. However, CASA will not be financially supporting these
events. If you would like to run a seminar with ASA attendance, Sale 26 Jun
please click the Avsafety request form and complete the details. Stawell 24 May
Every effort will be made to accommodate your requests,
Swan Hill 20 May
but this will obviously be easier to do if your proposed date
coincides with the schedule to the right. Warrnambool 12 Jun
Please note: some CASA seminar dates may change. Please go to www.casa.gov.au/avsafety
for the most current information.
CASA events Other organisations’ events
 FLIGHT SAFETY AUSTRALIA
Issue 92 May–June 2013 101
QUEENSLAND SOUTH AUSTRALIA WESTERN AUSTRALIA

Atherton 28 May Marree 7 May Derby 16 Jun

Emerald 27 May Mildura 27 May Geraldton 20 May
Georgetown 26 Jun Murray Bridge 24 Jun Hall Creek 27 May
Gladstone 1 May Parafield 20 May Kalbarri 20 May
Gold Coast 28 May Parafield 11 Jun Karratha 24 Jun
Horn Island 12 Jun William Creek 8 May Perth 6 May
Innisfail 22 May Wilpena 6 May Port Hedland 24 Jun
Karumba 29 Jun
Kingaroy 3 Jun INTERNATIONAL
Mackay 27 May 3 – 5 June
Mareeba 21 May Aerial Agricultural Association of Australia Convention,
Surfers Paradise
Mt Garnet 24 Jun www.aerialag.com.au/
Normanton 28 Jun
15 – 17 October
Rockhampton 1 May Safeskies, Canberra
Roma 13 May www.safeskiesaustralia.org/
Whitsunday 27 May 2 November
Warbirds Downunder, Temora, NSW
NORTHERN TERRITORY www.aviationmuseum.com.au/vistor_information/warbirds_
downunder_2013/index.html
Victoria River
Downs 13 May
UPCOMING EVENTS

7 – 9 June
Australian and New Zealand Societies of Air Safety Investigators
Conference
www.asasi.org/nzasasi/NZSASI_First_Page.html
24 – 27 June
Remotely Piloted Aircraft Systems Conference
Brussels, Belgium
www.rpas-2013.org/
19 – 22 August
International Society of Air Safety Investigators (ISASI) Annual
Seminar, Vancouver, British Columbia, Canada
www.isasi.org/
To have your event listed
here, email the details to 29 – 31 October
[email protected] International Air Safety Summit Washington, DC, U.S.A.
Copy is subject to editing. flightsafety.org/aviation-safety-seminars/international-air-
safety-seminar
102 CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Product review / next issue

PRODUCT REVIEW NEXT ISSUE

Informative and inspiring: CASA’s Out-n-Back July–August 2013
videos • High energy: the hazards and
potential of lithium batteries
Learning by doing is unbeatable, but at $200 or more
• Fatigue management update
an hour in a typical general aviation aircraft, it is also
expensive. For licensed VFR pilots CASA’s Out-n-Back • Risky business? Accidents and
is an effective and enjoyable way to review the central executive aviation
concepts of cross-country VFR flight – and it’s free. • … and more close calls

Out-n-Back is a six-part video series following a 6000

km VFR expedition in a Cessna 172. Capturing some of
Australia’s most magnificent scenery, the series explores
important general aviation safety topics including:
• daily inspection
• fuel management
• flight planning
• fatigue management
• and navigation over featureless terrain.
Key safety tips, articles and links to relevant safety
information accompany each video. You can find them
at www.casa.gov.au/outnback

The new online learning and event management

registration system is now live.
For further information see the CASA website
education page click here
 Out–n–back is a six-part
video series following
a 6000–kilometre round
trip in a Cessna 172.
The VFR flight begins and

OUT-N-BACK
ends in Bathurst, capturing
some of Australia’s most
magnificent sights along
the way.

PLAN | ARRIVE | SURVIVE

FUEL MANAGEMENT
AND REFUELLING DAILY INSPECTION WILDLIFE

PLANNING YOUR
ROUTE AND
ORDERING CHARTS OVER-WATER RULES

NOTAMS-
WEATHER IGNORE THESE
FORECASTS AT YOUR PERIL SARTIME SURVIVAL KIT

NAVIGATION
OVER FEATURE-
LESS TERRAIN FATIGUE
AND USE OF GPS MANAGEMENT

LOOKING AFTER OPERATIONS

YOUR AIRCRAFT THE LOWDOWN IN CONTROLLED
ON THE GROUND ON LAST LIGHT AIRSPACE

www.casa.gov.au/outnback