In August 2009, CASA commenced a project to review the Australian requirements for fuel and alternates (Project OS 09/13 – Fuel and alternate requirements). The terms of reference noted that the ATSB database had provided evidence that fuel quantity issues were becoming problematic, and it was proposed to strengthen CAAP 234, and to change CAR 234 in order to encourage industry to follow the contents of the CAAP. It also noted proposed amendments to ICAO Annex 6 for fuel and alternate requirements for commercial air transport operations ‘require CASA to explore this issue and identify any potential issues the proposed ICAO amendments may have within the Australian aviation operating environment’.
In addition to changes to the requirements relating to Australian remote islands (see Safety action AO-2014-190-NSA-035), this project has involved various activities in relation to fuel planning.
On 25 June 2012, CASA advised the ATSB that amendment 36 to International Civil Aviation Organization (ICAO) Annex 6, State Letter AN 11/1.32-12/10 detailed a number of new Standards and Recommended Practices (SARP) in regard to fuel planning, in flight fuel management, the selection of alternates and extended diversion time operations (EDTO). In this respect, CASA provided the following update:
CASA intends to review Civil Aviation Advisory Publication (CAAP) 234-1 relating to fuel requirements. The ICAO fuel and alternate Standards and Recommended Practices (SARPs) are the basis of these changes and will be coordinated by CASA project OS09/13. While this project will focus specifically on passenger-carrying commercial flights the project will also be reviewing fuel requirements generally. The project will now be conducted in four phases. The first three phases will involve amendments to the relevant Civil Aviation Order (CAO) applicable Civil Aviation Advisory Publication (CAAP) 234-1 and Civil Aviation Regulation (CAR) 234. The project objectives are as follows:
– Phase 1 will involve amendments to the relevant CAOs and a review of CAAP 234-1 for flights to isolated aerodromes in light of the ICAO amendments. This phase will encompass fuel and operational requirements for flights to isolated aerodromes and will also consider the provision for flight to an alternate aerodrome from a destination that is a designated isolated aerodrome. The CAAP 234-1 will also be expanded to provide guidance and considerations necessary for flights to any isolated aerodrome, in particular when, and under what circumstances, a pilot should consider a diversion.
– Phase 2 will involve amendments to the relevant CAOs and further review of CAAP 234 in light of the ICAO amendments. This phase will encompass regulatory changes related to the implementation of general fuel planning, in-flight fuel management and the selection of alternate aerodromes. This review will include the methods by which pilots and operators calculate fuel required and fuel on-board.
– Phase 3 will involve amendment to CAR 234 to specify that the pilot in command, or the operator, must take reasonable steps to ensure sufficient fuel and oil shall be carried to undertake and continue the flight in safety. In addition, for flights conducted in accordance with Extended Diversion Time Operations (EDTO), CAO 82 and CAR 234 shall be amended to require consideration of a "critical fuel scenario" taking into account an aeroplane system failure or malfunction which could adversely affect safety of flight. It is anticipated that the methods chosen by the pilot-in-command and operator will therefore be sufficient to meet the requirements of CAR 234 to enable a flight to be undertaken and continue in safety.
– Phase 4 will involve the publication of internal and external educational material along with conducting briefings where necessary.
The amendment to the ICAO Annex 6 standards will be considered, and where appropriate, incorporated into the relevant legislation/advisory publication. In addition it is anticipated that there will be guidance material for operators who can demonstrate a particular level of performance-based compliance. The intent is to provide a bridge from the conventional approach to safety to the contemporary approach that uses process- based methods and Safety Risk Management (SRM) principles.
The ICAO Fuel and Flight Planning Manual are reflected in the SARP to Annex 6. Inclusion of the provisions of the Amendment 36 SARPs will be captured throughout this project. The ICAO SARP becomes effective from November 2012.
CASA will endeavour to make the changes as soon as possible - subject to third party arrangements such as drafting and resource availability. However the timing of the CAR changes will be subject to a timetable that is not necessarily able to be controlled by CASA.
In January 2016, as part of the project commenced in August 2009, CASA issued Consultation Draft (CD) 1508OS – Fuel and oil quantity requirements. The CD included proposed amendments to CAR 234 and CAAP 234. The explanation of the changes stated:
Regulation 234 of the Civil Aviation Regulations 1988 (CAR) requires the pilot-in-command of an aircraft to take reasonable steps to ensure that the aircraft carries sufficient quantities of fuel and oil for the proposed flight to be undertaken safely. The regulation also requires the operator of an aircraft to take reasonable steps to ensure that an aircraft does not begin a flight unless it is carrying sufficient fuel and oil to allow the flight to be conducted safely.
Australian Transport Safety Bureau (ATSB) reports have revealed incidents and accidents directly related to carriage of insufficient quantities of fuel. CASA proposes to address this safety issue by amending regulation 234 of CAR to provide updated fuel and oil requirements.
The current regulation 234 of CAR allows courts to consider any guidelines provided by CASA when determining whether sufficient fuel and oil were carried on a flight, which includes the guidelines provided in CAAP 234-1(1). While some of the information provided in the CAAP should be read as a requirement empowered by the current regulation 234, other information is advisory in nature. CASA intends to the make clearer the distinction between the regulatory requirements and the guidance material by transferring the requirements for determination of fuel and oil quantity from the CAAP to a proposed legislative instrument.
The CD proposed included fuel planning and fuel management requirements in an instrument, referenced by an amended CAR 234. The proposed instrument incorporated the definition of minimum safe fuel for a flight to a remote island from CAO 82.0. However, there were no other changes associated with remote islands or isolated aerodromes.
In March 2017, CASA advised the ATSB:
CASA is continuing, as part of the standards development process for the development of CASR Part 91 (General Operating and Flight Rules), to consider how to address the generalities of the ‘isolated aerodrome issue’. The specific operational parts for air transport (CASR 121/133/135) and aerial work (CASR 138) will subsequently consider whether additional constraints or conditions are needed, or if alleviation is available under certain conditions. These provisions, along with the fuel and alternate determination provisions will be subject to public consultation as part of the operational part suite…
The application of ‘isolated aerodrome’ SARPs is a vexatious issue because it relies on the interaction of the various ICAO SARPs that underpin it. It is very difficult to apply exactly the requirements of one ICAO SARP whilst not applying exactly the others that support it. In this case, the isolated aerodrome SARP relies on the fuel and alternate SARPs. These provisions require, inter-alia, that an alternate be nominated in almost all cases and that fuel quantities be determined on that basis. The isolated aerodrome SARP then allows alleviation from that requirement under certain conditions, most notably, when the nearest alternate is beyond approximately 90 minutes flight time.
Australian legislation has provisions that accommodate our unique infrastructure, particularly the absence of predominately independent runways at many aerodromes supporting air transport operations. The Australian rule set also allows for flights to be conducted without an alternate under certain operating conditions, such as weather above set criteria.
In August 2017 (after receiving the draft ATSB report for the reopened investigation), CASA advised the ATSB:
As mentioned in the report, prior to this accident CASA had already commenced Project OS 09/13 - Fuel and Alternate Requirements – to develop improvements to CASA regulations and orders relating to fuel carriage, fuel guidance and isolated aerodromes policy in light of proposed ICAO changes.
On 23 December 2014, CAO 82.0 was amended to require RPT passenger carrying operations and aerial work operations for ambulance functions or for functions substantially similar to ambulance functions to meet the same remote island requirements that had applied to charter passenger carrying operations at the time of this accident.
As part of this Project, CASA extensively examined the ICAO concept of isolated aerodromes, the historical context that led to the CASA remote island policy in place at the time of the accident and reviewed these in light of technological changes and the scope of Australian aviation operations to the identified remote islands. CASA determined that the implemented policy - that all passenger carrying charter, RPT and aerial work ambulance flights must nominate and plan for an alternate for all remote island operations and that a nominated alternate cannot itself be a remote island - was more conservative than the ICAO isolated aerodrome concept.
More generically, the policy regarding when a flight can be conducted without providing for an alternate aerodrome is being examined as part of Project OS 99/08 - CASR Part 91.
The ATSB acknowledges CASA’s safety action has reduced the risk associated with flights carrying passengers to Australian remote islands. The ATSB also notes that Australian major airlines which operate to isolated aerodromes (other than Australian remote islands) have risk controls in place that exceed the current minimum regulatory requirements.
Nevertheless, the ATSB is concerned other types of operators carry passengers on flights to isolated aerodromes both in Australia and internationally, and there are still limited Australian regulatory requirements that specifically address the hazards associated with such flights.
The ATSB acknowledges CASA is still considering changes to fuel planning requirements for isolated aerodromes as part of its project on fuel and alternates. The ATSB also acknowledges the complexity of specifying more detailed regulatory requirements in this area in line with ICAO requirements. Nevertheless, the ATSB is concerned that this matter still has not yet been addressed, and accordingly it issues the following recommendation.