Aviation safety investigations & reports

Flight control system event involving Cessna 210N, VH-JHF, 48 km West of Bourke Airport, NSW, 12 September 2011

Investigation number:
AO-2011-115
Status: Completed
Investigation completed

Summary

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What happened

On 12 September 2011 at about 1000, the pilot of a Cessna 210N aircraft, registered VH-JHF, was conducting low-level aerial survey operations near Bourke Aerodrome, New South Wales. After encountering a brief turbulence event, the pilot had difficulty in making elevator control inputs and in maintaining height. The aircraft subsequently landed safely. There were no injuries.

What the ATSB found

The ATSB found that the reported elevator control input difficulties resulted directly from the fracture of the aircraft’s two horizontal stabiliser rear attachment brackets. The forward spar of the horizontal stabiliser was also extensively cracked. The fractures and cracking were all consistent with metal fatigue and, as such, were typical of the damage sustained by aircraft as they age and move beyond the manufacturer’s originally intended design life. Many manufacturers have addressed the growing potential for this type of damage by introducing supplemental inspections to the principal aircraft maintenance requirements.

The Australian Civil Aviation Regulations 1988 (CAR) were being misinterpreted by some class B aircraft registration holders, to the extent that they believed that their aircraft was exempt from the manufacturer’s supplemental inspections when their aircraft was maintained using the CASA maintenance schedule. While the CASA maintenance schedule did not make any specific reference to the incorporation of the manufacturer’s supplemental inspections, it was a CAR requirement that all aircraft be maintained in accordance with approved maintenance data that, by definition, included those inspections.

What's been done as a result

As a result of this occurrence, on 19 September 2011 the Civil Aviation Safety Authority (CASA) issued Airworthiness Bulletin AWB 55-001 issue 2; highlighting the failure of horizontal stabilisers on Cessna 200 series aircraft. The AWB made recommendations on the maintenance schedule and inspection of the stabiliser in order to ensure the structural integrity of the area.

CASA also published a series of Discussion Papers in December 2012, detailing a range of options for developing updated continuing airworthiness regulations for all aircraft not used in regular public transport operations. This included options for reform of maintenance program requirements for non-RPT aircraft – to bring the regulations up to date with modern technology and current international standards and practice.

The outcomes from the discussion papers were unresolved at the time of writing and therefore the Australian Transport Safety Bureau has recommended that CASA proceed with its program of regulatory reform to ensure that all aircraft involved in general aviation operations are maintained using the most appropriate maintenance schedule for the aircraft type, and to also ensure that the provisions of CAR Schedule 5 are clarified in relation to the incorporation of all relevant supplemental inspections specified for the aircraft type.

Safety message

This occurrence highlights the importance of comprehensive, periodic maintenance inspections and the role of supplemental inspections in maintaining ageing airframes. The ATSB strongly encourages registration holders of class B aircraft to review their aircraft’s maintenance schedule to determine if it is the most appropriate for their aircraft and to ensure that it adequately provides for the continuing airworthiness of the aircraft.

Download Final Report
[Download  PDF: 2.09MB]
 
 
 

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Safety Issues

Go to AO-2011-115-SI-01 - Go to AO-2011-115-SI-02 -

Regulatory requirements for class B aircraft maintenance

The Civil Aviation Regulations 1988 allow class B aircraft registration holders to maintain their aircraft using the CASA maintenance schedule in situations where a more appropriate manufacturer’s maintenance schedule exists.

Safety issue details
Issue number: AO-2011-115-SI-01
Who it affects: All registration holders of class B aircraft
Status: Safety action pending

Regulatory requirements for manufacturers’ supplemental inspections

The Civil Aviation Regulations 1988 lack clarity regarding the requirement for aircraft manufacturers’ supplemental inspections, where available, to be carried out when an aircraft is being maintained in accordance with the CASA maintenance schedule.

Safety issue details
Issue number: AO-2011-115-SI-02
Who it affects: All registration holders of class B aircraft
Status: Adequately addressed
General details
Date: 12 September 2011   Investigation status: Completed  
Time: 2245 EST   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): 48 km Bourke Airport    
State: New South Wales   Occurrence type: Fuselage/wings/empennage  
Release date: 16 August 2013   Occurrence class: Technical  
Report status: Final   Occurrence category: Incident  
  Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Cessna Aircraft Company  
Aircraft model 210  
Aircraft registration VH-JHF  
Serial number 21063845  
Type of operation Aerial Work  
Damage to aircraft Nil  
Departure point St George, Qld  
Destination St George, Qld  
Last update 14 November 2018