Recommendations and Safety Advisory Notices

Safety issue
The helicopter operator's induction checklist did not include the notation of instructors' ratings and validity periods.

Action taken by the ATSB
Unless operators actively track the qualifications, endorsements, ratings and recency of their staff, there is the risk that pilots and instructors may operate aircraft with invalid qualifications and not be at the specified competency standard required for the task. Pilots, including those who have gained their Australian ratings as part of the Trans Tasman Mutual Recognition Act 1997, need to be aware of the different requirements regarding rating renewals in Australia. A valid rating is an important measure of competency.

Operators need to be able to assure themselves that pilots' qualifications are valid, and their competence confirmed when allocating tasks. On that basis, the ATSB issues the following Safety Advisory Notice.

Safety Advisory Notice AO-2009-032-SAN-019
The Australian Transport Safety Bureau suggests that operators and pilots should consider the safety implications of this safety issue and take action where considered appropriate.

The Australian Transport Safety Bureau draws the attention of all operators of CFM56-7 and CFM56-5 engines and their variants to the safety issues identified by this investigation. In particular operators should be aware of the potential for premature wear within the compressor variable stator vane bushings and shroud to develop to levels where it may precipitate the failure of the engine while in-service, and within a timeframe that is less than the minimum threshold for the initial inspection for the problem (24,000 hours TSN, per S/B 72-0515). Operators are encouraged to review their procedures to ensure an appropriate awareness of the issues among maintenance personnel.

Safety issue

There was a lack of assurance that informal operator supervisory and experience-based policy, procedures and practices minimised the risk of pilots operating outside the individual pilot's level of competence. [Minor safety issue]

Action taken by the ATSB

In response to this safety issue, the ATSB issues the following Safety Advisory Notice (SAN).

Safety advisory notice

The Australian Transport Safety Bureau (ATSB) draws the attention of all operators to the potential lack of assurance that informal operator supervisory and experience-based policy, procedures and practices minimise the risk of their pilots operating outside the individual pilot's level of competence. Operators are encouraged to consider the safety implications of this safety issue and take action where considered appropriate.

This incident highlights the potential for unintended consequences when changes to standard operating procedures are introduced without first conducting an appropriate risk analysis. Therefore, the ATSB advises that all aircraft operators should consider the safety implications of this safety issue and take action where considered appropriate.

Safety advisory notice

The Australian Transport Safety Bureau draws the attention of all operators to the contributory and other factors identified by this investigation. Operators are encouraged to review their procedures to ensure an appropriate awareness amongst operating personnel of the implications for aircraft performance of the combination of aircraft weights and speed, and of the ambient conditions.

Safety issue

There was no regulatory requirement for simulator training in Australia.

Action taken by the Civil Aviation Safety Authority

A summary of CASA activities to facilitate the use of full flight simulators and/or flight training devices follows:

The following inter-related activities are in the process of implementation:

• A combined workshop activity with Ansett Aviation Training, Capiteq Limited trading as AirNorth, Network Aviation Pty Ltd, Skippers Aviation Pty Ltd, PelAir Aviation Pty Ltd and CASA was held on 27, 28 April 2009.
• CASA has initiated a review of CAR 217 Training Organisations and Training Centres. This programme of review was prompted following investigations that revealed AOC holder training inconsistencies.
• A Component of the 'CAR 217 Training Organisations and Training Centres Special Emphasis Review' is to establish the level of company oversight and involvement with training and simulation, programmes that have been outsourced.
• Civil Aviation Order 40.2.1 - Instrument Rating, Section 12A, `Renewal using an overseas flight simulator training provider' has been added to include the option of instrument proficiency checks being conducted by an overseas simulator provider. This is to enable an instrument rating renewal where a specific type simulator is not available in Australia:
  • This amendment needs to read in conjunction with Advisory Circular AC 60-2 (1) of May 2007;
  • The Advisory Circular identifies that CASA recognises the flight simulator qualifications certificates issued by Canada, Hong Kong (Special Administrative Region of China), New Zealand, the United States of America, Belgium, the Czech Republic, Denmark, Finland, France, Germany, Ireland, Italy, the Netherlands, Norway, Portugal, Spain, Sweden, Switzerland and the United Kingdom; and
  • Civil Aviation Order 40.1.0 - Aircraft Endorsement - Aeroplanes, Section 6. This facilitates an option for instrument rating renewals to be associated with the issue of an aircraft type rating.

ATSB assessment of response/action

The activities undertaken by CASA appear to have facilitated increased use of simulators for endorsement and other training. However, the ATSB remains concerned that there is no regulatory requirement for simulator training when a suitable simulator is available in Australia.

Safety Recommendation

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority address this safety issue.

CASA will address this issue and will commence a review of the legislation. In the course of that review, CASA will consider whether there is a need to mandate the use of simulators in connection with certain flight crew training requirements in the air transport sector, and other sectors where this may be appropriate.

This work will commence immediately.  It will involve consultation with industry and may come to involve a risk assessment, a cost-benefit analysis, and the preparation of a regulatory impact statement.  As this is likely to be a protracted process, CASA is not in a position to specify a specific completion date at this time.

CASA released a Discussion Paper (DP) in December 2009 on the subject of mandatory flight simulator training. The DP put forward a range of options to canvas the views of industry participants. Responses to this DP closed in February 2010. Numerous responses were received from a variety of organisations and individuals including airlines, pilots and flight simulator training providers. These responses are currently being reviewed and policy proposals are being developed.

The subject of mandatory flight simulator training is a high priority for CASA and as such it is expected that a Notice of Proposed Rule Making (NPRM) will be published in the 2nd quarter of 2010. This NPRM will put forward CASA's proposed policy on this issue which will in part be derived from the comments received on the DP. Depending on the results of an assessment of business compliance costs, the proposal may be subject to a formal Regulation Impact Statement (RIS) which may prolong the rule making process.

Safety issue

CASA did not seek information to establish whether conditions '...necessary for the safety of other airspace users and persons on the ground or water' were required prior to issuing the Special Certificate of Airworthiness.

Action taken by CASA

In its response to this safety issue, CASA provided the following reponse to the ATSB on 1 June 2009:

I refer to your email dated 15 May 2009 regarding a further draft of Transport Safety Report AO-2007-066. I understand CASA has already provided comments on the safety management issue for the pilot. However, the current draft of the report appears to have broadened this issue to include other persons ie "CASA did not seek information to establish whether conditions '...necessary for the safety of other airspace users and persons on the ground or water'" were required prior to issuing the Special Certificate of Airworthiness.

In CASA's view the new safety issue is irrelevant to the accident because no other airspace users and persons on the ground and water were affected. The person who was fatally injured was the pilot, a participant and fully aware of the risk. CASA did not seek information '...necessary for the safety of other airspace users and persons on the ground or water' were required prior to issuing the Special Certificate of Airworthiness, because it based the safety determination on the information submitted by the applicant initially as part of the application and subsequent flight test plan. This information and the conditions set out on the Special Certificate of Airworthiness and other required operational approvals (low level flight over water) are intended to ensure the safety of other airspace users and persons on the ground or water.

In those cases where such inquiries are or might be relevant, CASA will not hesitate to make them and formulate and impose such additional conditions (if any) as may be necessary in the interest of safety, on that basis.

ATSB assessment of response

The potential for risk to other parties in relation to the experimental flight test was identified by CASA in its advice to the engineer of 29 November. If there had been due consideration of that potential risk in the operator's application for a Special Certificate of Airworthiness and 'subsequent flight test plan', then the additional advice to the engineer, which was provided after the issue of the certificate, would not have been warranted. When considering the issue of future Special Certificates of Airworthiness in the experimental category, CASA needs to be able to assure itself that adequate information is gathered to enable an informed decision on the conditions '...necessary for the safety of other airspace users and persons on the ground or water'.

Safety Recommendation

The ATSB recommends that CASA address this safety issue.

Thank you for the copy of your Final Report on the above occurrence, and the formal safety recommendation included in that Report.

You have recommended that CASA address the safety issue that, when considering the issue of future Special Certificates of Airworthiness in the experimental category, CASA needs to be able to assure itself that adequate information is gathered to enable an informed decision on the conditions '... necessary for the safety of other airspace users and persons on the ground or water'.

In its response to the ATSB on 1 June 2009, CASA stated that it did not seek information to establish whether conditions .. .. .'necessary for the safety of other airspace users and persons on the ground or water were required prior to issuing the Special Certificate of Airworthiness, because it based the safety determination on the information submitted by the applicant initially, as a part of the application and subsequent flight test plan. Beyond this, and despite further advice from CASA to the engineer involved regarding the potential risk to other parties, CASA contended that this information and the conditions set out on the Special Certificate of Airworthiness, in addition to other legislative provisions and required operational approvals, were sufficient to ensure the safety of other airspace users and persons on the ground or water.

CASA has now reconsidered its initial response with due regard to the ATSB's safety recommendation (SR-081) as it applies to the issue of future Special Certificates of Airworthiness in the experimental category. In future, CASA will provide further advisory material designed to ensure that adequate information is made available to enable an informed decision on the conditions'...necessary for the safety of other airspace users and persons on the ground or water'.

CASA has initiated development of a Senior Management Instruction (SMI), an internal staff guidance document, which will include relevant text and checklists to provide updated guidance and advice on this subject. This information will be published by the end of November and will be included in the Certificate of Airworthiness and Special Flight Permits Manual at an appropriate time.

Safety Advisory Notice

The Australian Transport Safety Bureau encourages all organisations performing inspection, testing, maintenance and repair activities on aviation oxygen cylinders, to note the circumstances detailed in this preliminary report, with a view to ensuring that all relevant procedures, equipment, techniques and personnel qualifications satisfy the applicable regulatory requirements and established engineering best practices.

Safety Advisory Notice

The Australian Transport Safety Bureau encourages other operators of transport category aircraft fitted with pressurised gaseous oxygen systems, to note the circumstances detailed in this preliminary report, with a view to ensuring that all oxygen cylinders, and cylinder installations, are maintained in full accordance with the relevant manufacturer's requirements, statutory regulations, and established engineering best practices.

Safety issue

Some pilots operating at non-towered aerodromes do not fully understand the significance of hearing (or not hearing) the various ARFU transmissions.

Safety Advisory Notice

The Australian Transport Safety Bureau advises that pilots operating into non-towered aerodromes should consider the safety implications of this safety issue and take action where considered appropriate.

Safety issue

Following the release of the Preliminary Report into the accident, the helipad operator provided the additional following response on 12 May 2008:

With reference to the amended Preliminary Transport Safety Report, sent to us with your letter dated 7 March 2008, we make the following comments:

1. The helicopter pilots involved in the accident were, apparently to their knowledge, using the Pier 35 helipad unlawfully.
2. The Preliminary Investigation Report does not make clear precisely what safety action the ATSB recommends to address the perceived safety issue. Further, it is not apparent wha 'safety action' may be appropriate in the circumstances described in Paragraphs 3 & 4 below.
3. For reasons unrelated to the accident, SA Helicopters (the sub-lessee of the Pier 35 land) has recently ceased all helicopter operations at Pier 35. SA Helicopters is in dispute with D'Albora Marinas (the sub-lessor of Pier 35 land) regarding the termination of the sub-lease.
4. SA Helicopters does not authorise any on-going use of the Pier 35 land as a helipad by any person.

During their response to the draft report, the helipad operator advised that they had surrendered the Pier 35 lease back to the owners of the marina.

Safety Recommendation

The Australian Transport Safety Bureau recommends that Heli Air Pty Ltd takes action to address this safety issue.

Safety Issue

The aircraft manufacturer's maintenance manual contained insufficient instruction or guidance for operators and maintainers of Super King Air 200 aircraft for the lubrication of the landing gear torque tube support bearings.

Safety Advisory Notice

The Australian Transport Safety Bureau advises that Hawker Beechcraft should consider the safety implications of this safety issue and take action where considered appropriate.

Safety Issue

Parachutists are not required to utilise helmets while parachuting, thereby increasing their risk of head injury during parachuting and in the event of an aircraft accident. In the event of a head injury during an aircraft accident, their successful exit from an aircraft could be negatively affected.

Safety Recommendation

The Australian Transport Safety Bureau recommends that the Australian parachute Federation establish the safety benefits of requiring parachutists to wear helmets during parachute operations.

Safety issue

The current configuration of some sports parachuting aircraft may not be conducive to occupant survivability in the event of an aircraft accident.

Safety Recommendation

The Australian Transport Safety Bureau recommends that the Australian Parachute Federation conduct an audit of members' aircraft in order to identify and mitigate potential aircraft equipment-related crash survivability issues.

Safety Issue

Compliance with the APF Jump Pilot's Handbook & Aircraft Operation Procedures Manual was understood by the APF to not be mandatory for members of the federation. However, it appeared that the manual could be considered an applicable manual in accordance with the schedule. The clarification of the intent of Schedule A has the potential to mandate the adoption of the APF Jump Pilot's Handbook & Aircraft Operation Procedures Manual by APF members. In turn, that would enhance the safety and efficiency of APF members' parachuting operations.

Safety Recommendation

The Australian Transport Safety Bureau recommends that the Australian Parachute Federation (APF) clarify with the Civil Aviation Safety Authority (CASA) the intent of Schedule A of the Deed of Agreement between the APF and CASA as it affects compliance by APF members with APF documentation.

Safety issue

Currently, Civil Aviation Advisory Publication (CAAP) 42B-1(0) and Airworthiness Bulletin AWB 02-003 Issue 2, are ambiguous regarding required inspection intervals for Private category aircraft airframe items. This may result in the items being operated past the specified aircraft manufacturer's inspection interval.

Safety Recommendation

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review Civil Aviation Advisory Publication (CAAP) 42B-1(0) and Airworthiness Bulletin AWB 02-003 Issue 2, in order to clearly define the required inspection intervals affecting Private category aircraft airframe items.

CASA has no objection to the safety issue at 4.2.2 in the draft report and the recommendation. CASA is aware that this is an area that requires clarification and will pursue this further now that the final report has been released.

Safety issue

The practice of harnessing tandem parachutists together during the take-off roll and climb out of the aircraft could negatively impact occupants' survivability in the event of an aircraft-related emergency.

Safety Recommendation

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authorityadvise all self-administered sports parachuting organisations (other than the Australian Parachute Federation) to include instructions in their Training Operations Manual, or equivalent, to define when tandem parachutists should be harnessed together, with a view to optimising the likelihood of parachutists successfully exiting an aircraft in the event of an aircraft emergency, including when below the safe release point.

CASA wrote the Australian Skydiving Association on 11 December 2007 requesting that the organisation action this recommendation.

Safety issue

The current configuration of some sports parachuting aircraft may not be conducive to occupant survivability in the event of an aircraft accident.

Safety Recommendation

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority direct that non-Australian Parachute Federation sports parachuting organisations conduct a review of their aircraft in order to identify and mitigate potential aircraft equipment-related crash survivability issues.

CASA wrote the Australian Skydiving Association on 11 December 2007 requesting that the organisation action this recommendation.

Safety issue

The current US Federal Aviation Administration approved Supplemental Type Certificate SA2123NM supplemental operational documentation relating to usage of the auxiliary fuel pump in the Cessna U206 is ambiguous regarding the operation of the pump for takeoff. That ambiguity could result in the inappropriate use of the pump and subsequent engine operational issues.

ATSB comment

As at 24 November 2008, no further advice had been received from the US Federal Aviation Administration on their consideration of the recommendation and the ATSB reclassifies it as Closed - Not Accepted.

Safety Recommendation

The Australian Transport Safety Bureau recommends that the US Federal Aviation Administration require Aeromods Incorporated to amend the aircraft operational documentation supplement for the Cessna U206 aircraft relating to Supplemental Type Certificate SA2123NM, to include information on the recommended use of the auxiliary fuel pump for takeoff.

ATSB comment

Note: The same recommendation was issued to Airservices Australia as R20070026. On 21/12/2007, Airservices Australia responded to the recommendation and the ATSB classified it as Closed - Accepted (see /publications/recommendations/2007/R20070026.aspx).

Based on that response the ATSB classifies R20070025 as Closed - Accepted.

Safety Recommendation

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority, in consultation with Airservices Australia, review the requirements for the dissemination of SIGMET information with a view to minimising differences between air traffic control procedures contained in the Aeronautical Information Publication and those contained in ICAO Doc.4444 and ICAO Doc.7030.