Aviation safety issues and actions
Interim Recommendation issued to: Civil Aviation Safety Authority
|Date issued:||04 July 1997|
|Safety action status:||Closed|
SUBJECT:Emergency Medical Service (EMS) Installations in
Australian Registered Aircraft
The Bureau of Air Safety Investigation recommends that the Civil
Aviation Safety Authority:
(i) conduct an audit of all emergency medical service oxygen-equipped aircraft to determine the equipment standards in Australian registered aircraft;
(ii) issue design standards for emergency medical service oxygen equipment installations;
(iii) issue maintenance requirements for emergency medical service oxygen equipment;
(iv) provide surveillance requirements for emergency medical service oxygen equipment in the Aviation Safety Surveillance Program;
(v) ensure flight crew are provided with appropriate instuctions in the use of emergency medical service oxygen equipment in aircraft flight manuals or company operations manuals; and
(vi) provide educational material to the aviation industry on the installation, operation and maintenance requirements of emergency medical service oxygen systems.
|Date issued:||06 August 1998|
|Response from:||Civil Aviation Safety Authority|
|Action status:||Closed - Accepted|
I refer to BASI Interim Recommendation, IR970104, in relation to the Bell Helicopter accident at Tartrus Station, Queensland on 2 May 1997. This incident has clearly revealed some deficiencies in current CASA procedures regarding medical oxygen systems used in aircraft. These deficiencies require correction.
Issue design and maintenance standards for EMS 02 equipment installations (Recommendations ii and iii)
Role equipment such as that installed in EMS aircraft is installed on the basis of "No Hazard, No Interference." There are at present two Australian standards which relate to aircraft oxygen systems:
CAO 20.4, Provision and Use of Oxygen and Protective Breathing Equipment,
CAO 108.26, Systems Specifications - Oxygen Systems
Neither of these standards are directly applicable to EMS 02 systems, addressing instead supplemental oxygen for high altitude flight. However, Federal Aviation Administration AC 27-1, Certification of Normal Category Rotorcraft contains a section on EMS 02 systems. Unfortunately, this US AC has no legal standing under Australian law.
Thus, while much information is available, it is not clearly presented, is fragmented, and in some cases is out of date. I therefore intend to expedite the issue of a CAAP providing integrated design guidelines for this type of installation. This CAAP, expected to be issued by September 1998, will cover the design, installation and maintenance of Emergency Medical Services Oxygen Systems.
Provide surveillance requirements for EMS 02 equipment in ASSP. (Recommendation iv)
The ASSP program does not at present specifically address surveillance of aircraft internal role equipment, such as medical oxygen systems. This deficiency will be addressed, and the ASSP amended as necessary to include this type of equipment.
Conduct an audit of all emergency medical service 02 equipped aircraft to determine the equipment standards in Australian registered aircraft. (Recommendation i)
Because there is at present no readily available standard against which to audit existing EMS 02 installations, and because very few CASA (or industry) people have the knowledge or experience of oxygen systems necessary to conduct such an audit, I do not believe that an audit is appropriate at this stage.
Issue of the CAAP and clarification of ASSP requirements are expected to have a beneficial effect, resulting in improvements and upgrading of existing systems. However, should routine surveillance reveal widespread problems or raise further concerns, additional action will be taken to overcome the problems.
Provide educational material to the aviation industry on the installation, operation and maintenance of EMS 02 systems. (Recommendation vi)
CASA is planning to conduct an educational seminar in the latter part of this year involving CASA staff and industry personal, including designers, operators and other interested parties. Your assistance in conducting this seminar would be much appreciated, including a presentation on this incident and the BASI finding. The CAAP will also assist in this regard.
Ensure that flight crew are provided with appropriate instructions in the use of EMS 02 equipment in Aircraft Flight Manuals or Company Operations Manuals. (Recommendation v)
EMS systems are normally installed in aircraft as modifications, under the auspices of CAR 35. An important part of any such modification is the provision of the necessary amendments or supplement to the aircraft flight manual. The CAR 35 authorised person who approves the modification should be ensure that such data are available and included in the modification package. This requirement will be reinforced in the CAAP.