Aviation safety issues and actions

Operator’s risk controls for flight/fuel planning

Issue number: AO-2014-190-SI-01
Who it affects: Operator’s Westwind flight crew
Issue owner: Pel-Air Aviation
Transport function: Aviation: Air transport
Background: Investigation Report AO-2009-072
Issue release date: 23 November 2017
Current issue status: Adequately addressed
Issue status justification:

The ATSB acknowledges that the operator undertook substantial safety action to address its risk controls regarding fuel planning on its Westwind fleet. Although not every item in the safety issue was specifically addressed, the overall level of action substantially reduced the risk of operations to remote islands and isolated aerodromes.

Safety issue description

The operator’s Westwind pilots generally used a conservative approach to fuel planning, and the operator placed no restrictions on the amount of fuel that pilots uploaded. However, the operator’s risk controls did not provide assurance that there would be sufficient fuel on board flights to remote islands or isolated aerodromes. Limitations included:

  • no explicit fuel planning requirements for remote islands or isolated aerodromes
  • no formal fuel planning guidance for some relevant situations, such as a loss of pressurisation or flight below reduced vertical separation minimum (RVSM) airspace
  • no formal training for planning flights to remote islands or for international operations
  • no guidance information about potential hazards at commonly-used aerodromes
  • no procedure for a captain’s calculation of the total fuel required to be checked by another pilot
  • little if any assessment during proficiency checks of a pilot’s ability to conduct flight/fuel planning.

Proactive Action

Action number: AO-2014-190-NSA-023
Action organisation: Pel-Air Aviation
Date: 23 November 2017
Action status: Closed

In 20 November 2009, the operator issued a notice to flight crew stating that all flights to Australian designated remote islands (Norfolk Island, Lord Howe Island and Christmas Island) must carry fuel for a suitable alternate aerodrome.

Following the accident, CASA carried out a special audit of the operator’s operations between 26 November and 15 December 2009. The audit included an extensive assessment of the operator’s Westwind operations and a number of the operator’s organisational aspects. The operator voluntarily ceased its Westwind operations and collaborated with CASA during the special audit. A management action plan was developed to address a wide range of issues and provide the operator with confidence in the safety of its operations.

On 7 December 2009, the operator issued a notice to Westwind pilots that the Westwind standards manager would conduct the flight/fuel planning for all international air ambulance flights until the operator was able to install a standard flight planning software tool at all bases. In addition, the operator would provide all relevant weather information and NOTAMs to flight crews. Flight crew were able to conduct the flight planning for domestic flights, but only if they used the operator’s approved fuel planning data.

In addition, on 7 December 2009, the operator issued a new Westwind 1124/1124A fuel policy and interim flight planning procedures. Following consultation with CASA, a revised policy and interim procedures was issued on 21 December 2009. The policy and procedures included specified fuel burn for different ranges of flight levels (including non-RVSM levels). It also included specified fuel figures for an instrument approach, alternate fuel, fixed reserve, holding fuel and taxi fuel.

In addition, the policy and procedures required:

  • an alternate aerodrome be selected for all IFR flights unless the destination aerodrome was an isolated aerodrome, or the expected flight time was no more than 3 hours and there were two separate runways at the destination aerodrome and the forecast conditions indicated a VMC approach could be conducted
  • flights to Australian remote islands carry an alternate aerodrome at all times
  • remote islands only be used as a destination aerodrome (not used as a refuelling or technical stop)
  • flights to isolated aerodromes be planned with taxi fuel, flight fuel, variable reserve fuel and additional fuel to fly for 2 hours after arriving overhead the aerodrome (including the fixed reserve).[1]

Additional safety actions related to fuel planning included:

  • a requirement for both flight crew to review and cross check the flight plan before flight and acknowledge they had checked the fuel requirements were adequate for the flight
  • a review of flight planning resources available at each base and replacement of computers and other resources where required
  • introduction of a standard flight planning software tool, available at all bases, with operator-controlled figures and formal guidance for using the tool
  • formal ground-based training for all flight crew on flight planning, fuel calculations, the new fuel policy and use of the flight planning software tool
  • formal ground-based revision training for all flight crew on Westwind aircraft performance, Westwind aircraft systems, GPS principles, en route navigation, and IFR theory
  • formal guidance to flight crew for operations in RVSM airspace
  • a requirement for new captains to complete 10 international flight sectors before being recommended for a check to line
  • introduction of standard flight plans and navigation logs for some commonly-used routes.

In mid-2010, the operator ceased its relationship with CareFlight, and therefore ceased air ambulance operations in Westwind aircraft. The operator advised that, if it restarted these operations, it would conduct a formal change management process.

In addition to the Westwind fleet, the operator also revised its fuel policy on the Learjet fleet.

[1]     This requirement was subsequently amended in March 2010 to 90 minutes additional fuel with CASA approval.

Last update 23 November 2017