Aviation safety issues and actions

Operator’s installation of new aircraft systems on VH-NGA

Issue number: AO-2014-190-SI-07
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:

Given the aircraft was destroyed in the accident, the safety issue risk in relation to VH-NGA was no longer relevant. However, the ATSB is satisfied that the processes introduced by the operator satisfactorily reduced the risk of similar events in the future.

Safety issue description

Although the operator installed an enhanced ground proximity warning system (EGPWS) and traffic alert and collision avoidance system (TCAS) on VH-NGA in August 2009, it did not provide relevant flight crew with formal training on using these systems, or incorporate relevant changes into the aircraft’s emergency procedures checklists.

Proactive Action

Action number: AO-2014-190-NSA-032
Action organisation: Pel-Air Aviation
Date: 23 November 2017
Action status: Closed

Given the aircraft was the only one of the operator’s aircraft fitted with either EGPWS or ACAS, there was no safety action the operator could introduce that would specifically address this safety issue.

Following the accident, the operator advised CASA that it would provide the training to flight crew for any other aircraft that were subsequently fitted with the systems.

In October 2017, the operator advised the ATSB:

As foreshadowed in the report, complete and comprehensive training in the EGPWS and TCAS systems was subsequently provided to all crew.

All crew during their induction courses attend a formal and programmed TCAS/GPWS course prior to commencement of flying duties. In addition to this face to face training for all, there is a Computer Based Training module for the B200 Air Ambulance pilots due to the different operating method related to integration with the Proline 21 avionics pack fitted.

Since the accident, Flight Crew Operating Manuals (FCOM’s) were developed for all aircraft types and all contain detailed information (both technical and operational) regarding both TCAS and EGPWS.

Most importantly, in 2010, formal Change Management policy and procedure was implemented across the Rex Group of Companies as part of our Group Safety Management System Manual chapter 6…with specific and particular reference to Introduction or modification of new equipment.

This has been an integral part of all our business units ever since.

Although another example of the introduction of such equipment has not occurred since the accident, numerous formal Risk Assessments have been completed as part of this formal Change Management process including for example the introduction of and the operational use by crew of performance data derived from APG (Aircraft Performance Group).

The issue that was identified in relation to the introduction of the new equipment has not reoccurred and cannot occur in the future...

Last update 23 November 2017