The CASA Briefing
Your monthly CASA update

 Civil Aviation Safety Authority

August 2007

From CEO Bruce Byron

CEO Bruce Byron

CASA is carefully studying the Queensland Coroner's report into the May 2005 Lockhart River accident.  In a 54 page report Coroner Michael Barnes concludes that primary responsibility for the Metroliner accident in Far North Queensland must rest with the Captain of the aircraft.  The report says:

"He knew that the approach he was planning to undertake into Lockhart River on 7 May was inconsistent with official regulations and Transair's policies.  He must have also known that his departure from it was fraught with risk."

In examining the question of why the aircraft departed from standard published approach procedures, the Coroner states:

"It seems likely that when descending below the minimum safe altitude of 2060 feet, Mr Hotchin was relying upon a perception of terrain visibility that he hoped would continue and improve as he got lower.  Further, it seems he formed the equally false perception that he was closer to Lockhart River in the approach that he was attempting than he actually was.  It is impossible for me to accept that Captain Hotchin would have flown at the vertical speed he did with the nose pitched down as steeply as it was had he not seen the ground at some point.  The force with which the plane crashed into the mountain indicates he lost visual contact before impact.  The most likely explanation for his continuing with this flight path after losing sight of the ground is the attitude...of having made a decision, pressing on regardless."

The views expressed by the Coroner mirror the conclusions I came to when I studied the first Lockhart River accident factual report, which was released in late 2005.  This report contained information from the flight data recorder and after some careful analysis over several days it led me to believe that the aircraft was being flown with a deliberate high rate of descent, with the aim of gaining or maintaining visual contact with the ground.  I know this same view is held by a range of industry people with extensive experience and expertise.  I believe that to aviation people with a background in training and checking in this class of aircraft this is a logical conclusion.  Of course, no-one can prove this conclusion as the information from the cockpit voice recorder was not available - but there is a high probability it is the correct scenario.

Having decided this scenario was the likely explanation behind the accident, I was confident stating earlier this year that it was not possible to make a direct link between the actions of CASA and the failures that took place on the flight deck of the Metroliner.  While there have been various attempts to make a direct connection between CASA and the mistakes made by the crew, the Coroner's report does not support them.  The Coroner says CASA should not be blamed for the crash.  The report states:

"There is no compelling evidence that if it (CASA) had scrupulously followed all of its procedures and processes, the deficiencies that led to the crash would have been obviated, although it is impossible to avoid the conclusion that the risk may have been reduced.  I find that CASA could have done more to insist that Transair improved certain aspects of its operations but I do not believe that the evidence supports a finding that they could reasonably have stopped it from operating or prevented the crash."

I agree with the Coroner's key message - that CASA could not have prevented the accident but never-the-less must always be committed to supporting the aviation industry's safe operations.  CASA has a duty to make sure everything possible is done to influence, assist and direct the aviation industry to deliver the best safety outcomes.  The Coroner quite rightly pointed to shortcomings in the way CASA operated in the past and has recommended changes in a number of areas.  I do not shy away from accepting that in the past CASA should have been doing a better job in areas such as industry oversight.  That is why I have been leading a change program across CASA for the last three years, which is putting more inspectors on the tarmac and increasing surveillance of passenger carrying operations and using risk analysis to drive activities.

I have directed that the Coroner's recommendations be assessed and implemented as soon as possible, recognising that some of these improvements are already underway.  The recommendations included expediting the introduction of mandatory crew resource management training, consideration of firm guidelines for CASA staff who approve appointments of key personnel in aviation organisations such as chief pilot and reconsideration of measures to ensure the efficiency of training and checking in air transport operations. CASA will also co-operate fully with the implementation of the Coroner's fourth recommendation, which calls for the Federal Transport Minister to appoint an external consultant to examine the relationship between CASA and the Australian Transport Safety Bureau.  The Minister, Mark Vaile, has announced he will adopt this recommendation.

For people in the aviation industry I believe it is very important to take careful note of the findings of the Lockhart River accident Coronial report.  There are stark lessons for pilots and indeed anyone in a position of responsibility in the industry.  These lessons are best summed up by this statement in the report:

"...had the pilots adhered to the accepted aviation procedures and well published guidelines, the crash would not have occurred."

The Lockhart River accident is the second accident in recent years resulting in fatalities of fare-paying passengers that involved likely inappropriate pilot behaviour. The other accident was at Mount Hotham in Victoria. Given the vital role played by the flight crew as the 'last line of defence' in passenger-carrying operations, and CASA's stated priority of focussing on this sector of the industry, I have asked CASA's operational groups to develop oversight and educational strategies that target behaviours.

Regulations, standards and procedures exist for sound and sensible reasons: they provide the safety framework for everyone to work within.  Step outside the framework and you put your life and the lives of others at risk.

Keeping an eye on cabin air

CASA recently reconvened a special group which had been set up to examine issues relating to cabin air quality in passenger aircraft.  The Cabin Air Quality Reference Group includes representatives from major airlines, the Australian Federation of Air Pilots, the Australian Licensed Engineers Association, the Flight Attendants Association of Australia, the Australian Transport Safety Bureau, as well as several Commonwealth departments.  The group reviewed current international research on cabin air quality and contamination and agreed to meet again early in 2008 after the expected publication of a major United States study and standards.  After a number of years development work, the American Society for Heating, Refrigeration and Air-conditioning Engineers is set to release findings later this year on its work into cabin air quality.  This includes extensive in-flight measurements of air quality.  The Cabin Air Quality Reference Group will look carefully at the results to determine if further actions should be recommended in Australia.  CASA introduced a range of requirements for the BAe146 aircraft about six years ago in response to a number of contamination events.  Since then contamination reports from the BAe146 have dropped steadily, with none recorded this year.  Across the Australian aircraft fleet there have been only 138 contamination reports made over more than seven years.

Good news for Aussie manufacturers

There was great news for Australian aviation parts manufacturers from a recent visit by the United States Federal Aviation Administration.  A team from the FAA was in Australia earlier this month to review Australian Parts Manufacturer Approvals.  The aim is have these Australian approvals recognised in the US/Australian Bilateral Aviation Safety Agreement.  This recognition would allow much easier access to the US aviation market for Australian parts manufacturers.  The FAA team looked at Australia's aviation legislation, policies and procedures for the oversight and approval for the design, manufacture and modification of aircraft replacement parts.  CASA's CEO Bruce Byron says he raised the need for progress in this key area with the US Ambassador to Australia last year.  "I'm very pleased the FAA has responded by reviewing our approval system and they have a favourable view of how the controls are working.  They are now going back to the US to take the next steps in consideration of including the Australian Parts Manufacturing Approvals in the bilateral agreement. There are a few hoops to go through, but this is a great start to giving our manufacturing industry a competitive edge in the world market."

All's well in multi-crew pilot licence trial

A trial of a course based on the principles behind the proposed new multi-crew pilot licence is proving a success.  Six students from two Chinese airlines are taking part in the trial course, being run by Alteon in conjunction with the Australian Airline Academy at Archerfield in Brisbane.  The students are finishing the first phase of the training, which is being monitored by CASA.  One of the features of the proposed multi-crew licence training will be the greater reliance on large aircraft simulators, rather than the traditional flying in general aviation training aircraft.  CASA has found the students are displaying excellent cockpit teamwork at a very early stage in their training.  A CASA report on the training says:  "Through the use of high quality visual flight simulators and adherence to multi-crew phraseology and standard operating procedures, the MPL students have demonstrated sound two crew procedures.  This has started right from the ab initio stage where the student engaged in the pilot monitoring role uses the standard calls of 'altitude' or 'bank angle' to prompt the pilot flying during flight manoeuvres.  This results in a pilot's frame of mind that is 'multi-crew' from day one."  The multi-crew pilot licence proposal is based a new standard adopted by the International Civil Aviation Organization in late 2006.

Read more about multi-crew pilot licences

Save your life – get along to a safety seminar

CASA will hold more than 60 safety seminars for pilots during the current financial year.  The new program of evening pilot seminars is already underway, with events held in Queensland, Victoria and NSW.  The popular seminars are organised in conjunction with local aero and flying clubs and focus on key areas of safety.  CASA's field safety advisers make presentations on topics such as fuel management, the maintenance pilots can carry out on aircraft, visual flight rules operations into instrument conditions, operations in controlled airspace and situational awareness.  Feedback from the seminars is always positive, with attendances now running at more than 50 people at some clubs.

In September pilot seminars are scheduled for Camden, Maroochydore and Wollongong.  Read the full list of seminars

Cessna Conquest life limit

Operators of Cessna 441 Conquest aircraft have been directed to follow a new manufacturer's life limit on the aircraft type. Cessna has announced there is an unconditional life limit of 22,500 flying hours on the Cessna Conquest.  The manufacturer says it cannot assure the continued safety of the aircraft after the limit is reached. CASA's direction means that all Australian Conquests that have reached 22,500 hours must be grounded. Cessna Conquests with less than 22,500 flying hours may continue to operate normally. Cessna imposed the life limit after reviewing its structural maintenance program for the aircraft and determining that structural problems are likely to develop if the aircraft continues to operate. A structural maintenance program is in place to manage the safety of the aircraft up to the 22,500 life limit. CASA's direction to ground the aircraft will be place for one year and during this time avenues will be explored that could extend the safe operation of the Conquest beyond the current life limit. The direction to ground Conquests with more than 22,500 flying hours came into effect on 24 August 2007.

Find out more. 

Want air safety explained?  We do it.

CASA has launched a new initiative to help the general public understand more about aviation safety.  A new section has been created on CASA's web site called 'Aviation Safety Explained'.  The web pages contain information about CASA's role in aviation safety, what passengers need to know about air travel and advice for people planning to take an adventure flight.  The adventure flight information covers operations in Limited Category aircraft such as warbirds where people pay for flights.  CASA's deputy CEO Shane Carmody says the website information aims to take the mystery out of aviation, as well as providing specific advice in key areas.  Shane says:  "The popularity of adventure flights has been growing in recent years and the way safety is managed for these flights is quite different to everyday flying on commercial aircraft.  The risks are different and people must agree to accept these risks before taking an adventure flight.  CASA has now made it easy to get all the information you need on adventure flights by simply going to our website".

Find out more at Aviation Safety Explained

English is required

From 5 March 2008 the International Civil Aviation Organization's English language proficiency requirements take effect.  Pilots and flight engineers operating overseas using an Australian flight crew licence must have an endorsement on their licence showing they have been evaluated in English language proficiency to, at least, an operational level four in the six-level ICAO rating scale.  Level four is operational, level six is expert.  Pilots or flight engineers with Australian licences issued prior to 5 March 2008 will have met the English language requirement and may continue operating domestically without being subject to a re-evaluation.  CASA will not require or issue an endorsement of language proficiency in pilot licences for domestic operations – so there is nothing to do, unless they wish to fly overseas.  In that case they must apply to CASA for an updated licence with their Level 4 English Language Certificate of Proficiency endorsed on their licence.

However, where a new licence is issued after 5 March 2008 there will be requirement to meet the minimum ICAO Level 4 proficiency in English.  The English Language Certificate of Proficiency endorsement will be entered in the remarks section of licences.

Oxygen masks warning

Owners, operators and maintainers of aircraft fitted with quick-donning oxygen masks have been warned to check the equipment and schedule inspections and overhauls.  This follows an investigation by the Australian Transport Safety Bureau, which found some quick-donning oxygen mask head harness assemblies were faulty.  The problem is in the elastic of the mask, which can become stretched so that when it is released for use it fails to hold the mask firmly over the users face.  Manufacturers generally recommend a yearly user inspection be carried out, as well as an overhaul every five years.  CASA has issued an airworthiness bulletin which recommends inspections and a check of maintenance schedules to make sure the masks are included.

Read the airworthiness bulletin on quick-donning oxygen masks

Have your say on satellite navigation

People in the aviation industry have until the end of October to have their say on proposals to expand the use of satellite navigation technology in Australia.  A consultation paper has been released setting out how new technology can supplement and replace existing ground-based navigation aids.  The proposal is that from 2014 most aircraft operating in Australia would rely on Automatic Dependent Surveillance Broadcast (ADS-B) for en route surveillance and Global Satellite Navigation System (GNSS) avionics for air traffic surveillance and aircraft navigation.  Federal Transport Minister Mark Vaile said this move would cement Australia as a world leader in the use of these technologies.  Mr Vaile said: "The proposal includes the provision of financial assistance to general aviation for the widespread fitment of these avionics to the Australian aircraft fleet."

Find out more about satellite navigation

Action to ease engineer shortage

The Federal Government has taken action to help ease the growing shortages of avionics and mechanical aircraft maintenance engineers.  These occupations have now been added to the Occupations in Demand List.  This makes it easier for suitably qualified people to enter Australia through the Skilled Migration Program.  The Minister for Transport Mark Vaile said: "Research by the Civil Aviation Safety Authority and the Australian Bureau of Statistics tells us that Australia is experiencing shortages in the skilled aircraft maintenance engineers needed to service Australia's growing aviation fleet.  I recently wrote to my ministerial colleagues and the CEO of CASA to ensure that relevant Government agencies do all that they can to ensure that the continued growth of the Australian aviation industry is not jeopardised by shortages of key personnel."

New safety survey

Work is being finalised on the first safety survey of holders of air operator's certificates.  CASA will conduct the survey before the end of this year, with all holders of air operator's certificates to be required to fill in an electronic questionnaire.  The on-line survey will collect data about the general activities of air operators, including the aircraft being used, types of operations, hours flown and information about key personnel.  The survey will be emailed to air operators and should take no more than 15 minutes to complete, if organisations have the required data ready.  It is expected the survey will be carried out twice a year, with the data being used by CASA for risk and safety analysis of current aviation activities, as well as future planning A notice of proposed rule making is now open for comment until 10 September on proposed amendments to Civil Aviation Orders to give effect to the survey. 

Read the NPRM.