Flight Safety Pty Ltd
June 2010
Safety Alert
News from Flight Safety Pty Ltd
In This Issue
Audit Findings - Helidecks
OGP Major Accidents
The crash we'll never understand
Fast track for Jetstar pilots
Inadvertent IMC
Incredible recovery
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Dear Colleague,

This month we highlight a high frequency helideck inspection finding that relates to foam monitor testing.  Additional news items include: a fatal UK accident in 2008 that highlights the need for cockpit voice and flight data recorders in turbine aircraft, however small; while an important initiative in the US for sharing safety information (ASIAS) has the potential to give "an almost 360-degree capability to view problems or emerging threats" in aviation.


Colin Weir

Colin Weir, Managing Director
Flight Safety Pty Ltd
Helideck Inspection Finding Analyses


One of the safety-critical Helideck inspection testing procedures is to ensure that the Foam Monitors are fully functional - this can only be achieved through a practical test firing process.

Of concern is the fact that at least 40% of all Helidecks inspected have deficiencies relating to the Foam Monitors.  These include:
  1. Inadequate number of Foam Monitors and/or related backup systems
  2. Inadequate pressure.
  3. Inadequate foam tank content - mismatch with the minimum helideck size requirement, relevant calculations below (Reference UKCAA CAP 437 Sixth edition incorporating Amendment 01/2010).

    Foam monitor rules

    In short, a Helideck with a D-value of 22.2 metres requires 348 litres of foam if applied at 3% for 5 minutes. 

    Note: Additional supplies are needed, not only for training and testing, but also for replenishment if used.
  4. Delayed activation due to Foam Monitor valve problems, main isolation valve inadvertently left in the closed position or Foam pump failure.

    Foam monitor standards
It is recognised that Foam Monitor testing should not occur while the vessel is docked - in this instance it is imperative that a test is carried out before operations commence.
OGP Risk Assessment Data Directory - Major Accidents

Major Accidents datasheet The International Association of Oil & Gas Producers has access to a wealth of technical knowledge and experience with its members operating around the world in many different terrains. They collate and distil this valuable knowledge for the industry to use as guidelines for good practice by individual members.

This datasheet provides background historical information on major accidents in the onshore and offshore oil and gas production and process industries, to serve as background for QRA studies. The focus of this datasheet is on presenting an overview the range of accident types and their relative frequency of occurrence, rather than on absolute frequencies. Attention is focused on major accidents, taken to be those that have resulted in significant numbers of fatalities, asset damage and/or environmental pollution. Frequencies have been estimated for several of the accident types most commonly addressed in QRAs in other datasheets of this set.

Download the Major Accidents Data Sheet (PDF) >>
The crash we'll never understand

Cessna Crash (UK) When the Cessna Citation 500 crashed into houses near Biggin Hill aerodrome on 30 March 2008, it mystified all the aviators  with whom blogger David Learmont discussed it. Now the Air Accident Investigation Branch  (UK) has released its final report and we are not much the wiser despite their painstaking work. There were no recorders on board - there were not required to be.

The AAIB's verdict is that, two minutes after take-off while the aircraft was flying across the airfield on its cleared departure routeing, the crew misinterpreted vibration in the air conditioning unit as an engine fault, The Board says there was no evidence of a fault in either engine, ruled out fuel contamination and a host of other possibilities, but concluded that 70sec before impact neither engine was delivering any power. At impact both engines were powering up at different stages in their re-start procedure.

But we never will know what the crew saw and heard that made them act as they did. We don't even know for sure exactly what they did. It's time to demand cockpit voice and flight data recorders in turbine aircraft, however small, which is what the AAIB is calling for.

Read full Flight Global blog posting >>
ASIAS aims to identify aviation safety risks before they occur

Stats Building on the tremendous success of the CAST (Commercial Aviation Safety Team) program in improving US airline safety, aviation stakeholders embarked on the next major step toward eliminating fatal accidents.

According to Continental Airlines' Don Gunther, CAST industry co-chair, the goal is to "transition to a prognostic and diagnostic safety program" to identify potential problems before they occur. Speaking to media in Washington and by phone Tuesday, Gunther and other key participants in the effort outlined the goals they hope to achieve through a new tool, the Aviation Safety Information Analysis and Sharing system or ASIAS.

"We have demonstrated the capability to pull these data sources together, or fuse them," said Jay Pardee, director of FAA's Office of Accident Investigation and Prevention. This enables CAST to gain "insights into problems and emerging threats" that were not possible to identify using only some of the data sets.

Read the article on Air Transport World >>
Fast track for Jetstar pilots

Jetstar PILOTS with commercial licences will be able to graduate as first officers on Jetstar airliners in as little as three months, under a fast-track cadet pilot-training scheme the airline launched yesterday.

Those with no flying experience but who possess the right attitude and aptitude can go from zero to 11,000 metres in just 18 months under the innovative European-style scheme.

Both the short and long courses include about 65 hours of tuition in Airbus A320 simulators here or in Hong Kong. The cadetship circumvents the traditional pilot development path of having to build up extensive flight-time experience in general aviation.

Read full article at The Age >>
Inadvertent IMC

Nathaniel B Palmer vessel Inadvertent instrument meteorological conditions (IMC) encounters are some of the most demanding and disorienting conditions a pilot can experience.

These encounters also result in the highest percentage of death from helicopter crashes. When weather conditions make visual contact with the ground difficult or impossible, continued flight can only be conducted safely with primary reference to the flight instruments, whether the IMC encounter is entered deliberately or inadvertently. Attempting to re-establish the visual flight environment often results in dire consequences. Over the years, DOI has experienced several accidents where reduced visibility due to IMC conditions was a contributing factor.

The pressures and desires (whether internal or external) to proceed to your destination can be very powerful, especially if you're close to your destination. This Accident Prevention Bulletin is not about an aircrew's encounter with inadvertent IMC, but about a pilot who made the right decision to land the aircraft in order to prevent such an occurrence only 6 miles from their destination.

Download the Accident Prevention Bulletin (PDF) >>
Incredible Recovery by Matt Hall

Matt Hall On the 6th of June, the Red Bull Air Race competition made its way to Windsor, Ontario.

When Australian Pilot Matt Hall made his run, the former RAAF F/A-18 Hornet pilot made an incredible recovery after his plane hit the Detroit River. In the video he describes what went wrong any why.

The below blog post also contains links to interviews with Matt about the importance of visualisation in his racing.

Watch the video on Flight Global >>