Flight Safety Pty Ltd
March 2010
Safety Alert
News from Flight Safety Pty Ltd
In This Issue
Audit Findings - SMS
How Jetstar came close to disaster
Emergency Landing in the North Sea - Report
The Aviation White Paper
Cockpit Voice Recorders
Unusual Attitude - ASRS
Human Error the biggest obstacle
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Dear Regina,

Our Finding Analysis this month covers the establishment and maintenance of a formal SMS by AOC holders.

Among other issues covered are two in-depth incident/accident reports; the proposal to use cockpit voice recorders in the US; the Federal Goverment's recent Aviation White Paper and the human factor in aviation.

If you feel this publication will be of value to colleagues, please forward to them using the link at the end of the newsletter.


Colin Weir

Colin Weir, Managing Director
Flight Safety Pty Ltd
Audit Finding Analyses - Safety Management Systems

Finding 3 - Implementation of a formal Safety Management System

Tragically, the absence of current regulatory enforcement of Safety Management Systems as an integral part of Australian AOC compliance, has diminished aviation safety controls and effective oversight within the industry. 

The introduction of CASR Part 119 will address these shortfalls through Key proposals as described on the CASA website.

Key proposals:
  • A single standard for both regular public transport and charter operators
  • Identification of key personnel as defined in the Civil Aviation Act 1988;
  • Establishing a new designated person identified as the Safety Manager;
  • Making the Chief Executive Officer (CEO) responsible for the safety system and regulatory compliance;
  • Requiring operators to develop and maintain a Safety Management System (SMS);
  • Requiring operators to provide for crew training and checking, or to arrange for this to be conducted by an organisation approved under CASR Part 142 - Training and checking operators;
  • The requirement for an operator to prepare and operate to an exposition.
The critical issue now is to finalise the introduction and promulgation of this legislation without further delay.

Keep up to date with CASR Part 119 Developments >>
How Jetstar came close to disaster in 2007

VH-VQT DISTRACTED, stressed and confused by blaring cockpit alarms, the pilots of a Jetstar plane carrying 138 passengers came within 11.5 metres of the ground during an aborted landing attempt in heavy fog at Melbourne Airport, safety investigators have found.

The investigators also found Jetstar did not report the incident fully, reported it late, and had not tested revised cockpit procedures  as per their own SMS at the centre of the drama before implementing them.

The Australian Transport Safety Bureau yesterday released its final report on the July 21, 2007, incident on flight JQ156 from Christchurch to Melbourne.

The abstract begins:

"On 21 July 2007, an Airbus Industrie A320-232 aircraft was being operated on a scheduled international passenger service between Christchurch, New Zealand and Melbourne, Australia. At the decision height on the instrument approach into Melbourne, the crew conducted a missed approach as they did not have the required visual reference because of fog. The pilot in command did not perform the go-around procedure correctly and, in the process, the crew were unaware of the aircraft's current flight mode. The aircraft descended to within 38 ft of the ground before climbing."

It is important to read the full report in detail to get to the root causes of this incident, in which Jetstar's SMS played a critical part.

Download the complete ATSB Report AO-2007-044 >>

Read the Crikey Plane Talking blog article >>
Emergency Landing in North Sea, 21 December 2006

On 21 November 2006 at 23.28 hours a Bristow search and rescue helicopter, a Eurocopter AS332L2 Super Puma, with registration G-JSAR made an emergency landing in the North Sea, approximately 10 nautical miles North West of Den Helder in the Netherlands.

The 4 crew members and 13 passengers were rescued out of the water after approximately one hour and were transported ashore to Den Helder. One passenger suffered from light hypothermia and was taken to hospital, but was discharged within a few hours. The other occupants were not injured.

The main questions covered by this report into the accident by the Dutch Safety Board were:
  • Why was the decision taken to down-man the offshore installation by means of a search and rescue helicopter?
  • What were the events and conditions that resulted in the decision to make an emergency landing?     
  • Did all the life-saving appliances and procedures function as planned? If not, why did they not function properly?
This final report contains the results of the Board's investigation into the causes of the emergency landing. The Safety Board conducted a coherent investigation that was extended to all the events and conditions concerning the mission, including those regarding the decision to use this particular helicopter for the transport of personnel, the decision to make an emergency landing as well as to the evacuation and the subsequent rescue actions. These results provided additional value to the internal investigations performed by the individual parties involved.

Download the full Dutch Safety Board report >>
A National Aviation Policy Statement - the Aviation White Paper

"Aviation White PaperOn 16 December 2009 the Australian Government released the National Aviation Policy White Paper. This represents the first ever comprehensive aviation policy statement issued by an Australian government, bringing together all strands of aviation policy into a single, forward-looking document providing planning, regulatory and investment certainty for the aviation industry out to 2020 and beyond."

As these policies will begin to impact on all aviation-related operators within Australian, it is worth a read in depth, in particular Section 2: Safety & security - the highest priorities.

Some interesting points to note regarding Safety:
  • Further funding for CASA and the introduction of long term funding principles to strengthen its regulatory oversight and operations;
  • Ensure a well-trained and highly-skilled workforce in aviation by streamlining the process for aviation training organisations to access VET FEE-HELP and expanding the role of Industry Skills Councils in developing nationally consistent training programs;
  • Modernising air traffic management, including the use of satellite technology.
The policy was developed following rigorous public consultation, including over 530 submissions from the industry, state and local governments and the community.

Visit the Dept of Infrastructure Announcement >>

Download the complete Aviation White Paper (PDF) >>
Cockpit Voice Recorder Legislation Opposed By CAPA

Cockpit Voice RecorderThe US Coalition of Airline Pilots Associations (CAPA) which represents over 28,000 pilots, strongly opposes legislation introduced by Senator Jim DeMint to allow the use of Cockpit Voice Recorders (CVR's) as a means of punishing airline pilots found to be violating sterile cockpit and other established procedures while flying.  

Sen. DeMints' language would turn back the clock on every safety improvement the industry has attained in the last fifteen years of voluntary aviation safety programs. Neither the FAA nor NTSB supports the use of these devices as in-flight monitoring and disciplinary tools. The NTSB supports routine downloading of CVR data for use in voluntary safety reporting programs.  

Since their development as an accident investigation tool, CVRs have always been a forensic method to determine causal matters related to aircraft accidents. Expanding their uses to include the "real time" monitoring and punishment of pilots is misguided, and to expect airline flight crews to work in such an environment as a means of enhancing aviation safety is wrong.

Such a measure would actually harm flight safety by suppressing the necessary communications required to effectively manage the cockpit. "This bill would destroy voluntary safety reporting programs such as Flight Operations Quality Assurance (FOQA) and the Aviation Safety Action Program (ASAP)" said Captain Paul Onorato. 

Read the full article at AvStop >>
"Unusual Attitude" - More Tales from NASA's Aviation Safety Reporting System
Upside down planeEveryone who obtains a pilot's license receives training in how to recover from unusual attitudes - potential loss-of-control situations in which there is an excessive aircraft bank or pitch angle. But reporters to ASRS sometimes note that "unusual attitude" can convey another meaning that occasionally surfaces in ASRS reports - a state of mind that can lead to safety consequences for others.

Last month's ASRS provides a cross-section of incident reports that illustrate reporters' concerns for communication, professionalism, and courtesy. These narratives are a reminder that positive attitudes and thoughtful actions can go a long way toward making flying safer for everyone.

Read February Callback >>
Human error is the biggest obstacle to 100 percent flight safety
Pilot graphHuman factors were cited as the primary problem in 74 commercial aviation safety incidents reported at DIA since 2005, according to the NASA ASRS database of voluntary, anonymous reports from pilots and others.

Though advances in technologies that assist commercial pilots - alerting them, for example, to potential conflicts with other aircraft or mountains - have helped reduce accident rates over the past few decades, human factors stubbornly remain at the center of most airline disasters.

Read on at Denver Post >>