Mount Non-compliance & upcoming ICAO/FAA audit?

Latest CofFEE report and ICAO non-compliance with Annex 14Blush

Ref from BITN thread:  

(04-18-2019, 11:43 AM)Peetwo Wrote:  Also the latest excellent University of Newcastle CofFEE report has been tabled as a UFU supplementary submission:

Quote:10.1 Supplementary to submission 10 (PDF 1659 KB) 


In February 2019 the UFUA commissioned the Centre of Full Employment and Equity
(“CofFEE”) to research and examine issues relevant to the Senate Inquiry into the provision
of rescue, firefighting and emergency response at Australian airports. The subsequent
report (“the Report”), which is attached to this supplementary submission, covers the

 the current system of Aviation Rescue and Fire Fighting (“ARFF”) at Australian
 the regulatory system governing ARFF in Australia and the international system of
compliance to standards;
 the requirements of ARFF services and compares the Australian standards with
international best practice;
 how Australian standards comply with the international standards and
 the cost of ARFF provision at Australian airports and reviews the pricing model used
to finance ARFF services in Australia; and
 the economic benefits of tourism and shows the links between air transport and
tourism, particularly in Australia. It goes on to examine the safety of air transport,
people’s perception of the safety of air transport and the possible consequences of a
reduction in Australia’s reputation as a safe place to travel.

The Report as a whole provides a detailed and substantiated overview of ARFF services in
Australia. The UFUA respectfully highlights in particular the below key points, as contained
in the Report:

Section 3 “Regulatory system of ARFF provision” presents the delay in establishing ARFF
provision at Proserpine Airport despite it having reached the 350,000-passenger movement
threshold in the2016-17 financial year.

The Report further suggests ARFF provision be extended to secondary capital city airports
that see a large volume of aircraft movements.

Additionally, the Report covers the ineffectiveness of maintaining standards under the
current regulatory system due to the exemptions process and examples of non-compliance
with current regulations and standards. The Report recommends a greater degree of
oversight and transparency regarding the rationale behind the application and granting of
exemptions, and of addressing of non-compliance.

Reference is also made to the 450 differences listed by Airservices between ICAO SARPS
and Australian ARFF regulations and practices. It is noted that, while the majority are
probably not safety issues, the sheer number of differences creates a real risk of serious
safety concerns hidden among a multitude of somewhat trivial differences.

Section 4 covers ARFF best practice and presents a comparison between a variety of
standards with those of the minimum standards established by CASA for:

 the provision of a dedicated ARFF service at an airport (4.3)

 the number of ARFF vehicles required per category of airport (4.4); and
 the quantity of water, foam and agent (4.5).

The Report finds that in all instances CASA’s minimums fall below those recommended by
the recognised best practice of the National Fire Protection Administration (“NFPA”) 403.

Section 4.6 compares Airservices’ minimum staffing levels to those recommended by the
NFPA1, finding Airservices’ minimum levels fall below those established by NFPA. Of
particular concern here is the absence of a Task Resource Analysis (“TRA”) methodology by
Airservices in establishing staffing numbers. The TRA approach is recommended and
outlined by both ICAO and NFPA. The NFPA standard is that staffing levels shall be
established through a TRA based on the needs and demands of the airport. The TRA and
Workload Assessment are used to examine the effectiveness of staffing levels and to
analyse two levels of ARFF staffing, a minimum level and an optimum level. The NFPA
also provides a minimum number of ARFF-trained personnel that are required to be readily
available to respond to an incident, based on the minimum response times and extinguishing
agent discharge rates and quantities required. The staffing levels determined by the TRA
shall not be lower than the values specified in the NFPA standards.

Section 4.7 of the Report makes reference to the use of high reach extendable turrets, which
despite universal acceptance of their superiority in controlling post-crash fires and the fact
the technology has been in use for decades, are not fitted to any of Airservices’ ARFF

Section 5 covers Australia’s compliance with ICAO standards. In particular, the Report
notes that there are nineteen out of 462 differences listed regarding the provision of ARFF at
aerodromes, and of these nineteen differences, nine are classified as ‘less protective or
partially implemented / not implemented’.

Section 6 breaks down the cost of ARFF provision in Australia, the current pricing structure
and alternative models of funding ARFF services. The Report refers to a number of studies
that demonstrate passengers are willing to pay more for the provision of ARFF services.
Section 7 details the relationship between tourism and air travel, the economic benefits of
tourism, its impact specifically to the Australian economy and Australia’s aviation safety
record. Of particular note is a quotation from the Australian Safety Transport Bureau (page
59 the Report), which states:

“Australia holds one of the best safety records in the world. … However, a single

fatal accident involving a high capacity [regular public transport] jet aircraft would

lead to a major worsening in Australia’s international position with respect to

[regular public transport] fatality rates and there is no room for complacency.”

The Report subsequently examines the perception of air safety and its effect on demand
before assessing the economic loss to Australia from a potential air transport accident. It
notes that while the public’s perception of air safety is a subjective matter, there is evidence
that people avoid airlines involved in accidents and that demand for all air travel falls when
there are accidents.

The lack of confidence in travellers following a serious aviation accident also translates in
dollar terms. An attempt to measure the effect a serious aviation accident would have on
Australia’s tourism industry showed that total Gross Value Added would fall by almost $2.8

billion, based on a seven per cent fall in international tourists and a twelve per cent fall in
domestic tourists.

[Image: D37P4XeU8AAZHwj.jpg]

From page 36 of the CofFEE report:

Quote:[Image: CofFEE-1.jpg]

[Image: CofFEE-2.jpg]

[Image: CofFEE-3.jpg]

[Image: CofFEE-4.jpg]
And from the summary for section 3:
Quote:The ICAO was set up following the Convention on International Civil Aviation, also known as
the Chicago Convention, signed in 1944. The ICAO sets out Standards and Recommended
Practices (SARPs) for Aerodromes in Annex 14 to the Convention on International Civil
Aviation, with Rescue and Fire Fighting at airports dealt with in Chapter 9.2 of Volume 1 of
the Annex. It is a requirement by ICAO that Member States notify the ICAO of any differences
between their national regulations and practices and the SARPs, particularly where such a
difference is important for the safety of air navigation. ICAO monitor the implementation of
the SARPs of Member States through the Universal Safety Oversight Audit Programme

CASA has provided ASA with a variety of exemptions from standards and regulations, six of
which refer to ARFF. Aside from these six, it was recently revealed at Senate hearings that
ASA are non-compliant with a further two regulations despite not receiving an exemption.

There appears scope for an extra layer of oversight that may be useful in reviewing situations
such as these and exemption applications and providing recommendations on their necessity,
appropriateness and most importantly, their impact on safety standards. CASA’s Aviation
Safety Advisory Panel consists of Technical Working Groups (TWG), set up to deal with
particular sectors of the industry and to offer advice. Despite a TWG on ARFF being approved,
it has yet to be established.

The USOAP, set up by ICAO to monitor compliance with their SARPs, has evolved into a
Continuous Monitoring Approach, where the emphasis is on the availability of information on
the safety performance of Member States being provided to other Member States. The
notification of differences is at the heart of the CMA, yet the degree of non-compliance is not
clearly apparent when comparisons are made between countries. Button et al. (2004) point out

the problem with the ICAO structure is that it relies heavily on voluntary involvement and
application by its Member States and the ICAO has no formal mechanisms for imposing
penalties on non-compliant States even if they are identified. Similarly, Spence et al. (2015)
claim the ICAO is powerless to enforce its SARPs

& from summary section 6:
Quote:CASA only requires ARFF at Level 1 airports, which are airports receiving scheduled
international passenger air services or those above the threshold passenger numbers referred to
above. All airports with ARFF in Australia correspond to Category 6 or above. A survey of
similar countries and their requirements for airports to be serviced with ARFF found all other
countries had less restrictive obligations than Australia, such that if Australia adopted any of
the alternative systems, ARFF would be required at many more airports around the country.


As seen already CASA only requires... 
...ARFF services to be provided at airports in receipt of international passenger air services or
where passenger movements through an airport are above 350,000 over a 12 month period.

This means Australia has ARFF services at 28 airports, despite having 195 certified airports
around the country.

In the US and UK, ARFF services are required at all certified (or licenced) airports. In the US,
airports where scheduled flights with more than nine seats (or unscheduled flights with more
than 30 seats) take-off or land are required to be certified. In the UK, CAP 168 prescribes
“Rescue and fire fighting equipment and services shall be provided at an (licenced) aerodrome”
(CAA, 2019, p. 364). There, aircraft whose total maximum weight is greater than 2,730 kg
which are being used for commercial air transport of passengers or for instruction or tests for
a pilot’s licence are required to use a licenced aerodrome.

In preparation for the Regulatory Policy Review into ARFF services in 2015-16 (see section
3.4), the Department of Infrastructure and Regional Development published a public
consultation paper that, among other things, compared the levels of ARFF service provision at
airports in comparable countries, including the US and UK as above, as well as Canada and
New Zealand. In all four countries, airport operators are required to provide and to finance
ARFF services as part of their licencing arrangements. Canada, like Australia has passenger
thresholds, above which ARFF is required at an airport, however, their passenger threshold is
180,000, just over half of Australia’s threshold. New Zealand require certification at airports
used by aircraft with a passenger capacity of 30 in regular passenger transport and where there
are 700 movements in the busiest consecutive 3-month period.

All these other countries have much lower requirements for providing ARFF services at
airports than Australia. If Australia adopted the trigger used in any of those countries, many
more airports around the country would require an ARFF service.

MTF...P2  Cool

Non-compliance with ICAO Annex 14 - Part II.

Still amazes me that the significance of an independent academic paper, like the CofFEE report, is seemingly just ignored by the pollywaffles and bureaucracy involved in the oversight and administration of aviation safety in this country - UDB!  Dodgy    

However for now back to the CofFEE report, ref pg 37:

Quote:"...ICAO requires that where a Member State’s regulations and practices vary from a Standard

outlined in the Annex, notification of these differences must be made. Australia publishes all
differences in GEN 1.7 of the national Aeronautical Information Publication (AIP). In the
current version of this publication published in April 2018, there are 462 differences listed for
Annex 14 Volume 1..."

From my last count 462 differences for Annex 14 Vol 1 amounts to approximately 10% of the total notified differences to the ICAO SARPs. It should be remembered that those 462 NDs also include the OLS and RESA requirements around certified airports.

For example under OLS SARPs paras 4.4.1 & 4.4.2... 

Quote:4.4 Other objects

4.4.1 Recommendation.— Objects which do not project through the approach surface but which would nevertheless
adversely affect the optimum siting or performance of visual or non-visual aids should, as far as practicable, be removed.

4.4.2 Recommendation.— Anything which may, in the opinion of the appropriate authority after aeronautical study,
endanger aeroplanes on the movement area or in the air within the limits of the inner horizontal and conical surfaces should be
regarded as an obstacle and should be removed in so far as practicable.

...these are the NDs: ref -

4.4.1 - ...The effect of these objects must be assessed, particularly if they are within the ILS critical or sensitive areas.

4.4.2 - ...Australia does not have any legal authority outside of the aerodrome boundary...

That of course brings us back to the DFO accident at Essendon but first another relevant reference from page 36 of the CofFEE report:

Quote:...Australia agreed to a second safety oversight audit in 2012, which was carried out in 2017. As

part of this, Australia participated in an ICAO Coordinated Validation Mission (ICVM). The
ICVM is one of the activities prescribed under the CMA framework. This involved a team of
experts visiting Australia and working with Australian regulators and operators to measure and
improve compliance with ICAO Standards. Much of the work was on improving Australia’s
response to USOAP F&Rs from previous audits...
Which brought this 2008 finding to our attention:    

[Image: D3RcEsNU0AICvVH.jpg]

And then this follow up in the March 2018 ICAO ICVM audit report:

[Image: D3MghHxU4AEiH82.jpg]

This inevitably brings me back to to evidence given at Budget Estimates nearly two years ago:

Quote:Senator XENOPHON: I will ask this of you, Mr Carmody. I do not understand this. Has CASA actually got a view as to what buildings, and what height of buildings or structures, should be near an airport?

Mr Carmody : We certainly do. If I may, we are at cross-purposes here in terms of public safety zones at the end of runways versus buildings on and around airports. We have a very specific view on buildings and on penetrations through the obstacle limitation surface of buildings around airports. We have a very clear view and we are involved in that process. But with the debate on the public safety zone, which is routinely at the end of the runway, I think we are actually talking at cross-purposes in terms of the debate at the moment. We are actively involved if you use Essendon as an example, and the buildings that are onsite at Essendon—or any other airport; Canberra airport, for that matter.

Senator XENOPHON: So you do not have a view?

Mr Carmody : We always have a view.  Shy

Senator XENOPHON: So do you think that building, the DFO at Essendon, with its proximity to the end of the runway, would meet your criteria for fulfilling CASA's views as to the safety criteria for a building of that size, of that height, in that proximity to the runway?

Mr Carmody : Currently, my understanding is that it would. There was a building there prior to the DFO building. Prior to the DFO building process in, I think, 2004 or thereabouts there were buildings that preceded that on the same location.

Senator XENOPHON: You are quite comfortable, if there were going to be another airport plan, that you would not have an issue with a building with that proximity to the runway?

Mr Carmody : On that runway, in that location, I understand it fits within the template. Mr Tiede would be able to correct me if I am incorrect.

Senator XENOPHON: And you set the template? Is that your template?

Mr Tiede : CASA's interest is in the safety-of-air-navigation piece of this.
P2 - Under that logic if it is on the ground and no higher than the 1:7 OLS gradient and outside the airport perimeter fence, which technically the DFO is then CASA doesn't give a rat's - UDB!  Dodgy  ..There are obstacle limitation surfaces, in very broad description, around an airport, starting from the runway out to 15 kilometres, like an upside-down wedding cake. The take-off climb surface extends off the runway in a straight ahead thing for 15 kilometres, climbing at a slope that is dependent on the specification of the runway. So this, in significant part, overlies the public safety zone, third-party protection apparatus that is talked about. The DFO complex fits under the obstacle limitation surfaces, and so it meets the regulatory—

Senator XENOPHON: Do those obstacle limitation surfaces need to be reviewed in light of the DFO accident?

Mr Tiede : The obstacle limitation surfaces are drawn from some quite detailed ICAO specifications—International Civil Aviation Organization specifications—that are very detailed and very longstanding. We model our regulations on that information. ICAO is in a process of reviewing the OLS. The issue with that, of course, is that any outcomes are some time downstream. CASA participates in that work of ICAO as a member of the working group that is looking at this.

Senator XENOPHON: But you are not bound by ICAO? Or are you saying you are bound by ICAO in terms of recommendations for buildings in proximity to airports?

Mr Tiede : These are standards of ICAO that, yes, we have incorporated into our laws. We follow the ICAO specifications in their Annex 14, their aerodromes annex. We transfer.

Mr Carmody : We routinely follow their standards and recommended practices, unless we notify a difference. In this particular case, too, with Essendon, I might add that part of this discussion would depend upon the results of the investigation, at the end of the day.

Senator XENOPHON: So if the ATSB says, 'We need to review public safety zones—

Mr Carmody : I would be very interested if they came out with something like that. At the moment, the investigation is afoot, I understand. I do not know what the cause of the accident was. I know what the consequences were. But I think that that is part of the picture.

Senator XENOPHON: There is always the cause, but would the outcome have been different if that building were not in the way?

Mr Carmody : And that is correct. -  Huh

Senator XENOPHON: And it also is those on the ground, in that building. 

Hmm...and what have we done in the nearly two years since, in terms of mitigating the risk of a far more lethal crash potentially with far more casualties at the Essendon DFO complex?  - SFA that's what... Dodgy   

MTF...P2  Cool

Non-compliance with ICAO Annex 14 - Part III.

Moving right along with the NCN list for ICAO Annex 14; I go now to volume 2 of Annex 14 which of course deals with helicopter landing sites or heliports - see HERE. Referring to the ASA GEN 1.7 list for the notified differences for Annex 14 volume II, there is currently 87 pages:

Being a smaller SARP, plus given the smaller aviation safety niche, I naively assumed that volume II would have less non-compliances than volume I. Therefore I was extremely dismayed to discover that Annex 14 Vol II outstripped Vol I by approximately 100 notified differences... Undecided 

What is worse is there is not one ND that didn't exceed (improve) on the difference level of...

"..Less protective or partially implemented not implemented.."  

And the reason for that is because apparently anything that is outside of a Federally leased; or CASA certified ALOP airport perimeter fence is not within their remit; or the concern/responsiblity of CASA - UFB!  Dodgy 

This bizarre situation where the aviation safety regulator's oversight responsibilities apparently stop at the airport fence and airspace boundaries is perfectly highlighted in the recently publicly released consultation company AviPro's review of the proposed HLS for the new Tweed Heads hospital: ref -
Quote:Civil Aviation Safety Authority (CASA)

Engagement with CASA is not a normal part of an application for a development. CASA is normally only informed by AirServices Australia if there is deemed to be a risk to safety for a development.

HLS Compliance and Standards

Currently within Australia, there are no set rules or regulations applicable to the design, construction or placement of HLS’. The appropriate legislation at present for the use of HLS’ is Civil Aviation Regulation (CAR) 92 which places the onus on the helicopter pilot to determine the suitability of a landing site.

CASA, as the regulator of aviation in Australia, divested itself of direct responsibility in the early 1990s and currently provides only basic operating guidelines via Civil Aviation Advisory Publication (CAAP) 92-2 (2) Guidelines for the Establishment and Operation of Onshore Helicopter Landing Sites.

CASA does not provide design, structural information or advice beyond that provided in the CAAP.

CASA, as a component of a Regulatory Reform Program, does propose to prepare rules for helicopter landing sites and currently has a panel established for this purpose. The new rules will form Civil Aviation Safety Regulation (CASR) Part 139R, however it is not expected that they will be completed any time soonRolleyes  If and when they are introduced, there will be an implementation phase and “grandfather” clauses... rules will form Civil Aviation Safety Regulation (CASR) Part 139R...yet again Part 139 features?? One gets the impression that once totally completed Part 139 will be the ultimate behemoth of CASA regulations.

But why does the Part 139 reference ring a bell? 

PING!  Big Grin  From the Senate Estimates archive records: ref - Supp Estimates October 2012

Man Made Obstacles Located Away From Aerodromes - Risk review

Developed for CASA by AeroSafe Risk Management.

November 2009


Using the findings listed above and the treatment strategies outlined in the Risk Assessment Table the following recommendations have been developed. There are a total of 10 recommendations. The complex nature of the issues outlined in this report and the potential solutions are such that the recommendations have been represented in the following format:

• Legislative Framework
• Regulatory Structure
• Advisory Material
• Administration

Legislative Framework

R - 1 Authority to make Regulations: That the Civil Aviation Act is reviewed in the context of ensuring that CASA has the power to make regulations specifically concerning buildings, structures and objects that are located away from the vicinity of a certified or registered aerodrome.

R - 2 Removal of Compensation Requirements: That the Civil Aviation Act 1988 is reviewed in the context of removing the requirement to provide compensation for the installation of marking and/or lighting on buildings, structures and objects that have been determined to be a hazard to aviation.

Regulatory Structure

R - 3 Option 1 – Creation of Part 77 Objects that Affect Navigable Airspace

This option is designed to group all obstacle related regulation within one CASR Part. It is proposed that this CASR Part is designated CASR Part 77. This brings the regulation of obstacles in Australia in line with the regulatory structure applied in the United States and New Zealand.

For this option it is recommended that:

• CASA to start the process of developing new a CASR Part 77 that satisfies the recommendations outlined in ICAO Annex 14 Chapter 4
• the scope of the new CASR Part 77 includes all obstacles whether within the vicinity of an aerodrome or outside the vicinity of an aerodrome and the obstacle requirements and marking and lighting standards set out in CASR Part 139 be transferred to the new CASR Part 77
• the new CASR Part 77 include the standards for the notification of structures, buildings and objects that are in line with FAR Part 77
• the new CASR Part 77 include the following elements...

R- 3 Option 2 – Expansion of Part 139 to include Obstacles that are located away from the
vicinity of aerodromes

This option is designed to ensure that the current CAR Part 139 – Aerodromes sufficiently satisfies the ICAO requirements both for obstacles within the vicinity of aerodromes and for obstacles located away from the vicinity of aerodromes.
For this option it is recommended that:

• That CASA to start the process of updating CASR Part 139 to ensure it satisfies the recommendations outlined in ICAO Annex 14 Chapter 4
• That the scope of CASR Part 139 is expanded to include all obstacles whether within the vicinity of an aerodrome or outside the vicinity of an aerodrome.
• That CASR Part 139 Subpart E is expanded to include the standards for the notification of structures, buildings and objects that are in line with FAR Part 77
• That CASR Part 139 Subpart E is expanded to include the following elements... did we get from November 2009 with a regulator that was proactively putting forward recommendations to effectively mitigate safety risk and oversight aviation safety issues outside the airport perimeter fence, to the situation today where it is apparently acceptable to have 1000s of innocent public, totally oblivious to the latent safety risk of shopping at a DFO complex next to an active runway handling high capacity jet aircraft each day - UDB... Dodgy    

MTF...P2  Cool

Addendum: Somewhat depressing but with some interesting parallels when you check out CAA NZed's Part 77 - see HERE. Note that the Part 77 was originally promulgated in 1997.

Quote:77.1 Purpose (a) Subject to paragraph (b), this Part prescribes rules for persons within the territorial limits of New Zealand, including the New Zealand Defence Force, proposing— (1) to construct or alter a structure that could constitute a hazard in navigable airspace; 
Also from NZed I note the following blog piece from March 2017 that references the DFO tragedy: 

Quote:Runway Safety Extension Areas just 'Speed Bumps' at Wellington Airport

[Image: Crash2729px.jpg]


When I was over in Australia last week, a light aircraft crashed at Essendon Airport in Melbourne killing the pilot and four passengers but also putting hundreds of people at risk in nearby shopping complexes, workplaces and perimeter roads...

...The disaster has put airport safety under scrutiny, with special concerns arising from the commercialisation of land-use immediately adjoining the runways, as reported in the Melbourne Age  article: ‘Rampant airport development puts thousands in danger: planning expert, residents’ 
...Which brings me back to earth with a bump in Wellington where the Runway Extension Safety Areas [RESAs] are at the very minimum of what is required to meet international standards and the Runway Extension proposed by Wellington International Airport Ltd will worsen rather than improve the situation. 

At the same time, the airport is being increasingly ringed with shopping outlets - quite apart from being a close neighbour to both a major boy’s school and an indoor sports complex that serves the entire city.

As reported in the Dominion Post today []

That led me to this blog/forum link: The airport runway end safety area “can of worms”…

And in particular this passage:

Quote:The order came after the Airline Pilots' Association challenged the CAA's finding for Wellington Airport's safety area in its proposed runway extension.

The Court of Appeal said the CAA should not consider cost as a substantial factor in determining whether a longer RESA is practicable.

In a letter to Bridges on March 14th, released under the Official Information Act, the NZ Airports Association said the decision could have a “pronounced” impact on New Zealand's air services.

“The outcome may see some airports lose the ability to serve jet traffic and turbo prop services, or operating with significant payload restrictions,” the letter, written by chairman Steve Sanderson and chief executive Kevin Ward said.

“We think the best and most sustainable solution will be to review the intent and the wording of the current [Civil Aviation] Act” to give the CAA the mandate to balance cost with safety in the public interest. why does that sound so familiar?? -  Rolleyes

Reversing through the Swiss Cheese??

Following on from the last under the ICAO Annex 14 minimum standard and recommended practice for RESA it says...

Dimensions of runway end safety areas

3.5.3 A runway end safety area shall extend from the end of a runway strip to a distance of at least 90 m where:
— the code number is 3 or 4; and
— the code number is 1 or 2 and the runway is an instrument one.

If an arresting system is installed, the above length may be reduced, based on the design specification of the system, subject
to acceptance by the State.

Note.— Guidance on arresting systems is given in Attachment A, Section 10. 

3.5.4 Recommendation.— A runway end safety area should, as far as practicable, extend from the end of a runway

strip to a distance of at least:

— 240 m where the code number is 3 or 4; or a reduced length when an arresting system is installed;

— 120 m where the code number is 1 or 2 and the runway is an instrument one; or a reduced length when an arresting

system is installed; and
— 30 m where the code number is 1 or 2 and the runway is a non-instrument one...

And in Australia this is the notified difference (both of which are listed as less protective for those two SARPs:

Quote:Australia requires the RESA to be provided at the end of the runway strip and is to extend for the distance of 90m for a code number 3 or 4 runway used by air transport aeroplanes. In all other cases, the minimum length of the RESA is to be 60m for Code 1 or 2 runways.

With that in mind read the following article from two days ago by the Fort Fumble (white hats) at Flight Safety Australia magazine... Wink 

Quote:At the sharp end
By staff writers -
May 20, 2019

In a matter of seconds, with incomplete information, a flight crew has to make a life-or-death decision

 Ameristar flight 9363, Ypsilanti, Michigan, USA, 8 March 2017

The thing that makes aviation terrifying, or exhilarating, is that every time you advance the throttles to take off you are putting your reputation—not to mention your life—on the line. The impressive statistical safety of commercial flight may obscure this truth but does not cancel it. As the old hands say, ‘you are only as good as your last landing.’ The author Tom Wolfe put it more poetically, but equally accurately, in his phrase, ‘chosen or damned … it blows at any seam’.

The captain of this flight was a 54-year-old man with a solid, if unexceptional, aviation career of more than 15,000 hours. He had nearly 8500 hours in the Douglas DC-9 but was ‘back in school’ on this flight, undergoing type training on the DC-9’s derivative, the MD-83, under the eye of a check airman. This pilot was 41 years old with 9660 hours, also mainly on the DC-9.

From the beginning, it was clear that the afternoon’s flight would present distinct challenges, although nothing its two experienced pilots would not have dealt with over their long careers. It was a very windy day, with gusts of 50 knots, strong enough for the nearby Detroit Metro airport to be using its almost-forgotten east-west runways. The cockpit voice recorder (CVR) recovered from the wreck of the aircraft showed the two pilots factored weather into their flight plan from the outset.

A completed take-off speed card found on the flight deck showed they calculated V1 (take-off decision speed) at 139 knots, VR (rotation speed) of 142 knots, and V2 (minimum take-off safety speed) of 150 knots.

The CVR recorded the check airman advising the captain to ‘delay rotation until at least V2 … wait for me to call it’.
The captain also briefed about the effect the wind would have should there be an emergency. He emphasised the check airman should ‘really keep an eye out on what our airspeed is doing today. In the event of an engine fire or failure at or after V1, we’re going to continue the take-off … if you get any kind of a [windshear] warning, it’s going to be max thrust, all the way to the firewall thrust. If necessary … we’ll fly out of the shear, back me up on the airspeed calls.’ The captain concurred with the check airman’s briefing that in an emergency they would fly to Metro, rather than attempt a return to Ypsilanti.

At one point in these deliberations, a ground handler entered the flight deck for a sign-off and observed, ‘should be pretty fun getting this thing off the ground huh?’ Behind them, the cabin crew were ordering extra sick bags.

The MD-83 spent about an hour in taxi and holding, partly because high winds had closed the Ypsilanti tower and the flight crew had to broadcast their intentions for departure and obtain clearances by mobile phone. The captain’s brief, bitter and vulgar judgement on this state of affairs (‘what a cluster****!’) was the only utterance on the CVR not consistent with exemplary professionalism. In the light of what happened next, it would be churlish to deny him the momentary pleasure of this outburst.

By 1451:12 the aircraft was lined up for departure from the 2300 metre runway 23L.The check airman called for the captain to begin take-off roll. At 1451:55, the check airman said ‘V1’. Six seconds later (1452:01), he called ‘rotate’ followed three seconds later (1452:04) by ‘V2’. A second after that, the captain said, ‘hey, what’s going on?’, and three seconds later, ‘abort’. The check airman said, ‘no, not above … don’t abort above V1 like that’. The captain’s reply was succinct: ‘It wasn’t flying.’

Without hesitation, the check airman turned his attention to applying maximum reverse thrust, deploying the spoilers and assisting the captain on the wheel brakes. They had committed themselves to a most unenviable situation. At 173 knots, (89 metres/second) with the end of the runway 500 metres ahead, their predicament was exactly as described in the sour old pilot’s joke: they would be the first to arrive at the scene of the crash that was now inevitable. But no later analysis suggested any better decision than the one they had made in under five seconds.

The cabin crew had been similarly observant and decisive. The CVR recorded them in chorus, shouting, ‘Heads down! Stay down!’ as the aircraft sped towards the end of the runway.

The aircraft was travelling about 100 knots when it left the paved surface of runway 23L and overran a blast pad. It then travelled about 300 metres across a grassy surface before striking the airport perimeter fence and hitting a raised, paved road at about 40 knots. It came to a stop, fuselage intact, but on its belly. The check pilot called the cabin: ‘Evacuate! Evacuate! Evacuate!’

It was just over two minutes since take-off began and 19 seconds after the captain called ‘abort’.

Now it was the passengers’ turn to rise to the occasion. They were a college basketball team and staff, on their way to Washington DC, meaning that, unlike a typically composed passenger group, many of them knew each other. The cabin crew told the National Transportation Safety Board (NTSB) investigation the passengers were ‘incredibly calm and responsive … followed flight attendant directions … and did not take or attempt to take luggage or personal belongings with them’.

After exiting on the slides, the passengers remained orderly and quickly moved away from aircraft. All 110 passengers and six crew survived. There was only one injury—a cut knee that required stitches.

Why it happened

The ‘probable cause’ (in the NTSB’s words) of the crash was clearly visible on the hulk of the aircraft. The right elevator was deflected downward. Investigators found it was jammed and could not be moved by hand. An actuating crank and links were found locked over-centre beyond their normal range of travel and had been bent.

Analysis of the flight data recorder (FDR), which was recovered undamaged, showed the right elevator had been deflected 16 degrees down and even after the captain pulled strenuously on the yoke, had risen to no more than 13 degrees down.

The aircraft had been parked at Ypsilanti for two days, sheltered from the winds by an unusually large hangar (a building which had been part of the gigantic Ford Willow Run factory that made bombers during World War II). The combination of strong westerly winds and the building’s size had generated local turbulence, including vertical gusts which had moved the right elevator’s actuating crank and links beyond their normal range of travel and locked them over-centre. A computer simulation confirmed this.

The MD-83’s elevator design dates back to the Douglas DC-9 of 1965 and uses neither hydraulic power nor gust locks. Instead, the elevators are damped and moved by tabs, similar to the trim tabs of smaller aircraft. It is these tabs that are attached to the control yokes by unpowered pulleys and cables. When the crew had, quite correctly, made a full-and-free-movement control check before take-off, the tabs had responded perfectly. The NTSB concluded the deflection and damage on the T-tailed MD-83’s right elevator, 10 metres above the ground, could not have been detected in the crew’s walk-around.

The NTSB found the right elevator’s jammed condition ‘rendered the airplane unable to rotate during take-off’. Esteem for the crew shines through the deliberately bland and neutral language of the report. ‘The captain’s decision to reject the take-off was both quick and appropriate,’ and ‘the check airman demonstrated disciplined restraint in a challenging situation’.

‘Had the check airman simply reacted and assumed control of the airplane after the captain decided to reject, the results could have been catastrophic.’

The NTSB also noted how the airport’s runway safety area (RSA) had been upgraded to comply with Federal Aviation Administration (FAA) standards. The improvements included removing a taxiway, relocating the perimeter fence and road, filling in a 10-metre ravine (which might have broken the aircraft’s fuselage as has often happened in other overrun crashes), moving or making frangible approach lighting systems, and removing structures and concrete markers. The project had cost $US20 million, with the US Federal Government paying $19 million.

However, there were unresolved safety issues—how to identify jammed elevators on the DC-9/MD-80/Boeing 717 series was one. Others included the potential inadequacy of ground gust limit loads for the certification of transport-category aircraft, the lack of procedures for operators to monitor the wind that affects parked aircraft, and evacuation slide malfunction. The front right slide had not inflated, and the tail cone exit door had been jammed, briefly, by a seatbelt.

The combination of factors that had produced the crash was a textbook example of James Reason’s Swiss cheese analogy. Small holes aligned in layer after layer of supposedly impregnable defences, allowing chaos to sneak through. As the NTSB said, ‘Rarely could all of the safeguards in place to ensure an airplane is airworthy before departure (such as proper aircraft maintenance, pre-flight inspections, and control checks) fail to detect that an airplane was incapable of flight, as occurred with the jammed elevator on the accident airplane. Perhaps even more remarkable was that a flight crew would be placed in a situation in which the airplane’s inability to fly would not be discoverable until after it had accelerated past V1 during a take-off roll.’

But it is important to remember that Swiss cheese theory also works in reverse. Well-trained crews on the flight deck and in the cabin, disciplined passengers, and an airport operator that took its runway safety obligations seriously, had downgraded a tragedy into a hull loss and an anecdote to thrill future generations. The basketball team caught another flight and won their game.
The Swiss cheese in reverse: "....and an airport operator that took its runway safety obligations seriously, had downgraded a tragedy into a hull loss and an anecdote to thrill future generations..."

The ICAO SARPs are generally regarded as the minimum recommended standard that a signatory State should be complying with. How have we got to the point in Australia where we are actively encouraging to set safety risk mitigation standards below even the minimum recommended international practice... Dodgy  

TICK...TOCK miniscule - whom ever you maybe??  Confused

MTF..P2  Cool

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