Despite the pathetic slapstick comedy of conducting official business in such ways, the message was an extremely serious one, being a CASA advice that the company’s two separate air operator certificates (AOC) were suspended with immediate effect.

“CASA believes allowing Skymaster Air Services and Avtex Air Services to continue to operate while CASA completes further safety investigations poses a serious and imminent risk to air safety,” the regulator’s media relations manager Peter Gibson told the media.

This statement, although it appeared to be potentially defamatory, was immediately circulated around the world, with AviationAdvertiser first becoming aware of it from a daily air safety bulletin originating in the USA. Although the CASA statement referred to accidents and incidents, these involved only one of the two companies, the other having voluntarily suspended its Metro operations last February until sweeping changes to every aspect of the operation were implemented under CASA guidance and oversight. The only clues to all this were CASA’s statement that the two companies shared a common owner, and the statement: “CASA’s decision to suspend Skymaster Air Services and Avtex Air Services is also based on issues relating to the safety culture of the operations, aircraft maintenance control and pilot training.”

To our knowledge CASA (despite being pressed) has never been able to define what the buzz-word “safety culture” actually means.

All this of course has a familiar ring. The nature of the “serious and imminent risk to air safety” was not identified, there was no attempt to describe the rationale for CASA’s “belief”, and in fact the statement itself was an admission that “further safety investigations” were necessary to support the decision. It seemed we’d returned to the old back-door means of avoiding due legal process, where you’re shut down while long drawn out “investigations” sap your business’s ability to survive.

Uninvestigated allegations have rarely bothered CASA in the past as many well-documented examples confirm. But what  happened to the automatic stay provisions that were put in place as a defence against exactly this kind of corporate conduct?

Well, way back in 2004 CASA’s (then) Director Bruce Byron took a course of action that ran contrary to industry protest and was far from characteristic of his push for regulatory reform.

CASA decided it needed power to ground an organisation, but the industry said it needed an automatic 90 day stay as a safety valve. CASA settled this on the basis of: “Okay, but if we find a serious and imminent risk to air safety, we still need to have the power to ground an operator.” Hence Sect 30DC of the Civil Aviation Act 1988 which provides for serious and imminent risk.

So now, all it takes is for CASA to serve a notice, and the company is immediately on the ground. If CASA then files an application in the Federal Court within five working days of serving the notice, the operator remains grounded until such time that the Federal Court can deal with CASA’s application.

Of course they must prove that there exist good and sufficient reasons for the application, and must support that claim with facts. At that point the victim may challenge whether CASA’s information supports its claims of a serious and imminent risk to air safety.

This places the onus of proof back on CASA, if the victim acts promptly enough to get to a  substantive hearing on whether or not the allegations represent a serious and imminent risk. But given CASA’s well-known tactic of long-drawn-out legal manoeuvring and procrastination, this is never going to be a speedy process and it’s up to the AOC holder to seek an urgent “special fixture” hearing, because the legislation as it stands only requires the regulator to file an application within the five days and then walk away.

In 2004 when this trap was being set, well-known Canberra specialist aviation barrister Chris McKeown saw what was happening. With Chris’s permission, and because an understanding of these issues could become important to any operator at short notice any time, we publish his somewhat prophetic warning below. Also see his website www.mckeown.com.au.

New 21 February 2004 CASA Suspension Provisions.

Christopher McKeown, LL.B., M.C.I.L.T

© C. P. McKeown - May 2004

New Zealand’s Auditor-General Office (OAG) has delivered a scathing report on the way the NZ Civil Aviation Authority (CAA) meets its safety oversight roles.

Controller and Auditor-General Lyn Provost says that her office has carried out four audits since 1997 of the CAA’s certification and surveillance functions for civil aviation operators, the most recent of which examined compliance with earlier reports and recommendations.

Mrs. Provost says that although the CAA had accepted her office’s 10 recommendations following a 2005 audit, and had been reporting satisfactory progress, “in my view, the CAA has not made adequate progress in addressing our 2005 recommendations.

“Overall, the CAA has yet to make the changes necessary to better use its current resources to improve the effectiveness and efficiency of certification and surveillance. Some of the CAA’s new policies, processes, and tools have been delayed or have been only very recently introduced, and they are not yet fully implemented or consistently applied.”

Of the 10 recommendations made in 2005, she considers that only one – the introduction of a new risk assessment tool – has been fully addressed. Eight of the 2005 recommendations have been only partly addressed, and one recommendation has not been addressed.

She says the CAA’s operating environment has not changed significantly in the last five years, and the 2005 recommendations remain relevant: “The CAA’s weaknesses that we have previously identified remain. These weaknesses affect the rigour, consistency, and transparency of regulation.”

They include:

• Decisions to certify some operators, despite their non-compliance with the Civil Aviation Rules, are not supported by enough evidence to verify the discretion exercised. For example, the CAA told an operator that it “did not meet the requirements for recertification, and to qualify for recertification a major overhaul of the company was needed”. However, a week after the operator prepared a plan to address the CAA’s main concerns, the CAA issued a six-and-a-half month certificate to the operator. My staff were not able to find evidence on file of the CAA’s reasoning and judgement that the operator had the resources and capability to comply with the Civil Aviation Rules at the time that the certificate was issued. In my view, there had not been enough time for the operator to overhaul its organisation and it is doubtful that the operator met the requirements for certification.
• The depth of work completed before certifying operators is not adequately documented.
• Surveillance is not always targeted at higher-risk operators. My staff found that the General Aviation Group had increased the frequency of audits in response to the operator’s higher risk profile for only half of the highest-risk operators that we reviewed. Some operators remained on an annual audit cycle despite their high risk profiles.
• Instances of non-compliance found by CAA auditors are not consistently reported and followed up. For example, a general aviation operator had used the main rotor blade of a helicopter for more than 20 hours beyond its airworthiness limit. The CAA auditor did not issue a finding for this non-compliance with the Civil Aviation Rules. In addition, my staff were also concerned to note that only one of 13 critical findings identified during 2008/09 was addressed by the relevant operator and accepted as addressed by the CAA by the due date.

She says the CAA has failed to understand and effectively address the underlying causes of the weaknesses in its certification and surveillance work, and considers that factors contributing to the CAA’s inadequate response include:

• Governance of, and accountability for, the CAA’s certification and surveillance functions are ineffective.
• The strength of the CAA’s regulatory focus is unclear, and there is insufficient guidance to ensure that regulatory responses are appropriately and consistently applied.
• The CAA’s management practices are not focused on improving staff performance, and it has not been receptive to change.
• The CAA’s management oversight of implementing and using the new certification and surveillance processes is inadequate.
• The CAA has not given enough attention to improving its organisational proficiency in auditing.

The Auditor-General said the CAA had given commitments in the past but the necessary improvements had still not been delivered, and that responsibility for closer monitoring and follow-up required more resources than her office can provide:

“I recommend that the Ministry of Transport, as part of its ongoing monitoring of the CAA, focus specifically on the CAA’s progress in addressing the changes that we recommend. I am looking to the Board and the Ministry of Transport to provide assurance that real change has taken place.

CAA Chairman Rick Bettle says the Authority is committed to correcting the problems, accepts the recommendations’ and has already put in place a programme of fixes:

“This work will be carried through to completion. The CAA started this work after similar recommendations were made in the past, but the complete range of changes were not implemented. This will not happen again.”

Although the landing resulted in a recorded vertical force of 3.6g and caused severe damage which resulted in the event being classified as an accident, no injuries were reported and the crew taxied to the terminal without further incident. The copilot was the handling pilot throughout the descent, approach and landing, and the pilot in command (PIC) was the monitoring pilot.

The aircraft was later found to have suffered structural distortion in the fuselage above the wing area, under the fuselage behind the wing, in the rear cargo area and in one main undercarriage unit. It was repaired and returned in the latter half of 2008.

The Qantas owned and branded fleet of 11 Boeing 717-200s, first introduced into Australia by Impulse Airlines, is leased through Allco Leasing Pty Ltd of Sydney and flown under the Air Operator Certificate of Cobham Aviation (formerly National Jet Systems), which supplies trained flight and cabin crew, maintenance, and operational and safety management.

The investigation identified several symptoms of an unstabilised approach including late capture of the instrument landing system’s (ILS) glideslope, and un-necessarily large elevator control inputs which contributed to significant excursions from normal vertical speed (rate of descent) during the approach. Also noted were an automatic power reduction by the autothrottle just before touchdown, and the captain’s decision not to discontinue the approach when it remained unstabilised below the operator’s minimum stabilisation height of 400’ above aerodrome level.

The delayed commencement of the descent placed the aircraft above the normal approach profile, resulting in the failure of the autopilot to capture the glideslope and the copilot’s decision to disengage the autopilot to regain the descent profile.

The report comprehensively focuses on issues related to the “out-sourcing” of pilot training and aircraft endorsements (also referred to as type ratings) that are now common among low cost carriers:

The use by the operator of a third party training provider was reflective of the current commercial aviation environment, in which it is common practice for prospective airline employees to pay for some or all of their aircraft endorsement training before gaining employment with an aircraft operator.

ATSB discusses the diversity of backgrounds, experience levels and capabilities among pilots recruited immediately they obtain the aircraft endorsement, and the use of manufacturers’ generic training manuals which do not blend with operator-specific techniques and standard operating procedures taught separately after pilots join the company.

The risk with such a separation of training into ‘endorsement’ and ‘post-endorsement’ training, in which each is provided by different organisations, is that techniques or procedures may either be overlooked or taught differently, requiring trainees to modify previously-learned techniques. There is also the risk of pilots reverting to previously-learned techniques during critical or high workload situations

Also examined were the level of information exchange between crew bases which might better identify problem trends. ATSB noted that the copilot had voiced concerns to a number of check and training captains over difficulties with B717 landings, including another hard landing at Darwin three days earlier, as had other pilots:

Together with the base-specific approach to the reporting of training difficulties, that resulted in the operator’s senior flight operations management being unaware of the copilot’s previous landing difficulties in the 717

The ATSB report records that actions since taken by the operator have now adequately addressed issues related to proficiency training, company operational procedures and limits, manuals, internal reporting and communications, standardisation interaction with third party providers, and engineering issues related to hard landings.

Also identified were relatively minor issues including navigation chart discrepancies and runway lighting and markings which the agency says are now being satisfactorily resolved, although some of these reflect ATSB recommendations published on 4 March 2005.

The only Boeing 717 simulator in Australia is operated by Boeing-owned flight training organisation Alteon in Brisbane.

And CASA has advised the ATSB that as a result of this occurrence: “CASA will review, with operators, their oversight responsibilities in this area.” However it insists: “The air operator is responsible for all activities conducted under its Air Operators Certificate, including contracted training.”

Almost seven years ago on 22 July 2003, CASA issued a Notice of Proposed Rule Making in respect of CASR Part 142 – Training and Checking Operators, intending to formalise the responsibilities of third party training organisations. “However,” says ATSB, “The regulation had not been enacted at the time of writing this report.”

CASA has told the ATSB the matter: “is under review as a matter of priority and has been progressed to the Office of Legislative Drafting and Publishing.”

In a Statement filed on April 30, the applicants detail a range of alleged breaches of CASA’s and its officials’ obligations under the Commonwealth Authorities and Companies Act 1997 (the CAC Act) and other legislation.

They say the adverse actions began after a heated technical argument between Butson and a CASA official during a routine audit, over operational issues including CASA requirements as to asymmetric flying training procedures. They claim that the subsequent alleged harassment took many forms including officials’ failure to exercise their powers and functions in accordance with the provisions if the Civil Aviation Act, the Civil Aviation Regulations and Orders, the Civil Aviation Safety Regulations and the CAC Act.

Officials named as respondents are Terence Farquharson, now Deputy Director of Aviation Safety, Garry Presneill, formerly a Flying Operations Inspector at the CASA West Office; Robert Collins (now retired), who was then CASA Group General manager of General Aviation Operations; Jim Marcolin, now with CASA Operations in Sydney; Peter John, CASA operations – Eastern; and Alan Cook, former Operations Manager of CASA’s General Aviation Group, who has since left CASA.

Polar Aviation complains that it was flooded with “requests for corrective action” and “show cause notices” from various of the named officials, to all of which it responded, although many of the notices reiterated matters from previous notices that had already been acquitted.

The issue was escalated by a seventh notice on January 14 which cancelled the company’s flying school Air Operator Certificate (AOC) and Butson’s Chief Flying Instructor approval, and revoked his Chief Pilot and approved testing officer (ATO) approvals.

The Statement says: “The Cancellation of Butson’s Chief Pilot Approval and the revocation of Butson’s Chief Flying Instructor Approval immediately prevented Polar Aviation from carrying out any commercial flying operations; immediately prevented the Polar Aviation Flying School from operating; caused the immediate shut down of Polar Aviation’s business; and constituted a breach of the duties set out [elsewhere in the complaint.]

The Statement claims the actions of the respondents:

• “constitute a persistent attack on Polar Aviation’s capacity to carry out its flying operations;
• evidence a discriminatory approach to Polar Aviation and Butson;
• evidence a willingness and intent by the respondents to act outside their authority;
• evidence a willingness and intent by the respondents to act contrary to the provisions of the Act, and their obligations and duties under the provisions of the CAC Act;
• evidence an intent by the respondents, acting outside their authority, to injure the applicants or, alternatively, evidence a reckless indifference as to whether such acts outside their authority would or would not injure the applicants.”

The applicants say that Polar’s flying school was out of operation for a two and a half years which adversely affected the business, morale, goodwill and reputation of Polar Air and Butson, resulted in the loss of profitable contracts, and caused lost income to Butson. It also details various actions of the six officials which it asserts comprise misfeasance in public office.

A similar statement has been filed in the Federal Court in Perth by WA pilot Gerald Repacholi and his company Repacholi Aviation, involving some of the Polar Air respondents. At least three other aggrieved aviation businesses are understood to be preparing similar claims.

The Flight Safety Foundation says there is now an ‘Urgent Need’ for an International Civil Aviation Organisation (ICAO) task force on judicial interference in safety investigations

The FSF is an independent, non-profit, international organisation engaged in research, auditing, education, advocacy and publishing to improve aviation safety. Its mission is to pursue the continuous improvement of global aviation safety and the prevention of accidents.

At its 22nd Annual European Aviation Safety Seminar in Lisbon this week, the organisation embraced recommendations to form a multidisciplinary task force of legal experts from the aviation industry, law enforcement, judicial authorities, and the public to achieve “a balanced approach that is supportive of blameless reporting and sharing of critical aviation safety information, and the proper administration of justice.”

The Foundation also called upon governments worldwide to begin pooling resources, expertise, training, and authority better, and to form multinational, independent air accident investigation boards.

Citing recent criminal cases such as the ongoing criminal prosecution of Continental Airlines in the USA and of several individuals in France in connection with the Concorde July 25, 2000 crash, FSF General Counsel Kenneth Quinn, a partner at the Pillsbury law firm in Washington DC, stated, “Enough is enough. We can no longer stand idly by while prosecutorial abuse of discretion imperils the safety of the traveling public.”

The Foundation called upon an upcoming ICAO ‘High Level Safety Conference’ on March 29-April 1 this year in Montreal to convene a group of legal experts ‘to urgently provide better protection of sources of safety information, including protection of witness statements and admission of errors against criminal prosecution, except in the most egregious of cases involving willful misconduct, drug or alcohol abuse, or falsification.’

Taking into account a recent European Commission proposal on October 29, 2009 and a recent meeting of the EC’s Council of Ministers on March 13, 2010 calling for the creation of a ‘Network of National State Investigation Authorities,’ Quinn called the proposal “very well intentioned, but woefully inadequate to meet the urgent problems of disparate investigating capacity and expertise, tensions between safety investigations and judicial authorities, the unclear role of civil aviation authorities in safety investigations, unacceptable weaknesses in implementation of safety recommendations, and lack of common standards on passenger manifest and family assistance.”

“Reliance on voluntary cooperation is recipe for not getting adequate cooperation,” Quinn continued. “‘Networks’ represent poor substitutes for clear authority, binding rules, and jurisdictional clarity—industry, victims’ loved ones, and the traveling public deserve clear accountability and transparency.”

Mike Ambrose, Director General, European Regions Airlines Association, immediately endorsed the Foundation’s call for action saying: “The Commission’s proposal fails to seize an opportunity for major reform, remove the potential for bias, enhance professionalism and expertise in accident investigation, and improve efficiency.

“In light of increasing attempts by prosecutors to turn accidents into crime scenes, we must protect safety critical data and individuals who might otherwise be unwilling to come forward to admit mistakes.”

The US National Transportation Safety Board has adopted a study concluding that single engine aircraft with glass cockpits had no better overall safety record than aircraft with conventional instrumentation.

The warning comes as nearly all newly manufactured piston-powered light aircraft are equipped with digital primary flight displays.  And the number of older aircraft being retrofitted with these systems continues to grow.

Some sophisticated “glass cockpit” avionics include flight management systems, satellite navigation and advanced visual displays that are the envy even of many airline pilots.

IFR cockpit of yesteryear. Douglas DC-3 – Circa 1935

Cessna 172, 2010. Now delivered with full IFR capability

Although most Australian vendors offer detailed and structured training courses to new aircraft buyers, that initiative doesn’t guarantee that buyers of used aircraft will be offered (or seek) the same protection, and current anecdote suggests it’s not always happening.

There is also the temptation, given the inherent safety potential of the new systems, for pilots without adequate instrument flight experience and qualifications, to experiment with instrument flying and get into the well-known difficulties that can occur in that situation.

The safety study, which was adopted unanimously by the ATSB, was initiated more than a year ago to determine if light aircraft equipped with digital primary flight displays, often referred to as glass cockpits, were inherently safer than those equipped with conventional instruments.

The study, which looked at the accident rates of over 8,000 small piston-powered aircraft manufactured between 2002 and 2006, found that those equipped with glass cockpits had a higher fatal accident rate then similar aircraft with conventional instruments.

The Safety Board determined that because glass cockpits are both complex and vary from aircraft to aircraft in function, design and failure modes, pilots are not always provided with all of the information they need – both by aircraft manufacturers and the Federal Aviation Administration – to gain an adequate understanding of the unique operational and functional details of the primary flight instruments in their aircraft.

NTSB Chairman Deborah A.P. Hersman highlighted the role that training plays in preventing accidents involving these aircraft.

“As we discussed today, training is clearly one of the key components to reducing the accident rate of light planes equipped with glass cockpits, and this study clearly demonstrates the life and death importance of appropriate training on these complex systems,” said Hersman. “We know that while many pilots have thousands of hours of experience with conventional flight instruments, that alone is just not enough to prepare them to safely operate aircraft equipped with these glass cockpit features.”

“While the technological innovations and flight management tools that glass cockpit equipped aircraft bring to the general aviation community should reduce the number of fatal accidents, we have not – unfortunately – seen that happen,” said Hersman. “The data tell us that equipment-specific training will save lives. To that end, we have adopted recommendations today responsive to that data – recommendations on pilot knowledge testing standards, training, simulators, documentation and service difficulty reporting so that the potential safety improvements that these systems provide can be realized by the general aviation pilot community.”

Based on the study findings, the NTSB made six safety recommendations to the FAA:

• enhance pilot knowledge and training requirements;
• require manufacturers to provide pilots with information to better manage system failures;
• incorporate training elements regarding electronic primary flight displays into training materials and aeronautical knowledge requirements;
• incorporate training elements regarding electronic primary flight displays into initial and recurrent flight proficiency requirements for pilots of small light general aviation aircraft equipped with those systems, that address variations in equipment design and operations of such displays;
• support equipment-specific pilot training programs by developing guidance for the use of glass cockpit simulators other than those that are approved by the FAA as flight training devices; and
• inform the general aviation community about the importance of reporting malfunctions or defects with electronic flight, navigation and control systems through the Service Difficulty Reporting system.

The complete safety study will be available at www.ntsb.gov in several weeks.

Helicopter pilot training professionals contacting AviationAdvertiser say they were appalled to hear that the Australian Transport Safety Bureau (ATSB) was not investigating the training helicopter crash on Mount Barney near Kyogle on January 28.

According to reports and photographs, Robinson R44 Raven helicopter VH-RWN collided with a sharp rock-strewn ridge, at the very lip of an almost vertical precipice estimated at about 1,000 feet.

The accident occurred during a training flight and the three occupants were two Omani student pilots and an Australian instructor.

They say the pilot obviously failed to enter and maintain a hover and collided with the ridge, rolling on its right side at the brink the cliff. Industry identities say it was “almost a miracle” that the aircraft was not destroyed either by impact or falling from the cliff.

The reason the pilot was demonstrating that procedure in that environment has not been explained, and possibly never will be because the ATSB has decided not to investigate the accident.

When asked why ATSB was not investigation the accident, officials explained that the bureau’s resources are limited, that the annual number of accidents reported exceeds its capacity to investigate them all, and that ATSB’s priorities therefore had to focus on major accidents or incidents from which important safety lessons could be learned for the benefit of aviation as a whole.

Not good enough, we’re told by people who have been in helicopter operations and training all their lives. One of them says:

“It’s appalling. You could just about do the complete investigation without stepping out of your office in Canberra. The ridge top was about 4,300’, give or take 50 feet, and there wasn’t anywhere you could land, so one of the first things helicopter pilots – and especially instructors – learn, went out the window. That’s “don’t practice forced landings anywhere you can’t actually land.”

“But that’s not the worst bit. Take the empty weight of the helicopter, add the minimum amount of fuel it would have had to carry to do whatever the pilot was trying to do and return to base with minimum reserves, then add the weight of the three people on board, and the look at the density altitude which (given the ambient temperature) would have been over six thousand feet above sea level.

“Then look at the performance graphs for that model Robbo, and you’ll see that it was an attempt to do something that absolutely had to result in failure to arrest the descent, and the loss of control that followed. The aircraft was well above its full throttle height [the height above which normal engine performance begins to diminish even at full throttle] and there was simply no chance of recovering.”

Three other experienced helicopter pilot/instructors known to us have provided similar evaluations, also venting forceful views on the quality of training at some schools, the lack of adequate regulatory oversight in helicopter and other areas of flight training, and apparent ATSB disinterest in what one of them describes as “systemic failure to deliver competent training in an environment that appears to be full of incompetence, lack of oversight, and apparent corruption.”

We also called CASA, to check on statements that the regulator too had decided not to investigate, and explaining industry concerns at the reported decision.

CASA later some time returned the call and its spokesman told us CASA was now “taking an interest” in the matter.

Professional flying schools, both helicopter and fixed wing, have long expressed concern at the quality of some Australian flight schools, which they say may damage the reputation of the Australian pilot training industry to a point where it could close down businesses and their export income altogether.

They are hoping that both ATSB and CASA (whom they tell us are barely on speaking terms) might team up to become more positive, assertive and effective.

Qantas’ low-cost carrier Jetstar has changed its operating procedures following a mishandled missed approach during an attempted instrument landing system (ILS) approach at Melbourne on July 21, 2007.

A report released today by the Australian Transport Safety Bureau (ATSB) found that the go-around didn’t work as intended for two primary reasons. First, the engine thrust levers had been incorrectly positioned for the manoeuvre; and second, the flight crew had been unaware of the aircraft’s “flight mode status” during the first part of the missed approach because of the sequencing of the operator ’s flight procedures.

Following an uneventful flight from Christchurch with eight crew and 105 passengers, the Jetstar Airbus A320 was aligned for an instrument landing approach, but Melbourne airport was shrouded in fog, and several other inbound aircraft had already had to carry out missed approaches (also called “go-arounds.”)

Aligned with Runway 27 and approaching the “decision height” (the published minimum height unless the crew can see the runway), the pilot in command (PIC) moved the thrust levers forward to what he thought was the takeoff go-around (TOGA) position.

Movement of the thrust levers to that point re-sets the aircraft’s flight management computers to the vertical and horizontal flight modes necessary for a go-around and initial climb using the “speed-reference-system mode.”

However the flight data recorder shows the levers were moved only to a point just forward of the flexible-maximum continuous thrust (FLX/MCT) detent and did not reach the TOGA position. (A detent is a groove in the throttle quadrant that helps hold the levers in the selected position.)

When the “gear up” order was given, the PIC retarded the thrust levers back to the climb (CL) detent, as if conducting a missed approach with an early reduction of thrust – a manoeuvre known to Airbus flight crews as a “TOGA tap.”

However there was no confirmation from the aircraft ’s flight mode annunciator (FMA) that the thrust levers had reached the TOGA position before being retarded to the CL detent.

Normal procedures when changing the flight mode require pilots to check that the FMA is displaying the selected mode.

The copilot responded to the ‘go -around ’ command from the PIC and commenced the checklist actions required by the operator ’s standard operating procedures (SOP).

These included raising the flaps one stage, selecting gear up after a positive climb had been established, and monitoring the aircraft ’s rate of climb.

Vertical flight path and body angle clues available to a crew at this point include the ILS needles, vertical speed indicator, artificial horizon, airspeed indicator, altimeter, the aural warning (TOO LOW! GEAR!) from the enhanced ground proximity warning system (EGPWS), and automated aural readouts of actual height above ground triggered by the radio altimeter.

The EGPWS sensed that the aircraft was still descending with the gear selected up. The gear configuration warning, the master warning and aural alerts continued sounding despite the copilot’s attempts to cancel the gear warning.

The ATSB report says: “The reported distractions and increased workload possibly contributed to the copilot ’s momentary inability to recall the required announcement in the case of a continuing descent [“SINK RATE”], with the result that the go-around procedure did not progress at the point of the ‘positive climb ’ call. Following the initial movement of the thrust levers, neither of the flight crew identified the aircraft ’s actual flight mode. The announcement of the FMA status was an item that the aircraft manufacturer had included in the early part of its go-around SOP, in order to ensure crews’ awareness of the aircraft’s flight mode.

ATSB says: “As there were three simultaneous changes to the aircraft ’s flight mode during a go-around (thrust setting, vertical and lateral guidance modes), this announcement was pivotal in ensuring flight crew awareness of any changes in the aircraft ’s flight modes. The change to the go-around procedure that had been made by the aircraft operator, to move the order of that announcement from the third to the ninth item, meant that its crews’ flight mode awareness could be lost, as the majority of the procedure had to be performed, without error or delay, before the crew got to the item that confirmed the flight mode status of the aircraft.”

About 48 seconds after the PIC performed what had been intended as a TOGA tap, the thrust levers were again advanced, but this time far enough to reach the TOGA detent.

In the meantime the aircraft had continued descending towards the runway, accelerating to an airspeed of 164 knots and reaching a recorded radio altitude of 38 feet above the surface before recovery.

A second ILS approach was attempted and the aircraft behaved normally but the crew was again forced to make a missed approach, followed by a successful landing at Avalon.

The investigation found that Jetstar had changed its cockpit procedures and the FMA status checklist item had been moved from third to ninth position. ATSB noted that the operator had not conducted a formal risk analysis prior to the change: “In addition, the operator is reviewing its flight training requirements, has invoked a number of changes to its document control procedures, and has revised the incident reporting requirements of its safety management system.

“In addition to the safety action taken by the aircraft operator the aircraft manufacturer has, as a result of the occurrence, enhanced its published go-around procedures to emphasise the critical nature of the flight crew actions during a go-around.”

The ATSB adds: “This incident has prompted the operator to change its go-around procedures and to ensure that a formal risk assessment is done for any changes to aircraft operating procedures. The ATSB has also issued a safety advisory notice to all aircraft operators reminding them of the importance of conducting risk assessments before changes to operating procedures are implemented.”

The ATSB is also concerned that because of Jetstar’s reporting of the event, it almost went uninvestigated: “The ATSB assessed that the circumstances did not warrant the initiation of an investigation. On 11 September 2007, in response to media reports of a potentially serious incident at Melbourne Airport, the ATSB contacted the operator, who provided additional information on the 21 July incident. Based on that additional information, the ATSB re-assessed the circumstances to be of sufficient seriousness to warrant the initiation of an investigation.

“The ATSB investigation also found that Jetstar’s reporting of the occurrence had not met the requirements of the Transport Safety Investigation Act 2003.”

The ATSB report does not discuss whether any of the crew or passengers actually sighted the runway, although industry sources say the crew saw the runway markings, which is unsurprising at an altitude of 38 feet.

One of our readers throws some further light on the event:

“I was on the flight. I noticed the power spool up and then the runway sighted and thought it was quite close below us. A fleeting glance. Then the fog obscured it again. The rest was handled well. First thought was it was a bugger that the go-around was initiated and had to be continued when the runway appeared. I never felt threatened, but if it was as close as the data says then let’s get it out in the open. No cover-ups should be allowed. Why has this taken so long to come out?”

Good question.

The Swedish pilot was preparing a Corendon Airlines Boeing 737 for a flight to Ankara, Turkey, with 101 passengers aboard when arrest was prompted by a tipoff from Swedish authorities.

The low-budget airline had been thoughtfully warned of the arrest, and had a reserve pilot waiting to take over the flight.

The 41-year-old pilot admitted he had been flying for 13 years on a false licence and had logged at least 10,000 hours flying hours flying for airlines in Belgium, Great Britain and Italy.

Although the man actually had a pilot’s licence, it did not qualify him to fly passenger jets, so he had falsified it.

It’s not a new phenomenon. In the eighties a senior training and checking captain in Norway turned out to be a frustrated flight engineer, who had never held a pilot licence of any kind, but nobody had checked and he had been continually promoted.

Closer to home, a European migrant bought a Tiger Moth in the fifties and presented himself for a pilot licence test, having served in the Air Force of his home country. He was told he’d have to accumulate at least 40 hours flying training in Australia before he could do the test, and because fuel was expensive he started an unofficial flying school, teaching fellow-migrants to fly, to help pay the fuel bill.

When challenged by a Department of Civil Aviation official, he memorably stated (with hand on heart): “Brother, you do not need a little bit of paper in your pocket to say you can fly. It is in your heart!”

The summary below is extracted from the AAIB report.

The left main fuel tank temperature at takeoff was -2°C, which was not unique and data mining revealed that a small percentage of B777 flights had a fuel temperature below 0°C at takeoff.

During the flight from the fuel temperature reached a minimum of -34°C and the minimum TAT reached was -45°C.  These temperatures were unusual but were within the aircraft’s operating envelope and were not unique.

However data mining showed that the accident flight was unique amongst 175,000 flights as having a low cruise fuel flow and a high fuel flow during approach while at a low fuel temperature.

The co-pilot had taken control of the aircraft from the commander at 800 ft in accordance with the operator’s procedures.

At 720 ft agl (above ground level) the right engine suffered an uncommanded reduction in engine power to 1.03 EPR (engine pressure ratio) and seven seconds later the left engine suffered an uncommanded reduction to 1.02 EPR.

The right engine fuel flow reduced to 6,000 pph (pounds per hour) and the left engine fuel flow reduced to 5,000 pph, levels above those required by an engine at flight idle.

Both the left and right engine power levers moved to full open and the EECs with no effect on the fuel flow.

Data mining revealed only one other (non-accident flight, other than the G-YMMM accident flight and the N862DA incident flight, that had demonstrated similar symptoms.

The fuel temperature at the time of the engine rollback was -22°C.,  which was also the fuel temperature at which the rollback occurred on the other (incident) incident flight.

The flight crew became aware of a possible thrust problem with the only 48 seconds before touchdown. The co-pilot intended to disconnect the autopilot at 600 ft but became distracted by the engine rollback, so the autopilot remained engaged.

The loss of engine power led to a reduction in airspeed as the autopilot attempted to follow the ILS glideslope, leading to a nose-high pitch attitude.

Thirty-four seconds before touchdown the flight crew became concerned about the reduction in airspeed below the target approach speed and attempted manually to increase engine thrust to compensate; there was no response from the engines.

At 240 ft the commander retracted the flap from flap 30 to flap 25, which increased the distance to touchdown by about 50 metres; if left at flap 30 the touchdown would have still been within the airfield boundary.

At 200 ft the stick shaker [stall warning] activated and as a touchdown short of the runway was inevitable the commander transmitted a ‘MAYDAY’ call three seconds before touchdown.

At the operation of the stick-shaker, the co-pilot pushed forward on the control column and the autopilot disconnected.

The aircraft struck the ground within the airfield boundary at a recorded normal peak load of 2.9g, and a descent rate of about 1400 feet per minute, 330 m short of the runway and slid 372 m before coming to rest.

The AAIB determined that the restriction occurred on the right engine at its fuel oil heat exchanger (FOHE.) For the left engine, the investigation concluded that the restriction most likely also occurred at its FOHE. However, due to limitations in available recorded data, it was not possible totally to eliminate the possibility of a restriction elsewhere in the fuel system, although the testing and data mining activity carried out for this investigation suggested that this was very unlikely. Further, the likelihood of a separate restriction mechanism occurring within seven seconds of that for the right engine was determined to be very low.

The investigation identified the following probable causal factors that led to the fuel flow restrictions:

1) Accreted ice from within the fuel system released, causing a restriction to the engine fuel flow at the face of the FOHE, on both of the engines.

2) Ice had formed within the fuel system, from water that occurred naturally in the fuel, whilst the aircraft operated with low fuel flows over a long period and the localised fuel temperatures were in an area described as the ‘sticky range’.

3) The FOHE, although compliant with the applicable certification requirements, was shown to be susceptible to restriction when presented with soft ice in a high concentration, with a fuel temperature that is below -10°C and a fuel flow above flight idle.

4) Certification requirements, with which the aircraft and engine fuel systems had to comply, did not take account of this phenomenon as the risk was unrecognised at that time.