Crisis point for Australian aviation


Posted by: Paul Phelan Posted date: October 31, 2012 | comment : 2

On October 22 this year a Senate Committee inquiry into accident investigation processes began hearing submissions that focused on the relationships and interactions between the Civil Aviation Safety Authority and the Australian Transport Safety Bureau, and on the management of their investigations into the ditching of a Westwind medical evacuation jet at Norfolk Island on 18 November 2009.

The committee is focusing on the nature and protocols of inter-agency communications, CASA’s variable performance in responding to ATSB recommendations, and interaction with other interested parties during investigations. However, its terms of reference also invited input on “any related matters,” which was seen by numerous stakeholders as a broadening of the enquiry’s scope, particularly in matters that are now viewed as having serious, if overlooked, air safety relevance. The committee is tasked to report by November 29 although this could change, such has been the avalanche of submissions.

Concerns centre on the consequences, some of them possibly unintended, of the gradual emergence of CASA’s new regulatory framework from its 22-year gestation. Issues that are being raised include deficiencies in the regulatory oversight of pilot and maintenance engineer training, flight operations, infrastructure, ongoing rule development, compliance and enforcement, accident and incident investigation, and the foundering relationships between industry and regulator on all of those fronts – and more.

International obligations

In most industry sectors there is deep concern that the regulator is diverging ever further from conformity with the International Civil Aviation Organisation’s (ICAO) standards and recommended practices (SARP), despite avowals to the contrary. A comparison between the mission statements or equivalent documents from four aviation-involved nations is revealing.

Australian Act’s Objective   New Zealand CAA Objective
The main object of this Act is to establish a regulatory framework for maintaining, enhancing and promoting the safety of civil aviation, with particular emphasis on preventing aviation accidents and incidents.Civil Aviation Act 1988, s3A   The objective of the Authority is to undertake its safety, security, and other functions in a way that contributes to the aim of achieving an integrated, safe, responsive, and sustainable transport system.NZ CAA Statement of Intent 2009/12
Government of Canada   USA Federal Aviation Administration
Regulating smarter is one of the commitments made by the government. In practical terms, this means regulations that impose rules that are more focused on results with fewer interventions, and are designed, where appropriate, to give industry the flexibility to be innovative in meeting those outcomes.Transport Canada Current Perspectives 2010   Our continuing mission is to provide the safest, most efficient aerospace system in the world. We strive to reach the next level of safety, efficiency, environmental responsibility and global leadership. We are accountable to the American public and our stakeholders.“Our Mission” –FAA, 23/4/2010

While the other three statements reflect various laudable ideals and priorities, the Australian declaration starkly focuses on a single goal, which was set 24 years ago by the Act, and which we have yet to attain.

Senior managers, pilots, engineers and safety specialists believe that this is illustrated, among other things, by deficiencies in CASA’s regulatory compliance management systems, which use mountains of legal and technical compliance documentation and desktop audits, although practical and objective product quality and performance monitoring might well produce more safety relevant results. These problems, often identified increasingly as safety deficiencies in themselves, emerge in reactive post-event audits such as the one that followed the Pel Air ditching. In other cases, such findings have been cited as sufficient reason for action to shut down various operations, while being ignored in parallel interactions with other certificate holders. The question of why these problems were ever allowed to begin accumulating is rarely publically analysed.

However the current Senate committee hearings are focusing on many of the same questions, and there is hope among industry stakeholders that pressure for a major reorganisation is reaching a magnitude that government can no longer continue to ignore. Major issues which they would like to see examined are corporate governance including the relevance and apparent inertia of CASA’s Board, ICAO non-compliance in its various forms, the application and impact of incoming regulations, training personnel licensing in all maintenance/operational areas, compliance and enforcement activities, industry/regulator relations, and the need for a far more objective approach to delivering demonstrable enhancements in air safety.

In August 2012 CASA director John McCormick sought to allay industry concerns over what he described as “disturbingly misinformed debate within sections of the general aviation community about proposed new maintenance regulations.” He said: “It is clear some people believe all of the new maintenance regulations currently covering the regular public transport sector are to be directly applied to general aviation. Let me make it very clear: this is not the case.”

Mr McCormick went on to do describe the consultation process, saying: “We fully recognise the regular public transport maintenance regulations cannot simply be applied across the board. Each operational sector of aviation is different and the new regulations will reflect those important differences.”

This has failed to dispel the uncertainty, because our MRO contacts say that airworthiness inspectors are openly and bluntly telling them that Mr McCormick has got it wrong, that Part 145 will eventually be applied to small aircraft, and that many of them will soon be out of business as a result.

To date, 14 organisations have gained Part 145 accreditation, including one major MRO based in Shanghai and three in Singapore. Of the remainder, Hawker Pacific has made the transition, but most of the others are specialist component overhaul or modification services, an exception being GA operator Vee H Aviation in Canberra. Industry sources say Qantas has had a team of around 30 people working on the project, and has yet to “satisfy” CASA on a broad range of issues including “facilities.” A Qantas spokesman says: “Qantas in regular contact with CASA and our application is still on track.”

As presently written, Part 145 maintenance will apply to “public transport” under the forthcoming Part 135, which is more or less charter under the present rules. This contradicts Mr McCormick’s statements.

“We just don’t know who to believe,” says the proprietor of a Queensland maintenance organisation. “If I was John McCormick I’d see that as a leadership problem. I’d spell out in detail to those officials and to industry exactly what was going to happen and when, and any AWI, manager or lawyer who didn’t sign off on the policy and support it, would quickly find themselves disadvantaged.”

Meanwhile, certificate holders doubt whether CASA is committed to conformity with ICAO SARPs and its own legislative requirements, and they quote credible examples that support their concerns.

Safety versus micromanagement

Bankstown-based charter operator Skypac Aviation outlines one such example. The company, which holds an AOC authorising it for charter and aerial work operations, sought to upgrade the quality and safety of its services by adding a six-seat Cessna 510 Mustang twinjet aircraft to its fleet.

The C 510 is Cessna’s latest and smallest twinjet Citation. Like most other Citations, it is specifically designed and certified to be flown by a single pilot – i.e. without the need for a co-pilot. With first-jet customers in mind, Cessna went to unusual lengths to see that new owners flying their first jet would find the transition easy, enjoyable and safe. Having flown a Mustang on a pilot evaluation, ProAviation can confirm that once you’re familiar with the advanced flight management system and if you are instrument flight qualified, the aeroplane is at least as simple to fly as a Cessna 172.

The Mustang is certified to the US FAA’s FAR (Federal Air Regulation) 23, which prescribes airworthiness standards for the issue of type certificates, and changes to those certificates, for aeroplanes in the normal, utility, acrobatic, and commuter categories. The category is limited to aircraft with seating for nine or fewer passengers, and a maximum certificated takeoff weight of 5700 kg (12,500 lb) or less. Maximum takeoff weight of a Mustang is 3930 kg.

Most small jets in charter operations normally fly between 300 and 400 hours per annum because the work often involves a lot of waiting time. That workload is well within the capabilities of a single pilot, and common practice would be to train and engage a part-time pilot to cover for days off and holidays. Commonly, operators manage the maintenance of pilot proficiency through periodic checking by a CASA-approved ATO (approved testing officer) who is qualified on the aircraft type.

But one of the first requirements CASA imposed on this operation, was to issue an “instrument of direction” requiring the company to establish a training and checking organisation under CAR 217 by 30 September, 2010. That was later extended by a further authorisation. The requirement is normally limited to regular public transport services or to other operators of heavy aircraft with a maximum takeoff weight above 5700 kg, however the regulation adds: “and any other operator that CASA specifies.”

Although the reason for the direction was not stated, CASA verbally explained it by asserting that the aircraft was a “complex type.” In comparison with numerous turboprop and piston engined aircraft, from a pilot viewpoint the Cessna 510 is in fact a much simpler aircraft to operate, with circuit speeds similar to or lower than comparable turboprop types.

That decision means that the company must employ a qualified and CASA-approved pilot to conduct pilot check and training on the Mustang. That however requires two pilots to be approved and employed as training and checking pilots so each can check the other. Since none of these arrangements would increase the amount of revenue flying, it would have the effect that each pilot would share the 300 to 400 hours of annual revenue flying, thus heavily limiting their accrual of total type experience and arguably eroding the operation’s safety margins.

The next requirement related to aircraft flight manuals (AFM). Like any new US certified aircraft, the Mustang is delivered as certified by the FAA along with an AFM and separately what is known as a quick-reference handbook (QRH), an abbreviated flight checklist for carriage in the aircraft for in-flight use. The QRH is developed from the AFM, and both documents are part of the aircraft’s FAA certified equipment, which means that the FAA has certified that the QRH accurately reflects the AFM but in an abbreviated form. But CAR 138 (1988) requires that the pilot in command of the aircraft must comply with a “requirement, instruction, procedure or limitation” in the AFM. So if the content of the operations manual does not precisely match the content of the AFM, and if you have an insurance claim, it is sure to be contested because whichever manual you are using at the time contradicts the other document.

Also despite that certification, CASA apparently found it necessary to spend a great deal of a flying operations inspector’s time (at $160 per hour) cross checking the two documents to ensure that they conform with one another, raising questions over whether CASA accepts FAA certification without question.

Next, CASA generates a “requirement” that a version of the expanded checklist be developed but with directed modifications and inserted in the company operations manual, compliance with which is mandated by CAR 215. This requirement is supported by CAR 215(3) which authorises CASA to require the operator to include particular information, procedures and instructions in the manual, and to vary that information at any time. This means that the aircraft now has three separate sets of checklists: the expanded information in the AFM, the abbreviated information in the QRH, and the varied version of those two documents CASA requires to be published in the appropriate section of the company operations manual.

An industry analyst who works in these areas says: “In effect, CASA is claiming that regulation 215 authorises them to direct a certificate holder to violate the design certification standard of the aeroplane, and the conditions upon which its certificate of airworthiness is issued. I think they would be well advised to seek a legal opinion on their own liability if they plan to follow that path. Like it or not, you no longer have the legal right in Australia to demand changes to manufacturers procedures for operating the aircraft as laid down in the AFM.”

While all this is still being thrashed out, the Mustang is dispatched to Bathurst to pick up a medivac passenger for transportation to Sydney. On arrival, the HF aerial is seen to have been broken, possibly by a bird strike. Its removal is necessary before further flight, and would normally be carried out in about one minute by any available LAME with a 3/8th inch spanner. However CASA has deemed that this aircraft may only be maintained by a LAME from a Part 145 maintenance organisation, meaning that somebody has to be flown from Bankstown to Bathurst to carry out that simple task. The charter client organisation is forced to hire another aircraft to move the patient so that any revenue from the operation is forfeit, and two other things have to happen before the aircraft can be returned to Bankstown. First, an engineering order will have to be generated to allow the removal of the antenna, ($590) and second, a permissible unserviceability certificate will have to be issued at a cost of $320 to permit the aircraft to fly from Bathurst to Bankstown, a short flight over a route on which HF communications will not be necessary.

Shortly afterwards, the Mustang is dispatched to Karratha, WA, where it is contracted as a standby Medivac aircraft by a consortium of resource companies, to substitute for their normal contract aircraft which is absent for maintenance. Although the Mustang is a single pilot aircraft, the contract requires a safety pilot in addition to the pilot in command, as well as 24 hour crew standby availability. Four pilots, all with command endorsements and instrument ratings, standing by in rotation, can meet these requirements.

After two weeks, the company is asked to extend the contract for a further period of two weeks, during which time the instrument rating of one of the safety pilots will expire in the absence of a check flight. The chief pilot requests CASA approval for a suitably qualified and available ATO from Perth to carry out the rating renewal check. CASA refuses that request, because that particular ATO, although fully C510 qualified, is not listed as having CASA approval to carry out checking and training under the company’s CAR 217 approved training and checking system. The only available option is to fly the pilot from Karratha to Sunshine Coast airport and back, and conduct his rating check in a C510 simulator located there.

The options of either approving a two-week extension of the pilots 35-year-old command instrument rating, for consulting with CASA’s Perth office to approve the available ATO to append his to the company’s list of approved check pilot based on his experience, do not appear to have been considered by CASA.

Pilots flying the Mustang regularly believe that it, or something like it, represents the basic trainer of the future. Yet through a series of administrative decisions that are arguably outside CASA’s own guidelines, many of them made by one individual, the aircraft type could become all but unsaleable in a market that is searching for modern aircraft that are safer, more economical and more environmentally friendly than anything in the existing fleet.

Where have all the experts gone?

Processes like these have convinced many in the general aviation industry that the sector is now being systematically deprived of some of its most respected practitioners and mentors, and that recent events seem to support that concern.

An apparent campaign to remove approved testing officers (ATOs) has resulted in a worrying reduction in the pool of available and experienced flying school instructors, and of training and checking pilots for charter operators around Bankstown and similar airports. CASA’s system for the ongoing oversight of flight-testing provides ample opportunity to cancel the approvals of industry ATOs, who assess pilots for licences and upgrades, and also those of line pilots’ instrument ratings and other proficiencies.

CASA “approvals” of chief pilots, chief flying instructors and ATOs rely on periodic reassessments as well as random checks conducted by observing flight tests in progress, and in the recent past, a number of Bankstown’s most highly qualified and experienced instructors and ATOs have experienced aggressive flight-testing by CASA flying operations inspectors (FOI). Some have been stripped of their qualifications because of vigorously disputed CASA assessments. Injured parties link most, but not all of these adverse decisions with the arrival in the area of recently appointed individuals who command absolutely no industry respect that ProAviation has been able to identify.

Although a CASA “approval” as a company-appointed chief pilot had always been a valued qualification for pilots in their career advancement, operators are now complaining that nobody wants the chief pilot job any longer, saying they “can’t afford the aggro” that is generated by some of these individuals.

One contentious issue is the actual approval process for CASA ‘acceptance’ as a chief pilot. There are no published rules for deciding how the assessment is to be made in terms of what may be examined, to what level or to what degree. For example, a chief pilot holding a commercial pilot license can be asked questions pertinent to airline transport pilot license qualification, such as complex fuel or runway performance calculations. There is no legal requirement for this subjective type of approach, and there are numerous examples of its abuse. The chief pilot position is essentially an administrative appointment, and we’re told that under the regulatory regimes of some other countries, even a pilot unable to fly for medical reasons may be appointed in this role.

A secondary issue is the option to flight test applicants for chief pilot approvals. Although CAO 82 states that a flight test ‘may’ be conducted; there are no published parameters for this test; it is purely subject to the whim of the FOI. There are recorded cases where an aspirant chief pilot has been deprived of all ratings and reduced to student pilot status following a flight test, despite having recently passed or renewed several of the ratings.

For these reasons pilots now perceive the process as flawed, subjective, intimidating, and carrying the threat of losing a pilot license or other important career qualification. They are highly suspicious of the motivations for these actions. Former CASA CEO Mick Toller was once asked how many members of a particular pilot union had “failed” a chief pilot interview as compared with non-members of the union. No response was ever provided.

Also worrying are the rapidly escalating costs of “regulatory services” that almost any interaction with CASA now incurs. There is a widespread belief that CASA is now deliberately limiting the number of ATO’s working in industry, replacing them with FOIs, and creating new profit centres by diverting more and more flight-testing activity to its ATOs at around $160 an hour plus travelling time.

Does all this represent good value? Not necessarily, insist industry ATOs, CFIs and chief pilots. They believe that some checking and training practices suggest deficient knowledge and experience levels on the part of CASA staff who adopt or promote them. Some of the events below seem to support their concerns.

Increasing the risk

Fairchild-Swearingen Metro III turboprop commuter aircraft are fitted with an effective stability augmentation system (SAS), which because the aircraft has “undesirable stalling characteristics,” is a mandated item for all flying. Yet a highly experienced ATO who has undergone no fewer than 50 instrument rating renewals and literally dozens of assorted check rides throughout his career, was asked to demonstrate a stall and recovery in a Metro III. The procedure in any aircraft is to reduce power and raise the nose as necessary until the symptoms of an approaching stall are identified, and then to apply power, lowering the nose if required, and flying the aircraft out of the incipient stall condition.

Part of the role of the SAS (also known as the stall avoidance system) is to operate a “stick shaker” which provides a tactile and noisy warning to the pilot that the aircraft is approaching an aerodynamic stall. That prompts the pilot to initiate the recovery action we have described if he or she hopes to survive to fly another day.

In effect, the SAS does exactly what it was designed to do – avoid a stall – unless you defy all the warnings and the dictates of commonsense. And to be quite clear, Metro and Merlin aircraft have been involved in fatal training accidents when prescribed procedures were ignored, including a crash in a Merlin in Norway on July 20, 2008 during a training flight. (A Metro is a stretched variant of a Merlin.) The accident related to an “approach to stall” procedure with the aircraft in landing configuration. The aircraft’s altitude increased by 300 ft during which speed decreased and control was lost, followed by a 30-second dive from 6300 ft to the sea surface. Horizontal speed at impact was minimal, which is symptomatic of an unrecovered spin. Pilots familiar with the type say that the event could not have occurred if the SAS had been operative.

Against that background is difficult to understand why an experienced ATO was publicly vilified for refusing to accept a FOI’s ruling that ‘stalls’ were a mandatory requirement for co pilot endorsement and that the SAS must be disabled to achieve this goal. He pointed out that stalls were only required for command training, and that they were only to be conducted according to the manufacturers instructions. The aircraft’s pilot operating handbook emphasises that the aircraft must not be stalled, and simulated failure of the SAS is not discussed. There is an AFM procedure for a “failed” SAS unit, but the aircraft flight manual states categorically that the aircraft must not be operated with the SAS disabled under any circumstances. Such operations are also not permitted under a minimum equipment list (MEL).

It took a strongly worded letter from the aircraft manufacturer to produce a grudging acknowledgement from CASA, who despite that, resurrected the same argument ater in the Administrative Appeals Tribunal in support of claims that the pilot was a ‘danger to air safety’.

This same ATO was later “failed” in a simulator check ride to qualify a ‘simulator pilot’ under CASA supervision. Despite his having already demonstrated twelve previous stall recoveries, one of the fail items was “loss of height (200′) during a simulated stall.” As a result the ATO had both his aircraft type and instrument ratings suspended as a ‘risk to flight safety.’ CASA has administratively imposed impossible conditions for the return of those ratings. That dispute is ongoing, with simple commonsense apparently excluded from the debate.

Notably, in the now-famous crash of Air France flight 447, an Airbus A330 descended through 35,000 feet at about 10,000 feet/minute with the nose held at a high angle of attack and N1 thrust values of between 48% and 100% right up to the point of impact. We have spoken to numerous flying instructors and line pilots, all of whom confirm that setting an arbitrary maximum acceptable height loss during a stall recovery is a nonsense. This is because of variables such as the exact point in the stall manoeuvre where stall and recovery are initiated, the individual aircraft type’s control responsiveness and interaction, engine power, centre of gravity, density altitude, and even turbulence.

What appals observers of this ongoing drama is the fact that a single FOI can apparently wave aside not only the manufacturer’s recommendations, but CASA’s own guidelines. The following prescription from CASA’s Approved Testing Officers’ Handbook should be clear enough, and certainly calls for an explanation of why the FOI was unaware of these limitations:

GEN 1        Only emergency and abnormal systems failures listed in the test aircraft Pilot Operating Handbook are to be simulated by a prescribed ATO during the flight component.

GEN 2        A prescribed ATO or a prescribed person must not introduce simultaneous multiple unrelated simulated emergency or abnormal situations during the flight.

Another example….

….with apologies to those to those familiar with these issues if we explain something you already know:

A takeoff in a multi-engine airline aircraft certified for operations under the USA’s FAR Part 25, calls for three separate speeds to be calculated, which are defined as V1, VR and V2, and are normally called by the co-pilot during the takeoff run.

At V1 the crew is committed to continue the takeoff even if one engine fails, that speed being calculated as one from which they will be able to accelerate despite the partial loss of thrust, and is based on ambient values like temperature, atmospheric density and aircraft weight.

VR is the recommended speed at which the crew should begin to rotate the aircraft into a nose up attitude – usually about 10° depending on type and configuration – for takeoff, and….

V2, the recommended speed for initial climb, is based on a number of elements including stall speed with a factored percentage added, demonstrated minimum engine-out control speed, aircraft weight, landing gear and flap configuration changes, and obstacle clearance along the flight path. In general terms an aircraft that is rotated at the rate recommended in its flight manual, will have accelerated to V2 plus 10 to 25 knots (depending on aircraft type) as it lifts off. If it suffers an engine failure at or close to rotation, it should be at or close to V2 when it reaches the initial climb attitude.

A couple of generations ago, it was generally accepted that climbing at V2 would optimise climb angle, and this has now been interpreted by some FOIs as a “requirement” that should an engine failure occur during a normal climb, the pilot should bring the speed back to V2 to continue to climb. In one example, CASA’s type specialist is promoting this view. With that apparent exception, aircraft manufacturers and the flight departments of major airlines have long ago set the doctrine aside, especially since the fatal crash of a McDonnell Douglas DC 10 at Chicago in July 1989.

In that event, the NTSB found that damaged hydraulics had caused the left-hand leading edge slats to retract, increasing the stall speed of that wing whilst the right-hand slats remained extended with the wing not stalled, and the crew failed to recognise the resulting roll as a stall symptom.

American Airlines subsequently issued an Operations Bulletin (DC-10-73) which amended the procedure and states, in part:

The following climb speeds will be utilised to obstacle clearance altitude when an engine failure occurs after V1on takeoff:

–          If engine failure occurs after V1 but not above V2, maintain V2 to obstacle clearance altitude.

–          If engine failure occurs after V2, maintain speed attained at time of failure but not above V2 + 10 (knots) to obstacle clearance altitude.

–          If engine failure occurs at a speed higher than V2 + 10, reduce speed to and maintain V2 + 10 to obstacle clearance altitude.

In the relevant section of its further analysis, the NTSB said:

“The pilot’s adherence to the airspeed schedules contained in the company’s engine-out emergency procedure resulted in the aircraft’s entering the stall speed regime of flight. Had the pilot maintained excess airspeed, oreven V2 +10, the accident may not have occurred. Since the airspeed schedules contained in American Airlines’ emergency procedures at the time of the accident were identical to those currently contained in the emergency procedures of other air carriers, the Safety Board believes that speed schedules for engine-out climb profiles should be examined to insure that they afford the maximum possible protection.

“In summary, the loss of control of the aircraft was caused by the combination of three events: the retraction of the left wing’s outboard leading edge slats; the loss of the slat disagreement warning system; and the loss of the stall warning system — all resulting from the separation of the engine pylon assembly. Each by itself would not have caused a qualified flight crew to lose control of its aircraft, but together during a critical portion of flight, they created a situation which afforded the flight crew an inadequate opportunity to recognise and prevent the ensuing stall of the aircraft.”

And a senior Airbus A330 C&T captain confirms that similar practices are also established in Airbus fleets: “The A330 engine failure at V1 has you initially raising the nose to 12.5° to guarantee unstick, but at high weights (eg 233 tonnes) the SRS (speed reference system) will immediately command close to 10° nose up to avoid speed decay. Single engine acceleration altitude in a jet is normally 1500 feet, so if we have an engine failure any time below that altitude, we select V2 to V2+10 to meet certification climb gradient on one engine.”

Independent research by Boeing confirmed the findings of both the NTSB and the airlines, and Boeing promulgated similar recommended procedures. There is consensus among airline experts we have spoken to, that the same principles would apply at least equally to light jets, whose thrust/weight ratios are equal to or better than those of large commercial airliners.

Given the possibility that any engine failure can cause unknown airframe damage and resulting increase in minimum control speed, and also given that operators of all shapes and sizes around the world have now embraced these philosophies, airline training experts cannot understand why any CASA official would continue to advocate the safety-negative practice its FOI is suggesting. In short, maintain whatever speed you have, and determine the state of the aircraft, before you change anything. Reducing speed to V2, “for the sake of compliance”, could kill you.

But there’s more.

A dangerous approach

Most light twin engined aeroplanes are certified with no guarantees of specific single-engine climb performance figures, except for the expectation that they must have a demonstrated ability to climb at 1% gradient at 5,000’ with the critical engine inoperative on a “standard day,” and that only four IFR certification. To help pilots manage an engine-out situation, each such aircraft type has an optimum calculated airspeed to maximise rate of climb, and a blue line on the airspeed indicator indicates this speed, although the value may vary slightly according to gross weight and ambient conditions. Even then, climb performance at blue line speed may be disappointing to say the least in this category of aircraft. In most cases the best option in the event of a low level (gear down below manufacturers V safe single engine speed) engine failure before, at, or shortly after liftoff in that aircraft category, may usually be to put the aeroplane on the ground and do your best to stop while there is still some available runway ahead.

Now, consider a pilot approaching for a normal landing. The accumulated wisdom of hundreds of airlines around the world is that the best and safest landings are those that follow a stabilised approach, meaning one with only minimal changes such as undercarriage and flap deployment, and power/attitude adjustments to achieve a constant glide slope of (usually) 3°. In most light aircraft, pilots use a “reference speed” (Vref) that is typically equivalent to 1.3 times the aircraft’s stall speed (VS) in the landing configuration. And remember that the required runway length you’ve calculated is based on that airspeed or a similar one, so that any other approach speed you adopt will invalidate the calculation and could result in a runway overrun. CASA also “requires” demonstration of a stable approach.

So it was surprising during a pilot evaluation flight in a light twin at Essendon, when the demo pilot warned that our approach speed was too low, saying we should be approaching at “blue line” best one-engine-inoperative speed of 92 knots, which is 30 knots above this particular aircraft’s stall speed. We didn’t argue that point because there was plenty of runway left, and a good thing too, because the aircraft “floated” for a couple of hundred metres until it decelerated to a safer touchdown speed. It was later explained that most CASA FOIs were requiring pilots to conduct the whole approach at the “blue line” speed, which is considerably higher than the Vref that is recommended in the pilots operating handbook.

It was also explained that the reason for this “requirement” was provision for two separate and statistically improbable events to occur simultaneously. The first was an instruction from the tower to “go around” (i.e. abort the landing approach and carry out a missed approach) and the second was that while you are responding to that, the critical engine would fail and you’d need to carry out a single engined missed approach. This sort of unintelligent risk management has killed a large number of instructors and students over many years. The more mature instructors understand that if an average light twin is already in landing configuration and if both those events occur, you are in most cases already irreversibly committed to a landing. And if there’s another aircraft on the runway you do whatever is necessary to avoid a collision with it, either landing on the unoccupied section of the runway, a taxiway, or perhaps on the adjacent grass flight strip.

This issue has been discussed with a senior CASA official by a retired Qantas check captain who should know: “What is being taught is that the overriding consideration of every approach is a possible engine failure and a go-around, which is almost a statistical impossibility. What these inspectors are requiring, is that pilots should hazard every approach they make, to provide for that probability. That’s not intelligent risk management. CASA denies it all, just as they deny that inspectors are requiring instructors to fail engines at low level. That’s why I was so disturbed by that last Twin Comanche crash at Camden, which incidentally, the ATSB declined to investigate thoroughly.”

And a dangerous departure

For the same reasons, the training scenario of a simulated engine failure after takeoff needs to be managed with a degree of intelligent caution, which it doesn’t always receive, say experienced instructors and ATOs. In the light twin aircraft category (below 5700 kg MTOW) no certification data is available to arrive at values for V1, VRand V2. Most manufacturers limit their advisory material to suggesting that after liftoff, the aircraft be accelerated to well above single-engined minimum control speed (VMCA), to the manufacturers recommended safe single engine speed (SSE) for reasons such as improved performance, terrain clearance, pilot visibility and engine cooling.

All this, however, doesn’t dampen the enthusiasm of (some) FOIs for demonstrably dangerous practices such as simulating an engine failure before the aircraft has reached a safe height and speed with gear and flaps retracted and a steady climb established. This removes the pilot’s options to ‘safely stop or safely go’, a tenet that has been around since the first Cessna 310 appeared 59 years ago.

There is, of course, nothing to prevent an instructor simulating an engine failure after takeoff at a safe height with the aircraft in takeoff configuration, but a very large number of people over many years, have ignored that option with a fatal outcome. Despite this, it now seems that various FOIs and ATOs are interpreting the syllabus as requiring a flight testing procedure that carries an unacceptably high risk.

What seems to be missing from CASA’s Approved Testing Officer’s Handbook is some very firm guidance regarding unnecessarily high-risk procedures, especially in aircraft types with which the ATO is often unfamiliar. But the lack of consensus on these issues offers little promise that this will happen any time soon.

And as we’re about to see, the need for some straight talking and intelligent action on flight standards is not limited to fixed wing operations.

Purchasing an outcome

While Australia has a large number of high quality organisations training pilots for both fixed wing and helicopter licences, there has always been dissatisfaction in the industry at the regulator’s failure to identify those schools whose output is unsatisfactory, and to take corrective action. Because the demand for helicopter pilots is currently stronger, the situation is more serious in that industry but exists also in fixed winged flying. In some cases, it is clear that licence candidates are selectively seeking low-cost schools, which all but guarantee an outcome for a quoted price.

The chain of events recounted here has been provided to CASA by other sources, along with considerable detail. They relate to the adventures of a pilot we will call “Mr Smith”

A helicopter operator warned the (then) General Manager of the (then) Civil Aviation Authority that another operator at the same airport had been under-recording aircraft flight times. This malpractice, known to be common in some sectors of the helicopter industry, has grave implications for safety because it causes critical components such as rotors and gear trains to overrun their maximum service lives.

The regional manager was asked to investigate, and found that there were various anomalies that were confirmed as far as the operator was concerned, but which also drew attention to the way the operator was being regulated. He called in the CAA’s locally-based helicopter experts, who confirmed his concern that the responsible FOI, Mr Smith, was “too close” to the operator and also that his qualifications were somewhat suspect. In fact, he had been ‘moonlighting’ as a pilot for the operator.

This gave rise to an investigation of Mr Smith’s qualifications, which found that he had joined the Authority without an instructor rating. The CAA had paid for his Grade 3 training and rating, which was issued following a flight test by a helicopter-rated FOI.

Mr Smith’s Grade 2 rating had later been signed off by another FOI, and later reviewed again by a third, although both the latter FOIs were fixed wing pilots. It was also upgraded to a Grade 1 instructor rating at a later date, by the same FOI who had signed the Grade 2 upgrade.

One of the minimum experience levels required for a Grade 1 rating is 400 hours of ab initio flight instruction.

The question was flagged to the regional manager – how did Mr Smith, a helicopter FOI, accumulate 400 hours of “elementary instruction” as a CAA employee following the issue of his Grade 2 rating? And that question became the subject of the investigation.

As a result of that investigation the regional manager instructed an investigator to explore Mr Smith’s records, and he issued a show cause notice as to why Mr Smith’s instructor rating should not be withdrawn. The rating was subsequently withdrawn.

The Australian Federation of Air Pilots wrote to the regional manager asking why he was taking this action, saying that what he had done could not be substantiated legally. There was then a delay on the further investigation because there was a review of the (then) CAA by an ex-Qantas pilot consultant, because there was some concern as to how the CAA was being run.

During the delay another letter from an AFAP official said the matter had come under that organisation’s scrutiny and enquiring how he could pursue this course. The manager responded that he had taken the action, and that that was the end of the matter.

CAA’s lawyers then became involved, and the whole exercise was reduced to the question of the definition of “elementary instruction,” and of how fixed wing FOIs could conduct helicopter instructor flight tests – in aircraft on which they had no qualifications.

The lawyers said that the regional manager really didn’t know what was “elementary instruction,” that he had no backing for use of the phrase because there was no legal definition of it in the regulations.

Below are the current regulatory prescriptions. It is not known whether those definitions applied at that time, although the information would be available from CASA archives.

CAO 40.3.7

4.3        An applicant for the issue of a flight instructor (helicopter) rating grade 1 must:

(c) have at least 1,200 hours of flight time as a pilot in a helicopter, being flight time that includes at least 400 hours during which the applicant gave elementary helicopter flying training.

And in both definitions:

Elementary helicopter flying training means flying training in the sequences set out in the helicopter syllabus that are required before a person attempts the general flying progress flight test for helicopters. (From CAO 40.7.3)

However, the CAA lawyers in Canberra said there had been no definition of the qualifications of an FOI in the legislation or the rules either. The CAOs only said that an FOI, inspector (or whatever designation was in use in those days) may conduct tests but did not state the qualifications required of an FOI, although there were industrial agreements that referred to the designation. In effect, that meant a Boeing 747 qualified FOI could conduct a flight test on a helicopter pilot because there was no reference to qualifications for FOIs.

Mr Smith’s ratings were restored, but only based on advice from CAA lawyers that they lacked the authority to cancel them. Later he was told that Mr Smith would be “briefed on the difference between elementary or ab initio training” – definitions of which most Grade 1 instructors would already be aware.

“In effect,” says our source, “the outcome of all that was that CAA had acquired (at its own or at public expense), a flying operations inspector whose signed-off qualifications have never related to his entitlements, or his demonstrated abilities. And please be reminded, that the outcome of all this is that you have an individual who is now feeding other incompetent instructors into the training system, a situation that results in continuing degradation of the product quality of a large section of the helicopter pilot training industry.”

Having later left CAA/CASA with all those qualifications intact including his ATO designation, Mr Smith had been operating in that role ever since, and had become well known as the ATO of choice for many pilots with proficiency problems.

One of these, another pilot whom we’ll call Mr Jones, approached Smith seeking a renewal flight test for a Grade 1 helicopter pilot instructor rating. Mr Jones had recently undergone two separate rating renewals tests. The first was with the proprietor and CFI of an Archerfield flying school. A CASA FOI oversaw the flight test at the request of the instructor, because the CFI was aware that Mr Jones was a pilot of doubtful proficiency. He failed that test and the FOI confirmed the decision.

The proprietor and CFI of a Sunshine Coast flying school, also overseen by CASA FOI, conducted the second test but with an identical outcome,. Mr Jones was not seen for some time after that, because he had gone to New South Wales and contacted Mr Smith, who passed him on his Grade 1 instructor flight test.

On his next appearance in the area Mr Jones was flying a Bell Jet Ranger with its new owner aboard when he decided to demonstrate a simulated engine failure and auto-rotational landing. An extremely heavy landing seriously distorted the tail boom, but a court has been told that regardless of that Mr Jones flew to the opposite side of the airfield, and the helicopter was transported to another airport before details of the accident were notified. Related matters are still before the court.

The operators of reputable flying training organisations remain concerned that “rogue” ATOs acting both as individuals and in some cases CFIs, are continuing to put commercial pressures before their professional obligations. They also believe that the demand for well-qualified helicopter pilots is forcing CASA to engage underqualified FOIs.

CASA Director John McCormick recently admitted to a Senate committee: “It [staff recruitment] is always a struggle, particularly finding helicopter pilots. We compete with the industry for pilots with heavy helicopter experience. As I am sure you are aware, apart from the military, we do not find many people who have multi-engine helicopter experience and we certainly cannot pay the rates that the industry pays.”

In fact, the training industry observes that CASA has become a significant training ground for the heavy end of the helicopter industry. ProAviation is aware of instances of pilots with low to middle level experience being recruited, then undergoing enormously expensive advanced training in Australia and overseas at taxpayer expense, and disappearing into multi-engined IFR jobs in the resource industry. This may suggest a management problem that could be solved by engaging contractors who are prepared to sign return-of-service agreements.

The longer-established flying schools believe the heavy helicopter industry is well equipped to assess, check and where necessary train its pilots before or after induction. They believe that the more critical problem continues to be that of identifying and retaining FOIs with the necessary practical and credible training experience to take a proactive part in overseeing and enhancing the quality of basic commercial helicopter pilot training.

Is reform still possible?

There are of course, flying operations inspectors who relate to and have strong professional respect for their industry counterparts. In fact some of them share industry concerns and views with ProAviation They also share the disappointment of industry professionals, in the way they say CASA’s personal development program for CFIs and ATOs is being managed as a platform to talk down to instructors rather than as an opportunity for mutual improvement through professional dialogue.

One situation wholly evident in our discussions with certificate holders, is that a significant number of CASA inspectors, both in airworthiness and flying operations, exhibit an aggressive “do it my way” approach that sets aside industry’s valid expectations and their own duty definitions. Some reported incidents leave us convinced that there exist matters that merit forensic investigation, and that CASA would be unlikely to conduct such an investigation in a transparent way. We are also convinced that in at least some cases, networking between officials has impeded the employment elsewhere of victims of these individuals in a way that might well be investigated as to whether conspiracy has occurred. Credible accounts of specific incidents strongly suggest that there are flight operations and airworthiness inspectors who are not psychologically equipped to interface with industry.

Matters that have come to our attention range from untested but credible allegations that warrant investigation, to suggested lines of enquiry, to amply-documented fact. ProAviation is willing to share this information with any properly constituted and transparent investigation.

CASA chief John McCormick told the recent Senate hearing: “What I found when I got to CASA, as I think we have discussed before, is that there was a significant lack of direction, and perhaps some of the things that we see and we are here discussing may be direct outcomes of some of that lack of direction and focus.”

There are hopes that the next director will not be heard expressing similar frustrations.


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