Warning: Longish post following
UITA:
Go read the report, ask some questions of non-casa peple that you don't appear to frequent with (based on your comments and answers) [and when you give them]
Then form a real opinion as the whether atsb was correct, or Monarch just joins my list.
Hmm...took your advice UITA and reviewed the
BASI report 9301743, & subsequent knock on effect of Monarch crash, and I'm afraid to say I'm with Lefty on this one...
Maybe the report wasn't exemplary (for the then BASI standards) and FF eventually rolled over the top of most of the recommendations when reincarnated as CAsA but I really can't see where BASI have been negligent in the Monarch crash investigation...??
Ok let's go through the motions and cut to the chase of AAIR199301743 i.e. the Safety Actions section:
4. SAFETY ACTIONS
4.1 Interim Recommendations
During the course of this investigation a number of Interim Recommendations were made.
The IR documents included a ‘Summary of Deficiency’ section in addition to the actual interim recommendation. The texts of the interim recommendations are detailed below, with each IR commencing with its BASI reference number. The pertinent comments from the CAA
in response to the recommendations are also reproduced.
IR930214: The Bureau of Air Safety Investigation recommends to the Civil Aviation Authority that when an operator requests the issue of a Permissible Unserviceability to continue flight operations with inoperative equipment listed as an MEL item, then the terms of the Permissible Unserviceability should provide an extension of all MEL conditions for a specified period.
CAA response:
The recommendation reflects CAA policy. The Authority does not accept the finding in paragraph 5 of the Summary of Deficiency in that the Permissible
Unserviceability could be read as permitting “continued operations with a
significantly reduced level of safety (ie autopilot components removed) than that provided by the Minimum Equipment List”.
IR930223: The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority;
1. Review the need for approved maintenance controllers to hold maintenance qualifications appropriate to the position,
2. Restrict persons acting in the position of maintenance controller from acting in other positions that will detract from their ability to adequately perform their maintenance controller duties, and,
3. Review the need to limit periods of validity for certain approvals, such as
maintenance controller, and renew such approvals only when specified criteria are met which demonstrate adequate performance.
The CAA response in part stated:
Interim Recommendation 1 : The Authority has reviewed the need for maintenance controllers to hold maintenance qualifications and we have concluded that this is neither necessary or appropriate. It is essential that anyone approved as a maintenance controller has the ability to plan and co-ordinate maintenance activities but this does not extend to being qualified to carry out the actual work. The Authority believes this would be an unnecessary imposition on industry.
Interim Recommendation 2 and 3 : The Authority agrees in principle and these matters are being addressed.
IR930224: The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority reviews its procedures in respect to the issuing of Air Operators Certificates. This review should be conducted with a view to restricting the validity of Air Operators Certificates to a specified period, with the AOC renewal to depend on the operator’s previous performance and the demonstrated capacity of the operator to continue to meet the relevant standards specified in the CAA Manual of Air Operators Certification.
The CAA response in part stated:
While it has been Authority practice in the last few years to issue “open ended” AOCs, recent legal opinion advises that the Authority should issue AOCs for a finite period.
BASI comment:
The CAA “Aviation Bulletin” dated February 1994, states that AOCs issued
without a specific period of validity will have to be renewed on 1 July 1994, with all re-issued AOCs being of a fixed term.
IR930231: The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority review:
(a) the adequacy of instructions to flight crew for maintaining a safe height
above terrain at night.
(b) the phraseology used in AIP/DAPS IAL 1.5 with a view to making it less
susceptible to misinterpretation.
The CAA response in part stated:
The Authority believes that the requirements for descent below MDA specified in AIP DAPS IAL 1.5 are clearly enunciated and notes that it is more comprehensive than the guidance provided in ICAO documentation or by either the UK or USA.
The Authority will be monitoring more closely the conduct of Instrument Rating Tests and renewals to ensure that where incorrect training is occurring that it is corrected. The subject will also be covered by an educational article in Aviation Bulletin.
Further BASI correspondence to the CAA stated:
The Bureau believes that the DAPS IAL 1.5 ‘Note 1’ does not adequately describe where visual reference must be maintained. To achieve the required obstacle clearance along the flight path it would follow that visual reference must be maintained along that path. Note 1 specifies that ‘visual reference’ means in sight of ground or water, however it does not specify where this ground or water is to be. The Bureau believes that visual reference to ground or water directly along the aircraft’s flight path must be maintained and recommends that Note 1 be expanded to state that ‘visual reference’ means clear of cloud, in sight of ground or water along the flight path and with a flight visibility not less than the minimum specified for circling.
The CAA response in part stated:
There is no objection to the addition of the words “along the flight path” to note 1 as you suggest, and this will be done as part of the next AIP amendment.
IR930234: The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority review the obstacle terrain guidance information provided for flight crew in ‘other than high capacity RPT operations’. This review should ensure that flight crew have adequate knowledge of the terrain associated with the route flown, including the obstacle terrain information for non-precision and circling approaches.
The CAA responses state in part:
CAR 218 (1) (C) details the qualifications required of a pilot conducting RPT
operations, regardless of whether high or low capacity aircraft are involved. This includes knowledge of the terrain at the aerodromes to be used. This knowledge is normally acquired by conducting the flight required by CAR 218 (1) (b) supplemented by pre and inflight briefings.
The requirement to avoid obstacles by 300 feet is to be complied with using visual reference only, i.e. the pilot must be able to ensure all obstacles lit or unlit are avoided visually. At night this may not be possible. Thus the pilot may only be able to descend when he is aligned with the landing runway and able to use the documented obstacle limitation surface, and,
The CAA will review the practices of other authorities in respect to the provision of terrain information on instrument approach charts with a view to determining whether our current practices need to be changed.
IR930244: The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority:
1. review the current rates of surveillance to determine whether the target levels of the Annual Surveillance and Inspection Program detailed in the MAOC are being met for all RPT AOC holders; and
2. review the adequacy of the Annual Inspection and Surveillance Program in
the MAOC for RPT AOC holders.
CAA Response:
The Authority notes your recommendations and advises that a review of the Annual Surveillance and Inspection Program is currently being conducted.
4.2 Final Recommendations
With the conclusion of the investigation into this occurrence, the following final recommendations are now made:
R940181: The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority:
1. develop a system for CAA officers to advise DASR of known adverse financial situations of AOC holders;
2. ensure that surveillance and inspection action responds to reported adverse financial situations of AOC holders with particular reference to their ability to conduct safe operations; and
3. develop a system to provide an ongoing assessment of the safety health of AOC holders as part of routine surveillance activities.
R940182: The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority implement as a matter of urgency the ICAO PANS-OPS requirement for an instrument approach procedure which provides for a straight-in approach aligned with the runway centreline at all possible locations.
4.3 Safety Advisory Notice
The following Safety Advisory Notice is issued:
SAN940184: The Bureau of Air Safety Investigation suggests that the CAA review the final outcome of the United States National Transportation Safety Board 1994 study of commuter airline safety with a view to assessing the applicability to the Australian industry of the findings and recommendations.
Note: For those interested in the NTSB 1994 study report mentioned above here is a link:
NTSB Commuter Airline Study
It is also worth noting that the Monarch Airlines crash at Young was extensively referred to in the very comprehensive
Regional Airline Safety Study released by BASI in 1999. A further point is that in that safety study report R940181 (mentioned above) was further highlighted/reviewed by BASI. Although where the recommendation ended up is anyone's guess..
..as the ATsB internet database records no longer go that far back...
So UITA please explain to me how the Monarch BASI report is as defective/useless as per the ATsBeaker version of reporting these days...
