Department of Transport and Regional Development

Bureau of Air Safety Investigation

REGIONAL AIRLINES SAFETY STUDY:

Preliminary Information Paper

Released by the Secretary of the Department of Transport and Regional Development BASi under the provisions of Section 19CU of part 2A of the Air Navigation Act (1920). B m C l u O f A i I ~ I D V U & @ h

When the Bureau makes recommendations as a result of its investigations or research, safety, (in accordance with its charter), is its primary consideration. However, the Bureau fully recognises that the implementation of recommendations arising from its investigations will in some cases incur a cost to the industry. Readers should note that the information in BAS1 reports is provided to promote aviation safety: in no case is it intended to imply blame or liability.

ISBN 0 642 25630 6 I I

November 1996

' This report was produced by the Bureau of Air Safety Investigation (BASI), PO Box 967, Civic Square ACT 2608.

Readers are advised that the Bureau investigates for the sole purpose of enhancing aviation safety. Consequently, Bureau reports are confined to matters of safety significance and may be misleading if used for any other purpose.

As BASI believes that safety information is of greatest value if it is passed on for the use of others, readers are encouraged to copy or reprint for further distribution, acknowledging BASI as the source.

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CONTENTS

Page SYNOPSIS .......................................................................................................................................................................................... 1

1.

2.

3. 4.

5.

INTRODUCTION . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . ....................................................................................................................... 3 1.1 Safety Regulation and Surveillance 4 1.2 Previous Research ................................................................................................................................................ 5

OBJECTIVES _.,__..____.__________...................................................................,........,........................................................................ 6

METHOD ... ...... . _ _ . _ _ _ .. __. . _ _ _ .._. .. . _. .. ... . . . .._. _ _ _ _ _ _ _ . ... ._ .... ... ..... . .. . . .. . . ___. . .. . ._........ .... . . ..... ..................................-...............................6

PRELIMINARY RESULTS .......................................................................................................................................... 7 4.1 Database Information 4.2 Interview Results ............................................................................................................................................... 12

DISCUSSION . . . _ _ . . . . . . . . . . . . . . . . . . . .. . . . . . . . ._ . . . . . . . . . . . . . _. . . . . .. . . . . ... . . . . . . . . . . . . .. . .. .. . . . . . . . . . . . . . . . . . . . . . . . .. . .. . .. . .. . .. . . . . . . . . . . . . . . . . . .

APPENDIX 1 _______.__.__...__.....,,...............................................,,....,.............................................,...,............................................... 15

16 APPENDIX 2 ............................................ ............................................................................................................. -.-..

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . .. . .. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . .. . . . . . . . . . . .. . . . . . . . . . . . .. . . .. . . . . . . . . .. . .. . . . . . . . .. . . . . .. . . . . . . . . . . . .

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SYNOPSIS

The regional airline industry is an integral part of the Australian air transport system, and is particularly important in rural and remote areas. The industry has a major role in supplementing the high capacity airlines and providing feeder services into the capital cities.

The accident rate for regional airlines has remained relatively stable since 1990, although it is higher than the rate for high capacity air transport.

Partly as a result of a small number of highly publicised fatal accidents involving regional airlines, there has been considerable debate about safety standards within this sector of the industry both in Australia and overseas. BASI believes that there are opportunities for improving the safety levels of regional airlines through the identification of safety issues before they result in serious incidents or accidents.

Discussions with industry personnel have highlighted a range of issues which they believe need attention. This preliminary report outlines the issues raised.

As a follow up to these discussions, BASI is conducting a formal industry survey of the issues identified in this preliminary study. The results of that survey will be published in future reports.

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1. INTRODUCTION

Regional airlines (low capacity regular public transport) are a significant part of the Australian air transportation system, carrying 12% of the airline passengers within Australia in 1994 (BTCE,1995). However, there are significant differences between regional operators and high capacity domestic airlines. The regional airlines meet different legislative requirements, fly different types of aircraft, and frequently operate in uncontrolled airspace to airports which lack many of the support facilities found at major airports. Because regional airlines are an integral sector of the commercial aviation industry, there is a need to consider the specific safety issues of this industry sector.

Definitions Several terms and definitions have been applied to the regional airline industry. In Australia, the terms ‘regional’, ‘commuter’ and ‘third level’ are generally interchangeable in relation to regional airlines. CASA defines a commuter airline as a regular public transport (R€T) operation using low capacity aircraft to transport persons or cargo for hire or reward in accordance with fixed schedules. Aircraft with a seating capacity of 38 or fewer seats, or a maximum payload of less than 4200 kg are defined as ‘low capacity’.

For the purposes of this regional airline study, BAS1 has used the CASA definition of commuter airlines.

The Regional Airline Industry In December 1!995,42 companies were licensed to conduct low capacity regular public transport 0 operations in Australia. These companies operated 23 1 aircraft, ranging from the five passenger seat Beech Baron to the 34-38 seat class of turboprops including the Dash 8, Saab 340 and the Brasilia. The percentage of regional aircraft powered by turbine engines has increased steadily over the last five years. Approximately equal numbers of piston and turbine powered aircraft were in use in 1995 (Reid, 1995).

Although the industry contains a number of companies which use relatively large, complex, turbine powered aircraft, the majority of regional airlines operate small fleets of mainly piston powered aircraft such as Rper PA3 1 or Cessna 404s. In 1994, there were 44 regional airlines. The five largest airlines carried 67% of the industry’s passengers while the other 39 carried the remaining 33%. (DOT, 1995).

Safety Priority The Bureau places priority on those issues which affect the safety of the fare-paying passenger. The Bureau’s pro-active safety studies program aims to identify underlying factors within the aviation system that can impact upon safety in the cockpit, cabin, control tower, maintenance workshop, or on the ramp, before they result in serious occurrences (Lee, 1993). The Bureau proposes to work with the regional airline industry to identify significant safety issues which can be addressed.

The Regional Airline Safety Study The Bureau plans to work cooperatively with the regional airline industry by using questionnaires and interviews to identify safety issues. The scope of the study will be limited to organisations which meet the above definition of a regional airline, and organisations which support or regulate regional airlines. Where a company is authorised to conduct more than one type of flying operation, for example low capacity RFT and charter, the study will concentrate on the personnel, procedures,

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equipment and organisational structure associated with the low capacity RPT operations. The study will cover all aspects of regional airline operations, including training, flight operations, maintenance, publications, selection and qualification of personnel, support facilities, air traffic services, regulation and surveillance.

1.1 Safety Regulation and Surveillance Civil Aviation Regulations and Orders (CARs and CAOs) are a major factor in aviation safety as they set the minimum requirements in many areas directly influencing safety. One of the difficulties in considering the safety of regional airlines is the complexity of the regulations governing their operations. For example, there is no single set of regulatory requirements which apply to all low capacity RPT operations. Table 1 shows the ranges of minimum requirements applicable to some aspects of regional airline operations. Note that this table shows only some of the regulatory requirements; many additional conditions and requirements may also apply.

1 Less than 10 passenger seats ' 10 or more seats

Jet aircraft with MTOW more than 3500kg Normal category aircraft with 1 pilot Transport category aircraft with 1 pilot Multi-crew aircraft, MTOW 5700kg or less. Multi-crew aircraft, MTOW more than 5700kg 0- 15 passengers 16-19 passengers

Table 1 Selected Minimum Safety Requirements for Low Capacity RPT Operations

Aspect of Operations Number of pilots

Experience and qualification of pilots

Number of flight attendants

Aircraft climb performance after takeoff

failure of critical engine at V1

following

Fitment with ground proximity. warning system Fitment with weather radar

Condition

20-36 passengers More than 36 passengers MTOW 3500 kg or less MTOW 3500 - 5700 kg

MTOW more than 5700kg

MTOW more than 15000kg OR more than 30 seats

Aircraft crewed by 2 pilots, except for unpressurised turbine engine aircraft with MTOW less than 5700 kg and

Minimum Requirements

1 pilot 2 pilots 2 pilots Commercial Pilot Licence plus 700 fly hours Commercial Pilot Licence plus lo00 hours Air Transport Pilot Licence plus 1200 hours Air Transport Pilot Licence plus 2000 hours

Flight attendant (FA) not required. FA not required if pilots duties include passenger briefing and emergencies. 1 flight attendant required. 1 FA required for every 36 passengers. No requirements. Remain above obstacle free gradient (min 1.9%) for distance of 3ooOm. Clear by at least 35 ft all obstacles in takeoff area, allowing for gear and flap retraction and acceleration to best climb speeds.

Must be fitted with GPWS

Must be fitted with weather radar

I unpressurised piston engine aircraft.

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Commercial Regulation The intrastate routes flown by regional airlines are not regulated by state or temtory legislation in Victoria, South Australia, the Australian Capital Temtory or the Northern Temtory. Intrastate routes are partially regulated by state legislation in Queensland, Western Australia and Tasmania, and are fully regulated in New South Wales. Interstate routes are not regulated. (Moms, 1995)

1.2 Previous Research

Australian Research A report on the safety of the General Aviation sector by the House of Representatives Standing Committee on Transport, Communications and Infrastructure, commonly known as the Moms Report, was released in December 1995. Its objective was to report on the adequacy of air safety standards in the regional airlines and general aviation sectors in Australia. The committee concentrated on the regulatory aspect of safety. Moms found that ‘there is no hard evidence to show a deterioration of aviation safety ... in low capacity R € T (p.37). However, he did identify the lack of information on low capacity RIT operations and the absence of robust indicators on the safety of aviation as overall deficiencies.

Overseas Research In the USA, commuter airlines and air taxi operators operate under Title 14 Code of Federal Regulations Part 135. Under this code, commuter airlines operate scheduled services while air taxi operators provide an unscheduled or ‘on demand’ service. Both are limited to aircraft with 30 or fewer passenger seats. Legislation amendments recently made by the United States Government require United States commuter airlines operating aircraft fitted with 10 to 30 passenger seats to meet the same safety requirements as the major domestic airlines.

Since its establishment in 1967, the US National Transportation Safety Board (NTSB) has conducted three special studies of safety in the commuter airlindair taxi industry. The reports on these studies were published in 1972,1980 and 1995. The 1995 report ‘Safety Study: Commuter Airline Safety’ made recommendations concerning:

changes to regulations to have commuter operations conducted in aircraft with 10 or more seats meet the requirements, where possible, for operations by major domestic airlines, a review of pilots’ tasks between flights to ensure that they have sufficient time to complete duties essential to flight safety, changes to regulations to include all non-revenue flying in total flight time for the purpose of calculating flight time limits and crew rest periods, a requirement that all pilots receive crew resource management training, changes to aircraft certification regulations to ensure the availability of a flight simulator for each new type of commuter aircraft certified, the inclusion of actual use of emergency equipment under simulated emergency conditions during the recurrent training of flight attendants, the establishment of a safety officer position in all airlines, the review of training and qualification standards for FAA inspectors responsible for inspecting airlines, the level of safety at airports served by commuter airlines, the establishment of operational oversight programs by major domestic airlines which code- share with commuter airlines.

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While there are similarities between US commuter airlines operating under Part 135 regulations and Australian regional airlines, there are currently significant differences in regulations and some differences in the airspace and climatic environment. Recommendations from the NTSB study are not necessarily appropriate for Australian operations, but are worthy of consideration.

I Baker, Lamb, Li, & Dodd, (1W3), conducted a study of NTSB records of 1 18 accidents involving US commuter airline aircraft between 1983 and 1988. They found that the most common accident types were loss of control on takeoff or landing, and mechanical failure causing an inflight emergency. Of the 118 accidents reviewed in this study, 88 (74.5%) involved human factors relating to apparently inadequate pilot performance. The most common pilot performance factors were poor handling of emergency situations, improper Instrument Flight Rules (IF’R) procedure and fuel mismanagement.

2. OBJECTIVES The objectives of this BASI safety project are to: (a) identify the issues affecting the safety of regional airline operations in Australia; (b) identify means of reducing the safety impact of these issues.

3. METHOD The Bureau plans to work cooperatively with the regional airlines to gather information on safety matters. Information has been gathered from the following sources:

(a) Data was extracted from the BASI database to show the types and frequencies of safety matters reported to BASI by accident, incident and Confidential Aviation Incident Reporting ( C A R ) reports. Familiarisation flights were made on several regional airline aircraft. Interviews were conducted by the project manager with managers and employees currently employed by regional airlines, and inspectors employed by the Civil Aviation Safety Authority,

(b) (c)

Interviews The objective of the interview phase of the study was to identify those areas of the industry and its supporting agencies which warranted closer investigation. As it was not possible to visit every regional airline in Australia, a group of airlines was selected which was considered representative of the industry. By the end of the interview phase of this project, 23 of the 42 airlines currently operating had been visited. Interviews were also conducted with six CASA Flight Operations Inspectors (FOIs) and five Airworthiness Inspectors (AWIs) who had responsibilities for surveillance of regional airlines, and with the Director of the Regional Airline Association of Australia.

Individual interviews were conducted with managers and discussions were held with groups of pilots, flight attendants and maintenance sm. The interviews and discussions were loosely structured with the interviewees free to discuss any issue which was, in their experience, a safety hazard. Near the end of the interview/discussion, a checklist of possible safety subjects was reviewed to ensure that all areas had been considered. Notes were taken by the BASI project manager during interviewddiscussions but in order to ensure confidentiality, no names were recorded.

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Of the 53 requests for interviews, only one person declined a face to face interview but did provide comment by telephone. Another five persons, who were not available for interview at the time of the project manager’s visit, subsequently provided information by telephone. All requests for discussions with groups of employees were agreed to.

The next phase of the project is to distribute questionnaires to managers and employees of the regional airlines and supportinglregulating organisations. Response sheets will be mailed directly to BASI Central Office in Canbem. Respondents will not be asked to idenhfy themselves or their airline.

4. PRELIMINARY RESULTS Preliminary results from the search of the BASI database and the summaries of interviews with airline personnel are covered in this report. These preliminary results should be viewed as interim and may not reflect the final conclusions of the full study. Safety recommendations may be made at any time during the study and formally recorded in the final report.

4.1 Database Information Occurrence data concerning regional airlines for the period 1 January 1986 to 31 December 1995 was extracted fiom the BASI database. Prior to 1992, the term ‘supplementary air line (SAL)/commuter’ was used to describe airlines using aircraft with fewer than 38 seats. The statistical data contained in the following paragraphs is based on SAUcommuter data for the years 1986 to 1991 and low capacity FPT data for the years 1992 to 1995.

Accidents Involving Regional Aircraft The most common types of accidents involving regional airline aircraft fiom 1986 to 1995 are shown in figure 1. It should be noted that these accidents did not necessarily result in the destruction of the aircraft. Of the accidents which occurred over this period, the only fatal ones were the three in the Loss of situational awareness category. Two of these accidents were classed as Controlled Flight into Terrain (CFIT) and occurred during the approach and landing phase. The third accident occurred during take-off.

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Figure 1.

Australian Regional Airline Accidents 1986-95 By Accident Circumstances

Loss of control on takeoff or landing

Struck object while taxiing

Aircraft struck by hail or lightning

Engine failure

Other I I I I I I I

I I I I I I I I 0 2 4 6 8 10 12 14 16

Number of Accidents

Notes: The category of Gear collapsed during lunding or takeoff includes accidents in which the landing gear could not be extended or locked down and a wheels-up landing was made. It also includes one case of the f a h e of a float on a seaplane, but does not include unintentional wheels up landings.

Loss of control on takeoffhnding includes cases where the aircraft ran off the end or sides of the runway due to wet runway, brake failure or propeller malfunction. It does not include runway excursions after a landing gear collapse.

The most recent accident involving a regional airline concerns Metro VH-NEI at Tamworth, NSW on 16 September 1995 which was on a non-revenue training flight. Based on the BAS1 Interim Factual Report released on 13 February 1996, this accident has been allocated the interim classification of Loss of situational awareness.

One Engine failure accident was the result of mechanical failure of the engine; the other was an engine shutdown after loss of engine oil. Neither accident involved fuel starvation.

The five accidents in the Other category involved touching down short of the threshold, damage due to inflight overstress of the airframe, a cabin door separating from the aircraft inflight, a kangaroo strike on landing, and an unintentional wheels up landing.

A typical Gear collapse on takeoflor landing accident occurred at a remote airfield in northern Australia. During the takeoff run from a sealed runway, the nose-wheel broke through the runway surface, causing a failure of the nose gear mounting and the nose gear collapsed. No-one was injured.

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An example of a Loss of control on takeof or landing accident O C C U K ~ when the twin piston engined aircraft experienced a failure of the left brake during landing. On application of the brakes, the aircraft swung to the right and departed the runway. Although substantial damage was caused when the nose strut was tom from the aircraft, none of the crew and passengers were injured.

An Aircrafr struck by hail or lightning accident occurred when a Navajo aircraft, cruising at 10,OOO f i in cloud encountered hail. All the leading edges, propeller spinners, and engine cowls were extensively damaged and the left windscreen was cracked.

An Engine failure accident happened when a single engine aircraft on a visud flight rules (VFR) scheduled flight suffered a piston assembly failure. In the resulting forced landing, the right main gear struck a shallow depression in the ground and the gear was tom from the aircraft. None of the five passengers and crew were injured.

Fatal Accidents One of the three fatal accidents occurred when the Navajo aircraft was making a circling approach at Coffs Harbour at night in conditions of low cloud and rain. Turning onto a short right base leg, the aircraft continued to roll to the right, struck trees and crashed. Of the seven passengers and crew on board, three received fatal injuries, another three were seriously injured and one person suffered minor injuries.

The second of the fatal accidents occurred at Young NSW. The Navajo Chieftain aircraft, while on a right base leg for a landing approach to runway 01 in conditions of low cloud and darkness, struck trees at a height of 275 feet above the elevation of the aerodrome and crashed. All seven occupants, including the two pilots, received fatal injuries.

The third fatal accident involved a Metro III aircraft which was being used to conduct copilot endorsement training. During the takeoff run, failure of the left engine was simulated by the training captain and the copilot under instruction continued the takeoff as briefed. The aircraft struck trees and high voltage powerlines approximately 350 m beyond the upwind end of the runway and crashed. Two of the three persons on board received fatal injuries and one received serious injuries.

It should be noted that the accident on 2 October 1994 involving the Rockwell Aerocommander VH-SVQ, operated by Seaview Aviation, occurred during a charter flight, not a regular public transport flight, and therefore is not included in this study.

Accident Rates The accident rates for regional airlines, expressed as accidents per 100,OOO flying hours and fatal accidents per 100,OOO flying hours are shown in figure 2. Throughout the 19%, the accident rate has beenclose to the ten year mean of 1.92 accidents/l00,000 flying hours.

In comparison, the mean accident rate for Australian high capacity regular public transport carriers over the period 1986 to 1994 is 0.38 accidents per 100,OOO flying hours. It should be noted that none of the accidents to high capacity regular public transport in this period resulted in hull losses or fatalities.

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Figure 2.

-.- AccldenW 4 -. 1 oo,oO0 flying hours 3 5

Regional Airline Accident Rates 1986-95

--t All AccMents

I \ + Fatal Accidents I \

1986 1987 1988 1989 1990 1991 1992 1993 1994 1995

Notes: 1. Accident rates for 1994 and 1995 are based on interim data. 2. Flying hours data were provided by Department of Transport and Regional Development, Aviation Statistics Section.

Measuring Safety The most commonly used measure of airline safety is the accident rate in terms of accidents per 100,OOO flight hours or accidents per 100,OOO takeoffs. However, a major difficulty with accident rate data is that a large number of accidents need to have occurred in the time period being considered for the statistics to have any validity (USGAO, 1988). The small number of regional airline accidents in Australia in any one year results in large variation in the accident rate when considered on a yearly basis. This is well demonstrated by the 700% increase in the accident rate between 1987 and 1988, followed by the equally dramatic decrease to zero in 1989, as shown in figure 2. Clearly accident rate statistics on a yearly basis are not realistic indicators of airline safety. However the trend in the accident statistics can be determined by averaging the data over three or five years.

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Incidents Involving Regional Aircraft Over the period 1986 to 1995,2001 incidents involving regional airline aircraft were reported to BASI. The most commonly reported types of incidents are shown in table 1.

Table 1 r Most Commonly Reported Incidents Involving Regional Airline Aircraft 1986-95

Incident Type Percentage of Incidents

Component/system malfunction or failure 28.7 Air Traffic Service (ATS) related 19.2 Operations related 17.2

H Loss of separation 12.0 Engine power loss 9.4 Firdsmokdfumes 1.3 Other 12.2

Notes: 1. ATS related incidents include breakdowns in coordination between ATS agencies, problems with clearances and lack

2. Operations related incidents include incorrect airways and circuit area procedures, fight time limitations, penetration of of operational information.

controlled airspace and VFR aircraft in non-VMC. 13. Loss of separation incidents can occur in controlled or uncontrolled airspace,

Confidential Aviation Incident Reporting (CAIR) CAIR reports have been added to the OASIS database from 1 January 1992. Since this date, 23 reports involving regional airline aircraft have been received. The most commonly reported CAIR types are shown in table 2.

Table 2. Incident Types Involving Regional Airlines

Most Commonly Reported by CAIR 1992-95

Incident Type Number Percentage

Breaches of safety regulations 5 Radio communication problems 4 ATS related incidents 3 Fatigudflight time limits 3 Other 8

22 17 13 13 35

Nota: 1. Operations Inspectors, adequacy of training on a new aircraft type, seats infringing an aircraft emergency exit, unaccompanied minors on flights, flight characteristics of one particular aircraft, ATS SSR equipment difficulties, and the straight-in approach trial.

CAIR reports in the Other category related to the name change of Yulara airfield, policy on flying by Flight

As an example, a CAIR report was received from a pilot who stated that his company was regularly requiring its pilots to operate outside of the legal flight duty time limits. Pilots were not being given

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the required number of days off or were required to perform some duties during their rest period. Another CAIR report expressed concern at the frequency congestion on 126.7 MHz, the Common Traffic Advisory Frequency (CTAF) in the area from Yarrowee to Mount Gambier.

The CAIR system was introduced to encourage the reporting of human factor incidents by removing the possibility of recriminations to the reporter. This was especially intended to encourage the reporting of people's own mistakes without the fear of disciplinary action. A breakdown of the reports involving regional airlines, in table 3, shows that most CAIR reports relate to a third party, particularly employers or other airlines.

rable 3 Regional Airline C N R Reports 1992-96 by Agency Responsible for Subject Area

Agency Responsible for Report Subject Area

Self (reporter) Reporter's employer Airline other than reporters Airservices Australia CASA BAS1 FAC

Number of Percentage of Total Reports Number of Reports

4 36 26 22 4 4 4

Total 23 100

4.2 Interview Results The results of the interviews were collated and analysed. The list of safety issues which were suggested by the interviewees is shown in appendix 2. The most commonly discussed issues were as follows.

a. The regulations governing regional airline operations are difficult to understand, hard or impossible to enforce, and are open to interpretation.

b. Pilots are having difficulty achieving safe separation from VFR aircraft in CTAF and MBZ areas.

c. Lack of suitable regulations on subjects such as qualifications for check and training captains, training of flight attendants, climb performance of aircraft with MTOW less than 3500 kg.

Pilots are experiencing difficulty in achieving separation with other IFR traffic when descending from controlled airspace to uncontrolled airspace.

d.

e. Inconsistent interpretation of regulations by CASA inspectors results in inconsistent safety standards across the industry.

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f. Minimum qualification, experience and personal qualities of persons approved to hold Air Operators Certificates for airlines need to be defined.

g . Although individual inspections by CASA staff are thorough, levels of surveillance of regional airlines are too low to detect non-compliance. Specific areas mentioned are enroute surveillance by FOLS, surveillance of maintenance carried out at night, and no-notice inspections away from major airports.

h. The lack of standards in the training and assessment of pilots in training and charter organisations results in inadequately trained pilots entering regional airlines.

1. The time taken by CASA to approve changes to maintenance plans, minimum equipment lists and operations manuals is excessive.

j. Frequency congestion on some Flight Service frequencies results in IFR aircraft being unable to obtain timely information on conflicting aircraft.

k. The high rate of near-misses in controlled airspace is unacceptable.

1. Density of traffic, and particularly the mix of medium size RPT jets with regional airline aircraft and sightseeing aircraft at Ayers Rock airfield, a non-tower airfeld, makes it nearly impossible for the pilots to arrange separation from other aircraft.

m. Reliability of information on the condition of unlicensed airfields is a concern for some pilots who regularly operate from unlicensed airfields.

n. Lack of acknowledgment of Air Safety Incident Reports (ASIRs) discourages reporting of safety incidents.

0. Commercial pressures force most regional airlines to adopt the minimum level of safety required by the regulations.

It should be emphasised that some of these issues may have been suggested by only a few members of the industry and have not been substantiated. Further investigation will be carried out to identify which of these issues pose hazards to airline safety.

5. DISCUSSION Of the regional a i r h e accidents over the ten year period to 1995,16 (41%) were related to a failure of the landing gear. Ten different aircraft types were involved in these accidents. The large percentage of accidents in this category could be due to frequent use of runways with rough or broken surfaces. Marginal runway conditions, particularly runways with low surface friction were factors in some of the accidents in the second most frequent category-Zoss of control on tukeofs or landing. Even though the accidents in these two categories caused significant damage or the destruction of the aircraft, no fatalities resulted.

74% of all accidents, and 100% of the fatal accidents, occurred during the takeoff, approach or landing phase of the flight, confirming that these are the most safety critical phases of a flight.

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The three fatal accidents were of the Loss of situational awareness type, although both accidents involving Navajo aircraft could also be classified as Controlled flight into terrain (CFlT) accidents. All three fatal accidents occurred at night, two being in conditions of low cloud. Overseas studies have concluded that CFIT accidents are the leading cause of airline passenger fatalities (Khatwa 1996). Australian regional airline accident statistics for the period 1986 to 1995 support this conclusion. Takeoffs, landings and approaches at night are a si@icant safety issue for regional airlines.

In the last ten years there have been no midair collisions involving Australian regional airline aircraft. However loss of separation from other aircraft, both inside and outside controlled airspace, was frequently discussed during interviews, and loss of separation occurrences account for 12% of the air safety reports. Factors which contribute to the loss of separation occurrences, such as congested frequencies, inadequate radio procedures by VFR pilots and air traffic separation procedures were also frequently put forward as safety issues during interviews. Many of the difficulties of maintaining separation are associated with the airspace (controlled and uncontrolled) and traffic environment (IFR and VFR) in which these airlines commonly operate. Maintaining safe separation from other aircraft is a significant safety issue to regional operators.

For the period 1986 to 1989, the annual accident rate for regional airlines was very variable, however, since 1990, the rate has remained relatively stable, close to the ten year mean. The number of fatal accidents is fortunately too low to give any reliable trend information.

Further Research The factors in accidents, the range of topics raised during interviews, as well as the broad variety of CAIR reports received by BASI, point to a range of safety issues of concern to the people employed in the regional industry. These issues will be examined by BASI via formal industry surveys in early 1997 and discussed in subsequent reports.

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Appendix 1

REGIONAL AIRLINES VISITED

The following airlines were visited by the project manager as part of the regional airlines safety project:

Airline Locations Visited

Air Kakadu Air Link Air swift Aimorth Augusta Airways Aus-Air Cape York Air

Country Connection Airlines Eastern Australia Airlines Emu Airways Executive Air Flight West Airlines Hardy Aviation Hazelton Airlines National Jet Systems Skywest Airlines Southern Australia Airlines Sunstate Airlines Wimray Aviation

corgorate Air

Darwin Dubbo cairns Darwin Adelaide Moorabbin cairns Canberra Cootamundra Sydney Adelaide Darwin Brisbane Darwin

Adelaide, Perth, Darwin Perth Mildura Brisbane, Cairns Darwin

Sydney

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Appendix 2.

POTENTIAL SAFETY ESUES

The following issues were suggested, during interviews and discussions, as being safety hazards to regional airline operations:

regulations which had been drafted with large airlines in mind but which are impossible for small regional airlines to meet regulations (or lack of regulations) relating to:

qualification of check and training captains. Under current regulations, a captain with no experience or qualification in flying instruction can be approved as a check and training captain with responsibility for converting pilots to a new aircraft type. qualification of maintenance controllers. Under current regulations, a person with no experience in aircraft maintenance can be approved to be a maintenance controller. scheduled operations into unlicensed airfields in remote localities. training and qualification of flight attendants. Currently, no regulations on the training and qualification of flight attendants exist. flight time limits for flight attendants. Under current regulations, flight time limits for pilots exist but not for flight attendants. minimum performance capabilities of RPT aircraft of less than 3500kg. Under current regulations, aircraft of maximum takeoff weight (MTOW) of less than 3500 kg have lower minimum levels of performance, particularly climb performance after takeoff, than aircraft with MTOW greater than 3500 kg. definitions of RPT and charter operations. Current regulations allow charter operations to be conducted with lower levels of safety than RPT operations, but the distinction between RPT and charter operations is not always clear. Thus ‘pseudo’ RPT operations can be conducted by charter operators using a lower level of safety than is required for actual RPT. pilot check and training functions carried out under contract. Current regulations (CAR 217 (1)) require that operators of RPT services provide a check and training organisation to ensure that operating crews maintain competency. In small airlines, it is difficult to retain pilots who are qualified in the check and training role. Changing the regulations to allow small airlines to contract out the check and training role to other companies specialising in this work may improve the quality of checking and training of crews.

0 the effectiveness of the CASA programme for the surveillance of regional airlines standardisation of interpretation of regulations by CASA inspectors

0 airworthiness of aircraft over 20 years old the s@ndards of multi-engine training and instrument training received by commercial pilots effectiveness of synthetic flight trainers used for instrument flying currency and renewals

0 need for fitment of Airborne Collision Avoidance Systems (ACAS) to regional airline aircraft need for crew resource management (CRM) training of flightcrews acknowledging the receipt of Air Safety Incident Reports (ASIRs) as a means of encouraging more safety reporting congestion on flight service frequencies and delays in getting traftic information non-tower airfields with unsafe levels of traffic problems in getting M i c information and estabbshing separation with traffic outside controlled airspace when descending from controlled airspace.

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the reliability of SARTIhES lodged with ATS agencies the effect on regional airline operations of parachuting in busy circuit areas. poor radio procedures by VFR pilots in MBZs and CTAFs adequacy of W A M E training on a new aircraft type

0 the effectiveness of dangerous goods awareness training 0 the impact of numbers of unaccompanied children or medical case passengers on the ability of

flight crew to carry out their safety duties 0 the safety state of unlicensed airfields that are used for regular services in remote areas 0 the effectiveness of the present system for reporting the condition of unlicensed airfields in

remote areas 0 compliance with flight time limitations for pilots

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REFERENCES

Baker, S.P., Lamb, M.L., Li, G., & Dodd, R.S. 1993, Human Factors in Crashes of Commuter Airplanes. Journal of Aviation, Space, and Environmental Medicine, Jan 1993, pp 63-68.

BTCE, 1995, Australian Transport Statistics. Brochure produced by Bureau of Transport and Communication Economics, AGPS, Canberra.

DOT, 1995, Key Facts in Australian Aviation 1994. Brochure produced by Department of Transport, AGPS, Canbem.

Lee, R. 1993, New Directions in Air Safety. Paper presented to Chartered Institute of Transport ‘Transport Safe ty.... At What Cost?’ conference, Bnsbane, August 1993.

Morris, Hon. P. 1995, Plane Safe - Inquiry Into Aviation Safety: The Commuter and General Aviation Sectors, House of Representatives Standing Committee on Transport, Communications and Infrastructure, AGPS, Canberra.

NTSB, 1994, Safety Study: Commuter Airline Safety. Report by National Transportation Safety Board. US Government Printing Office, Washington DC.

Reid, G., 1995, ‘Regional Airline Directory’, Australian Aviation, December 1995, No 113, I

pp 50-60.

USGAO, 1988, Aviation Safety - Measuring How Safely Zndividual Airlines Operate. Report to Congressional Requesters by United States General Accounting Office. US Government Printing Office, March 1988.

Khatwa, R. & Roelen, A.L.C. 1996, An Analysis of Controlled Flight into Terrain Accidents of Commercial Operators 1988 through 1994, Report under contract to National Lucht- en Ruimtevaadaboratium (National Aerospace Laboratory NLR), Netherlands Department of Civil Aviation, Amsterdam, The Netherlands.

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