This page displays a list of safety recommendations that relate to the aviation mode. You can use the filter tool to refine the results and to search for keywords within the text of each recommendation.
Safety Recommendation
065/05
Issued To
CAA
on 29 Jul 05
publish educational material to remind IFR pilots about their mutual separation responsibilites in uncontrolled airspace, particularly when carrying out instrument approaches to the same aerodrome.
Implementation Status:
Open
Reply:
The Director will accept this recommendation and will publish an article in the November/December [2005] issue of the CAA Safety Magazine Vector, to this effect.
Safety Recommendation
038/05
Issued To
Alpine Adventures
on 31 May 05
include in the flight training programme for company helicopter pilots, slign load re-currency training as part their annual proficiency training programme.
Implementation Status:
Open
Reply:
Our company has included in the flight training program for the helicopter pilots the following:
Sling load re-currency training as part of the annual proficiency training.
Following the accident and on arrival of a new helicopter the pilot had a flight dedicated to sling load operations. This progressed well.
Safety Recommendation
063/05
Issued To
Auckland International Airport
on 13 May 05
examine runway visual indications with the objective of providing additional visual reminders to pilots that a displaced threshold is in operation.
Implementation Status:
Open
Reply:
Auckland International Airport Limited intends to implement the safety recommendation 063/05 and has already been looking for possible solutions. However, as there is no standard fix for this type of operation, it will not be something that can be implemented immediately. While we are unsure of the size of the task at this stage, it is likely to take at least 6 months, with perhaps a progressive roll out of different aspects in the interim.
Safety Recommendation
051/04
Issued To
CAA
on 11 Aug 04
Complete the recommendations of the independent report, New Zealand Aircraft Icing Hazards, in particular:
a. ensure all IFR operators provide adequate written guidance for operations in adverse or hazardous weather conditions,
b. audit air operators to ensure they have clear and unambiguous procedures for avoiding not only turbulence and thunderstorms, but also severe icing conditions, and
c. ensure pilot training requirements for inadvertent flight into hazardous meteorological conditions are adequately defined for commercial operations under Civil Aviation Rules, Parts 121, 125 and 135.
Implementation Status:
Open
Reply:
I will accept this recommendation, and will amend the Airline audit procedures check list to ensure that operator?s manuals provide adequate written guidance for operations in adverse or hazardous weather conditions. This will be completed by September 2004 and all operators will be audited against the new check list.
I will also ensure that an Advisory Circular is written for all IFR and night freight operators that will specify what the training specifications are for hazardous meteorological conditions. This will be completed by December 2006.
Safety Recommendation
050/04
Issued To
CAA
on 11 Aug 04
Ensure that, in addition to the current installation and operating requirements, all CVRs and FDRs are periodically interrogated to ratify the content and quality of the information recorded.
Implementation Status:
Open
Reply:
I will not accept this recommendation as the current rule is adequate, in particular Rule Part 21 sets out the requirements. I will however review Convair CVR and FDR modification, installation and maintenance instructions in conjunction with the design data holder to ensure that instructions for continued airworthiness meet rule requirements.
Safety Recommendation
028/04
Issued To
CAA
on 01 Jul 04
Publish guidelines for operators and maintenance facilities for the appropriate re-use and inspection of parts from accident damaged aircraft.
Implementation Status:
Open
Reply:
I accept this recommendation and will ensure that a new rule under CAR Part 91 that requires accidents to be recorded in the aircraft logbook will be proposed for inclusion in the 2005/2006 rules programme. No precise time frame can be stated.
Advisory Circular 43.9A [Modification and repair and the form CAA337] will be amended to detail guidelines for the use and inspection of parts from accident damaged aircraft. This will be completed by June 2005.
Safety Recommendation
050/03
Issued To
Singapore International Airlines
on 31 Oct 03
Develop guidelines for the use of the third pilot, for the times one is carried.
Implementation Status:
Open
Reply:
We are pleased to report that SIA has implemented all the TAIC?s safety recommendations with the exception of Safety Recommendation 050/03, which is still in discussion with Boeing (please see attached). As this aircraft is designed to be operated by two pilots, SIA is presently developing guidelines for the third pilot that will not impact the responsibility/accountability of a two pilot operation. As we need to discuss this further with the manufacturer and our civil aviation authority, we shall revert in due course.
Safety Recommendation
047/03
Issued To
Boeing
on 24 Oct 03
Implement a FMS software change on all various Boeing aircraft models that ensures any entries (such as V speeds and gross weight) that are mismatched by a small percentage are either challenged or prevented.
Implementation Status:
Open
Reply:
According to the NZ TAIC report, the load sheet provided to the crew contained the correct weights for the flight and the correct weight was entered into the FMS. However, the crew used an incorrect weight to manually calculate the takeoff speeds (V speeds) from airport analysis charts. The incorrect V speeds were entered into the FMS and used by the crew during takeoff, resulting in the tail strike.
Background
This event is another example of incorrect takeoff speeds, which has previously been identified by Boeing as an issue for the industry. The common feature among these cases is that the takeoff speeds used by the crew are inappropriate to the specific operating conditions (actual weight, runway length, etc). The error or errors leading to the incorrect speed can happen at various points along the computational path, which consists of both manual and automated operations. In all cases, the results are the same - a takeoff is attempted with rotation at an inappropriate speed. The consequential risks to the airplane (tail strike, overweight takeoff, increased runway length, reduced manoeuvre margin to stall, reduced climb gradient, etc) are the same regardless of the specific error that led to the incorrect V speeds. Boeing is working to ensure that adequate and appropriate defences are in place to reduce the possibility that such errors are made or propagated.
Prior to the Auckland event, Boeing had reviewed the takeoff speed calculation procedure, errors that could be introduced and methods to prevent their propagation. Based on that review, Boeing released the reference (b) Flight Operations Technical Bulletin and the reference (c) Aero Magazine article. These publications discuss the source of errors, steps taken by Boeing and steps available to operators to prevent the errors from occurring and propagating. Reference (b) is included with this letter and reference (c) was previously provided to the TAIC.
Discussion
Actions to reduce the occurrence of such of events will be most effective if they address all of the ways in which the error can occur. Among the incorrect takeoff speed events reported to Boeing, the Auckland event is unique in that the crew entered the correct weight figures in the FMC, but then overwrote the FMC speeds with manually calculated airport-analysis figures. In the other events reported to Boeing, the weight value entered into the FMC was incorrect, either because incorrect weight information was provided to the crew, or because the crew selected the inappropriate figure from the load sheet (e.g. selecting ZFW and entering it in the GW slot). The recommended software change to ensure that the speed and weight entries are not mismatched can identify the following two situations:
1. The crew enters the correct weight but overwrites the FMC-calculated speeds, or
2. The crew enters an incorrect weight and overwrites the FMC-calculated speeds with correctly calculated V speeds.
The recommended software check would be ineffective in preventing a large proportion of incorrect takeoff speed events - those in which an incorrect weight is entered into the FMC. Additionally, in the second situation cited above, the takeoff speeds are correct, but the recommended software change could reject or challenge them. Consideration must be given to the possibility that the crew might then elect to use the incorrect FMC-calculated speeds.
The takeoff speeds calculated by the FMC are balanced field length speeds which do not take into account the actual runway length, friction conditions, or specific techniques that take advantage of available runway length to gain improved climb performance. These factors are included in the airport analysis charts which crews use to manually calculate takeoff speeds. The effect of these factors can be significant. As an example, the following table lists takeoff speeds for a [Boeing] 737-700:
Model 737-700
Elevation 5330 ft
Runway Length 14,000 ft
Takeoff Weight 141,400 lbs
Temp 30C
Speed FMC Calculated(kts) Airport Analysis (Improved Climb)(kts)
V1 140 159
VR 141 162
V2 144 166
In the above example, the manually calculated speeds are approximately 20 knots faster than the FMC-calculated speeds. In the case of low runway friction, the manually calculated V1 speed can be up to 20 knots slower than FMS-calculated speeds. Thus, there are cases where the manually calculated speeds differ by more than a small percentage from the FMC-calculated speeds. The recommended software check would challenge or reject these valid entries creating nuisance warnings to the crew. Nuisance warnings reduce the effectiveness of a warning system and can defeat the original purpose of the warning system. We are, however, exploring the possibility of checking that the manually entered VR speed is not significantly lower than the FMC-calculated value. It appears that narrowing the check in this manner may produce the intended safety benefit while avoiding some of the problems mentioned above.
Boeing Action
Boeing will continue to examine the safety recommendation in the context of the broader issue regarding incorrect takeoff speeds. As the work progresses, we will determine whether changes to existing FMS installations may be warranted. Separately, we will also determine if such new features should be included in new FMS installations. At this point, no schedule has been set for the completion of our examination.
Safety Recommendation
051/02
Issued To
CAA
on 30 Nov 02
Enhance the policy and procedures for aircrew licensing written examinations, their purpose and construction, and the criteria that is applied to examination re-sits, so the "practice effect" does not undermine the examination process.
Implementation Status:
Open
Reply:
The Director will accept the recommendation as worded in that the current review of Rule Part 61 addresses these matters and a Notice of Proposed Rule Making is currently being drafted for public consultation in accordance with the requirements of the Civil Aviation Act.
Safety Recommendation
037/02
Issued To
CAA
on 18 Oct 02
Critically examine the requirements for duplicate inspections of aircraft control systems, with a view to including helicopter tail rotor drive trains as part of the duplicate inspection regime.
Implementation Status:
Open
Reply:
I accept this recommendation; I will initiate a review of Rule Part 43.113, duplicate inspection of controls. This review will examine the need for duplicate inspection of vital points in an aircraft, that if they were to fail would have a catastrophic effect on the flight. Helicopter tail rotor drive trains will be considered as part of this review.
The review will be completed by 31 March 2003 however no final date for any action arising from the review can be stated.
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