[Peetwo]

ATSB investigation: AO-2014-163

This accident final report was published last week and I found it interesting because it actually involved an ATSB rarity these days - the issuing of a safety recommendation to CASA..

First here is the summary:

What happened

On the afternoon of 10 October 2014, the pilot of an amateur-built One Design DR-107 aircraft, registered VH-EGT, was performing low-level aerobatic manoeuvres. The manoeuvres were being performed to the east of Goolwa Airport, South Australia.
Witnesses described the aircraft performing a series of similar manoeuvres. Each involved a vertical climb and tumbling manoeuvre followed by a vertical dive and a low altitude recovery.

Witnesses reported that, during recovery from the last vertical dive, the aircraft collided with terrain. The aircraft was destroyed by the impact and the pilot was fatally injured.

What the ATSB found

The ATSB found no evidence of pilot incapacitation or a mechanical fault with the aircraft that could have contributed to the accident. There was insufficient evidence to determine why the recovery was not accomplished above the pilot’s minimum authorised aerobatics height.

The Civil Aviation Safety Authority (CASA) recommends that pilots performing low-level aerobatics undertake regular peer reviews due to the high level of skill and fine safety margins involved. The ATSB found no evidence of the pilot undertaking a peer review of their aerobatic performance in the 15 months prior to the accident.

Finally, the ATSB identified a safety issue that CASA does not require builders of amateur-built experimental aircraft to produce a flight manual, or equivalent, for their aircraft following flight testing. Without a flight manual, the builder, subsequent owners and other pilots do not have reference to the operational and performance data necessary to safely operate the aircraft.

What’s been done as a result

In response to the identified safety issue, the ATSB has issued a safety recommendation to CASA to take action to require builders of amateur-built experimental aircraft to produce a flight manual, or equivalent, for their aircraft following flight testing.

Safety message

This accident highlights the risks inherent in performing low-level aerobatics. Applying the recommendations in CASA civil aviation advisory publication CAAP 155-1(0) Aerobatics will reduce these risks. Specifically, pilots are encouraged to always maintain minimum approved heights above the ground when performing aerobatics and to engage in regular peer reviews.

Owners of amateur built experimental aircraft are also encouraged to ensure a comprehensive and accurate flight manual, or equivalent, is available for reference by themselves, subsequent owners and other pilots who may fly the aircraft.

Amateur-built One Design DR-107 aircraft, registered VH-EGT

 
This was the ATSB identified safety issue, the response from CASA and finally the safety recommendation issued:

Flight manual requirements for amateur-built experimental aircraft

Issue number: AO-2014-163-SI-01
Who it affects: Operators of amateur-built experimental aircraft
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Background: Investigation Report AO-2014-163
Date: 14 April 2016

Safety issue description

The Civil Aviation Safety Authority did not require builders of amateur‑built experimental aircraft to produce a flight manual, or equivalent, for their aircraft following flight testing. Without a flight manual the builder, other pilots and subsequent owners do not have reference to operational and performance data necessary to safely operate the aircraft.

Proactive Action

Action organisation: Civil Aviation Safety Authority records
Date: 14 April 2016
Action status: Monitor

In response to this safety issue, the Civil Aviation Safety Authority (CASA) advised that:
CASA would like to note that an experimental aircraft must be placarded accordingly to ensure occupants are aware that they fly at their own risk, and that CASA does not set airworthiness standards for experimental aircraft (see Civil Aviation Regulation 1988 (CAR) subregulations 262AP(8) and (9)).

The experimental certificate regulations provide for this level of safety with as much flexibility as possible. The experimental certificate, including conditions specified on or attached to the certificate, is the primary means of maintaining these minimum standards. In the case of experimental amateur built aircraft, the necessary flight restrictions and information about the aircraft, such as weight and balance, are established as part of the flight test program and included on the experimental certificate, or other appropriate method such as placards or an Aircraft Flight Manual (AFM).

The regulations clearly provide that the experimental certificate system is only intended to establish minimum safety standards for other airspace users and people on the ground (see Civil Aviation Safety Regulation 1998 (CASR) subregulation 11.055(1C)). An AFM is not required under the regulations for experimental amateur built aircraft however CASA recommends an AFM be developed (see Advisory Circular (AC) 21.4, section 17).

CASA does not fully understand the rationale behind the ATSB recommendation about mandating, rather than recommending the production of AFM for these experimentally operated aircraft given the non-existence of an AFM for this aircraft had no effect on the incident (as acknowledged in the report on page 10).

CAR 138 states that if a flight manual has been issued then the pilot must comply with it. CASA acknowledges that mandating an AFM for experimental amateur built aircraft may improve safety for subsequent owners and other pilots than the original owner/builder/pilot. However, the experimental certificate system functions as intended by the current regulations (ie. to ensure the safety of other airspace users and people on the ground).

CASA currently recommends an AFM be produced for experimental amateur built aircraft, but changing this to a mandatory requirement would incur a significant cost to the owners/operators. CASA does not believe this incident in isolation provides sufficient justification this change to the legislation given the other safety protections that are already established.

It is noted that the Sports Aircraft Association of Australia (SAAA) Maintenance Procedures Course at Topic 4 (attached) on pages 14–16 recommends how to prepare a Pilots Operating Handbook (POH) for an amateur built using the General Aviation Manufacturer’s Association (GAMA) standards specification 1, this is available from the GAMA website: www.gama.aero/industry-standards.

CASA does not believe there needs to be a regulatory requirement for a POH, it is an SAAA recommended practice to develop one during flight testing and this should form the basis of educational information that could be sent through to all registered owners of these types of aircraft.

ATSB response:

The ATSB acknowledges that CASA and the SAAA recommend that an AFM/POH is produced as part of the flight test program required for experimental amateur‑built aircraft. However, the ATSB remains of the view that, while the absence of a flight manual, or equivalent, did not influence this accident, such a document should be mandatory for the following reasons:

• Without a flight manual the builder, other pilots and especially subsequent owners do not have sufficient reference to operational and performance data necessary to safely operate the aircraft.
  
• Accidents involving amateur‑built aircraft occur at a significantly higher rate than comparable factory‑built aircraft. A requirement to document important operational information would provide a valuable safety enhancement at minimal cost.
  
  

Recommendation

Action organisation: Civil Aviation Safety Authority records
Action number: AO-2014-163-SR-008
Date: 14 April 2016
Action status: Released

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority takes safety action to address the lack of a requirement for builders of amateur‑built experimental aircraft to produce a flight manual, or equivalent, for their aircraft following flight testing.
 
Current issue status: Safety action pending
 



Last update 14 April 2016

 
From the CASA initial response, in particular this bit...

"..CASA does not fully understand the rationale behind the ATSB recommendation about mandating, rather than recommending the production of AFM for these experimentally operated aircraft given the non-existence of an AFM for this aircraft had no effect on the incident (as acknowledged in the report on page 10).."

...I don't get the impression that the regulator will be rushing to proactively address this SR anytime soon, however kudos for the IIC (backed by Commissioner Manning I would assume) for having the balls to challenge CASA on this..

MTF...P2