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Aviation Safety Recommendations

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.

Urgent safety recommendations

Urgent safety recommendations released publicly in advance of a final report are available here until release of a final report at which time they are incorporated into the database.

 

 

Keywords: Recipient: Mode: Status:

Safety Recommendation 024/14
Issued To RNZAF on 16 Dec 14
There was a low likelihood of the weather conditions at Pegasus Field aerodrome deteriorating below minima after an aeroplane passed the point of safe return. However, the potential consequences of that happening were elevated for the Boeing 757 aircraft because of the lack of alternative approach paths and aerodromes suitable for this aircraft type.

There are five factors that were not considered, or only partly considered, but should have been when assessing the risk of using the Boeing 757 aircraft for Antarctica operations:

- the weather criteria for an aeroplane passing the point of safe return should consider the presence of low cloud and fog below the main cloud base as a limiting factor
- there is an increased likelihood of weather conditions deteriorating below minima early in the summer season
- the accuracy of instrument approaches should be treated with caution prior to calibration flights being conducted early in the summer season
- the RNZAF aircraft is capable of completing one type of instrument approach only in Antarctica - a GPS approach
- the lack of suitable diversion airfields and the consequences of a whiteout landing.

The Commission recommends that the Chief of Air Force review the risk assessment for using the Boeing 757 aircraft for Antarctic flight operations, taking into account these matters and any other matters not considered during the initial risk assessment.
Implementation Status: Open
Reply: The RNZAF accepts and will implement the Commission's final recommendations from Inquiry AO-2013-009 as follows.

- Effective 11 November 2014 the weather criteria for Antarctic operations for all RNZF aircraft were amended by temporary order to take in to account visible moisture below weather minima. This temporary order will be enshrined in General Orders for New Zealand Defence Force Military Aviation Operations on the next amendment cycle (02 March 2015).
- The Risk Management Plan (RMP) for Antarctic operations will be updated to include detailed recognition of the other four factors no later than 09
February 2015, which is before the next scheduled flight to Antarctica. I will write to you again with a copy of the updated RMP in due course.
- The RNZAF aviation operational risk management system is currently befing refined. In due course standard mission risk profiles capturing risks inherent to that mission will be published. These profiles will support the development of activity based RMPs. Once the risk management system is finalised, the risk factors you recommend will be captured in the Antarctic operations mission risk profile for each aircraft type. I do not have a completion date for this activity, but I will inform you when it is resolved.

Safety Recommendation 025/14
Issued To CAA on 10 Dec 14
Civil Aviation Rule 91.525 requires a life jacket to be available for each person on board a single-engine aircraft being flown beyond the gliding distance from shore. The life jacket is to be stowed in a readily accessible position. The Commission has previously recommended to the Director of Civil Aviation that on all flights, if at any point a ditching is likely to have a better outcome than a forced landing on unfavourable terrain, life jackets should be carried. Helicopters descend at a much higher rate in autorotation than an aeroplane does when gliding. Therefore, even if life jackets are carried, helicopter passengers are likely to be faced with minimal time to find and fit their life jackets if faced with a ditching.

On 10 December 2014 the Commission recommended to the Director of Civil Aviation that he promote the use of quick-donning life jackets for all occupants of single-engine aircraft flying over water.
Implementation Status: Open
Reply: The CAA advises there is specific reference to quick donning life jackets and their use in Vector publication, September/October 2003. The particular article is titled "The most useless things-keep emergency equipment accessible." To satisfy the intent of the recommendation, the Director is prepared to refresh the article along with the referenced Commission's accident inquiry number in a future Vector publication. An implementation date cannot be provided at this time.

Safety Recommendation 026/14
Issued To CAA on 10 Dec 14
An engine that had been involved in a sudden stoppage incident overseas was put through a conformity inspection and released to service in New Zealand without the required inspections having been completed. The regulator's guidelines for inspecting used parts of unknown origin was not well defined, and the company's approved procedures developed from these guidelines were not adequate in this case. A thorough research of the engine's history, seeking further details of the accident and clarification from the vendor, would have likely uncovered the sudden stoppage event, and the required inspections would have been carried out.

On 10 December 2014 the Commission recommended to the Director of Civil Aviation that he provide specific guidance to Civil Aviation Rule Part 145 certified companies, for the performance of conformity inspections of parts and components with unknown service histories or incomplete airworthiness documentation, or that have been stored improperly.
Implementation Status: Open
Reply: The CAA advises that the Director will not accept the recommendation as worded. However, the Director is prepared to review the general guidance material contained in AC00-1. This process is envisaged to take some time and therefore an implementation date cannot be provided at this time.

Safety Recommendation 015/14
Issued To CAA on 13 Jun 14
Note that the pilot check process can interfere with safe flight operations if not properly managed, and raise this potential safety issue with industry in the most appropriate manner.
Implementation Status: Open
Reply: ON 23 June 2014, the CAA advised that the recommendation was accepted, and would take appropriate action to implement it.

Safety Recommendation 006/14
Issued To CAA on 27 Feb 14
On 26 February 2014the Commission recommended that the Director of Civil Aviation continue to support the international work underway to improve the crash survivability of ELTs and to include GPS information in the data transmitted by such devices.
Implementation Status: Open
Reply: In the same response letter, the Director commented that the CAA already supports in principle the ICAO and manufacturers? efforts to improve the crash survivability of ELTs and accuracy of position reporting. The work is ongoing and in this context the CAA requests that the recommendation be closed.

Safety Recommendation 005/14
Issued To CAA on 27 Feb 14
On 26 February 2014the Commission recommended that the Director of Civil Aviation encourage the use of flight tracking devices, especially for use in aircraft operating in remote areas around New Zealand.
Implementation Status: Open
Reply: In our draft recommendation response 31 January 2014, the Director commented that the CAA provide for the fitment of Flight Tracking Devices (FTDs) by operators and this can be achieved in accordance with the relevant provisions of AC 43-14. The CAA will continue to encourage operators to fit FTDs in this manner. The CAA considers the action sufficient to satisfy the closure of the Commission's recommendation.

Safety Recommendation 018/13
Issued To CAA on 25 Jul 13
The findings from 2 separate inquiries show that general aviation maintenance practices in New Zealand are not always in accordance with Civil Aviation Rules or accepted industry practice. The findings show that non-compliance occurs in certificated maintenance organisations and by individual maintenance engineers exercising their individual licence privileges. This is an indication that the safety issue is not specific to just one sector of aviation maintenance. If left unchecked this situation is likely to have significant implications for aviation safety.

On 25 July 2013 the Commission recommended to the Director of Civil Aviation that he take action, in concert with the aviation industry, to improve the level of compliance with Civil Aviation Rules and conformance with industry best practice throughout the general aviation maintenance sector.
Implementation Status: Open
Reply: The CAA will not implement the recommendation as worded. However, the CAA will adopt the safety surveillance practices as described in our final draft report response letter 14 June 2013.

The relevant portion of the CAA letter of 14 June 2013 stated:

The CAA considers a recommendation that would address the relationship issues in terms of communications and record keeping between CAA Rule Part 43 maintenance providers and Part 135 AOC holders would be more effective. To this end, the CAA intends to profile Part 43 maintenance providers in order to identify poor performance or other risk issues.

Safety Recommendation 019/13
Issued To CAA on 25 Jul 13
The requirement for duplicate inspections after maintenance is performed on critical aircraft systems reduces the risk of a maintenance error remaining undetected and causing an accident. However, there are only a few specified control systems that are deemed critical and that require duplicate inspections. There are other important systems ? for example, the landing gear and brakes ? that are not subjected to the same level of scrutiny. This is a safety issue, particularly for aircraft used in air transport operations where the consequences of an accident could be greater.

The findings from 2 separate inquiries show that because duplicate inspections are currently confined to critical control systems only, the risk of undetected maintenance errors in important, but non-critical, aircraft systems is not sufficiently mitigated. This accident was a prime example of how maintenance errors that are made in an important system and that are not detected then or during subsequent maintenance can become causal factors in an accident. The risks were higher in this case because the relevant maintenance events had been performed by independent engineers on parts of an aeroplane sub-system that were not subject to duplicate inspections.

On 25 July 2013 the Commission recommended to the Director of Civil Aviation that he widen the range of aircraft systems that require duplicate checks after specified maintenance, at least for those aircraft used in air transport operations, in order to reduce the likelihood of recurring defects and incidents.
Implementation Status: Open
Reply: The CAA considers that widening the scope of aircraft systems requiring duplicate inspections [is] not sufficiently supported by the Commission's investigation. In this regard, the CAA prefers to remain in keeping with current world regulatory practice and therefore will not implement the recommendation.

Safety Recommendation 037/12
Issued To CAA on 14 Dec 12
On 14 December 2012 the Commission recommended to the Director of Civil Aviation that he urge operators to adopt QRH checklist formats that reduce the possibility of misreading or omitting a procedural step
Implementation Status: Open
Reply: On 16 Januray 2013 the Director of Civil Aviation confirmed that the recommendations would be implemented by the Aircraft Cetification Group and the Air Transport and Airworthiness Group (036/12 and 037/12, respectively). Implementation dates had yet to be finalised.

Safety Recommendation 032/12
Issued To CAA on 14 Dec 12
review the CAA?s data systems and processes, particularly regarding flying training data, including the information collected and the way this information is collected, categorised, recorded in the CAA?s occurrence database and analysed to ensure that meaningful and complete data on flying training in New Zealand is available
Implementation Status: Open
Reply:

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