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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 003/15
Issued To FAA on 23 Apr 15
Amend section 2(b) of Special Federal Aviation Regulation No. 73 -Robinson R-22/R-44 Special Training and Experience Requirements to make it clear that dual instruction in the ?effects of low-G maneuvers? is limited to discussion only, and to reiterate that deliberate in-flight reduced G conditions are prohibited.
Implementation Status: Open
Reply: No response was available from the Administrator at the time this report was published.

Safety Recommendation 007/15
Issued To FAA on 23 Apr 15
Require Robinson Helicopter Company to amend its flight manuals to include the use of "Warning" for those operating conditions and practices that involve a risk of personal injury or loss of life.
Implementation Status: Open
Reply: No response was available from the Administrator at the time this report was published.

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 012/13
Issued To MoT on 11 Oct 13
The post-mortem toxicology results for the pilot in the Carterton hot air balloon showed that he had a positive result for tetrahydrocannabinol (a constituent of cannabis). It was likely that this was due to 2 factors: first, the pilot smoking cannabis shortly before the accident flight; and, second, residual tetrahydrocannabinol, from ingesting cannabis over a longer term, redistributing in the pilot?s blood after his death.

The Commission found that the accident was caused by errors of judgement by the pilot. It also found that it could not exclude the possibility that the pilot's performance had been impaired as a result of ingesting cannabis.

This is not the first time that the Commission has inquired into occurrences where persons operating aircraft, vessels or rail vehicles, or where persons performing functions directly relevant to the operation of these, have tested positive for performance-impairing substances such as illicit drugs and alcohol. The Commission is increasingly seeing more occurrences where the use of performance-impairing substances is a feature.

Unless this safety issue is properly addressed, further occurrences where the use of performance-impairing substances is a contributing factor will occur. Legislative or regulatory reform in this area is necessary.

The Commission, therefore, recommends that the Secretary for Transport complete, as a matter of priority, all necessary work that will support the introduction of appropriate legislation or rules that will:
- prescribe allowable maximum levels for alcohol
- prohibit persons from operating an aircraft, vessel or rail vehicle if they are impaired by drugs
- require operators to implement drug and alcohol detection and deterrence regimes, including random testing
- prescribe post-occurrence testing requirements for drugs and alcohol.

This legislation or these rules should apply:
- across the aviation, maritime and rail transport modes
- to persons operating an aircraft or a marine craft for recreational purposes.
Implementation Status: Open
Reply: Below is the Ministry's response to the final recommendation, noting at this date that I have not seen the final report.

I wish to note that the determination of the need for legislation or rules is a matter for the Minister of Transport, rather than the Secretary for Transport. The Ministry's response to the recommendation is prepared with this in mind.

I also note that the inquiry's findings conclude that the accident was caused by errors of judgement by the pilot, but include the possibility that the pilot may not have been impaired. Before I respond to the recommendation I would like to take this opportunity to comment on relevant work in the transport sector.

Drug and alcohol impairment in the aviation, maritime and rail sectors

Alcohol and drug impairment in the transport sector is an issue that the Ministry takes very seriously. Impairment in driving is one of the largest causes of serious road crashes in New Zealand, contributing to about a third of all road deaths every year.

The impact of drug and alcohol impairment on the aviation, rail and maritime sectors has been an area of focus for the Ministry. Following the review of safety practices within the adventure and outdoors commercial sectors conducted by the previous Department of Labour, in August 2012 the Government agreed to amendments to aviation and maritime rules to improve safety in these sectors. These amendments are now in force and include a requirement for adventure activity operators to include a description of how they will manage the safety risks associated with drug or alcohol impairment in their relevant safety plans (Organisational Management Systems for aviation and Safe Operational Plans for maritime).

To assist maritime operators, Maritime New Zealand has produced safety guidelines for managing risks related to alcohol and other drugs for raft and jet boat operators. The Maritime Transport Amendment Bill 2013, which has had its third reading and will come into force in the next few weeks, will implement the internationally applicable alcohol limit for merchant seafarers established by the 2010 amendments to the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers, 1995 (STCW).

The Civil Aviation Authority has worked closely with adventure aviation operators to support the development and implementation of drug and alcohol management policies that include testing. A detailed advisory circular for adventure aviation operators outlines the expectations for drug and alcohol monitoring and management, and what acceptable policies should include.

Many transport operators, particularly those involved in transporting members of the public, already have drug and alcohol management policies in place in the workplace. Operators regard this as good business practice and meeting the duties of employers and employees set out in the Health and Safety in Employment Act 1992. Some operators that are involved in safety sensitive activities, such as Air New Zealand, Qantas, KiwiRail and Maersk Line have also introduced drug and alcohol policies involving testing regimes.

Statistics from the New Zealand Drug Detection Agency show that the number of workplace drug tests carried out in New Zealand increased 31 percent between 2011 and 2012, with an increase in alcohol tests of 32 percent over the same period. These results suggest that employers in safety sensitive areas, including transport, are taking workplace safety very seriously.

Drug testing on the road

The drug driving regime has been in force for just under four years. The Ministry has a project on its work programme to investigate developments in drug screening and testing technologies (and associated issues) that have occurred over this time. This work is due to take place during 2014.

Post accident testing

Aviation, maritime, and rail legislation does not currently provide for transport agencies, the Commission, or Police (except in relation to the STCW alcohol regime for international or large domestic vessels) to conduct toxicological tests following an accident. Only when a fatality occurs can a Coroner test for the presence and level of drugs and alcohol in the deceased as part of the post mortem investigation.

As a result there is a lack of New Zealand data to quantify the extent of alcohol and drug use in the aviation, maritime, and rail sectors, and its links to accidents and incidents. In comparison, the road sector's drug and random alcohol testing regime provides the necessary data to develop an understanding of the links between drug and alcohol use and accidents and incidents.

Compulsory post accident testing would provide valuable data on alcohol and drug use within the aviation, maritime and rail sectors in New Zealand. Aggregated data from the test results would inform future policy options, including the potential introduction of maximum limits and testing requirements, as noted in the Commission's recommendation.

In order to establish whether there is a case for a compulsory post accident drug and alcohol testing regime, the Ministry has commissioned the New Zealand Institute of Economic Research (NZIER) to investigate and report on:
- criteria to determine which accidents (and incidents) should be covered
- who should be tested
- the agency responsible for undertaking the testing
- the testing procedures to be used (with reference to current national and international standards) in order to safeguard the integrity and accuracy of the testing
- an offences and penalties regime for refusing to be tested or interfering with test results or samples
- the agency responsible for the data collection
- the cost of implementing a compulsory regime
- the legislative changes required to give effect to a compulsory regime.

Once we have the NZIER report, we will brief the Minister of Transport on the options. We expect to be able to do this in December 2013. The Minister may then need to take a paper to Cabinet regarding any further work.

Response to recommendation

This brings me to the Ministry response to your recommendation that the Ministry completes the work necessary to support the introduction of legislation or rules that will:
1. Prescribe allowable maximum levels for alcohol;
2. Prohibit persons from operating an aircraft, vessel or rail vehicle if they are impaired by drugs;
3. Require operators to implement drug and alcohol detection and deterrence regimes, including random testing; and
4. Prescribe post occurrence testing requirements for drugs and alcohol.

The completion of the first three parts of the recommendation is dependent on the fourth, prescribing post occurrence testing requirements for drugs and alcohol. As I have discussed earlier in this letter, the Ministry of Transport is already undertaking work, as a matter of priority, to determine the case for a compulsory post accident testing regime.

We will be able to confirm the next steps for post accident testing once the Minister has considered our advice. Of course we will keep the Commission informed of the progress of the post accident testing proposal, as well as any other work that relates to the Commission?s recommendation.

Finally, like the Commission, the Ministry also believes there should be zero tolerance of operator impairment where members of the public are being transported by sea, rail and air. We feel very deeply for the families of those who lost their lives in this accident.

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.

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