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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 019/16
Issued To CAA on 24 Aug 16
On 24 August 2016 the Commission recommended that the Director of Civil Aviation provide a clear statement to relevant sectors of the aviation industry on whether stock clearing is a permitted activity. If the Director decides it is a permitted activity under a particular Civil Aviation Rule part, he should provide clear guidance on the conduct of the activity.
Implementation Status: Open
Reply: In our response to the Commission's draft report, 11 August 2016, we explained there is no CAA rule provision for stock clearing; therefore, the Director cannot provide clear guidance on the conduct of the activity in the context of existing CA Rules.

However, the CAA recognises that an operation to a remote airstrip presents a risk to air transport in that the landing area may have visible hazards, including the presence of stock, which could affect the safety of a landing. Whilst there are no existing provisions in the rules to descend below 500 feet (aside for take-off/landing or a baulked landing/discontinued approach), the Director will agree to pursue a means to enable air transport operators to overfly a remote airstrip below 500 feet for the purposes of ensuring the landing area is visibly free from hazards.

The CAA remains focused on safety management based on risk mitigation. The CAA believes the alternative safety action will address the safety issue raised by the Commission and we will advise when the work has been completed.

Safety Recommendation 014/16
Issued To MoT on 27 Jul 16
On 27 July 2016 the Commission recommended to the Secretary for Transport that he promote, through the appropriate ICAO forum, the need for cockpit video recorders and/or other forms of data capture in the cockpits of certain classes of helicopter to address this safety issue.
Implementation Status: Open
Reply: The Ministry considers that such a recommendation is premature as the costs and benefits of such a recommendation have not been canvassed. The Ministry appreciates that the Commission may have been minded to make such a recommendation because of the lack of available data. The Ministry suggests that prior to making a recommendation, some more work should be undertaken to determine the benefits and costs of flight data and video recording in cockpits.

Safety Recommendation 015/16
Issued To CAA on 27 Jul 16
On 27 July 2016 the Commission gave notice to the Director of Civil Aviation that a recommendation has been made to the Secretary for Transport that he promote, through the appropriate ICAO forum, the need for cockpit video recorders and/or other forms of data capture in the cockpits of certain classes of helicopter to address this safety issue.
Implementation Status: Open
Reply: The Director has considered the recommendation and in view of the Secretary for Transport's response to the Commission on the matter of cockpit video recorders and/or other forms of data capture, the Director is prepared to accept the recommendation but with a caveat that reflects the Secretary's response, i.e, That the Director of Civil Aviation conduct a safety and cost benefit exercise of installing flight data and/or cockpit video in certain classes of helicopters.

In that regard the Director will initiate an issue assessment paper on recording devices for certain classes of helicopters. Given the timeframe of such a study is likely to be lengthy; the Director cannot provide a completion date at this stage.

Safety Recommendation 002/16
Issued To CAA on 25 Feb 16
The Commission recommended to the Director of Civil Aviation that he include the knowledge and training requirements of Special Federal Aviation Regulation No. 73, or an equivalent requirement, as a prerequisite for the issue of a Robinson R66 type rating.
Implementation Status: Open
Reply: On the basis that the FAA has twice rejected the inclusion of the Robinson R66 model in SFAR 73, the Director will not implement the recommendation, but will continue to monitor advice from Robinson Helicopters and the FAA with respect to the operation of R66 helicopters.

Safety Recommendation 004/16
Issued To FAA on 25 Feb 16
The Commission recommended to the Administrator, FAA that he
extend the knowledge and training requirements of Special Federal Aviation Regulation No. 73 to pilots of the Robinson R66 helicopter.
Implementation Status: Open
Reply:

Safety Recommendation 011/16
Issued To CAA on 25 Feb 16
The Commission recommended to the Director of Civil Aviation that he promptly publicise the recent changes to the Robinson R66 (and R44) Pilot's Operating Handbooks that caution against flight in high winds and turbulence, and which advise pilots to reduce power and speed if turbulence is expected or encountered.
Implementation Status: Open
Reply: The Director does not consider it necessary to promptly publicise the recent changes to the Robinson R66 (and R44) Pilot's Operating Handbooks that caution against flight in high winds and turbulence, and which advises pilots to reduce power and speed if turbulence is expected or encountered.

The amended safety notice by Robinson is freely available on their website. In addition, operators of Robinson helicopters are required to regularly amend their Pilot's Operating Handbooks and this activity includes incorporating changes to information such as safety notices.

Safety Recommendation 005/16
Issued To FAA on 25 Feb 16
Reinstate research into the dynamic behaviour of two-bladed, teetering, underslung rotor systems, taking full advantage of available technology, with the aim of achieving the original goal of NTSB recommendation A-96-12.
Implementation Status: Open
Reply: The FAA received this safety recommendation on May 4, 2016. We are evaluating the recommendation and will propose an action plan, if appropriate. We will coordinate with Robinson Helicopters during this process and provide an update by August 1, 2016.

Safety Recommendation 020/15
Issued To CAA on 25 Feb 16
On 25 February 2016 the Commission recommended that the Director of Civil Aviation, in conjunction with the chief executive of Airways, check that aerodrome runway lighting systems at all certificated aerodromes comply with Part 139.
Implementation Status: Open
Reply: The recommendation to check aerodrome lighting systems at certified aerodromes for compliance against Rule Part 139 will be implemented. However, the audit schedule to satisfy the work specified in the recommendation will take some time. Therefore an implementation date cannot be provided at this stage.

Safety Recommendation 006/16
Issued To CAA on 25 Feb 16
On 25 February 2016 the Commission recommended to the Director of Civil Aviation that he review all modifications to the cockpit lighting on BK117 helicopters for night vision use, to ensure they do not unduly increase the risk of a similar incident occurring. If they do introduce an unacceptable level of risk, changes to the installation, such as a low-fuel-level aural warning or brighter LED caution lights, should be required.
Implementation Status: Open
Reply: On 14 December 2015, the CAA responded to the draft final report and made observations and specific comment to the proposed recommendation.

Based on those observations and comments, the Director considered that the weight of evidence indicated pilot mismanagement of the engine start process not the annunciator lighting. Therefore, the subsequent safety lessons are more aligned to the pilot and the operator's adherence to the recommended practices contained within the aircraft flight manual and the observance of rules. Therefore, the Director will not implement the recommendation.

Safety Recommendation 007/16
Issued To Garden City Helicopters on 25 Feb 16
On 25 February 2016 the Commission recommended to the Chief Executive Officer of Garden City Helicopters that he amend company policies, procedures and practices relating to the management of pilot competency. These amendments should include annual recurrent training and regular proficiency checks for all pilots on all aircraft types flown. For pilots who lack recent experience on an aircraft type, the amendments should introduce increased supervision, additional training and the use of written checklists.
Implementation Status: Open
Reply: In response to your letter dated the 25th February 2016 Garden City Helicopters would like to confirm that the following changes have been incorporated into the company;

- GCH have implemented a new standard operating procedure requiring all pilots conducting EMS work to complete six monthly competency checks.- Effective immediately following incident
- Additional pilots have been added to the EMS roster. ?December 2014
- The company SOP regarding pilot?s competency has been revised. A matrix has now been incorporated to effectively track pilot currency and competency on all aircraft types they are rated to fly. This also records the aircraft type that the preceding check was completed in, to ensure where possible competency checks are rotated through the aircraft types a pilot is rated to fly. ? August 2015
- GCH replaced its training manager with an experience Airline Flight Examiner ? October 2015
- GCH carried out a comprehensive review of its CAA 141 Check and Training Procedures Manual. The manual has been rewritten and submitted to CAA for approval. ? March 2016

Garden City Helicopters would like to thank TAIC for the considerable time and resources that have been allocated to compiling the report. GCH have fully implemented all recommendations outlined in the TAIC letter dated 25th of February 2016.

Since the incident GCH have devoted a considerable amount of time and resources into reviewing and where necessary modifying our systems and procedures to ensure our personnel and clients will not be exposed to the circumstances that led to this incident again.

In addition to the recommendations found in the report, GCH have completely rewritten the company 141 Check and Training Procedures Manual. This was carried out in consultation with industry professionals to ensure compliance with CAA regulations and industry best practice.

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