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Tuesday, 31 May 1994
Page: 990

(Question No. 1290)

Senator Ian Macdonald asked the Minister representing the Minister for Transport, upon notice, on 30 March 1994:

  With reference to the answer to question on notice no. 833 (Senate Hansard, 14 March 1994, page 1545):

  (1) With reference to the answer to (1) of the question: (a) in what situation is an `Application for Concession DA 560' used; (b) what was it required for in relation to Piper Aircraft registered number VH-NDU; and (c) please provide a copy of the same issued on the last occasion prior to its crash on 11 June 1993; (d) with reference to the request by Monarch Aviation Group, dated 14 May 1993 and signed by R W MacLean, please advise Mr MacLean's standing or position with the company and his qualifications; (e) was Mr MacLean known to the Minister or the Civil Aviation Authority (CAA); (f) does his letter contain sufficient detail for an application for extension of the permissible unserviceability; (g) what is `our permit' for which Mr MacLean requested an extension of another 30 days; (h) is the information contained in Mr MacLean's letter sufficient information for the department to properly deal with the request; (i) in dealing with Mr MacLean's request, did the CAA make any additional enquiries of physically inspect the aircraft; if so, please provide details.

  (2) With reference to the answer to (2) of the question, whereby the Minister advised that if approval to operate with deactivated `associated equipment' was required, a separate application for permissible unserviceability would have had to have been made: (a) in what form would such an application have to be made; and (b) in the event of such an application being made, what additional information would have been required by the CAA, what inspections or other investigations would the CAA have made and what conditions, if any, would have been imposed.

  (3) With reference to the answer to (3)(a) of the question: (a) please advise what were the consequences of the removal of the standby inverter; (b) how was it that the removal of the standby inverter was not discovered during preflight checks in Sydney and is there some deficiency in the preflight checking which led to this failure to identify; (c) in what way were the preflight checks in Sydney different to the preflight checks in Los Angeles; (d) has any action been taken, or is it intended, against the maintenance crew or maintenance personnel involved in the deficiency, or with any member of the crew involved in the preflight checks in Sydney.

  (4) With reference to the answer to (3)(b) of the question: (a) what, if any, action is being taken against the licensed aircraft maintenance engineer involved in the failure, and what procedures are being adopted to ensure that similar incidences do not occur again; and (b) was there any requirement on the operating pilots to take any action when the `weight on wheels' caution light was illuminated shortly after takeoff, and did the pilots take such action; if not, why was this not done, has any action been taken against the pilots and are any steps being taken to ensure that such action does not occur again.

  (5) With reference to the answer to (4) of the question, please advise whether the Minister is prepared to consider the proposal of some officers of the Directorate of Aviation Safety Regulation to have the safety regulatory function of the CAA separated out from the Authority; if so, will these considerations involve wide consultation with all sections of the aviation industry; if not, why not.

  (6) With reference to the answer to (6) of the question: (a) please advise the criteria for a Category 3 investigation; (b) if there is any reason for an almost 600 per cent increase in Category 3 accidents in the period from November 1990 to November 1993, and of the 300 per cent increase in incidents in the same category in the same period; and (c) given that Category 3 incidents involve occurrences with regional or general aviation operators and aircraft which do not have multiple fatalities but which could easily have resulted in multiple fatalities, is it a fact that the lack of serious fatalities in Category 1 and Category 2 incidents is more a question of good luck than good regulation.

  (7) With reference to the answer to (7) of the question: (a) please clarify the answer with reference to the question asked; (b) is it a fact that the CAA's own restructuring policy required that officers were located at Tamworth Airport for the purposes of surveillance of Eastern Airlines aircraft operating from that airport; and (c) what is the difference between `airworthiness surveillance' and `flying operations surveillance'.

Senator Collins —The Minister for Transport has provided the following answer to the honourable senator's question:

  (1)(a) The form DA 560 is used currently as an application for an exemption against an Airworthiness Directive, Civil Aviation Order (CAO), or as an application for equivalent safety. Equivalent safety refers to, for example, carrying out maintenance of an aircraft in a different manner to that prescribed in the CAOs, but achieving the same level of safety.

  (1)(b) & (c) The only DA 560 concession in respect of aircraft VH-NDU was issued on 12 October 1990. A copy, which explains the details of the concession, has been provided to the honourable senator and additional copies are available from the Tables Office.

  (1)(d) to (i) The information sought by Senator Macdonald on the specific details of investigations in relation to Monarch Airlines Limited clearly forms part of the investigation being conducted by the Bureau of Air Safety Investigation and the work to be carried out during the coronial inquiry.

  It is therefore inappropriate at this stage to provide this material.

  This view was supported by the advice from the Clerk of the Senate to the Chair of Senate Estimates Committee E on 1 November 1993. He noted that there is a problem of inquiries by investigatory agencies being prejudiced by parliamentary debate or inquiry. He also noted that there was the possibility of prejudice to proceedings arising in relation to (coronial) inquests.

  The Bureau of Air Safety Investigation has recently issued a final draft report on the crash of the Monarch Airlines aircraft to designated interested parties directly involved in the accident and/or its immediate aftermath.

  In accordance with the Air Navigation Regulations this is not a public release document. Interested parties have 21 days to make comment to the Bureau on the content and findings of the draft accident report. Those comments may lead to modification of the draft report.

  A copy of the final draft report was made available to the Shadow Minister for Transport, Mr Sharp after Mr Sharp provided a written undertaking that he would treat the draft report on a confidential basis and for his information only. It should be noted that any public disclosure, or passing the document on to anyone else, constitutes a breach of Air Navigation Regulations.

  It is intended that the final report will be publicly released in July. A copy will be provided to Senator Macdonald.

  The coronial inquiry is scheduled to commence in August this year.

  (2)(a) An application for permissible unserviceability is required by the Civil Aviation Authority (CAA) to be made in writing.

  (2)(b) The Authority would ask the operator to supply information as to the effect of removal of the components on the aircraft and its systems.

  The response would then have been verified by reference to any approved data held on the respective aircraft, and/or by checking the components and the effect of removal of these on the aircraft and its systems.

  If no access to the aircraft was available, confirmation of the operator's information, as supplied, would have been sought from a Licensed Engineer rated on the aircraft and its systems.

  What conditions might be imposed depends on the circumstances surrounding the application.

  (3)(a) In the case of this particular Qantas Boeing 747 aircraft, there was no impact on the safety of the aircraft operation, because no other electrical systems failed. If there had been electrical failures, the standby inverter would have been required to provide electrical power essential for the safe operation of the aircraft.

  (3)(b) & (c) In Sydney, the aircraft remained on ground power. Therefore, the pre flight checks were commenced at a point where the missing inverter was not detected. Unlike Sydney, in Los Angeles the aircraft was not connected to ground power and the missing inverter was detected during the pre flight checks. The operator was advised of the deficiency and the flight crew have been provided with retraining.

  (3)(d) The Licensed Aircraft Maintenance Engineer (LAME), who certified for the replacement of the inverter in Australia, was asked by the CAA to show cause why his LAME licence should not be varied or cancelled. He was interviewed by the CAA, and then made a further statement in relation to the incident. His LAME file records the incident. No further action was considered necessary by the CAA.

  (4)(a) The LAME acknowledged that he'd carried out the maintenance without reference to any data. As such he could see no reason to adjust the "weight on wheels" switches. After appraisal of the ramifications of his actions he realised the seriousness of the incident. He has been counselled and his LAME file annotated.

  In relation to the second part of this question concerning procedures being adopted to ensure that similar incidences do not occur again, the operator's maintenance records now refer to the requirement to check the switches, and a signature is now required to confirm attention to the maintenance.

  (4)(b) Yes. There is a "weight on wheels" malfunction procedure, and the correct procedure was followed by the pilots on this occasion.

  (5) In deciding to locate the safety regulatory function within the CAA, the Government took the view that the task of regulating safety must be regarded as an integrated system in which all elements are coordinated to achieve maximum reliability and effectiveness.

  As a result of the findings of the Terrell Report, the Directorate of Aviation Safety Regulation is presently implementing a range of initiatives to improve the effectiveness of the CAA's safety regulatory role. These initiatives received the support of industry and unions at a round table meeting held on 1 September 1993. The effectiveness of these changes should be given the opportunity to be tested before further changes are contemplated.

  (6)(a) The classification of an occurrence into a particular category is primarily an assessment of the resources the Bureau of Air Safety Investigation (BASI) is prepared to put into the investigation of the specific occurrence. The assessment is based primarily, but not exclusively on the degree of threat posed by the occurrence to the safety of fare paying passengers and the general public. An occurrence classified as a category 1 investigation can generally be considered to have posed a significant threat to safety. A category 1 investigation will involve a full international standard investigation. An occurrence classified as a category 5 investigation can generally be considered to have posed a minimum threat to safety. A category 5 investigation will involve the minimum degree of effort to register the fact that the specific occurrence has occurred.

  Category 3 is the mid point between Category 1 and Category 5 and as such, a category 3 classification serves two purpose. Firstly it is used as a holding classification whereby preliminary investigation may result in the upgrading or downgrading of the classification. Secondly a classification of category 3 is a classification in its own right under which many investigations are finalised.

  In general, category 1 and 2 classification are subject to full investigations while category 4 and 5 occurrences are not subject to any detailed investigation. Category 3 occurrences are generally only subject to partial investigation.

  A matrix of investigation classifications is used to determine which type of occurrences get classified into which category. A copy of the matrix is at Table 1.

  (6)(b) The increase in the number of category 3 occurrences is attributable to a subtle change in the manner of occurrence classification described in the answer to the honourable senator's previous question ((a) question 1290). The increase does not represent any change in the overall number of occurrences or the broad status of aviation safety.

  In the answer to the previous question, the classification of "category 3" was described as having two roles. That is, a holding category for subsequent upgrading or downgrading, and also as a response category in its own right. This use of the categories was implemented in the latter part of 1992. Prior to 1992, category 2 was used as the holding category. By virtue of the fact that most of the occurrences assigned to a holding category are finalised within that category the subtle change referred to above leads to a situation where occurrences that would have been classified as category 2 occurrences in 1991 were in 1993 categorised as category 3 occurrences. From the figures provided to the honourable senator in response to Question 833 (see Table 2) it can be seen that between 1991 and 1993 the number of category 2 occurrences decreased as the number of category 3 occurrences increased. Summation of the category 2 and 3 occurrences indicates that for 1991, 1992 and 1993, there was no significant change in the combined number of occurrences.

  Not bringing the change in classification treatment to the honourable senator's notice at the time of providing him with the information in answer to Question 833 was an oversight by BASI.

  (6)(c) The Bureau is unable to provide any meaningful answer to this question.

  (7)(a) To further clarify the previous response, the CAA restructuring policy was predicated upon having District Offices close to where the surveillance activity is required. There are two major disciplines requiring surveillance in an airline—Airworthiness (engineering) and Flight Operations (flight deck, flight attendants and the operator's organisation and facilities).

  Airworthiness/engineering is a ground-based activity and can, therefore, be surveilled by the nearest CAA District Office. Eastern Airlines has their major engineering and maintenance activities at Tamworth, and thus it is more appropriate to have these activities oversighted by the CAA's Airworthiness staff located at Tamworth.

  In respect of flight operations activities, these are centred at Kingsford Smith Airport, and are, therefore, oversighted by the CAA's Flight Operations staff at Sydney Airport.

  (7)(b) No, it is not a fact. The CAA's restructuring policy was based upon all activities in the Tamworth area, which number some 60 aviation companies and some 500 registered aircraft. Eastern Airlines is only one such organisation.

  (7)(c) Flight Operations surveillance is aimed at ensuring that Flight Crew standards are in accordance with all Civil Aviation Regulations and Civil Aviation Orders applying to Flight Operations. This includes not only the oversight of pilots/flight engineers, but also the flight attendants' activities, together with the operator's facilities and organisation.

  Airworthiness surveillance refers to the oversight of the aircraft systems, engineering and ground support functions in accordance with all Civil Aviation Regulations and Civil Aviation Orders applying to Airworthiness.

Table 2

Accidents Incidents


Category 1 0 0

Category 2 24 22

Category 3 5 13

Category 4 199


Category 1 1 0

Category 2 19 10

Category 3 15 14

Category 4 218

Up to and including 30 November 1993

Category 1 0 0

Category 2 7 1

Category 3 29 38

Category 4 180

Date: 24 January 1994