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LICENCE TO LEARN
THE OPPORTUNITY TO LEAD N
othing is more important to our overall success than our members going home safe each and every day. Safety is a core value of our organisation and this is a commitment that I take personally and I require throughout every department in the organisation. We all have a role to play in aviation safety. By sharing this value across the organisation and cultivating a culture of enhanced safety, it does not become one person’s responsibility; rather, it is a shared responsibility across all levels of our organisation and broader aviation community. The most important thing we can do is to remain consistent with our safety message. RAAus is always looking at ways to better communicate safety messages; interrogate and interpret Occurrence Management System (OMS) data; and develop training resources to assist pilots and maintainers of all experience levels. RAAus continues to engage with our external stakeholders and industry to collaborate on areas of mutual interest, and ensure we remain proactive and prognostic in our efforts to enhance safe operations and overall aviation safety in the sport aviation sector. In order to protect and grow our privileges we must collectively put safety first, with everything we do. We must continue to work together to foster our Just Culture, whilst acknowledging the responsibilities we take on as aviation professionals. Our safety record has continued to improve year on year. This state has not arisen by chance – we have collectively realised and seized the opportunity to get better. Actually, ‘getting better’ is what society is demanding of all of us in industry and we must continue to work towards a greater state of enhanced safety. This additional resource is a testament to the on-going commitments aforementioned, and it re-affirms the passion and commitment to lead the conversation in aviation safety for the collective betterment of our membership and industry at large. It is expected that as we develop the themes, articles and ideas in this resource, you will find a joy in lifelong learning no matter your age or stage in aviation.
Michael Linke CEO Recreational Avitation Australia
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LICENCE TO LEARN PHILOSOPHY F
undamentally this organisation is about our people and our aviation community. It is a story about the passion and the commitment of thousands of members from all walks of life who cherish the joy of aviation, whether it be tinkering on airplanes on the ground or enjoying the freedom of flight in the air. This is an organisation born out of a movement and desire to progress and expand its limits. This is why the organisation started and this is why we continue to grow. The people within the organisation are committed to ensuring the privileges of flight is maintained for people from all walks of life, well into the future. To do so, we must ensure that our core values maintain centreline with everything we do – and Safety First is the aim point for which we strive. Our members spoke. And we listened. This resource has been developed as an ongoing mechanism to engage with members and the broader aviation community on key areas of relevance in the day-to-day operations of aviation activities. It is also a platform for RAAus to share deidentified safety-related data, trends, and statistics derived from our Occurrence Management System. The topics covered in this booklet have been specifically chosen to reflect new and existing themes that are relevant to all aviation participants whether they are members of our community or the aviation community at large. It will be a platform for insight and examination, and above all, a communication tool to facilitate the enhancement of safety education, no matter the age, stage or experience of each individual’s aviation journey. We all know the adage, “the day you stop learning is the day you stop living”, and this is no truer than in our industry. RAAus is committed to providing a platform to facilitate lifelong learning, and to ensure all our members are equipped with the skills and knowledge to engage in the privileges of flight. It is my pleasure to provide you with the first edition of License To Learn, and I trust that the information in the following pages and in the coming editions enriches your appetite for lifelong learning in aviation.
Lea Vesic Innovation & Improvement Executive National Safety Manager Recreational Aviation Australia
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CONTENTS The opportunity to lead............................... 1 Licence To Learn philosophy....................... 2 Aviation safety in the age of data and digital..................................................... 4 Understanding recreational aviation safety performance and key risk areas................. 6 Logbooks and aeroplanes........................... 7 Managing circuit separation at non-controlled aerodromes........................ 8 10 tips for a successful flight.................... 10 Don’t die for a deadline............................. 12 Aviation Safety Management System..... 15 Hims... “What the...”.................................. 18
THANK YOU TO OUR SPONSORS
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AVIATION SAFETY IN THE AGE OF DATA AND DIGITAL The use of data and the ability to turn data into information and insights is more crucial than ever in the aviation industry. RAAus captures safety data through the Occurrence Management System (OMS). The Occurrence Management System (OMS) is an online reporting system that allows members to submit reports relating to accidents, incidents, defects, hazards and complaints, and is found on the RAAus website in various locations as orange buttons “Report an Occurrence” or using the following link http://oms.raa.asn.au. RAAus members are obligated to report accidents in accordance with the following Regulations and Manuals: •
Transport Safety Act (TSI) 2003 Transport Safety Investigation (TSI) Regulations 2003
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Operations Manual Issue 7 Section 4.08 The OMS allows members to seamlessly abide by their obligations as reports are provided to the ATSB by RAAus.
So, what does RAAus do with the data? And how does it relate to the membership? •
We can measure overall safety culture reporting performance
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We can track and trend types of incidents and accidents, particularly by location or region
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We can monitor Flight Training School (FTS) activity and various training hot spots and areas of expansion
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We can provide accurate reports on hours and types of operations assist government and industry in collaborative decision making, stakeholder engagement and policy reform.
All of these insights and more provide us with a birds-eye view of what’s happening on the ground and in the air. This is particularly useful when developing personalised training packages for our FTSs, as well as provide themes for discussion in safety communiques, such as this booklet.
The data collected by the OMS operates under the principles of the Open and Fair Reporting Philosophy. That is to say, we believe that educating our members provides better outcomes than punishing them. Therefore, it is vital that we, at RAAus, are able to collect meaningful data from our pilots and maintainers.
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Over the coming editions of Licence To Learn, we will use this platform to display quarterly trends and statistics and provide comment as to how collectively, we can work together to enhance safe operations across the sector and continually reduce the types of incidents and accidents reported. The OMS is coming up to its 5th birthday, and with that comes the ability to interrogate an ever growing statistically relevant data set. RAAus will continue to develop the OMS to reflect best practice methodologies in safety reporting and analysis of data, and will continue to actively encourage all members of the RAAus and aviation community to report accidents, incidents, hazards and defects so that collectively we can provide meaningful tools and resources and enhance safety for the betterment of current and future generations of aviators.
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CURRENT TOP 10 REPORTING TYPES 1. Loss of Control issues 2. Abnormal engine indications 3. Engine failure or malfunction 4. Airspace infringement 5. Loss of separation/separation assurance 6. Hard landing 7. Runway incursion 8. Comms 9. Bird strike/Animal 10. Landing Gear/ Indications
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Understanding recreational aviation safety performance and key risk areas A
irservices Australia is committed to fostering a strong alliance with Recreational Aviation Australia (RAAus) in support of the ongoing growth of recreational aviation in Australia. Safety and Assurance Executive General Manager Claire Marrison says: “We are working actively with RAAus, along with other aviation government agencies, to gain a shared understanding of recreational aviation safety performance and key risk areas.” This is critically dependent on RAAus members’ open and proactive approach to safety reporting. “Safety occurrence reporting from RAAus members and air traffic controllers’ help address important questions such as why safety occurrences happened from a whole-aviation-system perspective, and where to focus our effort in improving the system,” adds Claire. Recent safety occurrence data has shown that Sunshine Coast, Moorabbin and Bankstown are the top occurrence locations involving RAAus-registered aircraft. The recurring themes include: •
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infringements into controlled airspace at Sunshine Coast, reflective of the complexity of integrating recreation aviation with regular passenger transport; pilot errors at Bankstown in the busy traffic environment around Sydney, with the most common issues being crossing the runway when on final and failing to follow the preceding aircraft; pilot errors and runway incursions at Moorabbin, with failing to follow the preceding aircraft, calling on the wrong frequency, tracking incorrectly in the circuit and jointing incorrect runway on final being the common issues. This is indicative of the complex airport environment and high level of flight training activities.
Many of these pilot errors highlight potential opportunities to improve pilot/controller communication. Claire adds: “We would like to encourage RAAus members to speak up and ask controllers to provide clarifications or reiterate clearances or instructions. The communication loop is fundamental to foster a shared mental model and reduce the potential for adverse safety outcomes.” “We are also working with RAAus to further assess the systemic causal factors, developing practical channels to increase RAAus members’ familiarisation with Air Traffic Control (ATC) operating practices and safety issues.”
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Pilot Information Nights Are you curious about what happens on the other end of the radio? Do you have any questions about air traffic control but never had the chance to ask them? Then book in to attend one of Airservices Australia’s Pilot Information Nights to learn about the air traffic system and what impact pilot activities, decisions and operations can have. All recreational, general aviation and professional pilots are welcome. Pilot Information Nights are available at their Brisbane, Melbourne and Sydney facilities. Please be aware that our sessions do not include visits to the tower at any of these locations. For more information visit airservicesaustralia. com Additionally, Airservices has produced a Communication with air traffic control fact sheet setting out some hints and tips for safe and effective communication with ATC.
LOGBOOKS AND AEROPLANES T
oo often when aircraft maintenance logbooks are inspected we page through the years and find nothing has been rectified on this machine. Everybody should own one of these! They never have any issues, must be exceptionally well built. This is just not the case, aeroplanes take maintenance. Things break and they are repaired. Put it in the logbook. 25, 50 and 100 hourly inspections are carried out and recorded quite well but they rarely result in the identification and/or rectification recording of issues. It is much better to have a logbook filled with entries than a logbook empty especially when it comes resale time. Prospective buyers want to see what problems were identified and fixed. At the end of the day aircraft inspections are carried out to find problems, not to give it a big tick and say no maintenance required. Owners that care for their logbooks are owners that most likely have cared for their aircraft. Section 12.5 of the RAAus Technical Manual relates to aircraft logbooks. Owners can find what information a logbook must contain and displays many examples of logbook entries. A survey was sent to RAAus Level 2 maintenance authority holders asking their opinions on the condition of owner maintained RAAus registered aircraft. The response regarding the overall
JARED SMITH
condition of the fleet on a five star scale from very poor to very good revealed the fleet to be in a satisfactory to good condition. However, the areas that required the most improvement were logbook compliance especially compliance relating to Airworthiness Notices (AN’s) and Service Bulletins (SB’s). It is very important to sit down and do the research on your aircraft and find what bulletins are applicable. Unlike the general annual inspection where you are checking that yes – that is still there, this is still connected – good, an AN or SB has been released because other aircraft have been found to be defective. It has been identified that this part has cracked, this item has broken, this has come loose, this has worn, LOOK at it. This is IMPORTANT. Fortunately for us it is rather easy to research bulletins on the web via manufacturer and regulator websites. The information supplied for the most part is well laid out and easy to follow and understand. Go on, spend 30-60 minutes every Sunday afternoon researching and updating your logbook. Flying is all about confidence. Confidence in yourself and your aircraft. Ensuring your logbook is compliant will go a long way to giving you the confidence that your aircraft is up to task.
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MANAGING CIRCUIT SEPARATION AT NON-CONTROLLED AERODROMES D
iscussions constantly occur with pilots about non controlled aerodrome procedures. Given that this is where the majority of recreational flight operations take place it’s a subject worthy of discussion, however we should make sure these discussions include references rather than opinions in the interests of safety, situational awareness and good airmanship. The definition of a non-controlled aerodrome is where an Air Traffic Control service (ATC) is not operating. Specific examples include: • • •
An aerodrome that is always in class G airspace An aerodrome with a control tower where an ATC is not currently provided An aerodrome that normally would have ATC services that are temporarily suspended or unavailable.
Modern navigation and arrival aids like GBAS and ILS assist in efficient arrivals for the big end of town, but a standard rectangular circuit provides a tried and proven pattern for general, recreational and sport aviation in uncontrolled operations and there are good reasons for this. The primary reason for the standard circuit, like all good things is based in common sense, is to avoid hitting someone in the air! Sounds basic but as all aircraft have to land and take-off from a common runway, effective separation and situational awareness are the first challenges when approaching or operating in the circuit area. The source reference, Civil Aviation Regulation CAR 163 states, The pilot in command of an aircraft that is being operated in the vicinity of a non-controlled aerodrome must: (a) M aintain a look-out for other aerodrome traffic to avoid collision; and (b) E nsure that the aircraft does not cause a danger to other aircraft in the vicinity of the aerodrome; and (c) Conform with, or avoid, the circuit pattern; and (dunless sub regulation (3) or (4) applies — when
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approaching the aerodrome to land, join the circuit pattern for the direction in which landing is to be undertaken on the upwind, crosswind or downwind leg; Note: a circuit pattern has upwind, cross-wind, down-wind, base and final legs. So let’s break this down. The departure process is fairly straight forward. We simply need to climb, maintaining runway centreline until 500 ft. AGL. Then we have only 2 real options, turn in the published circuit direction or continue straight ahead. If we want to head in a different direction we can’t turn contrary to circuit direction on the active side until we are clear of the area, defined as 3nm or above 1500 ft. AGL for non-controlled aerodromes. Circuits and arrivals can be a little more complex and this is where most reports and complaints occur. The basic issue is that pilots have choices and therefore decision making needs to be applied. Choosing to join the active or “live” side of the circuit by its very nature increases the risk of collision dramatically. Your eyes and radio can only provide so much information in such a potentially crowded window and time is your only real friend here. Time can best be gained by flying overhead the aerodrome at a minimum of 500’ above the known circuit height where you can gather assess and decide not only the traffic but wind conditions, runway surface, obstacles and other threats. Remember joining the circuit from the inactive “dead” side at the middle to upwind end of the runway is the safest option in the majority of cases. This provides maximum vertical separation from aircraft taking off. It doesn’t give you the right to overtake another aircraft established in the circuit itself and joining the circuit still has to completed so as not to endanger other aircraft as CAR 163 requires.
FLIGHT OPERATIONS additional challenges in busy circuits. Pilots should be comfortable with changing aircraft speed configuration whilst maintain accurate heading and height in the circuit. Finally, let’s not forget airmanship. There are opportunities provided in circuits where we are ideally placed to put our best foot forward. What a joy it can be to operate in a circuit with other pilots who have good situational awareness and radio skills. What a challenge when pilots either don’t communicate effectively or don’t make an effort to work well with others. These skills ideally come together in perfect harmony in the noncontrolled environment where risks are high. Building the picture through Situational Awareness, assessing options, deciding the best way to navigate a circuit, effectively listening and communicating are key ingredients to make sure the circuit is a joy to be involved in, provide a safe outcome in the non-controlled circuit environment and be perceived as a professional pilot, a goal we should all strive for. So now having looked at the basics for arrivals and departures let’s see how we can all play nicely together in the circuit itself. Size does matter! Even loosely defined a circuit area doesn’t exceed 3 nm in any direction from the reference point. However we have all seen aircraft practicing A380 approaches at our local airfield while the rest of us check if we have cross country endorsements to follow them around. Paul Bertorelli from AvWeb illustrates this best in his educational satire at https://youtu.be/f6q2VKsvQEQ. Even taking into account aircraft performance spacing (check out section 5.3 of CAAP 166.1 v4.1 for specific guidance) the circuit speed for most aircraft should be between 50 - 120 kt. Circuit spacing within a mile or less of the runway should provide enough configuration and manoeuvring requirements while providing the possibility of a modified glide approach if the noise up front goes quiet. Adding to this we always have the option to change speed to maintain separation although this provide
There has been more published on circuit operations and associated radio use including missed approaches, take off separation and mixed operations. We wrote about this in Pilot Talk for October 2018 as well as referencing specific legislation like CAR 163 and 166C and AIP. Good guidance in plain English is available using CAAP 166(1) version 4.1 and the Visual Flight Rules Guide (VFRG), which has just been released as a new version. Check the RAAus Member Portal https:// members.raa.asn.au/pilots/manuals-andresources/ for these and more. Safe Flying
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10 TIPS FOR A SUCCESSFUL FLIGHT It
’s no surprise to most of you that successful flights occur every day with hundreds of recreational pilots and aircraft all over our country. From countless hours of training to private sorties to places near and far; safe, fun recreational flying is happening. Unfortunately, and far too often in recent months, we are saddened to hear of another tragic end to what should have been another safe, successful flight. In tracing through the steps that led up to the tragedy, combing through and analysing the evidence and looking at contributing factors it is clear that some all too common trends and circumstances are regularly being repeated. So what are some of the successful actions, behaviours and attitudes that contribute to a safe flight that so often are missing in these tragedies? Let’s look at 10 things that will set you on the right track for that safe and fun flight.
1. Plan for success. We’ve heard it all before, the 6 P’s- Prior planning prevents … you know the rest. Just the very process of thinking about the flight will increase your safety, researching and recording the key elements will at very least identify possible areas of risk that at least you can then apply some judgement and redundancy and most important some flexibility. It’s the chapter before that picture of the plane flying off into the wide blue yonder that really makes the picture perfect. 2. Be compliant. Yes I know this sounds like administrative big brother but incredibly this is a significant contributor to most accidents, particularly fatal accidents. Inevitably whether it’s about currency, membership, operating in VMC conditions, operating at appropriate heights above terrain or the plethora of other rules and regulations that seem to surround us. They are there for a reason, and generally it’s because they were written in blood from fellow aviators in our past. Simply being compliant is a key contributor to being safe. 3. If you identify a potential problem- STOP and think about it. There is no room for red light running in aviation. This starts long before the actual flight. The last minute weather change, the late start, the forgotten items, a compromised pre-flight. Then during the flight, as we all know, accidents are seldom the result of one thing alone. The warning signs are there as all the holes in the Swiss cheese start to line up. If something’s not going the way you intended
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then persisting seldom makes it better. Now we can’t just park the plane in the air while we scratch our heads but making an early and safe decision, or pre-planning alternative actions regardless of the inconvenience or damage to our pride or plans is the only way you’re going to live a long happy life as a pilot. 4. Be humble and accept that as humans we are vulnerable. I know you’re good, you’ve been doing this for years. You hear all this mumbo jumbo and all that’s done has made you better at pointing the bone at all the other idiots out there. You are the pillar of the piloting community- guess what? You may be next! Research has shown an experienced pilot is just a vulnerable as an inexperienced pilot, for different reasons. Experience can be your greatest asset and your biggest threat. Wrestling an aeroplane to the grave is no way to end a love affair with flying. Recalibrate
FLIGHT OPERATIONS your human side before every flight just like you do the altimeter- reset a known standard and reference to a grounded level of vulnerability and risk. It’s that self-assessing look in the mirror that will remind you that better pilots than you have failed before. 5. Don’t double date. Getting caught out with an unexpected threat is never good. Only ever do one new thing at a time. If you’ve got a new aircraft, fly it in familiar conditions and a familiar place. When performing cockpit tasks focus on one thing at a time. Pick the best day to go to a new destination. Handling any one new situation is enough in our dynamic flying environment, it’s all about minimising risk ahead of the game. Too many first flight fatalities are testament to this truth. 6. Check it again, Sam. I could have sworn that I turned that tap on not off! Yep truth be told we’ve all probably done it, from something as simple as a fuel pump to a canopy or door unlocked or worse. Nine times out of ten you’ll probably get away with it. One day you won’t. CHECK-RECHECK and if you’re like the big boys and can, CROSS -CHECK. Using a checklist is a smart way to make sure important items are not forgotten or left out. 7. Lead me not into temptation- You can say NO. No to yourself, and no if under pressure. Get-there-itis leads the hit parade here, but it’s not the only one waiting to get you. The busy fly-in attendance, follow the leader, taxiing like sheep to use a tailwind runway and peer pressure can all be catalysts to do something you normally wouldn’t. By not succumbing to this threat you truly are demonstrating command thinking and the rewards will follow. Good piloting is not a popularity contest but a skilful and honest assessment of all elements that provide the safest outcome for your experience. 8. Star in your own movie. No I’m not talking about taking your GoPro and filming yourself for Facebook! Far from it. Take the leading role in the best performance of your
life every time you fly. Actors do it and so do all professionals. There is no room for complacency in the cockpit. If you don’t work to improve something on every flight in at least one aspect then dynamically you are destined to go backwards. True aviators never stop learning, they hunger for knowledge as much as they do for adventure and know the application of knowledge is the key to being a better pilot. They seek out information and different experiences like bloodhounds by flying different types. Become your own instructor as well, never forgetting those pearls of wisdom and fly like he or she is watching you all the time. On top of all of this, don’t wait for your BFR every two years, take a check flight with someone different at least once a year- perspective is a wonderful thing to be learned from. 9. Go Slow. Flying is the fastest way to travel so why rush it. Whether you are learning or a seasoned pro. When we slow down our mental approach to flying we create airspace for true decision making to take place. Our actions will be more deliberate and considered and visible to others. We allow a place for well-developed procedures to operate and most of all, we mitigate errors. Oh and yes we get to enjoy and savour the experience! Put on your pilot face before you leave home and keep it there until you safely return. 10. Enjoy the flight. I once read in a flying magazine an amazing line. It was captioned under a beautiful picture of a Stearman arcing over the top of a perfect loop as part of the centrespread. It read;
“One of the greatest safety devices in the world is a free state of mind, a happy state of mind on the part of those at the controls”
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DON’T DIE FOR A DEADLINE It
’s a cool, calm and cloudy winters day in Adelaide, but (in hindsight) not the kind you wake up to and decide that VFR flying is on the table. Nevertheless, the conditions are docile, there is a horizon and above all, the requirements are legal. Cloud base hangs relatively low at 4000 feet but not too low to impede on some basic training area solo flying only a stone’s throw from the airfield. I am scheduled to top up my remaining command hours to meet the minimum requirement for my Private Pilot’s Licence. The day that has been in the making for almost a decade, and a day longer just feels like an eternity. I am anxious but I am eager. The 1.2 hours left to log will be conducted today in my single engine trainer – one that I have accumulated all my hours in, and am very familiar and comfortable with flying. As I impatiently greet my instructor to confirm my interpretations of weather, airspace, TEM and NOTAM information I can sense my urgency build as this is the last boxticking exercise to complete before I receive my wings, literally and metaphorically. My instructor looks out to the west and dutifully assesses the conditions he sees outside with that written on the TAF and ARFOR. It is pretty much as expected. A chance of increasing showers of rain and a thunderstorm well into the afternoon. Its only just gone mid-morning, I have plenty of time. With some reservations, my instructor signs me out with the following stipulations: “the weather is safe but it can become marginal very quickly in this environment. I want you make a decision early on if you don’t have adequate visibility once you get to the outbound VFR waypoint. If you can’t see to the end of the training area I expect you back in the circuit immediately.” At this point my enthusiasm to get in the aircraft clouded any air of looming concern that my interpretations did not factor a change of weather, only a determination to complete the
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flight – rain, hail or shine as they say. Nonetheless, with my charts and headset in hand I dashed to the aircraft, confidently completed the pre-flight I have perfected throughout my sub-100-hour experience. And with that manner of youthful exuberance I closed and latched the door, started the engine and taxied to the holding point for my departure. As I cross the VFR waypoint, I change to area frequency and notice the mist descending off the clouds well into the distance. I can see past the training area – the dials are in the green. This flight is about consolidation and I immediately clear my view and begin conducting airwork as I track towards the far end of the training field. Momentarily I am surprised by the aircraft heading inbound to my left. Its only midmorning with most aircraft out on 2 to 3 hour navigation exercises. Surely they’re not back already? I think to myself. I return to the sortie at hand and continue to track further west. I have calculated that a 1.2 hour flight will require a little more time out in the training area than usual. So, I continue towards the mist off into the distance. Again, another aircraft passes by my left. Moments later, a third. Only this time the momentary pause is extended as I notice the wall of dark distortion that can barely be made into a cloud formation. It’s over the coast line and to my surprise it is headed inland toward the training area. I spend a moment reproducing the TAF lines in my head to confirm who has hoodwinked who – those ominous clouds were certainly not forecast this early in the day. My instructors voice echoes in my ears and I dutifully make a hesitated turn back towards the east, to the inbound VFR waypoint. I meander for a moment wondering whether the slight rise in blood pressure is due to the front approaching or my angst at the air switch that has barely made it to 0.7 of an hour.
Lea Vesic As I’m turning I continue to clear my view for traffic and look beyond my immediate line of sight out onto the horizon. To my surprise, there isn’t. much of one at all. All around me the mist has gradually darkened and the cloud base has lowered. As if the gods had run atop the fields of fluff and squashed them barely a thousand feet above my little airplane. All at once I felt the adrenaline take over and the panic set in. How did the weather turn so quickly? Irrespective, this was not the time to philosophise and I returned to ingrained procedure when it dawned on me. The aircraft enroute back to the airfield were indeed navexes that had aborted their sorties and were returning due weather. While tracking back with nerves tempered by my diverted attention on the rapidly fading horizon to the east, I knew the focus was on getting to the inbound point, making my call to tower and joining a downwind circuit. The only problem now was to slot in amongst the hoard of aircraft that seemed to somewhat appear out of thin air and in a conga line of inbound aircraft. I made a few hasty calls to allow for separation and slotted in, with hesitation knowing that I was now surrounded by aircraft not too far of me ether side.
Noting my dismay at unannounced weather, I knew I couldn’t be certain that we were still using the same runway as departure so the ATIS was my first port of call. I turned down the volume on my comms 1 system to a negligible sound to get the maximum clarity of the weather report through the ATIS on comms 2. As I looked down on my kneeboard to jot down the details I became distracted by the sudden loud and alerting beep from the TCAS – a seemingly innocuous device when one is in full visibility. Regrettably, I was not. The panic reset itself to a higher octave but I kept my cool and focussed now on approached the control zone and making my inbound call to the tower. I knew that as soon as I was identified by the tower that separation would be a joint burden to bare. The TCAS continued to shriek and with little visibility and a growing mist around the fuselage it became apparent to me that I was beginning to lose visual reference down to a kilometre or two at best. I made my call. No response. “It’s okay I know there’s a lot of traffic, I should expect to wait.” I made my call again. No response. As I approach the boundary zone where I am required to turn around and steer clear without permission to enter. I made my call again. No response. Radio failure - I convince myself.
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I begin the troubleshooting whilst encroaching far too close to the boundary, transmitting blind, unplugging and plugging my headset. The TCAS continuing to remind me of my proximity to what felt like a very grim situation; the control zone, the lowering cloud base and the potential mid-air collision with virtually no horizon or reference to the airfield at this point. “ALPHA BRAVO CHARLIE DO YOU COPY!? ALPHA BRAVO CHARLIE DO YOU COPY!?” The loud and resolute voice bellowed over comms 1 as I frantically fidgeted with the volume dial. I had been transmitting, I simply did not hear the response. The overwhelming sense of joy only dampened the beating of my heart by a mere nano-fraction. ATC had cleared the local airspace to allow for my smooth joining onto downwind, and as I rapidly descended through the thick mist to the safety of circuit height I could finally take in some well-deserved oxygen. It didn’t take long for my instructor to be alerted to the event. After all, I was clearly and very concisely bellowing my radio calls over the others on the inbound frequency which conveniently played through the school’s operations room. I managed to keep it together until the moment I sat down on a chair, planted firmly on terra firma. Without hesitation I tried to piece together what had happened. As I recounted every decision to my instructor it became very obvious that two things had fed the swisscheese model of events: I lost my situational awareness and my judgement was (literally) clouded by the impatience of the common ‘get-there-it is’ syndrome. I was adamant the weather conditions would favour my luck rather than objectively assess my options. And in reality, there was no pressing deadline other than the self-imposed desire to get on with it. Because of this, I did not take in the warning signs of aircraft returning from the very
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direction I was headed early on. I did not observe the greater environment well beyond my immediate vision that could have provided me with perspective to the changes. I remained steadfast on achieving the goal rather than continually assessing the situation. There wasn’t any one particularly grave element that impeded directly on achieving a safe flight, rather multiple elements that formed a potentially unsafe and unpredictable situation. It brought to light the necessity of objective assessment, personal minimums and the benefit of habitual procedures in an unlikely event. As aviators we all speak about the skill of aeronautical decision making and we all know why it is so important. Yet we still fail to recognise that no matter how diligent and intelligent we are, it can happen to the best of us. Situations like mine are a grim reminder, (noting the survival rates of a non-IFR rated pilot when entering zero visibility) how quickly a situation and an environment can become volatile. Flying is my life and my love. But it is not worth dying for. When planning any flight, no matter the frequency or routine nature of it, it is imperative to apply situational awareness well before you’re in the air. Ask yourself, what can happen if the environment changes to less than favourable or unexpected conditions (weather or a crowded airspace)? Do I know when my decision point going to be? What are my personal minimums? Simple things around knowing your emergency procedures for radio failures and circuit joining procedures. These are all questions that should derive from a self-interrogation of understanding and appreciating your skills of judgement and decision making, and honing the multi-faceted procedures before an emergency occurs.
AVIATION SAFETY MANAGEMENT SYSTEM Introduction As part of our intrinsic corporate values and strategic plan Recreational Aviation Australia (RAAus) places safety first, and members central to everything we do as we continue to progress and promote safe recreational aviation in Australia.
overarching cross-departmental influence on all that we do. This ethos ensures that all our communication and membership engagement promulgate the importance of safe operations for the viability of our members, the organisation and the community at large.
RAAus is progressively working towards improving safety outcomes through a holistic and pragmatic approach to safety management and the adoption of an open and fair reporting culture through our maturing Occurrence Management System (OMS) and collaborative relationships with government agencies and other Australian Sport Aviation Organisations (ASAOs).
Part of this cultural change is instigated by the changing regulatory environment and the implementation of CASR Part 149 (Approved Self-administering Aviation Organisations). To maintain compliance with the regulator and afford our members the unique benefits of recreational aviation, it is vital that RAAus demonstrates its maturity as an organisation through its commitment to safety and safe operations throughout our membership base and Flight Training Schools. A requirement of CASR Part 149 approval includes a Safety Management System (SMS) which is structured around the core principles of safety policy, risk management, assurance and promotion.
As outlined in our policy, safety is one of our core business values and functions and outlines our on-going commitment to developing, implementing, maintaining and innovating and improving strategies and processes to achieve safe operations. Organisational Culture RAAus has shifted its cultural focus on safety from an organisational input to an organisational output. This means that our approach to safety has relocated from a ‘silo’ endeavour of operations with its own department, to an
As many government agencies steer towards a more risk-based approach to governance and regulation, RAAus has remained ahead of the curve. RAAus’ unique value proposition to is member base lies predominantly in the pragmatic approach to a simple rule-set and
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owner maintenance. In many instances, RAAus is world-leading in its approach to progressing not only the sport aviation sector, but aviation in general. RAAus Flight Training School ASMS The Recreational Aviation Australia (RAAus) Aviation Safety Management System (ASMS) has been carefully designed to incorporate the basic requirements of a Safety Management System, required under the CASR Part 149 approval process. It is a pragmatic tool developed to cater to all our schools both large and small, ensuring the benefits of organisational safety is documented appropriately but more importantly provides useful guidance to establishing and maintaining a positive safety culture.
going development of a positive safety culture throughout our organisation. This is simply to ensure the recreational aviation sector continues to be administered in accordance with an appropriate organisational risk appetite and more importantly is accessible and sustainable for generations to come.
“The other positive about a good SMS is that if you take the word safety out of it, it’s a good management system. It improves the way you do business.” – Lindsay Evans. Founder of Network Aviation
RAAus has developed a suite of templated resources to accompany the Safety Manual based on the size and complexity of the FTS. It is not our intention to burden our FTSs with superfluous paperwork, rather assist in the on-
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What’s in it For You? Regardless of the size or complexity of an organisation we all recognise that risk exists in all of our operations and we take responsibility as a collective to ensure safe outcomes for all. Notwithstanding that, safe operations are also a commercially-driven incentive as none can afford the costs, financially or otherwise, of an accident.
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have insurance and workers’ compensation insurance for your employees.
While WHS focuses primarily on safety of the individual employee, SMS focuses on organisational safety. The two are not mutually exclusive. Let’s Be Practical
We know that individual accidents have repercussions on the entire aviation industry, not just on the individual operator involved. They affect how the public perceives our sector the industry, our commitment to safety and our expertise.
To be effective, a safety management system must be tailored to suit the type of operation. A “one size fits all” approach will not work, and is simply not pragmatic. The objective is to incorporate the principles of SMS into the day-today operations of the organisation.
Each aviation organisation can create a safe and informed culture that knows where the “edge” is without having the fall over it first. It can achieve this by implementing an effective safety management system.
This is not about telling anyone how to conduct their operation, but rather about following a small number of basic principles, and then adapting proven SMS components to fit the size, type and management style of the operation.
As a business owner you have legal responsibilities to implement health and safety practices in your workplace as soon as you start your business. You need to ensure that your business doesn’t create health and safety problems for your employees, contractors, volunteers, visitors, customers or the public. Knowing and understanding Workplace Health and Safety (WHS) laws and how they apply to business will help you avoid unnecessary costs and damage to your business caused by workplace injury and illness. Under Australian WHS/OH&S legislation businesses are legally obliged to: • • • • • •
provide safe work premises assess risks and implement appropriate measures for controlling them ensure safe use and handling of goods and substances provide and maintain safe machinery and materials assess workplace layout and provide safe systems of work provide a suitable working environment and facilities
Templated FTS Safety Manual The FTS Safety Manual Template has been written for Flight Training Schools (FTS) to meet their responsibilities as part of the RAAus Aviation Safety Management System (ASMS). Where text is written in [blue] the intent is that CFIs may choose to insert the relevant information or delete information to reflect the individual characteristics of their FTS and/or align with their tiered category. *Existing ASMS in place? Implementation of the RAAus ASMS is optional. If your school already utilises an existing suite of documents that incorporates the key components of an SMS, RAAus welcomes the continuation of your system once approved by RAAus. However, it is recommended that each CFI takes time to review the RAAus Safety Toolbox in the CFI portal and the templated documentation to ensure all the key components are covered and the system is pragmatic and easy to implement.
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HIMS... “What the...” T
he HIMS acronym has now been floating around the Australian pilot community vernacular for the last few years. It has been variously described as “industry catching up to Australian and international mental health best practices” to “McCarthyism refined for the 21st century”. But just what is it? At its very basic core, the HIMS methodology is designed to assist pilots with CASR Part 67 recertification requirements. It also involves many elements of our environment, ranging from workplace Just Culture, understanding of what constitutes addiction to society’s attitude or “conscience” towards chemical dependency (stigma). The Human Intervention Motivation Study (HIMS) is a voluntary aftercare, structured peer support and accountability process to assist pilots diagnosed with substance use disorder return to flying who would otherwise be faced with an indefinite period of medical certificate suspension. Up until the 1970’s, a pilot diagnosed
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with substance use disorder meant permanent cancellation of their medical certificate. HIMS came into being as a risk mitigation strategy (or Safety Management System) to assist pilots with their medical recertification (with special requirements) who would otherwise be lost to the industry. The HIMS methodology has been adopted in the USA since the mid 1970’s, but has only recently begun to evolve in the Asia-Pacific region. Just like any other occupational group, pilots are not immune to the ravages of substance abuse or substance dependence. Symptoms include compulsive use (overwhelming desire), preoccupation (neglecting responsibilities), tolerance and denial of consequences. Neurologists classify substance use disorder (chemical dependency) as a “chronic neurobiological disease” with some of the symptoms listed above with many other environmental factors underlying as the root cause of the disorder.
LAURIE SHAW Pilots who return a positive alcohol breath or drug test often display the symptoms listed above. This is not wilful behaviour; it’s an insidious, cruel and deceptive illness with testing often “catching” people only when the disease has progressed. Statistically, for every 100 pilots, 2 to 4 will develop a chemical dependency during their flying career. In the United States, FAA statistics indicate long term success of a HIMS process for afflicted pilots in the order of 90%. While HIMS is still relatively new in Australia, the success rate to date is indicative of overseas statistics. What is Addiction? It’s also important to have an understanding of the basic science of what constitutes “addiction” or “dependence”. In the words of a consensus statement by addiction experts in 2001, addiction is a “chronic neurobiological disease”, characterized by behaviours that include one or more of the following: impaired control over substance use, compulsive use, continued use despite harm, and craving”1. The key features of substance addiction are the use of drugs or alcohol despite negative consequences and recurrent relapse. Importantly, the issue is not the quantity or even the frequency, but the impact1. Addiction is any repeated behaviour, substance related or not, in which a person feels compelled to persist, regardless of its negative impact on his or her life and the lives of others. While addiction is definitely a medical condition, it is “all about” many things. It is a complex condition, a complex interaction between human beings and their environment; it has biological, chemical, neurological, psychological, medical, emotional, social, political, economic and spiritual underpinnings – to name but a few2. ICAO defines addiction (chemical dependency) as a “progressive and chronic illness” and is classified as a disease or disorder3. “Just Culture & Cultural Conscience”
cues fail. To conduct oneself with an approving conscience, to pursue principles along a line of reason as “straight and clear as a ray of light” (to quote the 18th century radical philosopher, Thomas Paine), seems a noble ambition.4 In human society, a ray of light is neither straight nor clear. It can be refracted, reflected, dispersed and warped. And what’s true for the metaphor is true for the subject: no person is an island; we exist within a continent of influences, compulsions and biases. We exist within culture. And culture has its own set of accepted values, behaviours and norms – each affirming, rebuking and modifying the thing we call conscience. In fact, by definition and by application, if culture is, as most definitions express it, “accepted values”, then “culture is conscience”.4 As pilots within our own group (cockpit, fleet, airline), we shape and define our own “cultural conscience” which can vary markedly, even between fleets within the same company. Society still attaches stigma to people afflicted with a substance use disorder and the pilot community is no different in many ways to this view, the “cultural conscience”. It is a very personal and internal struggle for most people who prefer to internalise their situation. To deride or belittle mental health issues or their support systems can create confirmation bias which can lead to a ripple effect, detrimental for an individual’s own well-being. Eventually this ultimately affects flight safety. The perplexing issue for most industries who have embraced the “Just Culture” philosophy is what determines deliberate, reckless, wilful and grossly negligent conduct? Does returning a positive drug or alcohol test constitute any of the above? Or could it be the event that finally penetrates the denial and enables the person to accept that they need help? Although many in the pilot and corporate community are divided on the answer to this question, most airline companies in the Asia-Pacific region still follow a zero tolerance discipline following a positive test.
Conscience is often portrayed as an internal compass providing true direction when other
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use, the demonstration of stability is a fundamental part of this “evidence”.
What is the HIMS process? First of all, what HIMS isn’t: it is not a regulatory process in any form. HIMS is a proven process that can assist pilots afflicted with substance use disorder, a proven way back to flying through the requirements of the regulations.
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HIMS offers a pilot-centred opportunity to seek support and treatment, and then build that “evidence” in an honest and transparent environment. This means that those involved in treatment and recovery are aware of how things are progressing, and consent is sought for the sharing of information with those parties at an early stage. It is not public knowledge. Privacy rules and obligations are strict.
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The pilot will then need prove stability and by definition that takes a period of time. This is generally a minimum period of 12 months demonstration of abstinence, before consideration of the issue or renewal of a Class 1 or Class 2 medical certificate.
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Peer led programmes such as HIMS offer many benefits, including stability, and may offer the opportunity to shorten the time period before re-certification
CASR Part 67.C Table 67.150 1.6 states: If there is any personal history of problematic use of a substance (within the meaning given by section 1.1 of Annex 1, Personnel Licensing, to the Chicago Convention): (a) the person’s abstinence from problematic use of the substance is certified by an appropriate specialist medical practitioner; and (b) the person is not suffering from any safety-relevant sequelae resulting from the person’s use of the substance; and (c) the person provides evidence that the person is undertaking, or has successfully completed, an appropriate course of therapy Note: In Annex 1, Personnel Licensing, to the Chicago Convention, ‘Problematic use of substances’ is defined as follows: ‘The use of one or more psychoactive substances by aviation personnel in a way that: a) constitutes a direct hazard to the user or endangers the lives, health or welfare of others; and/or b) causes or worsens an occupational, social, mental or physical problem or disorder.’. ‘Psychoactive substances’ is there defined as ‘Alcohol, opioids, cannabinoids, sedatives and hypnotics, cocaine, other psychostimulants, hallucinogens, and volatile solvents, whereas coffee and tobacco are excluded.’. •
If a pilot has “any personal history of problematic use of a substance” (as described above), there are three requirements which follow: (a), (b) and (c).
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(a) and (b) requires assessment by a range of relevant practitioners and professionals;
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(c) obliges the applicant to “provide evidence” that whatever management or intervention has been required is successful. Given the high risk of relapse in substance
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It is also important to understand the difference between HIMS, your company DAMP Policy and CASR Part 99 Requirements pertaining to “surveillance”. Managing substance use disorder (HIMS) is a continually evolving process. As more is understood about the disease, so does education and society’s attitude toward it. This is reflected in how many companies across a broad spectrum of industries have evolved their policies and procedures to tackle this insidious disease over time. HIMS is an integral component of an overall mental health awareness and pilot peer support programs.
References: 1. D .K. Hall-Flavin and V.E. Hofmann, “Stimulants, Sedatives and Opiates,” in Neurological Therapeutics, vol. 2, ed. J.H. Noseworthy (London and New York): Martin Dunitz, 2003), 1510–18 2. D r. Gabor Mate, “In the Realm of Hungry Ghosts”, “What is Addiction”, “A Different State of the Brain” 136 – 51, 386 3. M anual of Civil Aviation Medicine, Doc 8984 AN/895, Part III Medical Assessment, Ch. 9 Mental Health, III-9-9 4. Adapted from CASA Flight Safety Australia, with kind permission from Adrian Park, author. Laurie Shaw is an Airbus Captain with Cathay Pacific Airways, Australian HIMS representative for the Australian Aircrew Officers Association and Chairman of the HIMS Australia Advisory Group
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RAAUS.COM.AU Additional Aviation Safety Resources: members.raa.asn.au/safety/ www.airservicesaustralia.com/publications/safety-publications/ www.casa.gov.au/publications-and-resources www.defence.gov.au/DASP/Media/DASAPublications.asp airports.asn.au/airport-safety-week-resources/ www.aopa.org/training-and-safety/air-safety-institute 21
QBE MATT HALL