BASI Reshapes For The ‘90s

During 1989, 27 fatal accidents caused 63 deaths in Australia, while during 1990, 29 such accidents occurred, again with 63 fatalities. Though these figures represent a slight increase in the number of fatal accidents and though there have been steady increases in both number and rate of fatal accidents over the past five years, BASI does not believe Australia is facing a serious deterioration in aviation safety overall. In fact, in some areas safety has markedly improved, though other areas may come under closer analytical scrutiny. One example is the charter area, which experienced 43 accidents (an increase of 6) during 1989. However, analysis has also shown that charter hours also rose significantly in 1989 due to the pilots’ dispute.

BASI’s accident investigations can encompass all types of aircraft, particularly if they do prove fatal. One important example of BASI concentrating its resources on specific problem areas is the classic Mitsubishi Mu-2 case, the reason for the spate of Mu-2 crashes worldwide having until recently remained a mystery. When an Mu-2 crashed near Kalgoorlie in December 1988, BASI investigators noted that it appeared to have hit the ground whilst in a spin, though no mechanical defect which would have caused this could be found. T he Mu-2 crashes were alarming, so BASI concentrated resources on finding an answer, and with its new ideal of cooperation with industry released a survey through the BASI Journal for Mu-2 pilots to help determine problems which may have escaped attention. With answers from Mu-2 aircrew BASI had narrowed down the search for a common cause when a former BASI investigator, Mr Don Ende, was himself tragically killed in an Mu-2 crash at Meekathara, WA on 26 January 1990. A tribute to his skill as both an investigator and pilot was that Mr Ende was able to detail over the radio before the aircraft impacted what was actually happening during its fatal dive and the likely cause – icing. BASl’s investigation, relying heavily on information collected from Mu-2 aircrew, had determined that icing was a highly probable cause and the Meekathara crash confirmed this. As a result of BASl’s conclusions, it is hoped that measures will be implemented worldwide to tackle this problem.

To further enhance its knowledge of crash investigation methods, BASI investigators are regularly despatched to examine major accidents overseas, at the relevant authority’s invitation. In the past two years BASI investigators have observed or have assisted in a number of overseas airline investigations, including Auckland (Convair 580), Midlands, UK (737), Sioux City, USA (DC-10) and Long Island, USA (707) and the recent LA 737/ Metroliner collision. A BASI investigator in fact left Canberra for Sioux City less than three hours after the crash occurred. Attendance at these accidents both aids foreign investigating teams and acquaints BASI investigators with invaluable current crash investigation methods for use if (or when) a serious airline accident occurs in Australia.

But besides investigating accidents when they occur, the BASI team must under take considerable follow up study before conclusions can be reached. In the laboratories for instance, components and wreckage are meticulously examined (at times with the CAA, which operates a large examination facility in Canberra) to determine, for instance, why a key component failed, usually but not always causing an accident. When all research has been undertaken and a conclusion reached, BASI tables its report and recommendations to the relevant body, usually the CAA but often also other organisations or interested individuals, including relevant sport aviation groups or for instance the Gliding Federation. Reports and recommendations are produced at central office using the conclusions of several BASI investigators involved in the relevant investigation, who each cooperate during research but often have specific areas of interest. This, BASI believes, together with the fact that its investigators examine fewer accidents, produces better reports and recommendations.

But accident and mechanical fault investigations are not the only areas of interest to BASI. For instance the Bureau employs psychologists to analyze data to identify underlying human factors or emerging trends in accidents, a very important task given the fact that human factors are a primary cause for up to 80% of accidents. Of much concern is cockpit resource management, such as the misplacing of instruments within the cockpit which can (and has) caused confusion in the air, leading to accidents. Other human factors research involves how cabin crew cope with passengers during onboard emergencies or evacuation, or how procedures on the ground (for instance involving maintenance crews or ATC) can be improved. In another area of research, computer programmers can recreate on screen, using ground and onboard computer information, what occurred during an incident or accident, showing clearly the aircraft’s track with all relevant parameters such as location, altitude and speed displayed.

An important tool now in all areas of research, most importantly in human factors research, is CAIR (Confidential Aviation Incident Reporting). All aviation accidents must be reported to BASI immediately and all safety related incidents within 48 hours as Safety Incident Reports (the old ‘225s), however these reports are not confidential and there may be some trepidation when filling them out, possibly leading to some incidents not being fully explained or even not reported; others simply might not fall into the SIR category. CAIR therefore provides an alternative approach to reporting and identifying incidents or potential problems, guaranteeing as it does full anonymity for the reporter and providing BASI with information concerning human performance which would, almost certainly, not have been reported otherwise. A CAIR reporter perhaps may have feared bureaucratic action or becoming known as a ‘dobber’ (or may even have been instructed not to cooperate by certain bodies, such as was AFAP practice in several cases prior to the pilots’ dispute).

CAIR reports can cover a wide range of safety issues (but not industrial matters) and can be submitted by anybody in the industry, not just pilots. The scheme concentrates fully on identifying potential problem areas within the industry, be they the result of regulations needing review or the actions of individuals or companies within the industry. Such has been its success, that in CAIR’s first 30 months of operation 1,363 reports were submitted. Of these, 14% warranted further written action and/ or response by government or industry bodies. If response is needed, relevant authorities are contacted and some incidents are published in the BASI Journal to make others aware of potential problems.

CAIR’s success is put down to both the guarantee that the identity of reporters is protected and the fact that it is not run by the CAA. When the US FAA first started its similar scheme, the Aviation Safety Reporting Service (ASRS), it was found not to be working, the principal reason being that pilots were unwilling to submit reports to the regulatory authority, who of course could take action against them. The scheme was therefore contracted out to NASA and in turn is run by a sub contracted private company. Such is ASRS’s success, that in the light of the Challenger shuttle disaster NASA implemented a similar scheme for its own employees. Thus such programs are recognised worldwide (the UK, US and NZ for instance all run similar schemes) and with CAIR the Bureau has developed a system which has both gained the trust of the Industry and provides vital details of aviation safety related problems.

Having therefore now gained the trust and respect of industry by concentrating its resources on making aviation safer and not just seeking to find people to blame for accidents, BASI is providing the industry (and indeed the general travelling public) with a vital service.

Basi Expresses Amats Concerns

BASI has expressed some concern to the CAA about its Airspace Management and Air Traffic Services (AMATS) pro- posal. Though it agrees with the CAA statement that “the Australian airspace and air traffic management system has been the safest and most efficient in the world”, it is concerned that in some areas safety could be compromised under AMATS, particularly if an adequate transition period is not provided to maintain safety levels until industry is used to the new system.

Some of the key areas of concern to BASI are highlighted below, most concentrating on the AMATS’s heavy reliance of ‘see and avoid” flying.

See and avoid: BASI has expressed serious reservations about this aspect of AMATS. Human performance limits are often a significant problem in ‘see and avoid procedures. BASI is concerned “that even the most experienced and alert pilot cannot overcome these limitations. The Australian experience has shown that approximately 80% of accidents/incidents are attributed to human factors. ” Relying on see and avoid, two aircraft in the same vicinity may be on one of three different radio channels, without being aware of each other. The problem is obvious.

Controlled airspace penetrations: BASI believes that providing additional VFR lanes near major airports may in fact “increase the risk of penetrations unless other vital and long overdue actions are taken. The number of penetrations could have been reduced long ago by providing access to the existing radar coverage to the personnel responsible for management of non controlled airspace”. Petty industrial dis- agreements apparently prevented this.

Class D airspace: (Covers GA airport control zones and many country controlled aerodromes. ) BASI’s chief concern “relates to the intention to provide both IFR and VFR aircraft [in D airspace) with “traffic avoidance advice upon request’. . . should the “traffic information’ be insufficient to maintain visual separation. ” This may not be as safe, or practical, for aircraft at 10 to 15nm, or more, from minor airports without radar coverage such as Coffs Harbour, Tamworth, Hobart, etc. Class E airspace: This airspace may provide a lower level of safety than the former AFIZ, of which it will be similar. VFR aircraft will not be required to give notification, communicate or obtain an airways clearance. Route safety levels may therefore be reduced.

Class F and G airspace: (Essentially all uncontrolled air- space, covering most of Australia) This “represents the greatest area of concern”. In this airspace, services will be downgraded to a lower level, the only service in G being limited flight information. Unfortunately, “the CAA proposal does not acknowledge that a lower level of safety will exist in the proposed Class G airspace. . . Many airline destinations and enroute sectors will be in Class G without the provision of directed operational and traffic information services. ”

BASI’s response on AMATS is just one of a number of industry responses to the CAA about its airspace proposal. With concerns having been raised by several industry sectors. AMATS will be revised prior to the final form being implemented, which the CAA hopes to commence doing within the next two years. (Paul Caldwell)