Monarch & MiG Crashes Highlight CAA Problems

The investigation found that the circumstances of the accident were consistent with controlled flight into terrain (CFIT). Descent below the minimum circling altitude without adequate visual reference was the culminating factor in a combination of local contributing factors and organisational failures. The aircraft was being flown with an inoperative autopilot and with inoperative heading indicators on the pilot-in-command (PIC) flight instrument panel as a result of the removal of the autopilot computer amplifier. The PIC was forced to rely on the directional gyro in the copilot’s instrument panel for heading information.

A Permissible Unserviceability document (PUS) had been issued by the CAA District Airworthiness Manager (acting) for the continued operation of VH-NDU with an inoperative autopilot but it was not intended that this should be without the computer amplifier. The PUS required that a copilot be carried. Because of the bad weather prevailing at the time, the PIC was forced to carry out three NDB approaches, finally breaking clear on the last. He then elected to go below the minimum height for a circling approach of 2400ft in order to maintain visual reference. Having descended below 2400ft, the 400ft minimum obstacle clearance provided at the circling altitude was no longer guaranteed. Once below the minimum circling altitude the PIC was required to maintain a minimum obstacle clearance of 300ft along the flightpath. This, for reasons unknown, he did not do.

Among the factors considered by BASI as likely to have caused the crash were the weather, aircraft equipment deficiencies, inadequate flightcrew knowledge skills for the task, visual illusions, high cockpit workload, and, skill fatigue. An additional factor was that the undercarriage was not fully extended at the time of impact which might indicate an undercarriage malfunction problem. This possibility was considered because an extra circuit of the aerodrome was flown. Although maintenance personnel stated that a blanking plug had been fitted in the static line when the autopilot components were removed, no documentary evidence to support this could be found. Subsequent flight trials simulating the non-fitting of a blanking plug indicated that the altimeters would overreact by 90-110ft in level flight, the error increasing in a climb but decreasing in a descent. Wreckage examination could not determine if the static line had or had not been blanked. As best can be established, the copilot was only being carried to act as a ‘human’ autopilot, as required by the PUS, and is considered to have played no part in the cockpit decision making process.

The Monarch Company

BASI found that there were organisational deficiencies in the management and operation of RPT services by Monarch. Specifically, latent organisational failures identified within Monarch included:

• Management priorities which placed the continuation of revenue operations ahead of safety considerations
• Organisational factors, relating to management and structural deficiencies in the operation of the airline
• Inadequate resources allocated to safety, resulting from the financial situation of the airline
• Ineffective communications which inhibited the expression of concerns about safety by company personnel
• Poor planning and operational procedures, largely driven by financial considerations
• Poor control of the safety of flight operations
• Poor maintenance management and control
• Poor training of flightcrew

Organisational Failures Identified Within The Caa

As a routine part of the investigation, the role of the CAA was evaluated. Deficiencies in a number of organisational and local factors were identified; these were summarised as follows:

• A difference between the corporate mission statement of the Authority, which placed a clear primacy on safe air travel, and that of the SR&S Division which appeared to emphasise the viability of the industry as its primary concern
• Poor planning of flight operations surveillance
• Poor division of responsibility
• Inadequate resources, which restricted the ability of the CAA to conduct regulatory activities concerning the safety of flight operations
• Ineffective communications between the local CAA District Office and Monarch
• Poor control of the management of Monarch surveillance
• Poor operating procedures, particularly the practice of issuing AOC’s (Air Operators Certificate) for an indefinite period

Basi Recommendations

In its report, the Bureau has listed a number of safety action interim recommendations which the CAA has accepted in the main. Its final recommendations, which have yet to be addressed, recommended that the CAA:

• Develop a system for CAA officers to advise DASR (Directorate of Aviation Safety Regulation) of known adverse financial situations of AOC holders
• Ensure that surveillance and inspection action responds to reported adverse financial situations of AOC holders with particular reference to their ability to conduct safe operations
• Develop a system to provide an ongoing assessment of the safety health of AOC holders as part of routine surveillance activities

The Mig-15 Crash

The BASI synopsis of the MiG crash states that: “The MiG-15UTI VH-LSN, took off from runway 12 at Canberra Airport with the pilot and passenger onboard. After becoming airborne, the aircraft entered a climbing left hand turn and levelled off at about 1200ft above ground level. The pilot advised the tower controller that he was having a minor technical problem and requested a landing. After a short discussion, the aircraft was cleared to land on runway 35. When the aircraft was about 4km from the threshold of runway 35, it was seen to enter a steep nose-down attitude. The aircraft subsequently impacted the ground and the pilot and passenger were killed”.

BASI determined that an engine over-temperature, probably associated with an internal failure of the upper of two engine fuel pumps occurred. The excessive turbine temperatures led to turbine blade creep with consequent rub on the turbine casing. Fuel in the aft fuselage area, probably from a leaking fuel boost pump was ignited by the high temperature resulting in the rudder and elevator control tubes being burnt through. On subsequent strip examination it was discovered that the upper high pressure fuel pump swash plate was jammed in the near full stroke position, an internal loose servo piston grubscrew having contributed to the jamming.

In addition to the direct cause of the crash, the BASI investigation established that there were deficiencies in the aircraft’s maintenance documentation, and in the general understanding of some owners, operators, pilots and CAA field inspectors relating to compliance with the regulations or instructions governing the operation of ex-military aircraft; specifically:

• The CAA issued a Permit to Fly for test flight purposes even though the owner of the aircraft could not provide detailed records of the aircraft history. Times entered into the Australian aircraft logbooks could not be verified (the Polish Air Force refused to provide inspection details)
• The CAA did not document the process it applied when approving the pilot to test fly the aircraft
• While the test flight Permit to Fly was in effect, the aircraft was flown for other than test flight requirements and the carriage of other crew and passengers occurred
• On the accident flight the pilot planned a scenic flight which would place the aircraft over a built-up area, which was not in accordance with the restrictions of the existing Permit to Fly

In its interim safety action recommendations BASI recommended that a single document covering all aspects of warbird operations be produced and that the terms and conditions of Permits to Fly, use of ejection seats and the carriage of passengers be reviewed. In addition it recommended that a mandatory requirement to strip and inspect the fuel pumps be issued and that an inspection schedule be developed. The CAA, in its reply stated that it was hosting an ex-military aircraft conference in July 1993, four months after the fatal accident at which all the issues raised by BASI would be addressed. In its final recommendations, BASI recommended that the CAA review the procedures used to assess the safe life of aircraft and components imported without adequate historical documentation, before approving a Permit to Fly. It also recommended a review of the regulations covering pilot training and endorsement for warbird operations.

Government Reaction To The Monarch Crash

The Federal Minister for Transport, Mr Laurie Brereton, reacted to the BASI report on the Monarch crash by announcing that an inquiry will be held by the House of Representatives Standing Committee on Transport, Communications and Infrastructure to “examine and report on the adequacy of air safety standards, and the compliance with, and supervision of, air safety standards in the commuter and general aviation sectors in Australia”. The inquiry will be headed by ex-aviation minister, Peter Morris, and should report to Parliament during the course of this issue.

In addition, the Minister announced a recommendation that the government assume financial responsibility for the public interest regulation of aviation safety. He went on to say that this will eliminate any possibility of safety regulation being compromised by the 50% industry cost recovery of CAA functions under the present arrangements. The Minister also announced the establishment of an Aviation Safety Agency as a separate entity within the CAA with discrete financial and accounting arrangements, with its head, while still reporting to the Chief Executive Officer, to be an executive member of the CAA Board. Finally, in addition to brief announcements relating to a proposed passenger carrier’s liability and insurance increase to $500,000 per passenger, and further CAA Board appointments, the Minister has given the CAA six weeks to review the adequacy of all safety and regulatory functions in both of staff numbers and the requisite skills.

Comment

The parliamentary inquiry was certainly predictable, given the nature of prior press comment on both crashes, however it is to be hoped that the inquiry will not be limited to focusing in on the CAA alone, but will also address the government’s responsibility for the political decision to restructure the CAA as a GBE (Government Business Enterprise), and to cut its funding. The recommendation as to safety regulatory funding is a significant backdown from the previous government position of only funding $22.8m of the estimated $60m required to cover the annual costs of this function. This will certainly be welcomed in broad terms by all in the industry but as details have yet to be advised, further comment is not possible at this early stage. It does however raise the question of the amount of money and effort already spent on implementing the government’s previous directions on the recovery of the safety tax. This together with the back to the drawing board review of the airspace question, and the cost of the TAAATS tender reappraisal should perhaps be addressed by the inquiry. There is no question that the whole lot must amount to a tidy sum!

The proposed establishment of an Aviation Safety Agency will leave many in the industry pondering just what the recently established Directorate of Aviation Safety Regulation was set up for? Will the new agency be in addition to DASR or will it subsume the latter’s functions? At the time of going to press, nobody seemed to know. The announcement has, however, brought forth conflicting opinion as to whether the new agency should be a part of the CAA or a completely separate entity. On balance, provided there are clear cut financial and accounting lines, and there is no question of profit making, it is believed that the new agency should remain as part of the CAA. To have it otherwise would only create yet another bureaucracy with all its attendant trappings, but more important, walls of demarcation.

Finally, on the warbird issue, as outlined in the report on the conference mentioned above, it is understood that the ground work on a new set of comprehensive rules and regulations to cover their operation is essentially complete. However due to the need to go through the bureaucratic process of extensive consultation prior to finalisation, a date for them to come into force is not known. A further article will cover the new rules when they are finally promulgated.