I refer to BASI Interim Recommendation, IR970104, in relation to
the Bell Helicopter accident at Tartrus Station, Queensland on 2
May 1997. This incident has clearly revealed some deficiencies in
current CASA procedures regarding medical oxygen systems used in
aircraft. These deficiencies require correction.
Issue design and maintenance standards for EMS 02 equipment
installations (Recommendations ii and iii)
Role equipment such as that installed in EMS aircraft is
installed on the basis of "No Hazard, No Interference." There are
at present two Australian standards which relate to aircraft oxygen
systems:
CAO 20.4, Provision and Use of Oxygen and Protective Breathing
Equipment,
CAO 108.26, Systems Specifications - Oxygen Systems
Neither of these standards are directly applicable to EMS 02
systems, addressing instead supplemental oxygen for high altitude
flight. However, Federal Aviation Administration AC 27-1,
Certification of Normal Category Rotorcraft contains a section on
EMS 02 systems. Unfortunately, this US AC has no legal standing
under Australian law.
Thus, while much information is available, it is not clearly
presented, is fragmented, and in some cases is out of date. I
therefore intend to expedite the issue of a CAAP providing
integrated design guidelines for this type of installation. This
CAAP, expected to be issued by September 1998, will cover the
design, installation and maintenance of Emergency Medical Services
Oxygen Systems.
Provide surveillance requirements for EMS 02 equipment in ASSP.
(Recommendation iv)
The ASSP program does not at present specifically address
surveillance of aircraft internal role equipment, such as medical
oxygen systems. This deficiency will be addressed, and the ASSP
amended as necessary to include this type of equipment.
Conduct an audit of all emergency medical service 02 equipped
aircraft to determine the equipment standards in Australian
registered aircraft. (Recommendation i)
Because there is at present no readily available standard
against which to audit existing EMS 02 installations, and because
very few CASA (or industry) people have the knowledge or experience
of oxygen systems necessary to conduct such an audit, I do not
believe that an audit is appropriate at this stage.
Issue of the CAAP and clarification of ASSP requirements are
expected to have a beneficial effect, resulting in improvements and
upgrading of existing systems. However, should routine surveillance
reveal widespread problems or raise further concerns, additional
action will be taken to overcome the problems.
Provide educational material to the aviation industry on the
installation, operation and maintenance of EMS 02 systems.
(Recommendation vi)
CASA is planning to conduct an educational seminar in the latter
part of this year involving CASA staff and industry personal,
including designers, operators and other interested parties. Your
assistance in conducting this seminar would be much appreciated,
including a presentation on this incident and the BASI finding. The
CAAP will also assist in this regard.
Ensure that flight crew are provided with appropriate
instructions in the use of EMS 02 equipment in Aircraft Flight
Manuals or Company Operations Manuals. (Recommendation v)
EMS systems are normally installed in aircraft as modifications,
under the auspices of CAR 35. An important part of any such
modification is the provision of the necessary amendments or
supplement to the aircraft flight manual. The CAR 35 authorised
person who approves the modification should be ensure that such
data are available and included in the modification package. This
requirement will be reinforced in the CAAP.
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