Output Number
Approval Date
Organisation
Civil Aviation Safety Authority
Published Date Time
Recommendation type
Mode
Date released

Safety Issue

CASA's process for accepting an instrument approach did not
involve a systematic risk assessment of pilot workload and other
potential hazards, including activation of a ground proximity
warning system.

Safety Recommendation

The ATSB recommends that the Civil Aviation Safety Authority
address this safety issue.

Organisation Response
Date Received
Organisation
Civil Aviation Safety Authority
Response Text

CASA's current processes for periodic revalidation of instrument
approaches specifically address pilot workload and other potential
hazards. 

The approach design and validation methodology adopted in
Australia is ICAO compliant (see Doc 8071 - in which Australia
participated in the

development) and uses GPS United States Federal Aviation
Administration TSO receivers. These standards have all been subject
to international (risk

assessment) review and acceptance during their development, and are
therefore not included in the approach validation process.

The validation requirements do necessitate the consideration of
other potential hazards (refer Doc 8071 and MOS). This process is
part of the

overall procedure design and implementation methodology as defined
by ICAO.

ATSB Response

The ATSB acknowledges that although CASA may consider pilot
workload and potential hazards during instrument approach
revalidation, it does not intend to include such assessments in the
original validation process. In addition, hazards currently
assessed in the flight validation are very limited. In particular,
the flight validation process does not systematically consider
hazards such as GPWS activation, potential influence of turbulence,
the nature of terrain information provided on the approach chart,
and the nature of terrain close to the approach path.

Date Received
Organisation
Civil Aviation Safety Authority
Response Status
Response Text

In accordance with CASR Part 173, CASA issues procedure design
authorisations and, procedure design certificates. Such
authorisations have been provided to officers of Airservices
Australia. CASA may also determine an instrument approach procedure
under CAR 178(6). CASA validates new approaches by confirming that
they meet the PANS - OPS criteria and test flying.

In the case of revalidation of an approach, CASA also test flies
the approach concentrating on the identification of changes in
physical obstacles, airspace, or traffic which may affect the
approach.

CASA has developed a draft Advisory Circular (AC) which contains
guidance, procedures and checklists to validate instrument
approaches. This draft AC also covers issues such as approach
fly-ability, and pilot workload (based on the standard of a
recently rated pilot).

The draft AC is being used as the basis for the revalidation of
a number of approaches. This project commenced in February, and to
date CASA has completed approximately 100 approaches.

A final version of the AC will be settled once the revalidation
project is completed and is expected to be made available to
industry at the end of 2008.

ATSB Response

The ATSB notes the actions being taken by CASA to address this
safety issue and has amended the status of this recommendation to '
Monitor'.

ATSB Response date
Date Received
Organisation
Civil Aviation Safety Authority
Response Text

On 11 August 2008, CASA and Airservices staff flew the Runway 12
RNAV GNSS approach with an aircraft fitted with a Garmin 430w GPS
and TAWS-B. The first approach was flown using the 3.49 degree
profile on autopilot. No terrain or 'pull-up' warnings were
received. After flying the approach on profile, two lower than
profile approaches were flown, below the cloud base (around 2500')
along the laterally guided flight path. On each occasion the
terrain warning and pull up functions of the TAWS sounded well
before the significant ridges. It was also noted by the operating
pilot that the approach was no more difficult to fly than any other
he had experienced.

...

I have also attached, for your information, a more detailed
report with recommendations for further CASA action. I understand
that these outcomes have been communicated to your staff and that
it has been agreed that TAWS A warnings could be experienced on a
range of approaches besides RNAV GNSS depending on the aircraft
configuration and the nature of terrain in the vicinity and was
affected by any pilot decision to not fly the optimum profile as
published. This is not a circumstance unique to Lockhart River or
RNAV (GNSS) approaches.

...

Recommendations

...

4. Consideration be given to a CASA funded TAWS A to be fitted
to the Radiola (VH) conquest for CASA for project development
applications and CASA staff training.

ATSB Response

The ATSB is concerned that the flight test did not provide a
true validation test as the TAWS Class B (TAWS-B) as fitted to the
test aircraft is a reduced capability system aimed at reducing the
cost of the equipment for use in general aviation. The primary
difference between TAWS-A and TAWS-B is that TAWS-B does not
include the basic GPWS components, which are dependent upon a
height input from a radio altimeter. As such, it is our
understanding that the aircraft was not appropriately equipped to
conduct flying to validate (or otherwise) the activation of the
ground proximity warning system mode 2A warnings that was the
subject of ATSB recommendations R20070005 and R20070008.

The ATSB agrees with the observation 'TAWS A warnings could be
experienced on a range of approaches besides RNAV GNSS depending on
the aircraft configuration and the nature of terrain in the
vicinity ... This is not a circumstance unique to Lockhart River or
RNAV (GNSS) approaches.'

The ATSB agrees with the recommendation attached to the CASA
letter of 30 September 2008 with the aim that the TAWS A system be
used as part of the systematic validation of approach designs as
per ATSB recommendation R20070005.

Date Received
Organisation
Civil Aviation Safety Authority
Response Text

CASA further advised that:

  • CASA had published a number of articles regarding the use of
    stabilised approach techniques when flying non-precision
    approaches. CASA was also in the process of developing further
    educational material relating to the operation and use of terrain
    awareness warning system Class A (TAWS-A) equipment, with
    particular emphasis on the need for operators to ensure adequate
    pilot training in the characteristics of the equipment fitted to
    their aircraft, and operational practices that maximise the benefit
    of the equipment.
  • CASA had purchased a set of TAWS-A equipment that is currently
    being fitted to a Cessna Conquest aircraft for use in approach
    validation. The effort will initially focus on revalidating
    approaches at aerodromes in the vicinity of steep, high terrain to
    determine the potential for terrain alerts. The information will
    then be used in the consideration of the priority for the design of
    approaches with vertical guidance (APV), or for the redesign of an
    approach where that would be beneficial and feasible.
  • The new design for the Lockhart River Runway 12 RNAV (GNSS)
    approach is expected to be validated in early August 2009 using the
    TAWS-A equipped aircraft, and will be promulgated as soon as
    practical after the successful completion of that flight
    validation.

 

Date Received
Organisation
Airservices Australia
Response Text

On 18 September 2009, Airservices Australia advised the ATSB
that the Lockhart River runway 12 RNAV (GNSS) non-precision
approach had been redesigned and flight validated. The flight
validation was conducted with a TAWS-A equipped aircraft and the
'the procedure did not trigger terrain warnings'. The new approach
will be published in the Aeronautical Information Publication
amendment effective 19 November 2009.

Date Received
Organisation
Airservices Australia
Response Text

In response to the ATSB Safety Issue investigation AI-2007-010,
Airservices Australia advised the ATSB that Airservices would
redesign the Lockhart River Runway 12 RNAV (GNSS) non-precision
approach using the latest revision of the ICAO PANS-OPS procedures
that were released on 31 October 2008.

On 13 May 2009, Airservices Australia provided the ATSB with a
draft of a revised approach design. The redesigned approach had a
final approach path that was aligned with the runway (119° M),
which resulted in the approach moving to the south of the South Pap
ridge. The revised approach is currently being validated prior to
its approval for use.

Date Received
Organisation
Civil Aviation Safety Authority
Response Text

In response to the ATSB Safety Issue investigation AI-2007-010,
CASA advised the ATSB that CASA would support Airservices in the
design and approval of the Lockhart River Runway 12 RNAV (GNSS)
non-precision approach to the latest revision of ICAO PANS-OPS.