Improved alarms, training and software to be implemented following 2004 accident

Australian air traffic services provider Airservices Australia has implemented a range of safety improvements after the investigation into the controlled flight into terrain crash of a Piper PA-31T Cheyenne in Victoria in July 2004 uncovered a number of weaknesses in its procedures.

Air traffic controllers failed to inform the pilot that he had veered off course just before the crash, despite controllers receiving two route adherence monitoring (RAM) alarms informing them of the deviation. The Australian Transport Safety Bureau (ATSB) says it is unlikely to ever know why the aircraft went off course.

The aircraft was on a private flight from Sydney Bankstown to Benalla in Victoria with five passengers and one pilot. The pilot had flown the route every week since 1988 but on this occasion diverged between 3.5° and 4° left of track, with the pilot unaware of the tracking error. Contrary to procedures, following the RAM alarms the controller did not question the pilot about his position, believing that he was tracking to another waypoint. The aircraft crashed, nearly 30km (16nm) off course, in cloud-covered terrain, killing all on board.

Airservices has introduced an enhanced suite of audible and visual alarms to its air traffic management system; improved training and controller assessment; and removed any ambiguity about the required response to alarms. In addition, later this year it will implement a software upgrade to the air traffic maangement system to display an aircraft’s cleared route.

The ATSB has also recommended that the Civil Aviation Safety Authority review requirements for the carriage of on-board recording devices on Australian registered aircraft.


Source: Flight International