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AACM completes investigation on Air Macau’s loss of communication occurrence


With reference to media reporting of the occurrence regarding the loss of communication during cruise that took place on 01 October 2011 of an Air Macau wet leased operation, AACM has now completed its investigation. The occurrence and the investigation conclusions are summarized as follows: On 01 October 2011, the Air Macau wet leased flight (Air China Flight CCA101) which was destined to Hong Kong International Airport took off from Beijing Capital International Airport at 0844. From 0921 to 1037, the air traffic control centres that CCA101 passed through were not able to establish contact with the flight for more than one hour. The flight landed at Hong Kong International Airport at 1139. During this occurrence, the cabin conditions were normal and no passengers were affected. (A wet lease is a special leasing arrangement between two airlines whereby the lessor provides an aircraft, complete crew, maintenance, and insurance to the lessee. The lessor aircraft logo and the registration mark remain unchanged.) In accordance with the Mandatory Occurrence Reporting System established by the Civil Aviation Authority of Macao SAR (AACM), Air Macau notified the Authority on the same day after the occurrence. Having analysed the nature, AACM mobilized its investigation. Air Macau was also required to find out the root cause and submit their report. The operator subsequently suspended the duties of the two flight crew members to assist in the investigation. Air Macau submitted their report to AACM on 28 October 2011, which AACM has analyzed. The Authority has interviewed the flight crew members to obtain their statements as well as carried out a thorough review on all relevant information, including the maintenance records of the aircraft, the data decoded from the digital flight data recorder and cabin voice recorder, the training and the duty time records of the flight crew, the air ground communication records of the air traffic controllers and so on. After review and analysis of all factual information, data and the flight crew statements, the investigation did not find any factors on the part of the ground and air communication equipment and the air traffic control operations that could have contributed to the occurrence. The factual information indicated that the flight crew members are properly licensed with airline traffic pilot license and are technically qualified to operate the flight. Their duty time complied with the Air Navigation Regulation of Macau. AACM's investigation report concluded that the causal factor in this occurrence was the flight crew's negligence in maintaining an effective radio listening watch. In addition, the flight crew members' failure to set and monitor the guard frequency and their lack of situational awareness during flight are factors contributing to the occurrence. For the purpose of preventing recurrences in order that safety can be maintained, AACM's investigation report listed out 14 safety recommendations for Air Macau to take action, which include: the operator should take concrete steps to enhance flight crew members' understanding of and compliance with their operational procedures and instructions in flight operations, particularly in maintaining radio listening watch and setting and checking correct radio frequency; the operator should look into their certificate of maintenance review process for effective checking of compliance status to relevant regulations and requirements; the operator should take concrete steps to enhance line maintenance personnel's understanding of and performing maintenance work; the operator should study and increase the frequency of line proficiency checks conducted to flight crew members in wet lease flights and ensure that these checks are conducted on regular basis; the operator should, as part of their Safety Management Systems, assess the safety risks of mixed operations of wet lease flights and apply mitigation measures to control the risk probability. In the aspect of safety monitoring work, AACM will enhance oversight on aircraft equipment status during the renewal process of the aircraft certificate of airworthiness. Analysing the nature of this occurrence and the investigation conclusions, in accordance with Provisions 1 (3) and 3 of Article 20 of the Administrative Regulation No. 10/2004 and Paragraph 4 of the Thirteenth Schedule of the Air Navigation Regulation of Macau, AACM has decided to suspend the license of the two flight crew members for 6 months. AACM reiterates that the purpose of investigation is to look for the casual factors so that effective corrective actions can be implemented to avoid similar recurrences in the future.



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