Namibian Civil

Aviation Authority

4 Rudolf Herzog
Street
P/Bag 12003
Auspannplatz

Safety Promotion
and Quality
Department

[email protected]
Ph. 083 235 2511 or
083 235 2468

APRIL Safety
MATTERS
2023

Providing the Namibian aviation industry and users with

vital information on the latest aviation safety statistics
and reports for the continuous improvement of safety
systems:
Shared Knowledge = Improved Safety

www.ncaa.com.na
 This monthly publication will keep industry, NCAA, license
holders, and the general public updated in terms of what
has occurred in safety monthly within the industry. All
reports are de-identified and no attempt should be made
to identify the reporter in this or any other avenue unless
specific authorisation is given.

Contents
Safety Statistics........................3
Reporting Culture....................4
SPIs.........................................5
Quote of the Month..................5
Competition............................6
Meet the Team, AIR.................8
Occurrences............................9
Training feedback..................17
Reporting Practices................19
Drum Fuelling........................20
Safety Updates.......................21

Safety Bulletin - April 2023 www.ncaa.com.na Page 2

 The Safety Data Collection and Processing System (SDCPS) is the tool that drives the State
Safety Programme. The SDCPS collates information from sources such as reports and audit
findings, observations, investigation reports and many other means, and presents them in
meaningful graphs and tables. This data is presented in the next three pages.

Safety Statistics
April 2023
In April there were 35 safety reports, with six medium risk events, two high risk events (one
from March not reported in last month edition), and the remaining twenty eight were low
risk. Three of the medium events were wildlife encounters. There were no accidents reported
in April. There were no accidents reported in April.

The year-to-date figures for risks show approximately 78% low risk, 18% medium risk, and only
3.5% high risk. A small improvement over last month and a continuation of the positive start
to the year.

For more about classifications of risk see the definitions in Safety Bulletin 1-22.

Graphs included in this document show year to date figures unless specified.

Safety Bulletin - April 2023 www.ncaa.com.na Page 3

 In April NCAA recorded 19 voluntary reports inclusive of three hazard reports. There
were 13 mandatory reports, including the nine maintenance events. This brings the
total year to date down slightly to 72% non-mandatory reports and the total 12
month rolling accident rate is reduced to 0.257 per 1000 movements.

REPORTING CULTURE

An effective safety management system needs an effective reporting culture. Help

NCAA to help you by reporting quickly and effectively. Email [email protected] or
use the following link: https://forms.office.com/r/WhYcLFfmmu

Safety Bulletin - April 2023 www.ncaa.com.na Page 4

Safety Performance Indicators
April saw another positive month in terms of SPIs with NO events above target and NO

SPIs
alerts! Further there were four categories with no reports. The one global high risk
category with an event was loss of separation, an occurrence in unmanned airspace,
see more under occurrences. Maintenance and technical was below target with only
nine events and wildlife was well below the target and also below the ICAO
recommended level, with only three events.
Note: All alerts levels are calculated based on the "Standard Deviation Method" described in
ICAO safety Management Manual and targets are set approximately 10% below the previous
year average.

Safety Thought for the Month

”Practicing safety may get old -BUT- so do those who practice it!” - Anon

f e !
y Sa

Sta Reporting
Safety Bulletin - April 2023 www.ncaa.com.na Page 5
 Safety

NCAA is proud to announce an aviation safety social media competition for schools,
as follows:

1. Submit an aviation safety social media graphic or short video. This competition is
open only to school age children. Submissions shall include name, age, grade,
and school.

If you have any questions about this competition please ask us at [email protected].

Safety Bulletin - April 2023 www.ncaa.com.na Page 6

 Safety

NCAA is proud to announce an aviation safety story competition, as follows:

1. Submit an aviation safety article of 600 to 1000 words with one image. This
competition is open to anyone outside NCAA SPQ department (there are three
prizes for internal and three prizes for external);

If you have any questions about this competition please ask us at [email protected].

Safety Bulletin - April 2023 www.ncaa.com.na Page 7

 Meet the Team - AIR
About the Airworthiness Team
AIR is responsible for approval of aviation maintenance
organisations (AMOs) This includes initial certification, annual
and ad-hoc surveillance for all the Namibian AMOs and all the
AMOs which serve Namibian aircraft in other countries.
Currently this are 9 local and 22 foreign organisations surveilled.
AIR is also the department responsible for all the certificates of
registration and maintaining the aircraft register and they issue
and renew all of the certificates of airworthiness for
approximately 700 aircraft. AIR further issues or validates ferry
flight permits, required if you must fly an aircraft to a
maintenance base, and validates special flight permits for non-
type certified aircraft visiting from abroad. They assist OPS with
MEL approvals, and they are responsible when a maintenance
occurrence needs investigation. This is just to mention a few!

Isak Nangombe
Hamunyela Kayone

Under the leadership of Mr. Robert Mathe, Senior Manager, the AIR team work tirelessly to keep
our aircraft flying in an airworthy state and reducing technical or maintenance events. If you
have any questions about airworthiness, reach out to the AIR team on [email protected], the
designated inspector will respond.

NCAA aims to include one safety oversight section each month so you can get to know our
inspectors and the eight different safety/security oversight sections' roles and responsibilities.
These sections comprise, AGA, AIR, ANSSO, AvSec, CRR, OPS, PEL, and SPQ.

Safety Bulletin - April 2023 www.ncaa.com.na Page 8

 SAFETY OCCURRENCES
APRIL 2023

TECHNICAL FAULTS
(MANDATORY, LOW RISK, AIR)

There were nine technical events reported in April, as follows:

Of note is a flight control jam on a maintenance test flight. This

highlights the importance of adequate post maintenance and pre-flight
checks. The crew did well to pick up the fault prior to flight.

Note that nearly all unscheduled failures require an incident report. This
need not be a lengthy dissertation, that is, it shouldn't take you too much
time, only a brief summary of the most likely or determined cause of the
failure. This is important for trending and/or for preventative
maintenance. Please see the April 2022 article on service difficulty reports
(SDRs) and mandatory occurrence reports (MORs).

Safety Bulletin www.ncaa.com.na Page 9

 SAFETY OCCURRENCES
APRIL 2023

WILDLIFE STRIKES
(VOLUNTARY, MEDIUM RISK, AGA)

There were three wildlife events reported in April, two bird encounters and one
encounter with springbok. This is a positive step forward in our wildlife management
programmes.

Note: Bird strikes, while the damage is normally negligible, are a frequent occurrence
so fall into the medium risk category.

While it is a little early to determine if there are any trends in our wildlife report
tracking for interest sake we provide the below table illustrating the wildlife strikes
to date since establishing our safety data collection and processing system. UPDATE
TABLE!!

Safety Bulletin www.ncaa.com.na Page 10

 SAFETY OCCURRENCES
APRIL 2023

LOSS OF SEPARATION EVENT, UNMANNED

(MANDATORY, HIGH RISK, OPS)

There was one loss of separation event which occurred in unmanned

airspace.
Two company scheduled flights were inbound to an unmanned airport.
Another non-scheduled jet was inbound estimating around the same
time. The traffic was in contact with each other on the radio and was
acutely aware of the need to look out - however see and avoid has
limitations in high performance jets due to the speed of closure. The
scheduled traffic was also looking out on their TCAS, however no
targets were shown. When one of the scheduled arrivals acquired a
visual target on the non-scheduled arrival there was approximately
3nm clearance. This is very small given the relative closure rates.

All pilots are reminded of the importance of ensuring transponders are

on and working. They can be the difference between a non-event and an
accident!

Safety Bulletin www.ncaa.com.na 11

 SAFETY OCCURRENCES
APRIL 2023

GO AROUNDS AND DIVERSIONS

(VOLUNTARY, LOW RISK, OPS)

The following table details go arounds and diversions during April:

*Of note, in the go around reported at FYOG, the ATIS reported the
visibility and cloud as VMC, while when the approach was flown to
minimums no visual contact could be made. Even with the best of
meteorological equipment weather reports can sometimes be
inaccurate so always remember to be prepared!

FLIGHT AND DUTY PERIOD EXCEEDANCE

(MANDATORY, MEDIUM RISK, OPS)

There were two events of flight and duty period exceedance in April.

In one case a pilot was rostered off prior to a night flight and was called
into the office to attend to office duties.

Managers are warned that NCAA does not take such actions lightly. If a
pilot is rostered off the must be completely free from duties and no action
by management or other staff should cause them to make a decision to
attend to duties on their off time.

In a second case weather delayed the flight and the pilot elected to
utilise the 3 hour PIC discretionary period.

Pilots are advised to use PIC discretion with caution, however there is
sometimes good reason. Always submit a report following PIC discretion
report followg such an event.

Safety Bulletin www.ncaa.com.na Page 12

 SAFETY OCCURRENCES
APRIL 2023

MET FACILITIES
(MANDATORY, LOW RISK, ANSSO)

There were three MET services reports in April:

ATS FACILITIES
(MANDATORY, LOW RISK, ANSSO)

There were two ATS failures occurring in April, one which was recurrent:

Safety Bulletin www.ncaa.com.na Page 13

 SAFETY OCCURRENCES
APRIL 2023

PRECAUTIONARY LANDING - WRONG FUEL

(MANDATORY, HIGH RISK, OPS)

A helicopter refuelled from drum fuel on a farm location. While the

drum indicated Avgas and the pilot checked the labelling to ensure it
said Avgas, they omitted to complete a sample directly from the drum
prior to refuelling. A sample was taken from the fuel tank, however the
new fuel was resting on top and did not enter the sample so all
appeared satisfactory. The helicopter took off and immediately the
temperature gauges began to climb, whereupon the pilot began looking
for a place to land, and the engine began running rough. The pilot
completed a successful precautionary landing without further damage.
When the AMO inspected the engine it was discovered that the drum
labelled Avgas in fact contained Jet-A1.

NCAA has immediately taken action on this event by tracking the fuel
fault with the supplier and the event was tracked to one farm worker and
one drum being ordered to be filled incorrectly. Additionally, guidance
material has been sent out warning messages to all operators about the
precautions to use when fueling from drums. See more on page 20.
Fortunately, through the pilot's quick actions this was not more serious.

Safety Bulletin www.ncaa.com.na Page 14

 SAFETY OCCURRENCES
APRIL 2023

NOTAM FORMAT
HAZARD, LOW RISK, AIM)

It was reported that the format of NOTAMs for hazards and surveys is
very cumbersome to work with when there is only co-ordinates and no
location reference. It was requested that AIM consider to include an
aerodrome reference point, for example "15nm SSE of FYOA".

This report was referred to AIM, ANSSO, and OPS for further comment and
we will report back in the feedback section once a response is received.

ALLEGED LOW LEVEL FLIGHT

HAZARD, MEDIUM RISK, OPS)

There was a report of alleged low flying in the Swakopmund area. The
report was investigated and found to be unsubstantiated, however
pilots and operators are reminded of the importance of adherence to
NAMCAR 91.06.33 at all times.

NCAA will be vigilant on investigating all allegations of low flying.

Enforcement action will be taken where needed of these matters and
pilots/operators are warned of potential fines in the region of up to 30k.

Safety Bulletin www.ncaa.com.na Page 15

 SAFETY OCCURRENCES
APRIL 2023

ILLEGAL PARAGLIDING OPERATIONS

(MANDATORY, MEDIUM RISK, OPS)

A paraglider operation on the coast was discovered to be operating

contrary to Part 106 and Part 149, in that the operator was not a
member of a Part 149 operation and did not have a license or
certificate.

Under NAMCAR Part 98, 106, and 149, powered paragliders, paragliders,
and hang gliders are required to have a valid membership to a Part 149
association and all pilots are required to have a valid license or
certificate for operation.

OPS is investigating this matter for possible enforcement action.

INTOXICATED PASSENGER
(MANDATORY, LOW RISK, OPS)

A commercial operator off loaded a passenger due to intoxication.

Operators are reminded of the importance of not tolerating any

passengers that are intoxicated. Intoxication on board an aircraft is an
offence under Section 217 of the Civil Aviation Act, 2016.

Safety Bulletin www.ncaa.com.na Page 16

 Safety Updates
NCAA Safety Workshop
NCAA thanks everyone for their participation in the Safety Workshop
on the 27th April. We will be planning the next one for the 7th
September, and welcome industry participation, this must be a joint
venture. Watch this space!

For enquiries about presenting or sponsoring the next workshop:

Danielle Bruckert 083 235 2468, [email protected] or [email protected]

Safety Bulletin - April 2023 www.ncaa.com.na Page 17

 Safety Updates
NCAA Safety Training - AGA
Approximately 60 people from NCAA and industry were trained in two
courses presented by Airports Council International, namely, Runway
Safety Management and Global Reporting Format (for runway
surfaces). NCAA congratulates the AGA team on a job well done!

For enquiries about upcoming safety training courses keep watching

this space or contact [email protected].

Safety Bulletin - April 2023 www.ncaa.com.na Page 18

Safety Bulletin - April 2023

SAFETY ARTICLE:

REPORTING PRACTICES
Firstly we want to congratulate the industry on improved reporting practices.
However secondly we need to remind everyone that we still have a long way to go!

Of primary concern when we receive reports at the NCAA is that a large number of
incidents involve multiple reporting parties. For example an in-flight turn back
(IFTB), often a result of a technical event, can be a mandatory report. It should be
reported on the first instance by the pilot. However there should also be a report
from the air traffic controller, and further from the aviation maintenance
organisation, and in some cases also from the aerodrome operator. That is one event
can have a potential 4 reports. If we receive all these reports follow up is very quick
and trouble free. However in most cases we receive one and if we are luck two.

Further for any mandatory report it is essential that the safety manager submit the
closure of the SMS investigation to the NCAA. This allows us to know that action has
been taken and the matter resolved. Please do expect us to be asking for this, either
via your assigned inspector of through SPQ.

Finally, there is an aspect we see so little of, but is so crucial for our progression from
a reactive to proactive approach to safety, and that is Hazards. Please remind your
employees or members at your safety meetings to be conscious of hazards. Only by
identifying hazards before they create an event, can we truly become proactive and
not just reactive. The more aware we are of alerting others about any hazards we
observe, the more safety will improve for all of us. The safer our skies become the
better our chances of attracting tourism, more air carriers, and more jobs in the
industry, and the growth of the industry will prevail. So help us all help the industry
grow by proactively looking for and timely reporting of hazards.

Prepared by :
SPQ www.ncaa.com.na Page 19
Safety Bulletin - April 2023

SAFETY ARTICLE:

DRUM FUEL PRACTICES

A recent issue with incorrect fuel from a drum has led us to source some guidance
material for drum fueling. We remind aviators, farm owners, and aerodrome
operators, of the key importance of following safety protocols when refueling from
drums, including the following key points.
1. Drums should be clean correctly labelled and ONLY refill according to the label;
2. Ensure a qualified, trained, and briefed person only is sent to procure fuel refills;
3. Where the drum is from the factory check the batch and expiry date and keep a
record of the same;
4. When using a partial drum have a proper record of when the drum has been
used and what has been taken by which aircraft.
5. Always sample the fuel from the drum BEFORE decanting into the aircraft;
6. Always decant a small amount of fuel into a container before beginning fueling
(can be part of your sampling), to ensure that there is no sediment or water and
that the fuel is correct;
7. Always use a go/no-go filter when decanting from a drum and check the filter
before and after refueling;
8. When sampling after decanting into the aircraft allow sufficient time for the fuel
to mix and settle;
9. Always ensure proper grounding is completed, especially in our dry
environment;
10. Ensure all pipes are securely connected and clamped and electrical connections
are secure and shielded;
11. Always have a fire extinguisher present;
12. If you are a commercial operator, it is essential to ensure your drum refueling
procedure is in your operations manual.

Drum fueling is a critical function to our

beautiful expansive and sparsely populated
aviation environment, however only with
essential safety precautions can we ensure
that refueling does not introduce
unnecessary hazards and risks.

Stay safe!

Prepared by :
SPQ www.ncaa.com.na Page 20
 Safety Updates
Articles and Ask NCAA
NCAA values your input and we have created this forum for answering
questions industry may have or requests for publications. Feel free to drop us a
line and enquire: [email protected].

Publications
The National Aviation Safety Plan has
been approved by the Board and will be
available on the website soon.

Advisory pamphlets have been released

on SMS Implementation as promised,
including a gap analysis tool which is
compliant with NAMCARs. Another
Advisory pamphlet was released about
the confidential reporting system.

NCAA advises all those concerned that Part 187 is currently in

consultation and anyone wishing to discuss the draft regulation should
email [email protected].

Invitation to Contribute
Service providers and users are invited to contribute topics and ideas or articles
to NCAA SPQ department for consideration in our safety publications or safety
workshops. Remember the safety system only works with participation and
information sharing is key to continuous improvement and achieving global
aviation safety goals.

Further information requests, submissions, or queries can be sent to:

email: [email protected]
phone: 083 235 2468

Safety Bulletin - April 2023 www.ncaa.com.na Page 21