Aviation News, Headlines & Alerts
 
Category: <span>NTSB Advisory</span>

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FOUR RECENT UNCONTAINED ENGINE FAILURE EVENTS PROMPT NTSB TO ISSUE URGENT SAFETY RECOMMENDATIONS TO FAA

The National Transportation Safety Board today issued two
urgent safety recommendations to the Federal Aviation
Administration (FAA). The first recommendation asks that the
FAA require operators of aircraft equipped with a particular
model engine to immediately perform blade borescope
inspections (BSI) of the high pressure turbine rotor at
specific intervals until the current turbine disk can be
redesigned and replaced with one that can withstand the
unbalance vibration forces from the high pressure rotor. The
second recommendation asks the FAA to require the engine
manufacturer to immediately redesign the disk. The NTSB
issued an additional recommendation for a requirement that
operators perform a second type of inspection and another
recommendation related to the engine manufacturer regarding
the installation of the replacement disk.

All four recommendations apply to the low pressure turbine
(LPT) stage 3 (S3) rotor disk in the General Electric (GE)
CF6-45/50 series turbofan engines that can fail unexpectedly
when excited by high-pressure (HP) rotor unbalance.

An uncontained engine event occurs when an engine failure
results in fragments of rotating engine parts penetrating
and exiting through the engine case. Uncontained turbine
engine disk failures within an aircraft engine present a
direct hazard to an airplane and its passengers because
high-energy disk fragments can penetrate the cabin or fuel
tanks, damage flight control surfaces, or sever flammable
fluid or hydraulic lines. Engine cases are not designed to
contain failed turbine disks. Instead, the risk of
uncontained disk failure is mitigated by designating disks
as safety-critical parts, defined as the parts of an engine
whose failure is likely to present a direct hazard to the
aircraft.

In its safety recommendations to the FAA, the NTSB cited
four foreign accidents, which the NTSB is either
investigating or participating in an investigation led by
another nation, in which the aircraft experienced an
uncontained engine failure of its GE CF6-45/50 series
engine.

The date, location, and circumstances of these four events
(none had injuries or fatalities) are as follows:

On July 4, 2008, a Saudi Arabian Airlines (Saudia) Boeing
747-300 experienced an engine failure during initial climb
after takeoff from Jeddah, Kingdom of Saudi Arabia. This
investigation has been delegated to the NTSB.

On March 26, 2009, an Arrow Cargo McDonnell Douglas DC-10F,
about 30 minutes after takeoff from Manaus, Brazil,
experienced loss of oil pressure in one engine. The pilots
shut down the engine and diverted to Medellin, Columbia.
This investigation has been delegated to the NTSB.

On December 17, 2009, a Jett8 Cargo Boeing 747-200F airplane
was passing through 7,000 feet above ground level (agl) when
the flight crewmembers heard a muffled explosion and
immediately applied left rudder. With one engine losing oil
pressure, the airplane returned to land at Changi,
Singapore. The NTSB is participating in the investigation
that is being led by the Air Accident Investigation Bureau
of Singapore.

On April 10, 2010, an ACT Cargo Airbus A300B4 experienced an
engine failure while accelerating for takeoff at Manama,
Bahrain. The crew declared an emergency, rejected the
takeoff, activated the fire suppression system, and
evacuated the airplane. The NTSB is participating in the
investigation that is being led by the Bahrain Ministry of
Transportation – Civil Aviation.

The four recommendations to the FAA are as follows:
1. Immediately require operators of CF6-45/50-powered
airplanes to perform high pressure turbine rotor blade
borescope inspections every 15 flight cycles until the
low pressure turbine stage 3 disk is replaced with a
redesigned disk that can withstand the unbalance
vibration forces from the high pressure rotor.
(Urgent)
2. Require operators of CF6-45/50-powered airplanes to
perform fluorescent penetrant inspections of CF6-45-
50- low pressure turbine stage 3 disks at every engine
shop visit until the low pressure turbine stage 3 disk
is replaced with a redesigned disk that can withstand
the unbalance vibration forces from the high pressure
rotor.
3. Immediately require General Electric Company to
redesign the CF6-45/50 low pressure turbine stage 3
disk so that it will not fail when exposed to high
pressure rotor unbalance forces. (Urgent)
4. Once General Electric Company has redesigned the CF6-
45/50 low pressure turbine (LPT) stage 3 disk in
accordance with Safety Recommendation [3], require all
operators of CF6-45/50-powered airplanes to install
the newly designed LPT S3 at the next maintenance
opportunity.


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NTSB Parental Safety Alert

The National Transportation Safety Board today issued a
Safety Alert to advise parents of the dangers to young
children on aircraft when not restrained in an approved
child restraint system or device. The Safety Alert notes
that preventable injuries and deaths have occurred in
children younger than 2 years who were unrestrained.

Specific child passenger safety issues on aircraft include
the likelihood that parents and caregivers may not be able
to maintain a secure hold on a lap-held child during
turbulence and survivable accidents. Additionally,
unrestrained children have become separated from their
parents during survivable crashes and parents were unable to
locate them during the evacuation.

“As the summer travel season gets underway, the NTSB would
like to remind families traveling with children that child
restraints are the best way to keep youngsters safe –
whether traveling by car or air,” said NTSB Chairman Deborah
A.P. Hersman. “While the NTSB would still like to see a
federal regulation requiring the use of child restraints on
aircraft, we continue to recommend that, when traveling by
air, all parents purchase an airline ticket for every child
in the family and place each child in a size-appropriate
restraint system to ensure that everyone travels safely.”


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NTSB SENDING TEAM TO ASSIST GOVERNMENT OF INDIA WITH YESTERDAY’S AIRLINER ACCIDENT

National Transportation Safety Board
Washington, DC 20594

May 22, 2010

The National Transportation Safety Board is dispatching a
team of investigators to assist the government of India with
its investigation of yesterday’s airplane accident in
Mangalore.

At about 6:10 a.m. local time, Saturday, an Air India
Express B737-800 (VT-AXV), overran the runway during landing
at Mangalore International Airport. Preliminary reports
indicate that 158 of the 166 passengers and crew onboard
were fatally injured. Flight #182 originated in Dubai.

NTSB Chairman Deborah A.P. Hersman has designated Senior Air
Safety Investigator Joe Sedor as the U.S. Accredited
Representative. The U.S. team will also include an NTSB
flight operations specialist, an NTSB aircraft systems
specialist, and technical advisors from the Federal Aviation
Administration and Boeing. The team is expected to arrive
in Mangalore on Tuesday morning (local time).

The investigation is being conducted by India’s Directorate
General of Civil Aviation, which will release all
information on the progress of the investigation.


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NTSB Safety Recommendations

The National Transportation Safety Board makes the following
recommendations to the Federal Aviation Administration:
Work with the military, manufacturers, and National
Aeronautics and Space Administration to complete the
development of a technology capable of informing pilots
about the continuing operational status of an engine. (A-10-
62)

Once the development of the engine technology has been
completed, as asked for in Safety Recommendation A-10-62,
require the implementation of the technology on transport-
category airplane engines equipped with full-authority
digital engine controls. (A-10-63)

Modify the 14 Code of Federal Regulations 33.76(c) small and
medium flocking bird certification test standard to require
that the test be conducted using the lowest expected fan
speed, instead of 100-percent fan speed, for the minimum
climb rate. (A-10-64)

During the bird-ingestion rulemaking database (BRDB) working
group’s reevaluation of the current engine bird-ingestion
certification regulations, specifically reevaluate the 14
Code of Federal Regulations (CFR) 33.76(d) large flocking
bird certification test standards to determine whether they
should 1) apply to engines with an inlet area of less than
3,875 square inches and 2) include a requirement for engine
core ingestion. If the BRDB working group’s reevaluation
determines that such requirements are needed, incorporate
them into 14 CFR 33.76(d) and require that newly
certificated engines be designed and tested to these
requirements. (A-10-65)

Require manufacturers of turbine-powered aircraft to develop
a checklist and procedure for a dual-engine failure
occurring at a low altitude. (A-10-66)

Once the development of the checklist and procedure for a
dual-engine failure occurring at a low altitude has been
completed, as asked for in Safety Recommendation A-10-66,
require 14 Code of Federal Regulations Part 121, Part 135,
and Part 91 Subpart K operators of turbine-powered aircraft
to implement the checklist and procedure. (A-10-67)

Develop and validate comprehensive guidelines for emergency
and abnormal checklist design and development. The
guidelines should consider the order of critical items in
the checklist (for example, starting the auxiliary power
unit), the use of opt outs or gates to minimize the risk of
flight crewmembers becoming stuck in an inappropriate
checklist or portion of a checklist, the length of the
checklist, the level of detail in the checklist, the time
needed to complete the checklist, and the mental workload of
the flight crew. (A-10-68)

Require 14 Code of Federal Regulations Part 121, Part 135,
and Part 91 Subpart K operators to include a dual-engine
failure scenario occurring at a low altitude in initial and
recurrent ground and simulator training designed to improve
pilots? critical-thinking, task-shedding, decision-making,
and workload-management skills. (A-10-69)

Require 14 Code of Federal Regulations Part 121, Part 135,
and Part 91 Subpart K operators to provide training and
guidance to pilots that inform them about the visual
illusions that can occur when landing on water and that
include approach and touchdown techniques to use during a
ditching, with and without engine power. (A-10-70)

Work with the aviation industry to determine whether
recommended practices and procedures need to be developed
for pilots regarding forced landings without power both on
water and land. (A-10-71)

Require applicants for aircraft certification to demonstrate
that their ditching parameters can be attained without
engine power by pilots without the use of exceptional skill
or strength. (A-10-72)

Require Airbus operators to amend the ditching portion of
the Engine Dual Failure checklist and any other applicable
checklists to include a step to select the ground proximity
warning system and terrain alerts to OFF during the final
descent. (A-10-73)

Require Airbus operators to expand the angle-of-attack-
protection envelope limitations ground-school training to
inform pilots about alpha-protection mode features while in
normal law that can affect the pitch response of the
airplane. (A-10-74)

Require all 14 Code of Federal Regulations Part 139-
certificated airports to conduct wildlife hazard assessments
(WHA) to proactively assess the likelihood of wildlife
strikes, and, if the WHA indicates the need for a wildlife
hazard management plan (WHMP), require the airport to
implement a WHMP into its airport certification manual. (A-
10-75)

Work with the U.S. Department of Agriculture to develop and
implement innovative technologies that can be installed on
aircraft that would reduce the likelihood of a bird strike.
(A-10-76)
Require Airbus to redesign the frame 65 vertical beam on
A318, A319, A320, and A321 series airplanes to lessen the
likelihood that it will intrude into the cabin during a
ditching or gear-up landing and Airbus operators to
incorporate these changes on their airplanes. (A-10-77)

Conduct research to determine the most beneficial passenger
brace position in airplanes with nonbreakover seats
installed. If the research deems it necessary, issue new
guidance material on passenger brace positions. (A-10-78)

Require, on all new and in-service transport-category
airplanes, that cabin safety equipment be stowed in
locations that ensure that life rafts and/or slide/rafts
remain accessible and that sufficient capacity is available
for all occupants after a ditching. (A-10-79)

Require quick-release girts and handholds on all evacuation
slides and ramp/slide combinations. (A-10-80)

Require 14 Code of Federal Regulations Part 121, Part 135,
and Part 91 Subpart K operators to provide information about
life lines, if the airplane is equipped with them, to
passengers to ensure that the life lines can be quickly and
effectively retrieved and used. (A-10-81)

Require that aircraft operated by 14 Code of Federal
Regulations Part 121, Part 135, and Part 91 Subpart K
operators be equipped with flotation seat cushions and life
vests for each occupant on all flights, regardless of the
route. (A-10-82)

Require 14 Code of Federal Regulations Part 121, Part 135,
and Part 91 Subpart K operators to brief passengers on all
flotation equipment installed on an airplane, including a
full demonstration of correct life vest retrieval and
donning procedures, before all flights, regardless of route.
(A-10-83)

Require modifications to life vest stowage compartments or
stowage compartment locations to improve the ability of
passengers to retrieve life vests for all occupants. (A-10-
84)

Revise the life vest performance standards contained in
Technical Standard Order-C13f to ensure that they result in
a life vest that passengers can quickly and correctly don.
(A-10-85)

Conduct research on, and require 14 Code of Federal
Regulations Part 121, Part 135, and Part 91 Subpart K
operators to implement, creative and effective methods of
overcoming passengers? inattention and providing them with
safety information. (A-10-86)


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NTSB ISSUES UPDATE ON ITS INVESTIGATION OF FLIGHT 27 THAT DIVERTED TO DULLES AIRPORT

NTSB ADVISORY
National Transportation Safety Board
Washington, DC 20594
May 21, 2010

In its continuing investigation of a fire aboard a Boeing
757 that diverted to Dulles Airport (IAD) enroute to the Los
Angeles International airport (LAX) from New York’s John F.
Kennedy International airport (JFK), the National
Transportation Safety Board has developed the following
factual information:

On Sunday, May 16, 2010, about 9:17 pm (EDT) the pilots on
United Airlines flight 27, a Boeing 757, N510UA, noted a
strong acrid smell and observed smoke from the Captain’s
lower front windshield. The incident occurred about 30
minutes into the flight while the aircraft was level at
36,000 feet MSL. On board the aircraft were 7 crew members
and 105 passengers.

The Captain and First Officer reported that they donned
their oxygen masks and smoke goggles immediately after
observing the smoke and fire. The Captain then gave control
of the airplane to the First Officer and discharged a halon
fire extinguisher. The smoke and fire dissipated but then
re-ignited. The Captain obtained a second bottle from the
Purser. The fire remained extinguished after this second
bottle was discharged. At approximately 500 feet MSL on
final approach to Runway19L at IAD, the Captain’s windshield
cracked. The landing was uneventful. The airplane cleared
the runway, after which ARFF (Aircraft Rescue Firefighting)
entered the aircraft to check for residual heat and fire.
None was found and the airplane was towed to the gate for
deplaning. There were no evacuation and no injuries to the
flight crew or passengers.

Preliminary examination of the cockpit area revealed that
the inner pane of the Captain’s windshield had cracked. One
of the five terminal blocks attached to the inside of the
lower left windshield was consumed by fire and the portion
of the wire harness associated with this terminal block was
significantly damaged by fire. There was significant sooting
and paint peeling to the left hand side of the windshield
air frame support.

The Captain’s windshield was moved and will be examined by
Board investigators at the manufacturer.

Two previous windshield fire events on B757-200 aircraft
prompted the NTSB to issue Safety Recommendation A-07-50
http://www.ntsb.gov/recs/letters/2007/A07_49_50.pdf. The
Safety Board investigators will look closely at the
recovered hardware to determine if this latest event is
related.


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NTSB SENDING TEAM TO ASSIST GOVERNMENT OF LIBYA IN AVIATION ACCIDENT INVESTIGATION

The National Transportation Safety Board is dispatching a team of investigators to assist the government of Libya in its investigation of an accident involving an Airbus A330-200, which was equipped with General Electric CF6-8E1
engines. At approximately 6:00 am local time on May 12, 2010, the aircraft, operated by Afriqiyah Airways, crashed on approach to Tripoli airport in Tripoli, Libya. Of the 104 passengers and crew on board the airplane, there was one
survivor. The airplane originated in Johannesburg, South Africa.

As the State of design and manufacture for the engines, NTSB Chairman Deborah A.P. Hersman has designated Senior Air Safety Investigator, Lorenda Ward, as the U.S. Accredited Representative. The U.S. team will also include an NTSB engines specialist as well as technical advisors from the Federal Aviation Administration, and General Electric. The team is expected to arrive tomorrow afternoon.

The Bureau d’Enquete et d’Analyse (BEA) of France, representing the country of manufacture of the airplane, has also sent a team of investigators to Libya.

The investigation is being conducted by the Libyan Civil Aviation Authority, which will release all information on the progress of the investigation.


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Dutch Safety Board (DSB) Issues Accident Report on February 25, 2009 Accident of a Boeing 737-800 at Amsterdam Schiphol Airport (EHAM)

The National Transportation Safety Board assisted in the investigation of the accident of Turkish Airlines flight 1951, a Boeing 737-800, registration TC-JGE, which occurred on February 25, 2009, while on approach to runway 18R at Amsterdam Schiphol Airport (EHAM), Amsterdam, Netherlands.

Under the provisions of ICAO Annex 13, the investigation was conducted under the authority of the Dutch Safety Board ( – DSB) as the State of Occurrence. The United States, as State of Manufacture and Design of the Boeing 737, appointed an accredited representative from the NTSB’s Major Investigations Division to participate in the investigation and lead the U.S. investigative team. The U.S. team included NTSB technical advisors in flight crew operations, systems, powerplants, flight recorders, and survival factors. In addition, technical advisors from the FAA, Boeing, Honeywell, and CFM International were part of the team.

The accredited representative and advisors participated throughout the investigation in the Netherlands, the United States, the United Kingdom, and France. On December 16, 2009, the DSB provided a copy of the draft final report to the U.S. team for review and comment.

In accordance with ICAO Annex 13, the U.S. accredited representative provided the team’s comments to the DSB on February 13, 2010. The U.S. comments have been appended to the final version of the DSB report and consist of 1) a brief analysis of the factual data collected during the investigation; 2) detailed comments related to specific sections of the draft report; and 3) a summary of the findings from the engineering simulator testing conducted by the investigation.


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NTSB PUBLISHES AGENDA FOR PROFESSIONALISM IN AVIATION FORUM

National Transportation Safety Board
Washington , DC 20594

FOR IMMEDIATE RELEASE: May 5, 2010
SB-10-17

( Washington , DC ) The National Transportation Safety Board
today published its agenda for the Professionalism in
Aviation safety forum which will begin at 9:00 a.m.,
Tuesday May 18, 2010. NTSB Chairman Deborah A.P. Hersman
will chair the three-day, en-banc forum which is open to the
public (there is no registration for attendees).

Following the Chairman’s opening remarks and the keynote
presentation, 10 panels composed of invited representatives
from industry, government agencies, labor, academia and
professional associations, will address subjects relevant to
developing and ensuring professionalism in pilots and air
traffic controllers.

Below is the forum’s agenda of panel titles:

Tuesday, May 18
—————————————————–
* Welcome and Opening Remarks
* Keynote Presentation
* Screening and Selection Methods and Their Role in
Developing Professional Pilots
* Structured Development of Professional Pilots
* Developing Excellence and Professionalism in Air
Traffic Controllers Through Screening, Selection, and
Training

Wednesday, May 19
—————————————————–
* Developing Professionalism and Excellence Through
Operator Training
* Shared Responsibility to Reinforce Professional
Standards in Pilots
* Shared Responsibility to Reinforce Professional
Standards in Air Traffic Controllers
* The Captain’s Role in Ensuring Professionalism

Thursday, May 20
—————————————————–
* Ensuring Effective Pilot-Controller Communications
* Ensuring Excellence Through Data and Information
Sharing
* The Role of the Regulator in Ensuring Professionalism
in Aviation
* Closing Remarks
Organizations and/or individuals can submit input for
consideration as part of the forum’s archived materials.
Submissions should directly address one or more of the 10
subject areas (panel titles) of the forum and be submitted
electronically as an attached document not to exceed 10
pages to: Professionalism.Forum@ntsb.gov. The deadline for
receipt is June 3, 2010. Input received will be entered
into the Safety Board’s public docket on this forum.


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NTSB INVESTIGATING NEAR COLLISION OF SOUTHWEST 737 AND NEWS HELICOPTER OVER HOUSTON HOBBY AIRPORT

The NTSB has launched an investigation into the near collision of a Southwest Airlines jetliner and a news helicopter over a runway at Houston’s Hobby Airport last week.

At about 12:25 p.m. CDT on Wednesday, April 28, a Southwest Airlines 737, flight 1322 (N242WN) and a Bell 207 news gathering helicopter (N6YJ), came within an estimated 125 feet vertically and 100 feet laterally from each other as both were departing the airport.

The Baltimore-bound 737 with 135 passengers and a crew of five had been cleared to depart from runway 12R. At about the same time the helicopter was cleared to depart from another part of the airport. The near-collision occurred as the helicopter converged into the flight path of the 737 shortly after the jetliner lifted off from the runway. Both crews took evasive maneuvers to avoid colliding.

NTSB investigator Betty Koschig, an air traffic control specialist based in Washington, is traveling to Houston tomorrow to begin the investigation.

This is the second runway safety incident that the NTSB has investigated in the last two weeks. On April 19, a 737 and a small private plane came within about 200 feet of colliding over the airport in Burbank, Calif.

Improving runway safety has been on the NTSB’s Most Wanted List of Safety Improvements since 1990:
http://www.ntsb.gov/Recs/mostwanted/runways.htm


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NTSB: CREW ACTIONS AND SAFETY EQUIPMENT CREDITED WITH SAVING LIVES

National Transportation Safety Board
Washington, DC 20594

FOR IMMEDIATE RELEASE: May 4, 2010
SB-10-16

Washington, DC — In addition to the decisions and actions of
the flight crewmembers, overwater safety equipment likely
saved lives that might have otherwise been lost to drowning,
the NTSB said.

Today the Safety Board met to conclude its 15-month
investigation into the January 15, 2009, accident in which a
US Airways A320 jetliner bound for Charlotte was ditched
into the Hudson River after striking a flock of Canada geese
shortly after departing New York’s LaGuardia Airport. All of
the 150 passengers and five crewmembers survived.

Investigators said that had the airplane not been equipped
with forward slide/rafts, many of the 64 occupants of those
rafts would likely have been submerged in the 41-degree
Hudson River, potentially causing a phenomenon called “cold
shock,” which can lead to drowning in as little as five
minutes.

The accident flight had the additional safety equipment
available only because the particular aircraft operated that
day happened to be certified for extended overwater (EOW)
operations even though current FAA regulations did not
require the flight from New York to Charlotte to be so
equipped.

Good visibility, calm waters, and proximity of passenger
ferries, which rescued everyone on flight 1549 within 20
minutes, were other post-accident factors the Safety Board
credited with the survival of all aboard the aircraft.

“Once the birds and the airplane collided and the accident
became inevitable, so many things went right,” said NTSB
Chairman Deborah A.P. Hersman. “This is a great example of
the professionalism of the crewmembers, air traffic
controllers and emergency responders who all played a role
in preserving the safety of everyone aboard.”

The Safety Board said that the probable cause of the
accident was the ingestion of large birds into each engine,
resulting in an almost total loss of engine power.
Contributing to the severity of the fuselage damage and
resulting unavailability of the aft slide/rafts, the Board
cited the FAA’s inadequate ditching certification standards,
lack of industry training on ditching techniques, and the
captain’s resulting difficulty maintaining his intended
airspeed on final approach due to task saturation resulting
from the emergency situation.

The report adopted by the Safety Board today validated the
Captain’s decision to ditch into the Hudson River saying
that it “provided the highest probability that the accident
would be survivable.” Contributing to the survivability of
the accident was the crew resource management between the
captain and first officer, which allowed them to maintain
control of the airplane, increasing the survivability of the
impact with the water.

In addressing the hazards that birds pose to aircraft of all
sizes, the report noted that most bird strike events occur
within 500 feet of the ground while flight 1549 struck geese
at 2700 feet. Investigators said that this difference
demonstrates that “bird strike hazards to commercial
aircraft are not limited to any predictable scenario.”

Concluding that engine screens or changes to design would
not be a viable solution to protect against bird ingestion
events on commercial jetliners, the Board made it clear that
the potential for significant damage from encounters with
birds remains a challenge to the aviation community.

As part of its extensive examination into the behavior of
the passengers and crewmembers from the time the plane left
the gate at LaGuardia to the moment the last person was
rescued in the river, the Board noted that since most of the
passengers indicated that they had not paid attention to the
preflight oral safety briefing, “more creative and effective
methods of conveying safety information to passengers” was
needed. Survival factors investigators also found that
passengers had significant problems in donning the life
vests that were stowed under each seat.

The Board made 35 safety recommendations on engine and
aircraft certification standards, checklist design, flight
crew training, airport wildlife mitigation, cabin safety
equipment, and preflight passenger briefings.

“I believe the safety recommendations that have come out of
this investigation have an extraordinary origin — a very
serious accident in which everyone survived,” said Chairman
Hersman. “Even in an accident where everyone survives, there
are lessons learned and areas that could use improvement.
Our report today takes these lessons learned so that, if our
recommendations are implemented, every passenger and
crewmember may have the opportunity to benefit from the
advances in safety.”


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Press Release: NTSB CHAIRMAN ISASI SPEECH

National Transportation Safety Board
Washington, DC 20594

FOR IMMEDIATE RELEASE: April 29, 2010
SB-10-14

NTSB CHAIRMAN DISCUSSES ADVANTAGES – AND LIMITATIONS – OF USING DATA-DRIVEN SYSTEMS TO IMPROVE AVIATION SAFETY

National Transportation Safety Board Chairman Deborah A.P. Hersman said today that the use of data to manage and improve safety in the aviation industry has had a positive effect on the world’s improving aviation safety record but she cautioned against over-reliance on these systems to the neglect of forensic investigation.

Addressing a conference of the International Society of Air Safety Investigators in Chantilly, Virginia, Hersman noted that “we have reached an era when aviation accidents are extremely rare…” One reason is the use of data – particularly, but not exclusively, Safety Management Systems (SMS) – in accident prevention and investigation.

The Board has been advocating the use of SMS for a decade, having issued 17 recommendations in favor of implementing SMS in the aviation industry. When implemented correctly, Hersman said, “SMS holds real promise in a variety of scenarios.” She noted several instances where SMS helped
eliminate potential unsafe conditions, notably a corporate flight operation that used flight data to determine that high bank angles occurred on repositioning flights, and a review of commercial aircraft approach data that indicated a high rate of TCAS (Traffic Alert and Collision Avoidance
System) warnings at a particular airport. In these instances, she said, “data management adeptly identified a clearly measurable set of information and allowed for a relatively simple and effective solution.”

However, Hersman noted, SMS works well for companies that are already “getting it right,” but may provide little more than false confidence for companies with less than robust safety cultures.

Also, there are accidents caused by a combination of factors that SMS cannot possibly detect. As an example, Hersman mentioned the British Airways Boeing 777 crash at Heathrow Airport two years ago involving a dual engine failure on approach. It was not data analysis that solved the mystery, but detailed forensic analysis; the circumstances were so unusual that a data analysis system would not pick them up.

Hersman said she hoped that with all the focus SMS will place on data collection and analysis, “let’s not lose focus on outcomes. The success of SMS won’t be measured by how much data we collect, but by how many lives we save.”

“I will enthusiastically support any approach that will make our nation safer,” she said. “But I think we need a measured approach – one that acknowledges the potential benefits and limitations of SMS, and further, doesn’t discount tried and true methods for identifying vulnerabilities, such as accident investigations.”


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NTSB Hudson River Docket Opened

NTSB TO OPEN DOCKET ON INVESTIGATION INTO THE MIDAIR COLLISION OVER THE HUDSON RIVER

Washington, DC – In its continuing investigation of the midair collision of an air tour helicopter and a small plane over the Hudson River, the National Transportation Safety Board will open the public docket on Wednesday, April 28, 2010 at 10 a.m.

On August 8, 2009, at 11:53 a.m. EDT, a Eurocopter AS 350 BA (N401LH) operated by Liberty Helicopters and a Piper PA-32R-300 (N71MC) operated by a private pilot, collided in midair over the Hudson River near Hoboken, New Jersey. The certificated commercial pilot and five passengers onboard
the helicopter were killed. The certificated private pilot and two passengers onboard the airplane were also killed. Visual meteorological conditions prevailed and no flight plans were filed for either flight. The local sightseeing
helicopter flight was conducted under the provisions of 14 Code of Federal Regulations Part 136. The personal airplane flight was conducted under the provisions of 14 Code of Federal Regulations Part 91.

The information being released is factual in nature and does not provide any analysis. The docket includes: investigative group factual reports, interview summaries, crew statements, air traffic control transcripts, controller statements, the meteorology report, and other documents.

Additional material will continue to be added to the docket as it becomes available. Analysis of the accident, along with conclusions and a determination of probable cause, will come at a later date when the final report on the
investigation is completed.


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NTSB To Meet

National Transportation Safety Board
Washington, DC 20594

April 26, 2010

NTSB TO MEET ON US AIRWAYS 1549 HUDSON RIVER ACCIDENT

The National Transportation Safety Board will hold a public Board meeting on May 4 on its investigation into the accident in which a US Airways jetliner came to rest in the Hudson River near New York City after a low-altitude encounter with a flock of birds.

The purpose of the meeting will be to determine the probable cause of the accident and to consider proposed safety recommendations to reduce the likelihood of future such mishaps.

On January 15, 2009, at 3:27 p.m. EDT, US Airways flight 1549, an Airbus A320, lost engine power after striking a flock of Canada geese shortly after departing New York’s LaGuardia Airport. The captain brought the plane down into the Hudson River after determining that landing at an airport was not feasible. The plane, destined for Charlotte, N.C., carried 150 passengers and a crew of five. Four passengers and one flight attendant received serious injuries.


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NTSB INVESTIGATING NEAR COLLISION

NTSB INVESTIGATING NEAR COLLISION OF JETLINER AND SMALL PLANE OVER AIRPORT IN CALIFORNIA

The National Transportation Safety Board has opened an investigation into the near collision of a commercial jetliner and a small private plane at the intersection of two active runways at Burbank’s Bob Hope Airport in Southern California.

At about 10:58 a.m. PDT on April 19, Southwest Airlines flight 649, a Boeing 737-700 (N473WN) inbound from Oakland, carrying 119 passengers and a crew of five was landing on runway 8 while a Cessna 172, in the departure phase of a “touch and go” on runway 15, passed over the 737. A “touch and go” is a practice maneuver in which an aircraft briefly lands on the runway before accelerating and becoming airborne again.

According to the Federal Aviation Administration, the airplanes came within 200 feet vertically and 10 feet laterally of each other at the runway intersection. No one was injured in the incident, which occurred under a clear sky with visibility of 10 miles.

NTSB investigator Betty Koschig, an air traffic control specialist based in Washington, is traveling to Burbank today to begin the investigation.


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NTSB Press Release

NTSB TO HOLD A PUBLIC FORUM ON PROFESSIONALISM IN AVIATION

( Washington , DC ) The National Transportation Safety Board
will hold a safety forum on professionalism in aviation
beginning Tuesday, May 18, 2010. The three-day, en-banc forum
will be chaired by NTSB Chairman Deborah A.P. Hersman.

“NTSB’s investigations into the midair collision over the
Hudson River last August, the crash of Colgan Air flight 3407
in February 2009, and the October 2009 Northwest pilots’
overflight of their intended airport provided the impetus for
this forum because all of them clearly demonstrated the
hazards to aviation safety when pilots and air traffic
controllers depart from standard operating procedures and
established best practices,” Hersman said. “During the forum,
we will gather information on the screening, selection and
training of pilots and controllers and methods to reinforce
professionalism and excellence.”

Panelists participating in the forum will represent industry,
government agencies, labor, academia, and professional
associations. A technical panel composed of NTSB staff from
the Offices of Aviation Safety and Research and Engineering,
and the NTSB Board Members, who will make up the Board of
Inquiry, will question the panelists.

Dr. Tony Kern, an internationally recognized human factors and
pilot performance expert, is the forum’s keynote speaker. The
names of the participating panelists and the agenda will be
provided in early May.


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NTSB TO HOLD A PUBLIC FORUM


Washington, DC – The National Transportation Safety Board will hold a safety forum on professionalism in aviation beginning Tuesday, May 18, 2010. The three-day, en-banc forum will be chaired by NTSB Chairman Deborah A.P. Hersman.

“NTSB’s investigations into the midair collision over the Hudson River last August, the crash of Colgan Air flight 3407 in February 2009, and the October 2009 Northwest pilots’ overflight of their intended airport provided the impetus for this forum because all of them clearly demonstrated the hazards to aviation safety when pilots and air traffic controllers depart from standard operating procedures and established best practices,” Hersman said. “During the forum, we will gather information on the screening, selection and training of pilots and controllers and methods to reinforce professionalism and excellence.”

Panelists participating in the forum will represent industry, government agencies, labor, academia, and professional associations. A technical panel composed of NTSB staff from the Offices of Aviation Safety and Research and Engineering, and the NTSB Board Members, who will make up the Board of Inquiry, will question the panelists.

Dr. Tony Kern, an internationally recognized human factors and pilot performance expert, is the forum’s keynote speaker. The names of the participating panelists and the agenda will be provided in early May.

The forum, titled “Professionalism in Aviation: Ensuring Excellence in Pilot and Air Traffic Controller Performance,” will be held at the NTSB’s Board Room and Conference Center, located at 429 L’Enfant Plaza, S.W., Washington, D.C. The public can view the forum in person or by webcast on the NTSB’s web site.


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NTSB RELEASES 2009 AVIATION ACCIDENT STATST


FOR IMMEDIATE RELEASE: April 8, 2010

NTSB RELEASES 2009 AVIATION ACCIDENT STATISTICS; ON-DEMAND ACCIDENTS AT LOWEST LEVEL IN LAST 20 YEARS

Washington, D.C. – The National Transportation Safety Board today released preliminary aviation accident statistics for 2009 showing an overall decrease in U. S. civil aviation accidents that includes general aviation and on-demand Part 135 operations. In fact, on-demand Part 135 operations had the lowest number of accidents and fatal accidents for that type of air operation in the last 2 decades.

The total number of U.S. civil aviation accidents decreased from 1,658 in 2008 to 1,551 in 2009. Total fatalities also showed a decrease from 566 to 534. The majority of these fatalities occurred in general aviation and scheduled Part 121 operations.

General aviation accidents decreased from 1,566 in 2008 to 1,474 in 2009. There were 272 fatal general aviation accidents, down from 275 the year before. However, the accident rate increased to 7.20 per 100,000 flight hours in 2009 from 6.86 in 2008, due to the decrease in the number total of flight hours. Although fatalities decreased from 494 to 474, the fatal accident rate increased to from 1.21 to 1.33.

Last year, one fatal accident occurred involving a scheduled Part 121 operator. On February 12, 2009, a Colgan Air, Inc., Bombardier DHC-8- 400, operating as Continental Connection flight 3407, crashed outside of Buffalo , New York, resulting in 50 fatalities.

On-demand Part 135 operations reported 47 accidents in 2009, a decrease from 58 in 2008. Fatalities also decreased from 69 in 2008 to 17 in 2009. The accident rate decreased to 1.63 per 100,000 flight hours in 2009 from 1.81 in 2008.

Tables 1-12 providing additional statistics are available at: http://www.ntsb.gov/aviation/Stats.htm


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NTSB RELEASES 2009 AVIATION ACCIDENT STATISTICS

ON-DEMAND ACCIDENTS AT LOWEST LEVEL IN LAST 20 YEARS

Washington, D.C. – The National Transportation Safety Board
today released preliminary aviation accident statistics for
2009 showing an overall decrease in U. S. civil aviation
accidents that includes general aviation and on-demand Part
135 operations. In fact, on-demand Part 135 operations had
the lowest number of accidents and fatal accidents for that
type of air operation in the last 2 decades.

The total number of U.S. civil aviation accidents decreased
from 1,658 in 2008 to 1,551 in 2009. Total fatalities also
showed a decrease from 566 to 534. The majority of these
fatalities occurred in general aviation and scheduled Part
121 operations.

General aviation accidents decreased from 1,566 in 2008 to
1,474 in 2009. There were 272 fatal general aviation
accidents, down from 275 the year before. However, the
accident rate increased to 7.20 per 100,000 flight hours in
2009 from 6.86 in 2008, due to the decrease in the number
total of flight hours. Although fatalities decreased from
494 to 474, the fatal accident rate increased to from 1.21
to 1.33.

Last year, one fatal accident occurred involving a scheduled
Part 121 operator. On February 12, 2009, a Colgan Air,
Inc., Bombardier DHC-8- 400, operating as Continental
Connection flight 3407, crashed outside of Buffalo , New
York, resulting in 50 fatalities.

On-demand Part 135 operations reported 47 accidents in 2009,
a decrease from 58 in 2008. Fatalities also decreased from
69 in 2008 to 17 in 2009. The accident rate decreased to
1.63 per 100,000 flight hours in 2009 from 1.81 in 2008.


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NTSB Safety Recommendations A-10-44 and -45

The National Transportation Safety Board recommends that the
Federal Aviation Administration:

Require repetitive inspections for fatigue cracking of the
nose landing gear actuator attachment foot areas on all
Piper PA-46-310 and -350P engine mounts and require
replacement, if necessary. (A-10-44)

Require Piper to redesign the PA-46-310 and -350P engine
mounts so that they are not susceptible to fatigue cracking
in the attachment foot areas. (A-10-45)

The National Transportation Safety Board (NTSB) has investigated two accidents involving Piper PA-46-350P airplanes that resulted from fatigue cracking in the attachment between the nose landing gear (NLG) actuator and the engine mount. Such fatigue cracks can lead to the collapse of the NLG, which could cause a serious or catastrophic accident if the separation occurred at a critical point during takeoff or landing or if the aircraft collided with parked aircraft or aircraft waiting at taxiways.

On August 16, 2009, about 1130 eastern daylight time,1 a Piper PA-46-350P, N548C, experienced an NLG collapse during landing at the Orlando-Sanford International Airport, Sanford, Florida.2 The private pilot and passenger were uninjured, and the airplane sustained substantial damage. No flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 personal flight, nor was one required to be filed by the Federal Aviation Administration (FAA). Visual meteorological conditions (VMC) prevailed at the time of the accident.

On May 19, 2007, about 1305, a Piper PA-46-350P, N411MD, experienced an NLG collapse during landing at the Indianapolis Metropolitan Airport near Fishers, Indiana.3 The pilot and passenger were uninjured, and the airplane sustained substantial damage. No flight plan was filed for the 14 CFR Part 91 personal flight, nor was one required to be filed by the FAA. VMC prevailed at the time of the accident.

The NLG actuator on Piper PA-46-350P airplanes is bolted via two attachment feet to the lower aft engine mount, which is constructed of welded tubes (see figure 1). The NLG actuator extends down and forward from the attachment feet and attaches to the NLG. During taxi, takeoff, and landing, the attachment feet transmit loads from the NLG to the engine mount, thus creating repetitive tensile stress in the engine mount attachment feet areas and, in some cases, leading to fatigue cracking.

Piper PA-46-310 and -350P airplanes have either an original engine mount or a redesigned engine mount (see figure 2).5 In the original design, each attachment foot is a two-piece part consisting of a metal disk welded to the end of a metal tube, which is then welded to the engine mount support tubes. In the redesigned engine mount, each attachment foot is a one-piece machined part made from a single piece of steel, eliminating the welding within the feet themselves. However, on both the original and redesigned engine mounts, the attachment feet are welded to the engine mount support tubes, which is where fatigue cracking has been identified by the NTSB.

The airplane in the Sanford, Florida, accident was equipped with a redesigned engine mount that was installed at the time of manufacture. The NTSB’s postaccident examination of N548C revealed that the right attachment foot had fractured at the engine mount support tube. The NTSB materials laboratory’s examination of the fractured foot revealed a fatigue crack emanating from multiple origins at the exterior of the joint where the attachment foot was welded to the support tube. At the time of the accident, the airplane was 8 years old and had accumulated 711 flight hours with 878 cycles since new (CSN).

The airplane in the Fishers, Indiana, accident had a redesigned engine mount that was installed on March 21, 2003. The airplane had accumulated 542 flight hours and an estimated 1,400 cycles since then. At the time of the accident, the airplane was 7 years old and had accumulated a total of 772 flight hours.6 The NTSB’s postaccident examination of N411MD revealed that the right attachment foot had separated from the rest of the engine mount due to fatigue cracking7 where the attachment foot was welded to the support tube.
The NTSB also notes that a similar incident of fatigue cracking of an NLG attachment foot was found on September 29, 2009, during a routine inspection of a Piper PA-46-350P airplane. The airplane was 5 years old and had accumulated a total of 678 flight hours with 600 CSN and was equipped with the redesigned engine mount.

On April 22, 2002, Piper issued mandatory Service Bulletin (SB) 1103, recommending that operators of PA-46-310P, -350P, and -500TP8 airplanes inspect the NLG actuator attachment foot area of the original engine mounts for evidence of fatigue cracking. The SB indicated that such cracking had been found in this area of some original engine mounts.

The inspection included visual and liquid penetrant inspection at the next regular scheduled maintenance event and each 100 hours in service or at the annual inspection, whichever occurred first. If cracks were found, the original engine mounts were to be replaced with the redesigned engine mounts before returning to service. SB 1103 does not subject the airplanes with redesigned engine mounts to repetitive inspections, and replacing the original engine mount with the redesigned engine mount relieves the need for repetitive inspections. Piper issued several inspections.

The NTSB is concerned that the redesigned engine mounts on Piper P
A-46-310 and -350P model airplanes have attachment foot areas susceptible to fatigue cracking similar to the fatigue cracks identified by Piper on the original engine mounts. The NTSB concludes that the tensile stresses applied to the redesigned engine mounts could lead to fatigue fractures in the NLG actuator attachment foot areas. However, redesigned engine mounts are not currently subject to the inspection provisions of SB 1103, nor is compliance with SB 1103 required.10 Although the NTSB is not aware of incidents or accidents involving original engine mounts that have not been inspected, the NTSB believes that inspections of the original engine mounts should also be mandatory in order to detect fatigue cracking.

Therefore, the NTSB recommends that the FAA require repetitive inspections for fatigue cracking of the NLG actuator attachment foot areas on all Piper PA-46-310 and -350P engine mounts and require replacement, if necessary.

As previously noted, Piper redesigned the engine mounts on the PA-46-310 and -350P in an effort to prevent fatigue cracking at the attachment foot areas. However, based on the accidents discussed above, this redesign does not appear to have been successful since fatigue cracking has also occurred in the redesigned engine mounts. Therefore, the NTSB recommends that the FAA require Piper to redesign the PA-46-310 and -350P engine mounts so that they are not susceptible to fatigue cracking in the attachment foot areas.
Therefore, the National Transportation Safety Board recommends that the Federal Aviation Administration:

Require repetitive inspections for fatigue cracking of the nose landing gear actuator attachment foot areas on all Piper PA-46-310 and -350P engine mounts and require replacement, if necessary. (A-10-44)

Require Piper to redesign the PA-46-310 and -350P engine mounts so that they are not susceptible to fatigue cracking in the attachment foot areas. (A-10-45)

In response to the recommendations in this letter, please refer to Safety Recommendations A-10-44 and -45. If you would like to submit your response electronically rather than in hard copy, you may send it to the following e-mail address: correspondence@ntsb.gov.


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CHARLESTON, WEST VIRGINIA RUNWAY OVERRUN

NTSB TO OPEN PUBLIC DOCKET ON JANUARY 2010 CHARLESTON, WEST VIRGINIA RUNWAY OVERRUN

As part of the Safety Board’s investigation into the runway overrun at Yeager Airport, Charleston, West Virginia, the NTSB will open the public accident docket on Thursday, April 8, 2010.

On January 19, 2010, PSA Airlines d.b.a. US Airways Express flight 2495, a Bombardier CL600-2B19, registration N246PS, rejected the takeoff and ran off the end of the runway at Yeager Airport, Charleston, West Virginia. The airplane stopped in the engineered materials arresting system (EMAS).

There were no injuries to the 31 passengers or 3 crew members onboard and the airplane received minor damage. The flight was operating under the provisions of 14 CFR Part 121 and its intended destination was Charlotte/Douglas International Airport, Charlotte, North Carolina.

The Transportation Safety Board of Canada has assigned an Accredited Representative to assist the investigation under the provisions of ICAO Annex 13 as the State of the Manufacturer of the airplane.

The information being released is factual in nature and does not provide any analysis. It will include investigative group factual reports, photographs, and other documents from the investigation. Additional material will be added to the docket as it becomes available. Analysis of the accident, along with conclusions and a determination of probable cause, will come at a later date when the final report on the investigation is completed.


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NTSB Release: Maintenance Causes 2008 Crash

FOR IMMEDIATE RELEASE
April 6, 2010
SB-10-10

POOR MAINTENANCE STARTED ACCIDENT CHAIN THAT RESULTED IN HIGH-SPEED RUNWAY EXCURSION THAT KILLED FOUR IN 2008, NTSB DETERMINES

Washington, DC – A chartered business jet crashed at a South Carolina airport 18 months ago because of the operator’s inadequate maintenance of the airplane’s tires and the decision by the captain to attempt a high-speed rejected takeoff, which went against standard operating procedures and training, the NTSB determined today.

On September 19, 2008, at 11:53 p.m. EDT, a Bombardier Learjet Model 60 (N999LJ) operated by Global Exec Aviation and destined for Van Nuys, California, overran runway 11 during a rejected takeoff at Columbia Metropolitan Airport. After the airplane left the departure end of runway 11, it struck airport lights, crashed through a perimeter fence, crossed a roadway and came to rest on a berm. The captain, the first officer, and two passengers were killed; two other passengers were seriously injured.

The investigation revealed that prior to the accident the aircraft was operated while the main landing gear tires were severely underinflated because of Global Exec Aviation’s inadequate maintenance. The underinflation compromised the integrity of the tires, which led to the failure of all four of the airplane’s main landing gear tires during the takeoff roll.

Shortly after the first tire failed, which occurred about 1.5 seconds after the airplane passed the maximum speed at which the takeoff attempt could be safely aborted, the first officer indicated that the takeoff should be continued but the captain decided to reject the takeoff and deployed the airplane’s thrust reversers. Pilots are trained to avoid attempting to reject a takeoff at high-speed unless the pilot concludes that the airplane is unable to fly; the investigation found no evidence that the accident airplane was uncontrollable or unable to become airborne.

The tire failure during the takeoff roll damaged a sensor, which caused the airplane’s thrust reversers to return to the stowed position. While the captain was trying to stop the airplane by commanding reverse thrust, forward thrust was being provided at near-takeoff power because the thrust reversers were stowed. The Safety Board determined that the inadvertent forward thrust contributed to the severity of the accident.

The Safety Board also found that neither the Federal Aviation Administration nor Learjet adequately reviewed the Airplane’s design after a similar uncommanded forward thrust accident that occurred during landing in Alabama in 2001. While the modifications put into place after the Alabama accident provided additional protection against uncommanded forward thrust upon landing, no such protection was provided for a rejected takeoff.

“This accident chain started with something as basic as inadequate tire inflation and ended in tragedy,” said NTSB Chairman Deborah A.P. Hersman. “This entirely avoidable crash should reinforce to everyone in the aviation community that there are no small maintenance items because every time a plane takes off, lives are on the line.”

The safety recommendations that the NTSB made to the Federal Aviation Administration as a result of this investigation are: provide pilots and maintenance personnel with information on the hazards associated with tire underinflation, including the required intervals for tire pressure checks, and allow pilots to perform pressure checks in air taxi operations to ensure that tires remain safely inflated at all times; require tire pressure monitoring systems for all transport category airplanes; identify and correct deficiencies in both Learjet’s thrust reverser system safety analysis and the FAA’s design certification process to ensure that hazards encountered in all phases of flight are mitigated; require that simulator training for pilots who conduct turbojet operations include opportunities to practice responding to events other than engine failures near takeoff speeds; require that pilots who fly air taxi turbojet operations have a minimum level of pilot operating experience in an airplane type before acting as pilot-in- command in that type; and require that airplane tire testing criteria reflect the loads that may be imposed on tires both during normal operating conditions and after the loss of one tire.


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CAPTAIN’S INAPPROPRIATE ACTIONS LED TO CRASH OF FLIGHT 3407 IN CLARENCE CENTER, NEW YORK, NTSB SAYS

NTSB PRESS RELEASE

National Transportation Safety Board
Washington, DC 20594

FOR IMMEDIATE RELEASE: February 2, 2010
SB-10-02

CAPTAIN’S INAPPROPRIATE ACTIONS LED TO CRASH OF FLIGHT 3407 IN CLARENCE CENTER, NEW YORK, NTSB SAYS

The National Transportation Safety Board determined that the
captain of Colgan Air flight 3407 inappropriately responded
to the activation of the stick shaker, which led to an
aerodynamic stall from which the airplane did not recover.
In a report adopted today in a public Board meeting in
Washington, additional flight crew failures were noted as
causal to the accident.

On February 12, 2009, a Colgan Air, Inc., Bombardier DHC-8-
400, N200WQ, operating as Continental Connection flight
3407, was on an instrument approach to Buffalo-Niagara
International Airport, Buffalo, New York, when it crashed
into a residence in Clarence Center, New York, about 5
nautical miles northeast of the airport. The 2 pilots, 2
flight attendants, and 45 passengers aboard the airplane
were killed, one person on the ground was killed, and the
airplane was destroyed by impact forces and a postcrash
fire. The flight was a 14 Code of Federal Regulations (CFR)
Part 121 scheduled passenger flight from Newark, New Jersey.
Night visual meteorological conditions prevailed at the
time of the accident.

The report states that, when the stick shaker activated to
warn the flight crew of an impending aerodynamic stall, the
captain should have responded correctly to the situation by
pushing forward on the control column. However, the
captain inappropriately pulled aft on the control column and
placed the airplane into an accelerated aerodynamic stall.

Contributing to the cause of the accident were the
Crewmembers’ failure to recognize the position of the
low-speed cue on their flight displays, which indicated that
the stick shaker was about to activate, and their failure to
adhere to sterile cockpit procedures. Other contributing
factors were the captain’s failure to effectively manage the
flight and Colgan Air’s inadequate procedures for airspeed
selection and management during approaches in icing
conditions.

As a result of this accident investigation, the Safety Board
issued recommendations to the Federal Aviation
Administration (FAA) regarding strategies to prevent flight
crew monitoring failures, pilot professionalism, fatigue,
remedial training, pilot records, stall training, and
airspeed selection procedures. Additional recommendations
address FAA’s oversight and use of safety alerts for
operators to transmit safety-critical information, flight
operational quality assurance (FOQA) programs, use of
personal portable electronic devices on the flight deck, and
weather information provided to pilots.

At today’s meeting, the Board announced that two issues that
had been encountered in the Colgan Air investigation would
be studied at greater length in proceedings later this year.
The Board will hold a public forum this Spring exploring
pilot and air traffic control high standards. This
accident was one in a series of incidents investigated by
the Board in recent years – including a mid-air collision
over the Hudson River that raised questions of air traffic
control vigilance, and the Northwest Airlines incident last
year where the airliner overflew its destination airport in
Minneapolis because the pilots were distracted by non-flying
activities – that have involved air transportation
professionals deviating from expected levels of performance.
In addition, this Fall the Board will hold a public forum
on code sharing, the practice of airlines marketing their
services to the public while using other companies to
actually perform the transportation. For example, this
accident occurred on a Continental Connection flight,
although the transportation was provided by Colgan Air.

A summary of the findings of the Board’s report are
available on the NTSB’s website at:
http://www.ntsb.gov/Publictn/2010/AAR1001.htm
-30-


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NTSB ADVISORY: NTSB TO MEET ON FINAL REPORT ON COLGAN AIR DASH-8 ACCIDENT NEAR BUFFALO, NEW YORK

************************************************************
NTSB ADVISORY
************************************************************

National Transportation Safety Board
Washington, DC 20594

January 29, 2010

************************************************************

NTSB TO MEET ON FINAL REPORT ON COLGAN AIR DASH-8 ACCIDENT
NEAR BUFFALO, NEW YORK

************************************************************

The National Transportation Safety Board will hold a Board
meeting on Tuesday, February 2, 2010, at 9:30 a.m. in its
Board Room and Conference Center, 429 L’Enfant Plaza, S.W.,
Washington, D.C. The Board will consider a final report on
the following investigation:

On February 12, 2009, a Colgan Air, Inc., Bombardier DHC-8-
400, N200WQ, operating as Continental Connection flight
3407, was on an instrument approach to Buffalo-Niagara
International Airport, Buffalo, New York, when it crashed
into a residence in Clarence Center, New York, about 5
nautical miles northeast of the airport. The 2 pilots, 2
flight attendants, and 45 passengers aboard the airplane
were killed, one person on the ground was killed, and the
airplane was destroyed by impact forces and a postcrash
fire. The flight was a 14 Code of Federal Regulations (CFR)
Part 121 scheduled passenger flight from Newark, New Jersey.
Night visual meteorological conditions prevailed at the
time of the accident.

A live and archived webcast of the proceedings will be
available on the Board’s website at
http://www.ntsb.gov/events/Boardmeeting.htm. Technical
support details are available under “Board Meetings” on the
NTSB website. To report any problems, please call 703-993-
3100 and ask for Webcast Technical Support.

A summary of the Board’s final report, which will include
findings, probable cause and safety recommendations, will
appear on the website shortly after the conclusion of the
meeting. The entire report will appear on the website
several weeks later.

Verizon wireless cellular service is accessible in the Board
Room and Conference Center.

Directions to the NTSB Board Room: Front door located on
Lower 10th Street, directly below L’Enfant Plaza. From
Metrorail, exit L’Enfant Plaza station at 9th and D Streets
escalator, walk through shopping mall, at CVS store (on the
left), take escalator (on the right) down one level. The
Board Room will be to your left.

NTSB Media contact: Keith Holloway
202-314-6100
hollowk@ntsb.gov

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