What: Republic of Poland Tupolev en route from Warsaw to Smolensk
Where: Smolensk, Russia,
When: October 4, 2010
Who: 7 crew
Why: The report blames the pilots.
Final Report .pdf (very large)
11004
From the SAFO:
Recommendations describe a top down approach, a coordinated effort to mitigate identified hazards. Suggestions include management emphasis and training of pilots and support personnel (air carrier mechanics, ground personnel, and tug/tow drivers.)
There are recommendations in each of these categories:
The full pdf is available here
https://airflightdisaster.com/wp-content/uploads/2011/06/SAFO11004.pdf
Volcano Nabro erupted today throwing ash clouds up to 13.5 kilometres.The Volcanic Ash Advisory Center (VAAC) said Monday that the 5,331 ft volcano has resulted in a large ash plume of up to 13.5 kilometres (8 miles) high. The scale of the eruption, compared to the ongoing eruption in Chile and 2010?s eruption at Eyjafjallajökull in Iceland, remains unclear. Ash is falling on the northern Ethiopian town of Mekele. The ash advisory issued by the VAAC (see below graphics) is predicting that the Ash plume will spread towards the Middle East Monday night.
The Puyehue eruption began June 4th, 2011 when 3,500 people were evacuated. First the local airport was closed, then cancellation of hundreds of flights have continued this last week and a half. As of Friday, the cloud spread causing cancellations across South America towards Uruguay and into Brazil.
*Eritrea, is a country in the Horn of Africa.
A power outage in Phoenix knocked out all of US Airways computers, grounding flights all over the US.
Boarding pass scanners are also down.
US Airways has published three press releases regarding the outage:
3:
US Airways Releases Third Update Regarding System Outage
TEMPE, Ariz., Jun 10, 2011 (BUSINESS WIRE) —
US Airways’ (NYSE: LCC) website, usairways.com and airport computer systems have been restored following a systems outage earlier today.
As the operation returns, flights may continue to be delayed.
Early reports indicate that the systems outage was the result of a power outage near one of the airline’s data centers in Phoenix.
We strongly encourage our customers to check their flight status before arriving at the airport by visiting usairways.com or by calling US Airways Reservations at 1-800-428-4322. (LCCG)
SOURCE: US Airways
US Airways
Media Relations, 480-693-5729
2:
US Airways Releases Update Regarding System Outage
TEMPE, Ariz., Jun 10, 2011 (BUSINESS WIRE) —
US Airways’ (NYSE: LCC) website – usairways.com – and the airline’s airport computer systems are back online and we are working to restore operational order following a systems outage earlier today.
Flights throughout the US Airways system have been impacted and are delayed. While usairways.com is back online, it may perform unreliably and in a delayed fashion.
Early reports indicate that the systems outage was the result of a power outage near one of the airline’s data centers in Phoenix.
We strongly encourage our customers to check their flight status before arriving at the airport by visiting usairways.com or by calling US Airways Reservations at 1-800-428-4322. (LCCG)
SOURCE: US Airways
1:
US Airways Issues Statement Regarding System Outage
TEMPE, Ariz., Jun 10, 2011 (BUSINESS WIRE) —
US Airways (NYSE: LCC) is experiencing a computer systems outage that has impacted usairways.com and the airline’s airport computer systems.
Early reports indicate that the systems outage is the result of a power outage near one of the airline’s data centers in Phoenix.
Some airport computer systems are coming back online now and we are working to restore operational order.
We strongly encourage our customers to check their flight status before arriving at the airport by calling US Airways Reservations at 1-800-428-4322. (LCCG)
SOURCE: US Airways
US Airways
Media Relations, 480-693-5729
Media excesses, and rumor mongering (my words) have moved the BEA to publish an informational note for the families of the victims, and the general public. The following “chain of events” comes from the initial reading of the Flight Data Analysis of the Cockpit Voice Recorder. There are new facts in the timeline, but the interim report will not be published until the end of July. Interested parties should remain aware that this is not a substitute for later reports. Causes of the accident and safety recommendations will only be revealed and understood after “long and detailed investigative work.”
Point Enquête 270511 on site
NTSB Identification: DCA10FA076
Scheduled 14 CFR Part 121: Air Carrier operation of DELTA AIRLINES INC
Accident occurred Thursday, July 15, 2010 in
Probable Cause Approval Date: 04/29/2011
Aircraft: BOEING 767, registration: N184DN
Injuries: 1 Serious,201 Uninjured.
The NTSB full Narrative:
History of Flight:
On July 15, 2010, at about 0200 UTC, a Boeing 767-332ER, registered in the United States as N184DN and operated by Delta Airlines, encountered turbulence at flight level 360 near TOESS intersection north of Antonio B. Won Pat International Airport (GUM) Guam. One flight attendant suffered a broken ankle during the turbulence event. The flight had departed GUM at 1125 UTC and landed at Narita International Airport (NRT), its original destination, at 0344 UTC. None of the other 192 passengers or 9 crewmembers were injured. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121, and was on an instrument flight rules flight plan, and flying in visual meteorological conditions at the time of the event.
According to the captain of the flight, at the time of the turbulence encounter he was navigating around scattered cloud build-ups. Nothing was showing on radar, as he adjusted the antenna tilt between -1 and -5 degrees. At that time the seatbelt sign was not illuminated.
According to the injured flight attendant, she was walking down the aisle between the mid galley and the aft galley and fell to the floor at the time of the turbulence encounter.
Injuries:
None of the other 9 crewmembers or the 192 passengers were injured.
Damage to Airplane:
The airplane was not damaged.
Meteorological Information:
According to the operator, no turbulence was forecast for the area in which the airplane was flying at the time of the turbulence encounter. In addition, satellite imagery revealed that the airplane was in an area not conducive to turbulence when the event occurred.
Medical and Pathological Information:
The injured flight attendant was examined by a physician passenger who did not provide a diagnosis. She declined medical treatment upon arrival at Narita and proceeded to her home base of Minneapolis before seeking further medical advice. Upon arrival home, she saw a doctor who stated that her ankle was broken.
Flight Data Recorder:
According to the flight data recorder, the vertical acceleration during the turbulence encounter varied between +1.5 g and -0.3 g. The encounter lasted about 5 seconds.
On April 25, the NTSB released information about the April 1 Southwest Airlines Boeing 737-300 fuselage incident where the rupture in the fuselage caused depressurization and forced pilots to make an emergency landing in Yuma.
From the release
|
The NTSB Materials Laboratory work is actively conducting additional inspections and examinations in the following areas:
|
Of 136 airplanes inspected worldwide four had crack indications at a single rivet and one plane was found to have crack indications at two rivets.
In spite of these findings, Boeing Chief Executive Jim McNerney told Reuters“I think the initial data that I think we’re all seeing is suggesting a possible workmanship issue on an airplane, rather than a design issue across a fleet of airplanes.”
If Boeing believes that the problem was workmanship on a single plane, then how did other planes reveal conditions precursing the same type of rupture incident as was incurred on Southwest Airlines Flight 812?
Partial summary of what is included
We’ve been studying Ethiopia Flight 409 for a while, and now that the official investigation Progress Report is out, we have looked at it with quite some interest. The 28 page report is attached as a pdf at the end of this editorial, so if you haven’t seen it yet, we have it handy–
In some places, we find that the report corroborates some of the the points we made (or discovered in our research.)
According to the report:
“Instruments meteorological conditions prevailed for the flight, and the flight was on an instrument flight plan. The accident occurred at night in dark lighting conditions with reported isolated cumulonimbus clouds and thunderstorms in the area.”
Their report also states:
The Lebanese Civil Aviation Authority reviewed the data from the Lebanese Meteorological Services that was collected on 25 January, 2010 after the accident. Meteorological data revealed some significant meteorological conditions in the area at the time of the accident. Relevant meteorological documents are included in the investigation file and will be analyzed during the investigation.
1.7.1 General meteorological situation
At the time of the accident, there was thunderstorms activity southwest and west of the field, as well as to the northwest on the localizer path for runway 16.
We had found a satellite photo of the area at the time in question and found something more turbulent than isolated cumulonumbus clouds. Here are the details we turned up
(thanks to Prof. Robert H. Holzworth
Departments of Earth and Space Sciences, and Physics
Director, World Wide Lightning Location Network )
WWLLN lightning strokes between (45,35.2) and (33.6, 35.7) coordinates on25 Jan 2010 between 00 and 06 UTC
.
2010/01/25,00:26:01.675091, 33.7925, 35.3157, 18.6, 15 2010/01/25,00:32:36.535404, 33.6762, 35.3223, 2.6, 5 2010/01/25,00:35:33.147928, 33.8152, 35.3989, 17.1, 9 2010/01/25,00:36:46.386409, 33.7880, 35.4182, 6.3, 6 2010/01/25,00:37:57.880969, 33.7473, 35.4083, 12.9, 8 2010/01/25,00:38:56.307703, 33.8144, 35.4480, 6.7, 5 2010/01/25,00:39:52.170965, 33.8098, 35.4486, 22.5, 1 02010/01/25,00:47:07.877656, 33.7658, 35.5138, 16.3, 7 2010/01/25,00:47:08.129640, 33.7532, 35.5187, 6.8, 5 2010/01/25,00:51:28.917459, 33.7313, 35.4897, 15.8, 8 2010/01/25,00:57:16.994854, 33.7712, 35.5668, 6.2, 5 2010/01/25,00:57:17.172976, 33.8877, 35.6009, 3.1, 5 2010/01/25,00:57:16.970924, 33.8230, 35.5664, 9.2, 5 2010/01/25,01:05:02.878083, 33.6379, 35.5348, 10.9, 5 2010/01/25,02:58:51.961652, 33.6073, 35.3703, 2.3, 5 2010/01/25,03:00:31.235850, 33.6450, 35.3881, 5.8, 7 2010/01/25,03:02:45.342786, 33.6157, 35.3553, 4.5, 7 2010/01/25,03:30:07.101084, 33.6511, 35.3185, 17.5, 7 2010/01/25,04:06:25.411422, 33.8432, 35.3648, 10.9, 5 2010/01/25,04:07:31.723296, 33.9087, 35.3844, 7.0, 5 2010/01/25,04:13:12.295902, 33.9543, 35.4151, 17.0, 10 2010/01/25,04:29:17.203911, 33.9865, 35.4613, 20.7, 10 2010/01/25,04:33:22.703869, 33.9637, 35.3229, 7.6, 6 2010/01/25,04:35:07.805894, 33.8709, 35.3297, 13.3, 8 2010/01/25,04:46:45.611497, 33.9634, 35.4145, 12.9, 6 2010/01/25,05:19:51.913652, 33.6442, 35.4520, 19.5, 8 2010/01/25,05:35:10.788571, 33.9139, 35.2087, 9.5, 7 2010/01/25,05:56:25.149281, 33.6332, 35.6535, 14.0, 7
and the satellite photo:
The plane’s on board radar would have normally registered this unacceptable massive super cell in the area where the airplane hit the ocean and the pilot would have adjusted the flight path accordingly. This makes us question if the on board radar was intact and operable. The weather system pictured in the satellite photo is not weather a pilot would voluntarily fly into. So we were not surprised to see this included in the report:
1.17.1.6 Procedure for use of on-board Weather Radar
ET provided its SOP and Boeing procedure for the operation of the weather radar during departure. The procedure will be addressed during the analysis phase.
OTHER POINTS
Our investigation pointed out that when an aircraft fails, it is a crucial part of the research to look at timely Airworthiness Directives (issued before and after) on the type of plane involved and indeed, this has become part of the ongoing research:
1.16.4.1 Removal and Analysis of the Trim Tab section:
ADs were issued (Emergency AD, AD 2010-09-05, AD 2010-17-19) by the FAA respectively on March and August 2010 regarding trim tab control mechanism and this airplane (with serial number 29935) was found affected by these ADs.
Therefore, and in accordance with the Airworthiness Group recommendation, the Investigation Committee decided the removal of the trim tab control mechanism for further test and research.
This is not the final report. The final report is due out this summer. We are looking forward to seeing if it answers some of our questions.
NTSB DETERMINES THE CAPTAIN’S DECISION TO ATTEMPT A GO- AROUND LATE IN THE LANDING ROLL WITH INSUFFICIENT RUNWAY REMAINING CAUSED THE 2008 ACCIDENT IN OWATONNA
The NTSB has released a conclusion in the 2008 plane crash at Owatonna Degner Regional Airport, Owatonna.
According to the NTSB report, probable cause was determined to be the captain’s decision to attempt a go-around late in the landing roll with insufficient runway remaining. Contributing factors were cited as “pilots’ poor crew coordination and lack of cockpit discipline; fatigue, which
likely impaired both pilots’ performance; and the failure of the Federal Aviation Administration (FAA) to require crew management training.”
The synopsis is available here:
http://www.ntsb.gov/events/2011/Owatonna_MN/synopsis.html
The webcast from todays meeting on Aircraft Accident Report – Crash on landing of Hawker Beechcraft BAE 125-800A, N818MV, Owatonna, Minnesota, July 31, 2008 will be available here.
http://www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/safo
A SAFO contains important safety information and may include recommended action. SAFO content should be especially valuable to air carriers in meeting their statutory duty to provide service with the highest possible degree of safety in the public interest. Besides the specific action recommended in a SAFO, an alternative action may be as effective in addressing the safety issue named in the SAFO.
Subject: Embraer ERJ-190 Series Thrust Reverser Cowling Safety Purpose: This SAFO notifies maintenance personnel of a potentially hazardous situation which
can cause serious injury while working on or around the EMB 190 thrust reversers.
Background: During a visit to Embraer Aircraft Maintenance Service (EAMS), a Maintenance Repair Organization (MRO), technicians reported that instances have occurred where the thrust reverser power door opening (PDO) actuator failed. Also, during high wind conditions, with the thrust reverser cowl open, the cowling can flex sufficiently enough to displace the locking feature of the PDO actuator. The failure of the PDO actuator can cause the thrust reverser cowl- door to come down on personnel, causing serious injury. As a precautionary safety means, and an interim option, EAMS installed the trust reverser hold-open-jib which is part of the engine- change boot-strap-kit. The jib is utilized to provide additional support to the PDO thrust reverser cowling-door in the event of a PDO failure. Embraer is evaluating the development of a tool to support the thrust reverser cowling while opened. However, until this tool is available, extreme caution is recommended during maintenance of the thrust reverser.
Recommended Action: It is recommended that air carriers who operate this type of equipment, immediately alert maintenance to exercise extreme caution working around the area with the thrust reverser cowling opened, especially during high wind conditions. In addition, it is recommended that maintenance personnel utilize the thrust reverser hold-open-jib which is part of the engine change boot-strap-kit, to secure the door. The jib is utilized to provide additional support to the PDO thrust reverser cowling door in the event of a PDO failure.
Contact: Questions or comments regarding this SAFO should be directed to Aircraft Maintenance Division, AFS-300, at (202) 385-6422.
Distributed by: AFS-200 OPR: AFS-300
National Transportation Safety Board
Washington, DC 20594
The National Transportation Safety Board recommends that the Federal Aviation Administration:
Require Boeing to develop a method to protect the elevator power control unit input arm assembly on 737-300 through -500 series airplanes from foreign object debris. (A-11-7)
Once Boeing has developed a method to protect the elevator power control unit input arm assembly on 737-300 through -500 series airplanes from foreign object debris as requested in
Safety Recommendation A-11-7, require operators to modify their airplanes with this method of protection. (A-11-8)
Require Boeing to redesign the 737-300 through -500 series airplane elevator control system such that a single-point jam will not restrict the movement of the elevator control system and prevent continued safe flight and landing. (A-11-9)
Once the 737-300 through -500 series airplane elevator control system is redesigned as requested in Safety Recommendation A-11-9, require operators to implement the new design. (A-11-10)
Require Boeing to develop recovery strategies (for example, checklists, procedures, or memory items) for pilots of 737 airplanes that do not have a mechanical override feature for a jammed elevator in the event of a full control deflection of the elevator system and incorporate those strategies into pilot guidance. Within those recovery strategies, the consequences of removing all hydraulic power to the airplane as a response to any uncommanded control surface should be clarified. (A-11-11)
Office of Inspector General Report
On December 16, 2010, we issued our report on the Federal Aviation Administration’s (FAA) Air Transportation Oversight System (ATOS). FAA uses ATOS to conduct surveillance of nearly 100 airlines that transport more than 90 percent of U.S. airline passenger and cargo traffic. While ATOS is conceptually sound, our prior reports have found that FAA needs to strengthen national oversight of the system. Following safety lapses at a major airline in 2008, the Senate Committee on Science, Commerce, and Transportation and the House Committee on Transportation and Infrastructure asked us to assess weaknesses systemwide. Accordingly, our audit objectives were to determine (1) whether FAA has completed timely ATOS inspections of air carriers’ policies and procedures for their most critical maintenance systems; (2) how effective ATOS performance inspections have been in testing and validating that these critical maintenance systems are working properly; and (3) how well FAA implemented ATOS for the remaining Part 121 air carriers and what, if any, oversight challenges FAA inspection offices face.
While FAA has worked to continuously improve ATOS, we found that FAA inspectors did not complete ATOS inspections of air carriers’ maintenance policies and procedures or systems performance on time. In addition, FAA transitioned all of its Part 121 inspection offices to ATOS at the end of 2007, but–due in part to training gaps–some inspectors for smaller air carriers had difficulty adapting ATOS to those carriers’ operations. We made seven recommendations to FAA to improve its data, training, and risk assessment processes for ATOS. FAA concurred with four of our seven recommendations and partially concurred with three.
Read the full .PDF report here
Pictured: Couger-owned Sikorsky S-61N Helicopter
Click to view full size photo at Airliners.net
Contact photographer Phil Earle
On March 12, 2009, about 0926 ADT, Atlantic Daylight Time, a Sikorsky S-92A helicopter, Canadian registry C-GZCH, operated by Cougar Helicopters, impacted the waters of the North Atlantic about 28 miles east of Cape Spear near St. John’s, Newfoundland. There were two pilots, Pilot Matthew William Thomas Davis, 34, of St. John’s, Newfoundland and Labrador and First Officer Tim Lanouette, 48, of Comox, British Columbia, both of whomdied in the accident, and 16 passengers on board the helicopter. One passenger, Robert Decker, survived with serious injuries, but the other occupants were fatally injured. The helicopter was en route from St. John’s International Airport (CYYT) to an offshore oil platform in the Hibernia oil field. The pilot made a MAYDAY call due to a mechanical difficulty, and was returning to St. John’s at the time of the accident. Visual meteorological conditions prevailed at the time of the accident, and the sea state had 3 – 5 meter swells. An instrument flight rules (IFR) flight plan was filed.
The NTSB has recommended that any gearbox losing oil pressure should have the capacity to run dry for 30 minutes before failure. In the case of Flight 491, the elapsed time between the warning light and the ditching of the aircraft in the sea was 11 minutes. Two of the three main gearbox mounting studs were broken. When they broke, the helicopter lost oil rapidly and the gears began to overheat.
On March 23, 2009, Sikorsky released a bulletin that most of the world’s S-92TM helicopter fleet already had complied with the company notice to retrofit the aircraft’s gearbox oil bowl with steel mounting studs.
NTSB Advisory
National Transportation Safety Board
Washington, DC 20594
February 10, 2011
NTSB SENDING TEAM TO ASSIST IRELAND IN METROLINER INVESTIGATION
The National Transportation Safety Board is sending three investigators to assist the Government of Ireland as it investigates the crash of an airliner this morning.
At about 9:45 a.m. local time today, a Swearingen SA-227 Metroliner (Spanish registration EC-ITP), operated by Flightline/Manx2 Air as flight 7100 from Belfast, Northern Ireland, crashed after attempting a landing at Cork Airport, Cork, Ireland. Twelve people were aboard the aircraft, and there are reports of both fatalities and survivors.
NTSB senior air safety investigator Dan Bower has been designated the U.S. Accredited Representative and is being assisted by an NTSB systems investigator and an NTSB operations investigator. A Federal Aviation Administration investigator is also joining the team.
Information about the progress of the investigation will be released by the Air Accident Investigation Unit of Ireland, +353 (0) 1-604-1293.
###
WASHINGTON, Feb. 10, 2011 /PRNewswire/ — OAG (www.oag.com), the global leader in aviation intelligence reports that worldwide scheduled airline capacity increased 5% in February, year-on-year, to a total of 285.7 million seats. The number of flights increased 4%, to 2.3 million departures worldwide during the month.
In its monthly Frequency and Capacity Trend Statistics (FACTS) report, OAG finds all regional markets recorded year-on-year growth in February, with the exception of capacity to and from Central and South America. This region lost 3% of its seat capacity, when compared to the same month last year, feeling the impact again this month of the loss of Mexicana services.
Although capacity fell in Central and South America, overall; within Lower South America, scheduled capacity increased 12% year-on-year. The Brazilian market is showing the strongest growth in the region, with a 14% increase in domestic capacity in February compared to the same time last year.
“The current expansion in some South American markets may be at the height of a growth period. The impending rationalization of carriers in the region, and the development of larger alliances such as that proposed by the LAN Group and TAM, could lead to capacity consolidation as network rationalization occurs,” said Peter von Moltke, Chief Executive Officer, UBM Aviation.
Year-on-year, the two fastest growing markets in the world are those to and from the Middle East, and to and from Asia Pacific, in terms of frequency of service. The total number of flights offered to and from the Middle East grew 13% to a total of 49,014; flights to and from Asia Pacific increased 13% to a total of 55,965.
Scheduled frequency and capacity to and from Europe was the second fastest growing region among the largest markets with scheduled capacity increasing by 11%, to a total of 21.3 million seats; frequencies increased 10%, to a total of 93,558. Growth within Europe, however, increased a modest 2% in both seat capacity and the total number of flights to a total of 59.5 million seats and 493,150 flights.
“Medium to long haul carriers continue to build their presence in European markets, with the objective of securing greater shares of the longer haul markets, which traditionally deliver higher yields,” continued von Moltke. “Carriers such as Emirates, Etihad and Qatar Airways will continue to increase flights and open new markets as their development progresses, and increased frequencies to a number of European destinations are expected by these airlines throughout the year.”
The number of scheduled services both within and to and from North America remained constant year-on-year, although a slight increase in average capacity per flight resulted in more seats being offered. Total capacity to and from this region increased 3%, to a total of 15.5 million.
This data comes from the February 2011 edition of OAG FACTS (Frequency And Capacity Trend Statistics), a monthly report with interactive graphs to display performance trends of specific airports, routes, countries or regions, sourced from OAG’s consolidated database of global airline schedules. A more detailed review of this month’s OAG FACTS statistics – including information about specific regions, routes and airports – is available to download at: (http://www.oagaviation.com/OAG-FACTS-February-2011-EXECUTIVE-SUMMARY
SUMMARY: We are adopting a new airworthiness directive (AD) for the products listed above. This AD requires installing two warning level indicator lights on the P2-2 center instrument panel in the flight compartment for certain airplanes. For a certain other airplane, this AD requires activating the cabin altitude warning and takeoff configuration warning lights. For all airplanes, this AD also requires revising the airplane flight manual to remove certain requirements included by previous AD actions, requires new pressure altitude limitations for certain airplanes, and advises the flightcrew of the following changes: revised emergency procedures to use when a cabin altitude warning or rapid depressurization occurs, and revised cabin pressurization procedures for normal operations. This AD was prompted by a design change in the cabin altitude warning system that would address the identified unsafe condition. We are issuing this AD to prevent failure of the flightcrew to recognize and react properly to a valid cabin altitude warning horn, which could result in incapacitation of the flightcrew due to hypoxia (lack of oxygen in body), and consequent loss of control of the airplane.
Safety of the American Traveling Public and Crewmembers Must be Maintained, Unions Say
WASHINGTON, Feb. 7, 2011 — Today, the International Brotherhood of Teamsters Airline Division and Transport Workers Union (TWU) commended PBS “Frontline” on its investigative report into airline maintenance. The two unions also stated that much remains to be addressed to ensure the safety of the traveling public.
The report brought to light the increasing use by U.S. airlines of maintenance, repair and overhaul (MRO) facilities that are not part of the airlines maintenance departments. In many cases, it noted these facilities use non-licensed technicians or mechanics with little or no training on the aircraft. In some cases the workers had very limited or no understanding of English, making it impossible to read maintenance repair manuals that specify the FAA required procedure to fix an aircraft.
According to the report, one facility used by major U.S. airlines, when notified in advance of an upcoming FAA safety inspection, hid unauthorized and illegal parts from FAA inspectors, and subsequently returned them to inventory after the inspection for use. Incidents of “pencil-whipping,” a practice of signing off aircraft logbooks indicating repairs had been accomplished when they had not, were also reported. The report also revealed that internal airline documents stated that these falsified repairs came to light only after the aircraft was returned to service and in some cases, could have resulted in loss of the aircraft and loss of lives.
On Jan. 20, 2011 it was announced that the FAA has proposed a $1.025 million civil penalty against San Antonio Aerospace, L.P., for failing to conduct FAA required pre-employment drug tests or waiting to properly verify those tests before hiring as many as 90 people to perform safety-sensitive functions between March 2007 and May 2008. The company is a subsidiary of Singapore Technologies Aerospace and in Nov. 2009 was renamed ST Aerospace San Antonio. According to U.S. Department of Transportation Secretary Ray LaHood, the agency alleges that 25 total employees performed “safety-sensitive” work before the results of the drug testing had been verified, and that 62 workers were not administered the test.
Teamsters Airline Division Director David Bourne, commenting on the report and proposed FAA fines said, “The airline industries increasing use of MRO’s with problems similar to those mentioned in the documentary has been a concern for some time. Hearing the nature and gravity of the FAA inspection and proposed fines at ST Aerospace is even more troubling.”
“When an airline has a fully staffed facility on its property, with mechanics and technicians that are fully trained and licensed on the specific airplane that needs to be repaired and a complete and legal parts inventory, we have to question the reasoning behind sending airplanes elsewhere to get repaired at substandard facilities,” Bourne said. “Compromising safety to increase the bottom line is simply unacceptable. Doing so during a time when many airlines are now reporting record profits, is even worse. This is not a new issue. We have watched with great concern at airlines who have taken aircraft from airports in the U.S. with fully staffed and qualified mechanics and technicians and flown them, in some cases, halfway around the world to get repaired in a facility where English is at best, sometimes a second language, just to save money.”
John M. Conley, Administrative Vice President of the Transport Workers Union, also commented on the issues exposed in the PBS report.
“More often than not, this work is done with minimal or substandard oversight to ensure a proper repair and FAA compliance,” said Conley, who is also a member of the FAA’s Future of Aviation Advisory Committee (FAAC). “When we have a situation where properly trained and skilled airline maintenance professionals are pushed aside to increase profits, we are left with an environment where pilots have no way of knowing who repaired an aircraft or if the repair was properly accomplished; in effect they become flying guinea pigs along with the flight attendants and passengers.”
Conley, whose union represents airline professionals at several U.S. airlines explained, “We all say we are committed to safety, but sometimes safety is elusive. Maintenance, repair and overhaul work can and should be done properly and safely by the airlines maintenance facilities utilizing trained and qualified employees — to find that the FAA has fined ST Aerospace and also Pemco troubles us as well.
“In the Pemco case, the FAA had asserted that Pemco could not comply with even basic FAA requirements on three occasions. This again brings into question why any airline would use a facility that can’t meet the same requirements that they themselves must adhere to. It starts with a commitment to safety and a safety culture; something that does not appear to be a high priority with some of these facilities,” Conley said.
In December, the Teamsters and TWU sent a joint letter to Chairman Jerry Costello (D-IL) supporting his call for additional oversight hearings on MRO facilities.
“Airline management must be held to the highest standards when it comes to the maintenance of commercial airliners and the people who work on them. Accepting the minimum standard should never be good enough for the FAA. The traveling public and the crews that operate these airliners must never be compromised. They should not have to guess if the airliner they are travelling on was properly repaired or if the work was done by the cheapest bidder,” Conley stated.
Bourne continued, “We are pleased to note that recently, FAA Administrator Randy Babbitt, himself a former airline pilot, was quoted as saying, ‘Safety is compromised when our regulations are skirted or ignored. The traveling public has to be confident that the people who perform work on their planes are complying with those regulations.’ We agree completely with the administrator,” Bourne said.
Transport Workers Union of America represents 200,000 workers and retirees, primarily in commercial aviation, public transportation and passenger railroads, including the majority of ground workers at American Airlines, American Eagle and Southwest Airlines and dispatchers at most major carriers. The union is an affiliate of the AFL-CIO. For more information, visit www.twu.org.
Founded in 1903, the International Brotherhood of Teamsters represents 1.4 million hardworking men and women throughout the United States, Canada and Puerto Rico. For more information, please visit www.Teamster.org.
The National Transportation Safety Board has been investigating an operational error that occurred near New York City in January.
The Safety Board was notified of a Traffic Collision and Alerting System (TCAS) resolution advisory that occurred due to a near midair collision involving American Airlines flight 951 on January 20, 2011, at about 10:30 p.m. Eastern Standard Time. The American Airlines aircraft, a Boeing 777-200 (N7CA), had taken off from John F. Kennedy International Airport en route to Sao Paulo, Brazil and was flying southeast. A flight of two U.S. Air Force C-17s was heading northwest toward McGuire Air Force Base, New Jersey. There were no injuries in the incident.
The NTSB has interviewed air traffic controllers on duty at the time of the incident, and is gathering information from American Airlines and the Air Force.
The air traffic controllers talking to each of the aircraft received conflict alerts, and immediately provided traffic advisories and turned their aircraft to resolve the conflict. In addition, the American Airlines crew responded to directions provided by TCAS. Radar data indicate that the aircraft came within a mile of each other at their closest point. The incident occurred about 80 miles southeast of New York City.
Betty Koschig has been designated the NTSB’s Investigator-in-Charge for this incident. Further information will be released as it becomes available.
U.S. Department of Transportation
Federal Aviation Administration
SAFO
Safety Alert for Operators
SAFO 11002 DATE: 2/4/11
Flight Standards Service Washington, DC
SAFO URL
A SAFO contains important safety information and may include recommended action. SAFO content should be especially valuable to air carriers in meeting their statutory duty to provide service with the highest possible degree of safety in the public interest. Besides the specific action recommended in a SAFO, an alternative action may be as effective in addressing the safety issue named in the SAFO.
Subject: Beechcraft Duke (BE-60) Flap Preflight Check Purpose: This SAFO informs Beechcraft Duke (BE-60) model airplane operators and those who oversee
them on the need to properly check flap operation prior to takeoff.
Background: On December 4, 2007, a Beechcraft Duke (BE-60) was destroyed when it crashed after takeoff. The pilot was killed and the aircraft was destroyed. The investigation revealed that the flap actuators may have undergone improper maintenance practices. One actuator was fully retracted and the other was fully extended which may have contributed to the accident.
Recommended Action: Pilots and operators of the Duke (BE-60) should properly verify the full operation of their wing flaps prior to takeoff in accordance with the Before Takeoff procedures. The Pilot’s Operating Manual reads “Flaps – Check operation and set.” This can include a visual verification of flap position and corresponding agreement with cockpit indicators. If improper operation is suspected, they should visually inspect each flap position.
Contact: Questions or comments concerning this SAFO can be directed to the Flight Standards Service, Commercial Operations Branch, AFS-820 at (202) 267-8212.
Distributed by: AFS-200 OPR: AFS-820
National Transportation Safety Board
Washington, DC 20594
FOR IMMEDIATE RELEASE: February 3, 2011
SB-11-06
Washington, DC – The National Transportation Safety Board is hosting a conference to share best practices and promote post-accident family assistance in all modes of transportation. Family Assistance: Promoting an International Approach for the Transportation Industry, will be held in Washington, DC on March 28 and 29, 2011. The conference will bring together family members, transportation accident investigation agencies, industry representatives, government agencies, and the news media to share perspectives on lessons learned in providing family assistance following transportation accidents in an international context.
“Following a major aviation or passenger rail accident in the US, the NTSB has the responsibility to coordinate support for survivors and families,” said NTSB Chairman Deborah A.P. Hersman. “With this conference, we are marking the 15th anniversary of the enactment of the Aviation Disaster Family Assistance Act and the 10th anniversary of ICAO Circular 285, with a unique forum to identify lessons learned and draw from international experiences to improve the support for families in the wake of transportation tragedies worldwide.”
The first day of the conference will include panel discussions featuring family members, transportation industry representatives, vendors, non-governmental organizations, transportation accident investigative agencies, and the news media examining their perspectives on transportation family assistance.
The second day will feature a series of presentations by NTSB Transportation Disaster Assistance staff as they discuss the Board’s family assistance model from an operational perspective.
This conference, being held at NTSB’s headquarters, is provided free of charge to those interested in the provision of family assistance in all modes of transportation. A complete agenda and list of speakers will be published prior to the conference. The first day will be webcast at www.ntsb.gov.
National Transportation Safety Board
Washington, DC 20594
February 4, 2011
The National Transportation Safety Board has been investigating an operational error that occurred near New York City in January.
The Safety Board was notified of a Traffic Collision and Alerting System (TCAS) resolution advisory that occurred due to a near midair collision involving American Airlines flight 951 on January 20, 2011, at about 10:30 p.m. EasternStandard Time. The American Airlines aircraft, a Boeing777-200 (N7CA), had taken off from John F. Kennedy International Airport en route to Sao Paulo, Brazil and wasflying southeast. A flight of two U.S. Air Force C-17s was heading northwest toward McGuire Air Force Base, New Jersey. There were no injuries in the incident.
The NTSB has interviewed air traffic controllers on duty at the time of the incident, and is gathering information from American Airlines and the Air Force.
The air traffic controllers talking to each of the aircraft received conflict alerts, and immediately provided traffic advisories and turned their aircraft to resolve the conflict. In addition, the American Airlines crew responded to directions provided by TCAS. Radar data indicate that the aircraft came within a mile of each other at their closest point. The incident occurred about 80 miles southeast of New York City.
Betty Koschig has been designated the NTSB’s Investigator-in-Charge for this incident. Further information will be released as it becomes available.
NTSB Holding Family Assistance Symposium
Panel discussions during the March 28-29 event will help the transportation industry, the media, and investigative agencies learn how families are helped after accidents around the world.
The National Transportation Safety Board will hold a two-day conference March 28-29 for family members, transportation accident investigation agencies, transportation industry representatives, government agencies, and the media to discuss family assistance after transportation accidents in an international context. The event coincides with the 15th anniversary of the Aviation Disaster Family Assistance Act and the 10th anniversary of ICAO Circular 285 and will give those who attend the chance to learn firsthand from those involved worldwide in family assistance, according to NTSB.
Day one features four panel discussions and will be webcast. Day two includes training by the NTSB Transportation Disaster Assistance staff, who will give an overview of the NTSB model for family assistance operations.
The tentative agenda shows the panel discussions will be:
Family Members: Perspectives from those affected by accidents, a discussion of their needs, and how those needs are met through family assistance programs.
Transportation industry, vendors, and non-governmental organizations: Responsibilities of the industry, their vendors, and non-governmental organizations.
Government transportation accident investigation agencies: How investigative agencies provide information about accident investigations and their role in family assistance.
Media: How the media report on family members following accidents and how family assistance has affected such reporting.
The event will take place at the NTSB Conference Center, 429 L’Enfant Plaza SW, Washington, DC 20594. Registration is free and is being conducted separately for each day. Visit this page to register and for links to transportation family assistance resources.
Tentative Agenda
Perspectives from Family Members, Industry, Government, and Media
Welcome and Introductions: The Honorable Deborah A.P. Hersman
Commemoration of the 15th Anniversary of the Aviation Disaster Family Assistance Act
Four high-level panel discussions designed to share best practices and lessons learned in the provision of family assistance in transportation accidents internationally.
Family Members: Perspectives from those impacted by accidents, a discussion of their needs, and ways in which those needs are met through family assistance programs.
Transportation industry, vendors, and non-governmental organizations: Perspectives on the responsibilities of the industry, their vendors, and non-governmental organizations in providing assistance.
Government transportation accident investigation agencies: How investigative agencies provide information about the accident investigation and their role in family assistance.
Media: How the media reports on family members following accidents and how family assistance has impacted such reporting.
March 29, 2011
The NTSB Family Assistance Model: An Introduction
NTSB family assistance legislation overview; information flow and timelines; family assistance operations; conducting effective family briefings; personal effects best practices; victim identification concerns; site visits, memorials, anniversaries.
The importance of maintaining situational awareness and the risks of pilot distraction are two of the major safety lessons featured in the latest edition of the ATSB’s investigation bulletin, released today.
Situational awareness was a factor in air proximity events, breakdowns of separation, ground handling and wirestrikes. An example of a situational awareness issue occurred when a Pilatus PC-12/45 and Aeronautica MacchiAL60 passed within close proximity to each other while flying. This incident highlighted the need for aircrew to conduct diligent radio broadcasts and continual visual scanning to minimise the risk of collision.
The bulletin also identified how pilot distractions can affect the safety of aircraft operations. This was highlighted when the pilot of a Cessna 206 was distracted by other traffic operating in the area and consequently did not change the fuel tank selection. This resulted in an engine failure and subsequent forced landing.
Other safety lessons featured in the bulletin cover:
the importance of pilots using all available resources to confirm clearances from the air traffic control
the importance of not over-extending an aircraft glide after an engine failure
the difficulties associated with managing an in-flight engine failure at low altitude
the steps pilots can take to avoid wirestrikes, especially when flying in unfamiliar areas
the techniques pilots can use to maintain separation from other aircraft.
Released quarterly, the bulletin provides a summary of the less-complex factual investigation reports conducted by the ATSB. The results, based on information supplied by organisations or individuals involved in the occurrence, detail the facts behind the event, as well as any safety actions undertaken or identified. The bulletin also highlights important safety messages for the broader aviation community, drawing on earlier ATSB investigations and research.
The report is here
National Transportation Safety Board
Washington, DC 20594
February 1, 2011
The National Transportation Safety Board makes the following safety recommendations to the Federal Aviation Administration:
Require Cessna Aircraft Company and other manufacturers whose restraint system designs permit an occupant to use an inactive airbag restraint system not intended for use in his or her seat to modify their restraint system designs to eliminate that possibility, and require them to modify restraint systems in existing airplanes to eliminate the possibility of misuse.
Revise the guidance and certification standards concerning restraint systems to recognize and prevent potential misuse scenarios, including those documented in this safety study.
Modify the special conditions for the installation of inflatable restraints on general aviation airplanes (at Federal Register, vol. 73, no. 217 [November 7, 2008], p. 66163) to provide specific guidance to manufacturers as to how they should demonstrate that the protection is effective for occupants that range from the 5th percentile female to the 95th percentile male.
Require the retrofitting of shoulder harnesses on all general aviation airplanes that are not currently equipped with such restraints in accordance with Advisory Circular (AC) 21-34, issued June 4, 1993.
Evaluate the potential safety benefits and feasibility of requiring airbag-equipped aircraft to have the capability to capture and record, at a minimum, data concerning crash dynamics and airbag deployment criteria that can be reviewed after a crash to determine whether the system performed as designed.
Develop a system to track individual aircraft information about aircraft safety equipment, such as restraint systems, airbags, aircraft parachutes, and other specific aircraft equipment, designed to improve crash outcomes.
