NTSB

National Transportation Safety Board

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    FAA Approves Boeing Certification plans

    Although the Federal Aviation Administration approved Boeing Company’s certification plan for the redesigned 787 battery system, after thoroughly reviewing Boeing’s proposed modifications, the National Transportation Safety Board said Boeing didn’t inform investigators about what it planned to say in the March 15 briefing in Tokyo, which is “inconsistent with our expectations.”

    On March 15, Boeing reps provided their own analysis and conclusions regarding the NTSB investigation but they apparently signed paperwork that “must refrain from providing opinions or analysis of the accident.”

    The NTSB was not amused.

    Boeing plans to demonstrate that the system will meet FAA requirements but they are also concerned with damage control.

    The certification plan is the first step in the process to evaluate the 787’s return to flight and requires Boeing to conduct extensive testing and analysis to demonstrate compliance with the applicable safety regulations and special conditions.

    The Jan. 7 fire in Boston was composed of three-inch flames on the front of the connector’s battery box.

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    NTSB: Pilots Manage Risks to Ensure Safety

    Good decision-making and risk management practices can help prevent accidents
    The problem
    Although few pilots knowingly accept severe risks, accidents can also result when several risks of marginal severity are not identified or are ineffectively managed by the pilot and compound into a dangerous situation. Accidents also result when the pilot does not accurately perceive situations that involve high levels of risk.
    Ineffective risk management or poor aeronautical decision-making can be associated with almost any type of fatal accident across all general aviation (GA) sectors.

    See Full Alert

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    NTSB: Mechanics: Manage Risks to Ensure Safety

    Carefully follow maintenance and inspection procedures to help prevent aircraft accidents
    The problem
    Mistakes made while performing aircraft maintenance and inspection procedures have led to in-flight emergencies and fatal accidents.
    System or component failures are among the most common defining events for fatal accidents across various sectors of general aviation (GA)

    See Full Alert

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    NTSB: Is Your Aircraft Talking to You? Listen!

    Pay attention to signs of potential mechanical problems
    The problem
    Some pilots do not pay adequate attention to indications of aircraft mechanical problems, which can lead to in-flight emergencies and accidents.
    Powerplant system or component failure is the third-most common defining event for fatal accidents in the personal flying sector of general aviation (GA). Nonpowerplant system or component failure also ranks high on the list.

    See Full Alert

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    NTSB: Reduced Visual References Require Vigilance

    Historically, about two-thirds of all general aviation (GA) accidents that occur in reduced-visibility weather conditions are fatal.1 These accidents typically involve pilot spatial disorientation or controlled flight into terrain.
    Even in visual weather conditions, flights at night over areas with limited ground lighting (which provides few visual ground references) can be challenging.
    See Full Alert

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    NTSB: Prevent Aerodynamic Stalls at Low Altitude

    Avoid this often deadly scenario through timely recognition and appropriate responses.

    Many stall accidents that occur in VMC result when a pilot is momentarily distracted from the primary task of flying, such as while maneuvering in the airport traffic pattern, during an emergency, or when fixating on ground objects.

    See Full Alert

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    NTSB Issues 5 Alerts


    March 12, 2013
    WASHINGTON – Today the National Transportation Safety Board issued five Safety Alerts that focus on the most frequent types of general aviation accidents.

    “Because we investigate each of the 1,500 GA accidents that occur in the United States every year, we see the same types of accidents over and over again,” said NTSB Chairman Deborah A.P. Hersman. “What’s especially tragic is that so many of these accidents are entirely preventable.”

    Each year, about 475 pilots and passengers are killed and hundreds more are seriously injured in GA accidents in the United States, which is why GA Safety is on the NTSB’s Most Wanted List.

    A Safety Alert is a brief information sheet that pinpoints a particular safety hazard and offers practical remedies to address the issue. Three of the Safety Alerts focus on topics related to some of the most common defining events for fatal GA accidents. These include low-altitude stalls, spatial disorientation and controlled flight into terrain, and mechanical problems. The other two Safety Alerts address risk mitigation.

    The five Safety Alerts issued today are:

    • Is Your Aircraft Talking to You? Listen!
    • Reduced Visual References Require Vigilance
    • Avoid Aerodynamic Stalls at Low Altitude
    • Mechanics: Manage Risks to Ensure Safety
    • Pilots: Manage Risks to Ensure Safety

    The NTSB is creating five short videos – one for each Safety Alert – which will be rolled out this spring. The videos will feature regional air safety investigators sharing their experiences and observations of the many accident investigations they conducted as well as advice on how pilots and mechanics can avoid mistakes that can have such tragic consequences.

    “GA is essentially an airline or maintenance operation of one, which puts the responsibility for sound decision making on one person’s shoulders,” Hersman said. “We are promoting and distributing the alerts to reach pilots and mechanics who can benefit from these lifesaving messages.”

  • NTSB TO CONSIDER NEW SAFETY ALERTS


    March 8, 2013
    WASHINGTON – The National Transportation Safety Board will meet to consider five Safety Alerts aimed at reducing the number of general aviation accidents. A Safety Alert is a brief information sheet that pinpoints a particular safety issue and offers practical remedies to address the hazard.

    Each year the NTSB investigates about 1500 GA accidents in which about 475 pilots and passengers are killed and hundreds more are seriously injured.

    The safety issue areas under consideration at the Board meeting will include:

    • Reduced-visual-reference accidents, including controlled flight into terrain and uncontrolled descent to the ground due to spatial disorientation
    • Aerodynamic stalls at low altitude in daylight visual weather conditions
    • Pilot inattention to indications of mechanical problems
    • Risk management for aviation maintenance technicians
    • Risk management for pilots
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    NTSB Reports on Dreamliner Battery Fire in Boston

    briefing
    Briefing March 7, 2013

    We no longer have to conjecture about the Japan Airlines 787 battery fire in Boston because the National Transportation Safety Board has released an interim factual report with nearly 500 pages of related documentation.

    A live webcast forum is scheduled for April in Washington to investigate the design, technology and certification lithium-ion batteries.

    Attached is the report which contains the details of what happened, and examination findings to date.

    Interim Report on Battery

  • AVIATION ACCIDENT IN THOMSON GEORGIA


    NTSB LAUNCHES TEAM TO AVIATION ACCIDENT IN THOMSON GEORGIA

    February 21, 2013
    WASHINGTON – The National Transportation Safety Board is launching a go-team to investigate yesterday’s accident in Thomson, Georgia involving a Beech 390 that overran the runway during landing and crashed into the woods.

    Senior Aviation Investigator Ralph Hicks will serve as the Investigator-in-Charge. Board Member Robert Sumwalt is traveling with the team and will serve as the principal on-scene spokesman. Public Affairs Officer Terry Williams is also accompanying the team and can be reached at 202-557-1350.

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    Safety recommendations

    AVIATION
    NTSB releases safety recommendations to Hawker Beechcraft Corporation addressing fatigue cracks of nose landing gear end caps on Beechcraft 1900D airplanes

    February 14, 2013
    The National Transportation Safety Board makes the following recommendations to Hawker Beechcraft Corporation:

    Determine the fatigue life (life limit) of the Beechcraft 1900D nose landing gear (NLG) end cap with the longitudinal grain direction both aligned and not aligned with the longitudinal axis of the NLG. (A-13-004)

    Develop and implement a replacement program for all Beechcraft 1900D nose landing gear end caps based on the fatigue life determined in Safety Recommendation A-13-004. (A-13-005)

    Revise the Beechcraft 1900D nose landing gear end cap repetitive inspection procedure and time interval to ensure that fatigue cracks are detected prior to failure and issue updated guidance to operators regarding the inspections. (A-13-006)

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    Boeing Test Flights Cleared

    The ten test flights Boeing is being allowed to schedule will be designed to provide more data for inspectors who are still investigating the failed 787 batteries. The NTSB is planning to release a report around March 7.

    First there was a flight to move a 787 from Texas to Washington State, then the Federal Aviation Administration said it would permit the test flights, if flown under stringent rules, in order to to monitor the batteries in while in use.

    The NTSB determined after an exhaustive examination of the JAL lithium-ion battery that the majority of evidence from the flight data recorder and both thermal and mechanical damage pointed to an initiating event in a single cell, out of eight. That cell showed multiple signs of short circuiting, leading to the thermal runaway condition, which then cascaded to other cells. The temperature inside the battery case exceeded 500 degrees Fahrenheit, charring the battery components.

    Currently the assumption is that the potential causes of the initial short circuit include battery charging, battery construction and design, and manufacturing defects.

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    NTSB IDENTIFIES ORIGIN OF JAL BOEING 787 BATTERY FIRE


    NTSB IDENTIFIES ORIGIN OF JAL BOEING 787 BATTERY FIRE; DESIGN, CERTIFICATION AND MANUFACTURING PROCESSES COME UNDER SCRUTINY
    February 7, 2013
    WASHINGTON – At a news conference today, NTSB Chairman Deborah A.P. Hersman identified the origin of the Jan. 7 battery fire that occurred on a Japan Airlines 787 parked at Boston Logan Airport, and said that a focus of the investigation will be on the design and certification requirements of the battery system.

    “U.S. airlines carry about two million people through the skies safely every day, which has been achieved in large part through design redundancy and layers of defense,” said Hersman. “Our task now is to see if enough – and appropriate – layers of defense and adequate checks were built into the design, certification and manufacturing of this battery.”

    After an exhaustive examination of the JAL lithium-ion battery, which was comprised of eight individual cells, investigators determined that the majority of evidence from the flight data recorder and both thermal and mechanical damage pointed to an initiating event in a single cell. That cell showed multiple signs of short circuiting, leading to a thermal runaway condition, which then cascaded to other cells. Charred battery components indicated that the temperature inside the battery case exceeded 500 degrees Fahrenheit.

    As investigators work to find the cause of the initiating short circuit, they ruled out both mechanical impact damage to the battery and external short circuiting. It was determined that signs of deformation and electrical arcing on the battery case occurred as a result of the battery malfunction and were not related to its cause.

    Chairman Hersman said that potential causes of the initiating short circuit currently being evaluated include battery charging, the design and construction of the battery, and the possibility of defects introduced during the manufacturing process.

    During the 787 certification process, Boeing studied possible failures that could occur within the battery. Those assessments included the likelihood of particular types of failures occurring, as well as the effects they could have on the battery. In tests to validate these assessments, Boeing found no evidence of cell-to-cell propagation or fire, both of which occurred in the JAL event.

    The NTSB learned that as part of the risk assessment Boeing conducted during the certification process, it determined that the likelihood of a smoke emission event from a 787 battery would occur less than once in every 10 million flight hours. Noting that there have been two critical battery events on the 787 fleet with fewer than 100,000 flight hours, Hersman said that “the failure rate was higher than predicted as part of the certification process and the possibility that a short circuit in a single cell could propagate to adjacent cells and result in smoke and fire must be reconsidered.”

    As the investigation continues, which will include testing on some of the batteries that had been replaced after being in service in the 787 fleet, the NTSB will continue to share its findings in real time with the FAA, Boeing, the Japan Transport Safety Board, and the French investigative agency, the Bureau d’Enquêtes et d’Analyses.

    “The decision to return the fleet to flight will be made by the FAA, which underscores the importance of cooperation and coordination between our agencies,” Hersman said.

    She also announced that the NTSB would release an interim report of factual findings within 30 days.

    Additional information, including a video of the today’s media briefing, the PowerPoint presentation, the FAA’s Special Conditions for the B-787 battery system, and related documents, can be accessed at http://go.usa.gov/4K4J.

  • SECOND MEDIA BRIEFING ON B-787 Battery


    February 6, 2013
    WASHINGTON – Tomorrow, National Transportation Safety Board Chairman Deborah A.P. Hersman will provide an update on the NTSB’s investigation into the Jan. 7 fire that occurred on a Japan Airlines Boeing 787 at Logan International Airport in Boston.

    Chairman Hersman will brief credentialed members of the news media on the progress of the investigation, after which she and senior staff will take questions. Those unable to attend in person can call in to a teleconference line.

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    NTSB Sends Investigators to Paraguay

    February 4, 2013
    WASHINGTON – The National Transportation Safety Board is sending investigators to assist in the investigation of a Robinson R44 II helicopter that crashed about 80 miles north of Asuncion, Paraguay. Initial reports indicate that the pilot and two passengers were fatally injured.
    The investigation is being led by the Paraguay Civil Aviation Authority (CIPAA). The NTSB has designated senior investigator Paul Cox as the U. S. accredited representative to the CIPAA’s investigation and he will be accompanied by representatives from NTSB, the FAA, Robinson Helicopters, and Lycoming Engines. The U.S. team is expected to arrive Wednesday morning. Further information regarding the investigation will be released by the CIPAA.

  • AOPA and ALEA TAKE ACTION ON NTSB SAFETY RECOMMENDATIONS


    National Transportation Safety Board Chairman Deborah A.P. Hersman today praised two organizations for their response to NTSB safety recommendations.

    The Aircraft Owners and Pilots Association took action that exceeded the NTSBs recommendations following the investigation into the Aug. 9, 2010 airplane accident in Alaska that killed former U.S. Sen. Ted Stevens. The NTSB recommended that AOPA educate pilots about the benefits of notifying passengers about the location and operation of survival and emergency communication equipment aboard the airplane.

    In response, AOPA produced a video to educate pilots about briefing passengers on emergency equipment such as basic VHF radio operation, the cockpit emergency locator transmitter switch and the location of emergency gear. The video also included a sample passenger safety briefing. AOPA also developed a printable checklist for use in the aircraft. All this information is available on its website at www.aopa.org/asf/video/passenger-safety-briefing.html.

    “This is a perfect example of an organization embracing not only the letter, but the spirit of our recommendation,” said Deborah A.P. Hersman, chairman of the NTSB. “This will result in a higher level of safety for general aviation passengers, who often are friends and family.”

    Hersman also praised the action of the Airborne Law Enforcement Accreditation Commission in implementing multiple NTSB recommendations as a result of its investigation into the June 9, 2009 crash of a helicopter operated by the New Mexico State Police. The NTSB recommended rest standards to prevent pilot fatigue, training in encountering instrument meteorological conditions and encouraged the installation of flight-tracking equipment and 406-megahertz emergency locator transmitters on their aircraft.

    “The fact that the Airborne Law Enforcement Accreditation Commission implemented all of the NTSB’s recommendations in just six months is to be highly commended,” Hersman said.

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    Seventh update on JAL Boeing 787 battery fire investigation


    WASHINGTON – The National Transportation Safety Board today released the seventh update on its investigation into the Jan. 7 fire aboard a Japan Airlines Boeing 787 at Logan International Airport in Boston.

    The auxiliary power unit battery, manufactured by GS Yuasa, was the original battery delivered with the airplane on December 20, 2012. It is comprised of eight individual cells. All eight cells came from the same manufacturing lot in July 2012. The battery was assembled in September 2012 and installed on the aircraft on October 15, 2012. It was first charged on October 19, 2012.

    Examination and testing of an exemplar battery got underway earlier this week at the Carderock Division of the Naval Surface Warfare Center laboratories in West Bethesda, MD. The tests consisted of electrical measurements, mass measurements, and infrared thermal imaging of each cell, with no anomalies noted. The cells are currently undergoing CT scanning to examine their internal condition. In addition, on Thursday, a battery expert from the Department of Energy joined the investigative team to lend his expertise to the ongoing testing and validation work.

    In Seattle, NTSB investigators and Boeing engineers examine the type of lithium ion battery used on the Boeing 787 to start the auxillary power unit and to provide backup power for flight critical systems.
    NTSB investigators were made aware of reports of prior battery replacements on aircraft in the 787 fleet, early in the investigation. As reported Tuesday, Boeing, a party to the investigation, is providing pertinent fleet information which investigators will review to determine if there is any relevance to the JAL investigation.
    An investigative group continued to interpret data from the two digital flight data recorders on the aircraft, and is examining recorded signals to determine if they might yield additional information about the performance of the battery and the operation of the charging system.

    Next week, the NTSB battery testing team will initiate a non-invasive “soft short“ test of all cells of the exemplar battery. This test will reveal the presence of any high resistance, small or “soft” shorts within a cell. Also, an NTSB investigator will travel to France with the battery contactor from the JAL event battery, for examination at the manufacturer. The battery contactor connects a wiring bundle from the airplane to the battery.

    Investigators are continuing their work in Washington and Japan and the team in Seattle continues to observe the FAA-led review of the certification process for the 787 battery system. The flow of information from these observations helps to inform NTSB investigative activity in the US and around the world.

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    Lithium Ion Batteries Remain a Point of Concern

    Both Airbus and Boeing say the designs for their litium-ion systems are safe, in spite of known risk of flames, explosion, smoke and leakage.

    Those are some pretty hefty “known” risks.

    Now ANA says that prior to the fire, it had replaced batteries on its 787 aircraft some 10 times because of low charges.

    Now the Kanto Aircraft Instrument Co whose system monitors voltage, charging and temperature of lithium-ion batteries is also under scrutiny, in addition to GS Yuasa who makes the batteries.

    The National Transportation Safety Board is conducting a chemical analysis of internal short circuiting and thermal damage of the battery.

    NTSB ISSUES SIXTH UPDATE ON JAL BOEING 787 BATTERY FIRE INVESTIGATION

    January 29, 2013
    WASHINGTON – The National Transportation Safety Board today released the sixth update on its investigation into the Jan. 7 fire aboard a Japan Airlines Boeing 787 at Logan International Airport in Boston.

    The examination of the damaged battery continues. The work has transitioned from macroscopic to microscopic examinations and into chemical and elemental analysis of the areas of internal short circuiting and thermal damage.

    Examination and testing of the exemplar battery from the JAL airplane has begun at the Carderock Division of the Naval Surface Warfare Center laboratories. Detailed examinations will be looking for signs of in-service damage and manufacturing defects. The test program will include mechanical and electrical tests to determine the performance of the battery, and to uncover signs of any degradation in expected performance.

    As a party contributing to the investigation, Boeing is providing pertinent fleet information, which will help investigators understand the operating history of lithium-ion batteries on those airplanes.

    An investigative group continued to interpret data from the two digital flight data recorders on the aircraft, and is examining recorded signals to determine if they might yield additional information about the performance of the battery and the operation of the charging system.

    In addition to the activities in Washington, investigators are continuing their work in Seattle and Japan.

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    Preliminary Report Issued in Piper Crash

    According to one report, the piper that crashed on Jan 12 near Paris Texas killed Passengers Michael Dale Bradley, 44, and Michael Endo, 51, and pilot Rob Thompson, 49. After takeoff, the plane lost its rudder and crashed in “foggy and drizzly” conditions between 8:54 and 9:00 a.m., a minute after talking to ATC in Fort Worth.

    Witnesses heard the engine backfire several times, and saw black smoke coming from the field where the plane crashed near Glory Texas.

    The horizontal stabilizer/rudder separated from the airframe and the report recorded that it was was found “approximately 30 feet behind the main wreckage.”

    The report was issued on Jan 22.

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    IMPROPER MAINTENANCE LED TO Vegas AIR TOUR HELICOPTER CRASH

    What is it that I’ve always said? Maintenance, Maintenance, Maintenance.

    Looks like the NTSB Findings agree with me! See their report below about a helicopter crash in December 7, 2011, that occurred in my home away from home, Las Vegas Nevada.

    PRELIMINARY REPORT
    On December 7 at 4:30 Pacific Standard Time, a Eurocopter AS350-B2, operated by Sundance Helicopters as flight Landmark 57, crashed in mountainous terrain approximately 14 miles east of Las Vegas. The flight, a sightseeing tour, departed Las Vegas McCarran International Airport (LAS) en-route to the Hoover Dam area was operating under visual flight rules. The helicopter impacted in a narrow ravine in mountainous terrain between the cities of Henderson and Lake Mead. The pilot and four passengers were fatally injured.

    The National Transportation Safety Board determined today (Jan. 29, 2013) that the probable cause of the Dec. 7, 2011, air tour helicopter crash near Las Vegas, Nev., was inadequate maintenance, including degraded material, improper installation, and inadequate inspections.

    “This investigation is a potent reminder that what happens in the maintenance hangar is just as important for safety as what happens in the air,” said NTSB Chairman Deborah A. P. Hersman.

    At about 4:30 p.m. Pacific standard time, a Sundance Helicopters Eurocopter AS350, operating as a “Twilight City Tour” sightseeing trip, crashed in mountainous terrain about 14 miles east of Las Vegas, Nev. The helicopter originated from Las Vegas McCarran International Airport at about 4:21 p.m. with a planned route to the Hoover Dam area and then return to the airport. The accident occurred after a critical flight control unit separated from another, rendering the helicopter uncontrollable. After the part separated, the helicopter climbed about 600 feet, turned about 90 degrees to the left, descended about 800 feet, began a left turn, and then descended at a rate of at least 2,500 feet per minute to impact. The pilot and four passengers were killed and the helicopter was destroyed.

    The NTSB found that the crash was the result of Sundance Helicopters’ improper reuse of a degraded self-locking nut in the servo control input rod and the improper or non-use of a split pin to secure the degraded nut, in addition to an inadequate post-maintenance inspection.

    Contributing to the improper (or lack of) split pin installation was the mechanic’s fatigue and lack of clearly delineated steps to follow on a “work card” or “checklist” The inspector’s fatigue and lack of a work card or checklist clearly laying out the inspection steps to follow contributed to an inadequate post-maintenance inspection. As a result of this investigation the NTSB made, reiterated and reclassified recommendations to the Federal Aviation Administration.
    “One of the critical lines of defense to help prevent tragedies like this crash is improved maintenance documentation through clear work cards, or checklists,” Hersman said. “Checklists are not rocket science, but they can have astronomical benefits.”

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    Fourth Investigative Update on Boeing 787 Battery Fire


    NTSB Provides Fourth Investigative Update on Boeing 787 Battery Fire in Boston

    January 27, 2013
    WASHINGTON – The National Transportation Safety Board today released a fourth update on its investigation into the Jan. 7 fire aboard a Japan Airlines Boeing 787 at Logan International Airport in Boston. The fire occurred after the airplane had landed and no passengers or crew were onboard.

    The event airplane, JA829J was delivered to JAL on December 20, 2012. At the time of the battery fire, the aircraft had logged 169 flight hours with 22 cycles. The auxiliary power unit battery was manufactured by GS Yuasa in September 2012.

    NTSB investigators have continued disassembling the internal components of the APU battery in its Materials Laboratory in Washington, and disassembly of the last of eight cells has begun. Examinations of the cell elements with a scanning-electron microscope and energy-dispersive spectroscopy are ongoing.

    A cursory comparative exam has been conducted on the undamaged main battery. No obvious anomalies were found. More detailed examination will be conducted as the main battery undergoes a thorough tear down and test sequence series of non-destructive examinations.

    In addition to the activities at the NTSB lab, members of the investigative team continue working in Seattle and Japan and have completed work in Arizona. Their activities are detailed below.

    ARIZONA
    The airworthiness group completed testing of the APU start power unit at Securaplane in Tucson and the APU controller at UTC Aerospace Systems in Phoenix. Both units operated normally with no significant findings.

    SEATTLE
    Two additional NTSB investigators were sent to Seattle to take part in FAA’s comprehensive review. One of the investigators will focus on testing efforts associated with Boeing’s root cause corrective action efforts, which FAA is helping to lead. The other will take part in the FAA’s ongoing review of the battery and battery system special conditions compliance documentation.

    JAPAN
    The NTSB-led team completed component examination of the JAL APU battery monitoring unit at Kanto Aircraft Instrument Company, Ltd., in Fujisawa, Kanagawa, Japan. The team cleaned and examined both battery monitoring unit circuit boards, which were housed in the APU battery case. The circuit boards were damaged, which limited the information that could be obtained from tests, however the team found no significant discoveries.

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    NEVADA AIR TOUR HELICOPTER ACCIDENT

    January 25, 2013
    WASHINGTON – The National Transportation Safety Board will hold a Board meeting to determine the probable cause of the crash of an air tour helicopter near Las Vegas.

    On December 7, 2011, at about 4:30 pm PST, a Eurocopter AS350-B2 helicopter, operated by Sundance Helicopters, Inc., on a sightseeing trip, crashed in mountainous terrain about 14 miles east of Las Vegas, Nevada. The pilot and four passengers were killed, and the helicopter was destroyed by impact forces and postimpact fire.
    Event: Board Meeting
    Date/Time: Tuesday, January 29, 2013, 9:30 am EST
    Location: NTSB Board Room and Conference Center
    429 L’Enfant Plaza, SW
    Washington, DC 20594
    Participants: NTSB Board Members
    Live Webcast: A link to the webcast will be available on the following page shortly before the start of the meeting: http://www.capitolconnection.net/capcon/ntsb/ntsb.htm
    ###

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    INVESTIGATION OF BOEING 787 BATTERY FIRE IN BOSTON

    NTSB CHAIRMAN SAYS ‘WE HAVE NOT RULED ANYTHING OUT’ IN INVESTIGATION OF BOEING 787 BATTERY FIRE IN BOSTON
    WASHINGTON – In a press conference today, National Transportation Safety Board Chairman Deborah A.P. Hersman released preliminary findings from the NTSB’s ongoing investigation into the Jan. 7, 2013, Boeing 787 battery fire in Boston. “We have not ruled anything out as a potential factor in the battery fire; there are still many questions to be answered,” Hersman said.

    Noting that there was a B-787 battery incident in Japan on Jan. 16, 2013, which is being investigated by the Japan Transport Safety Board, Hersman said, “One of these events alone is serious; two of them in close proximity, especially in an airplane model with only about 100,000 flight hours, underscores the importance of getting to the root cause of these incidents.”

    The investigation revealed that the battery in the B-787 fire in Boston showed signs of short circuiting, and had indications of thermal runaway, a situation in which a significant temperature increase can initiate a destructive chain reaction.

    Chairman Hersman also expressed concerns about the adequacy of the systems to prevent such a fire from occurring. “The investigation will include an evaluation of how a fault that resulted in a battery fire could have defeated the safeguards in place to guard against that,” said Hersman. “As we learn more in this investigation, we will make recommendations for needed improvements to prevent a recurrence.”

    Investigators developed the following timeline of the events on Jan. 7, which was released at today’s briefing:

    10:06 am EST – Aircraft arrived at gate in Boston from Narita, Japan
    10:32 am – Cleaning and maintenance crew noticed smoke in cabin
    10:35 am – Mechanic noted flames coming from APU battery in aft electronics bay
    10:37 am – Airport Rescue & Fire Fighting notified
    10:40 am – Fire and rescue personnel arrive on scene
    12:19 pm – Fire and rescue personnel report event was “controlled”

    The batteries were manufactured by GS Yuasa for the Thales electrical installation and are unique to the Boeing 787. The same battery model is used for the main airplane battery and for the battery that is used to start the auxiliary power unit, which is the one that caught fire in Boston.

    Radiographic examinations of the incident battery and an exemplar battery were conducted at an independent test facility. The digital radiographs, or computed tomography (CT) scans, generated from these examinations allowed NTSB investigators to document the internal condition of the battery prior to disassembling it.

    Ongoing lab work includes an examination of the battery elements with a scanning-electron microscope and energy-dispersive spectroscopy to analyze the elemental constituents of the electrodes to identify contaminants or defects.
    NTSB INVESTIGATIVE TEAMS

    In addition to the activities at the NTSB lab in Washington, members of the investigative team have been conducting work in Arizona, Seattle and Japan. Their activities are detailed below.

    ARIZONA
    – The acceptance test procedure of the APU battery charging unit was conducted at Securaplane in Tucson, Ariz., on Jan. 21.
    – The battery charging unit passed all significant tests and no anomalies were detected.
    – Members of the airworthiness group examined the APU start power unit at Securaplane in Tucson. The same team traveled to Phoenix to conduct an examination of the APU controller at UTC Aerospace Systems.

    SEATTLE
    – NTSB investigators are working with Boeing teams as part of root cause analysis activities related to the design and manufacturing of the electrical battery system.
    – The two JAL B-787 general purpose module units, which record airplane maintenance data are being downloaded at Boeing to obtain information that was recorded after the airplane’s electrical power was interrupted.

    JAPAN
    – The NTSB-led team conducted component examination of the JAL B-787 APU battery monitoring unit at Kanto Aircraft Instrument Company, Ltd., in Fujisawa, Kanagawa, Japan.
    – The team cleaned and examined both battery monitoring unit circuit boards, which were housed in the APU battery case. The circuit boards were damaged, which limited the information that could be obtained from tests.

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    NTSB PROVIDES INVESTIGATIVE UPDATE AND PHOTO OPPORTUNITY OF LAB WORK RELATED TO BOEING 787 BATTERY FIRE IN BOSTON


    January 23, 2013
    WASHINGTON – Tomorrow, National Transportation Safety Board Chairman Deborah A.P. Hersman will provide an update on the NTSB’s investigation of the Jan. 7 fire aboard a Japan Airlines (JAL) Boeing 787 at Logan International Airport in Boston.

    Chairman Hersman will brief credentialed members of the news media on the progress of the investigation, after which she and senior staff will take questions. Those unable to attend in person can call in to a teleconference line.

    Reporters will then be invited to view the materials laboratory where the battery is being examined. Photography will be allowed but no “stand-ups” or taped reporting from the lab will be permitted.

    For planning purposes, RSVP is required for those planning to either attend in person or call in.

    Location: NTSB Boardroom and Conference Center, 429 L’Enfant Plaza East, SW, Washington, DC

    Date: Thursday, January 24, 2013

    Time: 2:30 p.m.

    Participants: Chairman Deborah A.P. Hersman; John DeLisi, Director of NTSB Office of Aviation Safety; and Dr.
    Joseph Kolly, Director, NTSB Office of Research and Engineering.

    The following factual information has been developed about the battery: It consists of eight cells of 3.7 volts each. All eight cells had varying degrees of thermal damage. Six of eight cells have been CT scanned and have been disassembled to expose their electrodes. All electrode windings in the battery are in the process of being photo-documented and are undergoing microscopic examination. In the coming days, the remaining two cells will undergo the same examination. Additional information will be provided tomorrow.