NTSB

National Transportation Safety Board

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    NTSB SAFETY RECOMMENDATION

    National Transportation Safety Board
    Washington, DC 20594

    July 7, 2011
    http://www.ntsb.gov/doclib/recletters/2011/A-11-056-059.pdf
    The National Transportation Safety Board makes the following recommendations to the Airborne Law Enforcement Association:

    Revise your standards to define pilot rest and ensure that pilots receive protected rest periods that are sufficient to minimize the likelihood of pilot fatigue during aviation operations. (A-11-56)

    Revise your accreditation standards to require that all pilots receive training in methods for safely exiting inadvertently encountered instrument meteorological conditions for all aircraft categories in which they operate. (A-11-57)

    Encourage your members to install 406-megahertz emergency locator transmitters on all of their aircraft. (A-11-58)

    Encourage your members to install flight-tracking equipment on all public aircraft that would allow for near-continuous flight tracking during missions. (A-11-59)

  • NTSB INVESTIGATING CRASH OF WORLD WAR II-VINTAGE B-17

    The National Transportation Safety Board is investigating Today’s crash of a B-17 (N390TH) vintage airplane. The crash occurred approximately 3-4 miles southeast of the Aurora
    Municipal Airport near Oswego, Illinois. It has been reported that there was an in-flight fire prior to impact. There were 7 persons on board. No injuries have beenreported at this time.

    NTSB investigator Tim Sorenson will be the Investigator-in-Charge and is en route to the accident scene. Moreinformation regarding the investigation will be releasedwhen it becomes available.

    NTSB Media Contact:
    Keith Holloway (202) 314-6100
    hollowk@ntsb.gov

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    Beech Crashes House in Miami Gardens

    What: Beech 18 (N18R)
    Where: near Opa-Locka Airport, Miami Gardens Florida
    When: May 2, 2010
    Who: pilot Harry Trauffer
    Why: Right after takeoff, the pilot of the twin engine Beechcraft 18 cargo plane that was carrying household goods to the Bahamas radioed he was going down, before he clipped trees, crashed through a fence and 2 cars and into a residential yard. Neighbors were at home at the time of the crash, and witnessed it.

    More than 90 Miami-Dade firefighters were on the scene. Although we saw reports that the fire only caused smoke damage to the exterior of the home, and that it did not strike the building, it is clear in the video that the house was breached by the plane, and there were several areas of the house that were on fire. The family is staying elsewhere and no one in the house was injured.

    and was toxic while burning,
    The pilot who was killed in the crash was 64 year old Harry Trauffer, who regularly flew clothing, bedding and auto parts to the Bahamas.

    Near the accident site on 38th Avenue and 150th Street., the NTSB is holding a 3:00 PM press briefing conducted by NTSB Investigator-in-Charge, Todd Gunther

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    NTSB Reports on July 15 Flight, Turbulence, Injury

    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.

    See Flight Attendant Injured in Clear Air Turbulence

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    NTSB Directive Contradicts Boeing Statement

    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:

    1. Removal of rivets and examination of rivet hole dimensions, rivet dimensions, and rivet hole alignment between upper and lower skins.
    2. Detailed fractographic analysis of the skin fractures emanating from the rivet holes using optical and scanning electron microscopes.
    3. Fatigue striation analysis using a scanning electron microscope of specific skin fractures to determine the rate of crack propagation.
    4. Additional portions of the lap joints from the accident aircraft.

    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?

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    Airbus 320 Reboot Confounds United Airlines Pilots

    United Airlines pilots guilty as charged again, in that Airbus 320 that had to make an emergency return to New Orleans on April 4. A pilot in command should know he can’t skip procedures on the checklist (especially an Airbus checklist) or else there are consequences. In this case, the emergency restore didn’t work.

    Ok, lest anyone accuse me of being incorrectly legal instead of correctly tongue-in-cheek, no one was “charged” with anything.

    On April 4, 2011, the United Airlines Airbus 320-232 (N409UA), serial number 462, left Louis Armstrong New Orleans International Airport and returned 20 minutes after take-off due to electrical difficulties and an indication of smoke in the cockpit.

    But the NTSB investigation points to pilot error. And as far as I am concerned any error that does not result in damage, but does result in amended procedures is a good thing. What has happened as a result of this pilot error is a revision to the pilot checklist that pilots have to follow when they are handling electrical malfunctions. The malfunction was not really the pilots however. There was a faulty fire-warning sensor, but the reboot procedures just made it worse since in the reboot procedure, a generator didn’t get turned back on.

    Consequences the pilots had to deal with as a result of the absent generator included a blank screen for the copilot, steering issues with the jet’s nose gear and antiskid protection for the brakes, and the intercom.

    It must have been a pretty exciting 20 minute ride for the passengers, as it ended on emergency slided.

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    NTSB TEAM Investigating New Orleans Emergency Landing

    On April 4, 2011, a United Airlines Airbus 320-232 with 109 passengers and crew aboard returned to the airport about 20 minutes after take-off due to electrical difficulties and smoke in the cockpit. On landing, the crew described a loss of anti-skid braking and nose-wheel steering and passengers had to exit via slide. (The right front slide failed.) Dan Bower is investigator-in-charge of the NTSB team including reps of Federal Aviation Administration,United Airlines, the Air Line Pilots Association, theAssociation of Flight Attendants, and the International Brotherhood of Teamsters and an Airbus rep appointed by the Bureau d’Enquêtes et d’Analyses (BEA) of the Government of France.


    What: United Airlines Airbus A320-200 en route from New Orleans,LA to San Francisco,CA
    Where: Louis Armstrong Airport
    When: April 4 2011 7:20 a.m. after a 13 minute flight
    Who: 100 passengers 5 crew
    Why: After takeoff, the pilot reported smoke in the cockpit, and returned to the airport. The pilot reported losing all instruments, and landed on backup power, blowing out a tire and running off the runway. Passengers evacuated via slides.

    After landing, passengers were taken to the Hilton.

    TRANSCRIPT OF AIR TRAFFIC CONTROLLER, PILOT CONVERSATION
    UA 497: Clear for takeoff runway 19, thank for you very much.
    UA 497: We need to vector back to the airport, we got a smoke issue with the airplane.
    N.O. Approach: Turn right 030 (degrees) and maintain 4,000 (feet.)
    UA 497: 030 4,000. And we’d like the longest runway please.
    N.O. Approach: There are men and equipment on the runway – they’re going to try to get them off now. Descend at pilot’s discretion. Maintain 2,000.
    UA 497: We are declaring an emergency and please roll equipment for our landing please.
    N.O. Approach: We are unable for (runway) 10, can you take (runway) 19?
    UA 497: ..no..
    N.O. Approach: Roger, we are clearing the runway now.
    Airport operations: How much time do we have?
    New Orleans Tower: I’d say they are about 11 miles to the west.
    Airport operations: Tower, we can start trying to pull them off, but I don’t think we will get them all off in time.
    N.O. Approach: United 497, Say souls on board and fuel remaining.
    UA 497: 106 souls on board, fuel remaining 32,400 pounds.
    N.O. Approach: They are still trying to get all the vehicles off the runway and 19 is still available if you like….
    New Orleans Tower: … working as fast as they can (unintelligible) There is a bunch of equipment on there they’re tying to get off now.
    UA 497: You need to clear it for us.
    New Orleans Tower: I understand, sir. We’re getting them off as fast as we can.
    N.O. Approach: Turn right heading 140, main 2,000 ….cleared ILS runway 10 approach.
    New Orleans Tower: Can you verify the vehicles are exiting?
    Airport operations: We are attempting to get the vehicles off right now, I’m removing the cones also.
    New Orleans Tower: OK, cause I haven’t seen any of the vehicles move and the aircraft is ten to the northwest and they have to have runway 100.
    N.O. Approach: United 497, Turn right heading 180.
    UA 497: um…. We only have one… um … (Alarms sounding in background.)
    N.O. Approach: United 497 say again sir?
    New Orleans Tower: We need three minutes to get the runway clear.
    UA 497: (alarms blaring) We’ve lost all our instruments right now and we’re going to need (directions)
    N.O. Approach: United turn left heading, 20 degrees left
    N.O. Approach: Just continue left turn, I’ll tell you when to stop.
    UA 497: (unintelligible) What vector are we from the airport?
    N.O. Approach: Right now sir you are on the 330 degree heading from the airport. Northwest of the airport for runway 19er. If you continue on this present heading you’ll set up on the shoreline for 19.
    UA 497: Shoreline for 19.
    N.O. Approach: I can set u up there or I can vector you, what’d you need?
    UA 497: That’s fine.
    N.O. Approach: (unintelligible…)You got the water, right?
    UA 497: Yeah, we got the water and we’re going to stop here about 600 feet.
    N.O. Approach: Roger that. The airport’s currently at your 1 o’clock and five miles.
    UA 497: 1 o’clock and five miles roger.
    New Orleans Tower to fire crews: Fox-6, next arrival runway 19er is our aircraft. And the aircraft is approximately 3 miles northwest runway 19er.
    N.O. Approach: If you start your right turn now I can set you up on final.
    UA 497: Start turn on final.
    New Orleans Tower to fire crews: The aircraft is over the shoreline around two miles out. You do have permission to proceed on to the runway after he lands.
    N.O. Approach: Make a right turn. The airport is off to yoru right side,
    N.O. Approach: 497, clear to land 19er. You’ll be able to make it sir? Winds 180 at 16, gusts to 20, Clear to land. Runway 19er.
    New Orleans Tower to fire trucks: Fox-5, this is our aircraft touvh ing down bow.
    New Orleans Tower: Follow the aircraft down the runway.
    New Orleans Tower: We’re going to need runway 10 operational. Runway 19er is fouled at this time.

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    NTSB Releases Safety Recommendations

    Partial summary of what is included

    • incorporate in Aircraft Flight Manuals a committed-to-stop point in the landing sequence
    • subpart K operators and Part 142 training schools to incorporate the information
    • establish, and ensure that pilots adhere to, standard operating procedures.
    • principal operations inspectors ensure that pilots use the same checklists in operations that they used during training for normal, abnormal, and emergency conditions.
    • require manufacturers to revise existing, checklists to require pilots to clearly call out and respond with the actual flap position
    • revise/describe terms severe thunderstorms, such as “bow echo,” “derecho,” and “mesoscale convective system.”
    • revise regulations and policies to permit appropriate prescription use
    • require fatigue education (training and policy for doctors and pilots)
    • runway excursion prevention development
    • wet runway landing data information provided to pilots
    • pilot in command line checks demonstrating expertise

    Safety Recommendation .pdf

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    NTSB – 2008 Accident at Owatonna Airport

    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.

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    Pilots Avoid Weather Towers


    In case you didn’t know, planes should not fly into Meteorological Evaluation Towers.

    The NTSB has just issued a warning for pilots to avoid these towers, which at 200 feet are below the threshold for markings. The biggest danger, apparently is that they can be built quickly and whoever builds them is not required to inform aviators.

    So pilots, if you didn’t know to avoid them, you know now. Read the alert here.

    http://ntsb.gov/alerts/SA_016.pdf

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    Newfoundland Sikorsky Crash: Final


    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.