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

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NTSB REQUESTING COMMENTS ON PROPOSED PROCEDURAL RULES FOR AVIATION CERTIFICATE ENFORCEMENT CASE

The NTSB has issued an Advance Notice of Proposed Rulemaking (ANPRM) seeking comments from the public regarding amendments to its procedural rules dealing with review of Federal Aviation Administration (FAA) certificate actions and its rules concerning applications for fees and expenses under the Equal Access to Justice Act.

The NTSB listed three main reasons for its undertaking a review of 49 CFR parts 821 and 826: (1) to respond to parties’ suggestions for changing the rules; (2) to update rules that may be outdated; and (3) to modernize the rules to accommodate prospective electronic filing and document availability in case dockets.

The ANPRM indicates that certain parties have approached the NTSB concerning emergency certificate actions, which involve cases in which the FAA issues an immediately effective order revoking or suspending a certificate. In such cases, the NTSB’s procedural rules allow a party to challenge the emergency status of the case, and provide an expedited timeline for doing so. The rules currently require the NTSB’s administrative law judges to “consider whether, based on the acts and omissions alleged in the Administrator’s order, and assuming the truth of such factual allegations, the Administrator’s emergency determination was appropriate under the circumstances.” The ANPRM invites public comments concerning this standard of review, as well as other aspects of the emergency review process, such as whether a hearing should occur to allow parties to provide evidence concerning whether the case should be treated as an emergency. The ANPRM further invites comments concerning whether parties should have an opportunity for another level of appeal to challenge the emergency status determination.

In addition, the ANPRM also solicits comments concerning electronic filing of documents for aviation certificate cases, and requests specific consideration as to whether such electronic filing is feasible for individuals who opt not to retain an attorney. The ANPRM further seeks feedback concerning whether any outdated information exists in the current procedural rules.

The 60-day comment period for the ANPRM concludes on February 22, 2011. The ANPRM may be accessed at the following link: http://origin.www.gpo.gov/fdsys/pkg/FR-2010-12-22/pdf/2010-32056.pdf.


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DOT PANEL’S RECOMMENDATIONS IDENTIFY CHILD SAFETY IMPROVEMENTS IN AVIATION BUT DO NOT GO FAR ENOUGH, NTSB CHAIRMAN SAYS

National Transportation Safety Board Chairman Deborah A. P. Hersman said that the recommendations issued today by a federal advisory panel dealing with child safety in aviation are a step in the right direction, but they do not go far enough to ensure the safety of the smallest children in airplanes.

The Department of Transportation’s Future of Aviation Advisory Committee (FAAC) presented 23 recommendations to DOT Secretary Ray LaHood today. Among those recommendations was a call that Secretary LaHood utilize the full resources of his office to educate the flying public about the dangers of lap children in aviation. The FAAC also requested that the Secretary to update economic and safety data concerning small children, and to take decisive steps, which may include rulemaking, to address child passenger safety in aviation.

Chairman Hersman stated, “We appreciate the FAAC acknowledging the dangers associated with children flying on their parents’ laps, but we would have preferred to see the FAA be mandated to require that every person including our youngest children be restrained appropriately for their age and size.” She continued, “We know that the safest place for children younger than age two traveling on airplanes is in an appropriate child safety seat. The era of the lap child on airplanes should come to an end.”

The NTSB recently held a Public Forum on Child Passenger Safety in the Air and in Automobiles on December 9, 2010. A webcast of that forum, and presentations and videos concerning child passenger safety are available at www.ntsb.gov/children.

The NTSB will continue its efforts to promote child passenger safety in the coming year through education and advocacy that is aimed toward the caregivers of children, regulatory agencies, and the transportation industry.


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NTSB KICKS OFF YEAR-LONG EFFORT ON CHILD PASSENGER SAFETY, DEBUTS EDUCATIONAL VIDEO

National Transportation Safety Board
Washington, DC 20594

FOR IMMEDIATE RELEASE: December 9, 2010

The National Transportation Safety Board today concluded its public forum, Child Passenger Safety in the Air and in Automobiles. NTSB Chairman Deborah A.P. Hersman announced in her opening remarks that the forum marked the beginning of a year-long effort by the Board to promote child passenger safety across all modes of transportation.

“Safety for our smallest travelers should not be considered optional or a luxury,” said Chairman Hersman.

As part of the NTSB’s safety advocacy efforts, a short video focusing on the importance of properly securing children in cars and on airplanes was debuted at the start of the forum. The full video is now at www.ntsb.gov/children, as well as two shorter versions – one focused on highway safety and one focused on aviation safety. All three versions soon will be available in Spanish.

“The laws of physics don’t change, whether you are on an airplane or in an automobile,” said Chairman Hersman. “Children rely on their parents to know what is safest for them. The purpose of our forum was to make sure that parents have the information to do the right thing.”

Chairman Hersman also noted that 18 other states, as well as American Samoa and Puerto Rico, should amend their existing booster seat laws to reflect the Safety Board’s longstanding recommendation.


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IMPROPER CONTRACTOR ACTIONS AND INSUFFICENT FEDERAL OVERSIGHT LED TO 2008 FATAL FIREFIGHTING HELICOPTER CRASH NEAR WEAVERVILLE, CALIFORNIA, NTSB SAYS

FOR IMMEDIATE RELEASE:
December 7, 2010

The National Transportation Safety Board today determined that a series of improper actions by the contractor and insufficient oversight by the U.S. Forest Service (USFS) and the Federal Aviation Administration (FAA) led to the August 5, 2008, fatal crash of a Sikorsky S-61N helicopter near Weaverville, California. The contractor’s actions included the intentional alteration of weight documents and performance charts and the use of unapproved performance calculations.

Contributing to the accident was the failure of flight crewmembers to address issues related to operating the helicopter at its maximum performance capability. Contributing to the fatalities and survivors’ injuries were the immediate and intense fire that resulted from fuel spillage from the fuel tanks that were not crash resistant, the separation from the floor of the cabin seats that were not crash resistant, and the use of an inappropriate mechanism on the cabin seat restraints. The pilot-in- command, the safety crewmember, and seven firefighters were fatally injured; the copilot and three firefighters were seriously injured.

On August 5, 2008, a Sikorsky S-61N helicopter (N612AZ), which was being operated by the USFS as a public flight to transport firefighters battling forest fires, impacted trees and terrain during the initial climb after takeoff at a location about 6,000 feet above sea level in mountainous terrain near Weaverville. The USFS had contracted with Carson Helicopters, Inc. (CHI) of Grants Pass, Oregon, for the services of the helicopter, which was registered to CHI and leased to Carson Helicopter Services, Inc. (CHSI), also of Grants Pass.

“The probable cause of this accident had to do with Carson’s actions and the oversight entities’ inactions,” said NTSB Chairman Deborah A.P. Hersman. “Carson engaged in a bargain that violated the trust of their crewmembers, the firefighters that they carried onboard, and the aviation industry. But the FAA and the Forest Service did not hold up their end of the deal to oversee Carson’s actions. Public aircraft have been made the orphans of the aviation
industry. It’s now time for the FAA and other government agencies to step up and take responsibility.”

In order to prevent similar accidents and to improve the survivability of such accidents when they do occur, the NTSB issued 11 new recommendations to the FAA and reiterated one from 2006. Ten recommendations were issued to the USFS.

Recommendations to the FAA include oversight of 14 Code of Federal Regulations Part 135 operators with aircraft that can operate part of the time as public aircraft and part of the time as civil, clarification of oversight responsibilities for public aircraft, accuracy of hover performance charts, pilot performance, fuel tank crashworthiness, and occupant protection.

To the USFS, the NTSB recommended the development of mission-specific operating standards for firefighter transport operations, a requirement that its contractors adhere to these standards, and the creation of an oversight program that can monitor and ensure contractor compliance with all standards and requirements. Other issue areas for the USFS recommendations included pilot training, occupant protection, weather instrumentation, and onboard recorders.

A synopsis of the NTSB report, including the probable cause conclusions and safety recommendations, will be available on the NTSB website.


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NTSB TO OPEN DOCKET ON INVESTIGATION INTO THE CRASH OF A PILATUS AIRCRAFT IN MONTANA

As part of its continuing investigation into a plane crash in Montana, the National Transportation Safety Board will open the public accident docket on Friday, December 3, 2010.

On March 22, 2009, at 1430 mountain daylight time, a Pilatus PC-12/45, N128CM, crashed near the approach end of runway 33 at Bert Mooney Airport (BTM), Butte, Montana. The airplane was owned and operated by Eagle Cap Leasing of Enterprise, Oregon, as a personal flight under the provisions of 14 Code of Federal Regulations Part 91. All 14 people on board the airplane were killed in the accident. There were no ground injuries. The flight departed Oroville Municipal Airport, Oroville, California, at 1110 Pacific Daylight Time (1210 mountain daylight time) on an instrument flight rules flight plan and was destined for Gallatin Field, Bozeman, Montana. The airplane was diverting to Butte at the time of the accident. Visual meteorological conditions prevailed at the time of the accident.

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

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

The docket material will be made available at 10:00 am ET on December 3 on the NTSB website at http://www.ntsb.gov/dockets/foia_fri-dockets.htm#Aviation2010 in the FOIA electronic reading room. Details are listed by date.

This will be a document release only. No interviews will be conducted.


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NTSB TO OPEN DOCKET ON INVESTIGATION INTO THE CRASH OF A PILATUS AIRCRAFT IN MONTANA

NTSB Advisory
National Transportation Safety Board
Washington, DC 20594
December 2, 2010

As part of its continuing investigation into a plane crash in Montana, the National Transportation Safety Board will open the public accident docket on Friday, December 3, 2010.

On March 22, 2009, at 1430 mountain daylight time, a Pilatus PC-12/45, N128CM, crashed near the approach end of runway 33 at Bert Mooney Airport (BTM), Butte, Montana. The airplane was owned and operated by Eagle Cap Leasing of Enterprise, Oregon, as a personal flight under the provisions of 14 Code of Federal Regulations Part 91. All 14 people on board the airplane were killed in the accident. There were no ground injuries. The flight departed Oroville Municipal Airport, Oroville, California, at 1110 Pacific Daylight Time (1210 mountain daylight time) on an instrument flight rules flight plan and was destined for Gallatin Field, Bozeman, Montana. The airplane was diverting to Butte at the time of the accident. Visual meteorological conditions prevailed at the time of the accident.

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

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

The docket material will be made available at 10:00 am ET on December 3 on the NTSB website at http://www.ntsb.gov/dockets/foia_fri-dockets.htm#Aviation2010 in the FOIA electronic reading room. Details are listed by date.

This will be a document release only. No interviews will be conducted.


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NTSB TO MEET ON 2008 U.S. FOREST SERVICE CONTRACT FIREFIGHTING HELICOPTER CRASH IN WEAVERVILLE, CALIFORNIA

National Transportation Safety Board
Washington, DC 20594

December 1, 2010

The National Transportation Safety Board will hold a public Board meeting on Tuesday, December 7, at 9:30 a.m., in its Board Room and Conference Center, 429 L’Enfant Plaza, S.W., Washington, D.C.

There is one item on the agenda. The Board will consider a final report on the following accident:

* On August 5, 2008, a Sikorsky S-61N helicopter (N612AZ), impacted trees and terrain during the initial climb after takeoff, located at an elevation of about 6,000 feet in mountainous terrain near Weaverville, California. Impact forces and a post- crash fire destroyed the helicopter, which was being operated by the U.S. Forest Service as a public flight to transport firefighters and was contracted with Carson Helicopters, Inc. As a result of this accident, nine occupants were fatally injured and four were seriously injured.

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

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

NEW TEMPORARY DIRECTIONS (due to ongoing construction) to the NTSB Board Room: Front door located on Lower 10th Street, directly below L’Enfant Plaza. From Metro, exit L’Enfant Plaza station at 7th and D Streets escalator, turn left, cross 7th Street, walk a half block, take stairs on left and walk into the entrance marked La Promenade, walk through shopping mall, turn right at florist shop, see the CVS store (on the left) and take escalator (on the right) down one level. The Board room will be to your left.


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NTSB CITES LACK OF BIRD STRIKE RESISTANT WINDSHIELD REQUIREMENTS IN FATAL CRASH OF HELICOPTER IN LOUISIANA

FOR IMMEDIATE RELEASE: November 24, 2010
SB-10-45

NTSB CITES LACK OF BIRD STRIKE RESISTANT WINDSHIELD REQUIREMENTS IN FATAL CRASH OF HELICOPTER IN LOUISIANA

The National Transportation Safety Board today released a final report on a fatal crash involving a transport-category helicopter caused by a bird strike. The Board said the lack of requirements for bird strike-resistant windshields contributed to the crash, and called on the FAA to develop such requirements.

On January 4, 2009, a dual-engine Sikorsky S-76C++ helicopter (N748P), registered to and operated by PHI, Inc., crashed into marshy terrain near Morgan City, Louisiana approximately 7 minutes after takeoff from Amelie, Louisiana, on a charter flight to an oil rig in the Gulf of Mexico. Both pilots and 6 of the 7 passengers were killed in the crash.

The aircraft had reached level cruise flight at 850 feet mean sea level and 135 knots when the cockpit voice recorder recorded a loud bang, followed by sounds consistent with rushing wind and a power reduction on both engines. The aircraft crashed several seconds later. Feathers and other bird debris were collected from the canopy and windshield of the aircraft. Laboratory analysis identified the remains as coming from a female red-tailed hawk; the average weight of such a bird is 2.4 pounds.

The investigation revealed that the impact of the bird on the canopy just above the windshield near the engine control quadrant likely jarred the fire extinguisher T-handles out of their detents and moved them aft, pushing both engine control levers into or near the flight idle position, reducing fuel to both engines. The pilots were probably disoriented from the broken windshield and rushing air and were unable to react in time to maintain control of the helicopter.

The helicopter was originally equipped with laminated glass windshields that complied with European bird-strike resistance standards. PHI replaced the windshields with lighter-weight, aftermarket cast acrylic windshields that did not have any bird-strike resistance standards.

The NTSB determined that the helicopter crashed because of the sudden loss of power to both engines following the bird strike and the subsequent disorientation of the crewmembers. Contributing to the accident, the Board said, were the lack of FAA regulations and guidance requiring helicopter windshields to be resistant to bird strikes, the lack of protections that would prevent the T-handles from inadvertently dislodging out of their detents, and the lack of a master warning light and audible system to alert the flight crew of a low-rotor speed condition.

Recommendations were issued to the FAA dealing with, among other things, the design of S-76C++ fire extinguisher T- handles and engine control quadrants, and similar designs of other helicopters, and of audible low-rotor alarm systems; certification standards for helicopter windshields; and simultaneous dual-engine power loss training for helicopter pilots.


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NTSB PRESS RELEASE: NTSB CITES LACK OF BIRD STRIKE RESISTANT WINDSHIELD REQUIREMENTS IN FATAL CRASH OF HELICOPTER IN LOUISIANA

National Transportation Safety Board
Washington, DC 20594

FOR IMMEDIATE RELEASE: November 24, 2010
SB-10-45

The National Transportation Safety Board today released a
final report on a fatal crash involving a transport-category
helicopter caused by a bird strike. The Board said the lack
of requirements for bird strike-resistant windshields
contributed to the crash, and called on the FAA to develop
such requirements.

On January 4, 2009, a dual-engine Sikorsky S-76C++
helicopter (N748P), registered to and operated by PHI, Inc.,
crashed into marshy terrain near Morgan City, Louisiana
approximately 7 minutes after takeoff from Amelie,
Louisiana, on a charter flight to an oil rig in the Gulf of
Mexico. Both pilots and 6 of the 7 passengers were killed
in the crash.

The aircraft had reached level cruise flight at 850 feet
mean sea level and 135 knots when the cockpit voice recorder
recorded a loud bang, followed by sounds consistent with
rushing wind and a power reduction on both engines. The
aircraft crashed several seconds later. Feathers and other
bird debris were collected from the canopy and windshield of
the aircraft. Laboratory analysis identified the remains as
coming from a female red-tailed hawk; the average weight of
such a bird is 2.4 pounds.

The investigation revealed that the impact of the bird on
the canopy just above the windshield near the engine control
quadrant likely jarred the fire extinguisher T-handles out
of their detents and moved them aft, pushing both engine
control levers into or near the flight idle position,
reducing fuel to both engines. The pilots were probably
disoriented from the broken windshield and rushing air and
were unable to react in time to maintain control of the
helicopter.

The helicopter was originally equipped with laminated glass
windshields that complied with European bird-strike
resistance standards. PHI replaced the windshields with
lighter-weight, aftermarket cast acrylic windshields that
did not have any bird-strike resistance standards.

The NTSB determined that the helicopter crashed because of
the sudden loss of power to both engines following the bird
strike and the subsequent disorientation of the crewmembers.
Contributing to the accident, the Board said, were the lack
of FAA regulations and guidance requiring helicopter
windshields to be resistant to bird strikes, the lack of
protections that would prevent the T-handles from
inadvertently dislodging out of their detents, and the lack
of a master warning light and audible system to alert the
flight crew of a low-rotor speed condition.

Recommendations were issued to the FAA dealing with, among
other things, the design of S-76C++ fire extinguisher T-
handles and engine control quadrants, and similar designs of
other helicopters, and of audible low-rotor alarm systems;
certification standards for helicopter windshields; and
simultaneous dual-engine power loss training for helicopter
pilots.


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NTSB Safety Recommendation A-10-130

National Transportation Safety Board
Washington, DC 20594

November 4, 2010

The National Transportation Safety Board recommends that the
European Aviation Safety Agency:

Require Eurocopter to review the design of the fuel flow
control lever (FFCL) and/or its detent track on AS350-series
helicopters and require modification to ensure that the FFCL
is protected to prevent unintentional movement out of its
detents and that it does not move easily to an unintended
position. (A-10-131)


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Seats Available for NTSB Event

National Transportation Safety Board
Washington, DC 20594
November 2, 2010

The National Transportation Safety Board’s course,
“Transportation Disaster Response – A Course for Emergency
Responders,” scheduled for November 16-18, 2010, at the NTSB

Training Center in Ashburn, Virginia, still has openings for
those who may have a role in responding to major
transportation accidents.

NTSB specialists and speakers from the FBI, the New Jersey
State Police, and other emergency response agencies and
organizations with response roles in recent accidents will
discuss the operational and organizational challenges
encountered in responding to large-scale, high-profile
transportation accidents.

The complete course description, agenda, and information on
registration process and cost are available at:
http://www.ntsb.gov/Academy/CourseInfo/TDA402_2010.htm


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NTSB ANNOUNCES AGENDA FOR AIRLINE CODE-SHARING SYMPOSIUM

The National Transportation Safety Board has published the agenda for the symposium on airline code-sharing, which will take place on October 26-27 in the NTSB Board Room and Conference Center (429 L’Enfant Plaza, SW, Washington, DC 20594). The symposium is open to all and free to attend (there is no registration). The event will also be webcast live on www.ntsb.gov.

A description of the symposium, a detailed agenda, and biographies of the presenters, panelists and moderator are all available at http://go.usa.gov/aZ6

The media advisory announcing the symposium is available athttp://go.usa.gov/aZF


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NTSB Release: TRANSPORTATION FATALITIES DROP IN 2009; PIPELINE AND MARINE DEATHS RISE

National Transportation Safety Board
Washington, DC 20594

FOR IMMEDIATE RELEASE: October 6, 2010

Washington, DC – Transportation fatalities in the United
States decreased by 9.2 percent in 2009 from 2008, according
to preliminary figures released today by the National
Transportation Safety Board.

The data indicate that transportation fatalities in all
modes totaled 35,928 in 2009, compared to 39,569 in 2008.
Although highway, rail, aviation, deaths declined, pipeline
and marine fatalities showed an increase.

“While statistics show that transportation fatalities have
declined this past year,” said NTSB Chairman Deborah A. P.
Hersman, “we continue to see far too many accidents in all
segments of the transportation community. There is still
much work to do to prevent the loss of life on our roads,
rails, waterways, and skies.”

Pipeline fatalities increased by six (8 to 14), with an
increase in both categories – gas pipelines and liquid
pipeline operations.

Marine deaths increased from 783 to 817, with the vast
majority occurring in recreational boating (736). Other
marine categories, including cargo transport and commercial
fishing, showed increases as well, although commercial
passenger vessels showed a slight decrease.

Highway fatalities, which account for nearly 95% of all
transportation deaths, decreased from 37,423 in 2008 to
33,808 in 2009. In fact, highway fatalities decreased in all
categories including motorcycle fatalities (down 16 percent)
which had been on the rise in recent years.

Aviation deaths decreased from 574 to 538. Nearly 90% of
aviation fatalities occurred in general aviation accidents
(471), but they still represented a decrease from the
previous year (494).

Rail fatalities decreased 4% from 781 to 751. The vast
majority of these fatalities were persons struck by a rail
vehicle.

Aviation statistics are compiled by the NTSB. Marine numbers
are provided by the Department of Homeland Security, and
numbers for all other modes by the Department of
Transportation.


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NTSB INVESTIGATING NEAR MIDAIR COLLISION

National Transportation Safety Board
Washington, DC 20594

September 23, 2010

NTSB INVESTIGATING NEAR MIDAIR COLLISION OVER MINNEAPOLISINVOLVING COMMERCIAL JETLINER AND SMALL CARGO AIRCRAFT

The National Transportation Safety Board is investigating a near midair collision between a commercial jetliner and a small cargo aircraft that came within an estimated 50 to 100 feet of colliding near the Minneapolis-St. Paul Airport (MSP).

On September 16, 2010, about 6:49 a.m. CDT, US Airways flight 1848 (AWE 1848), an Airbus 320, was cleared for takeoff on runway 30R en route to Philadelphia, Pennsylvania, carrying five crewmembers and 90 passengers. At the same time, Bemidji Aviation Services flight 46 (BMJ46), a Beech 99 cargo flight with only the pilot aboard, was cleared for takeoff on runway 30L en route to La Crosse, Wisconsin. Weather conditions at the time were reported as a 900-foot ceiling and 10 miles visibility below the clouds.

Immediately after departure, the tower instructed the US Airways crew to turn left and head west, causing the flight to cross paths with the cargo aircraft approximately one- half mile past the end of runway 30L. Neither pilot saw the
other aircraft because they were in the clouds, although the captain of the US Airways flight reported hearing the Beech 99 pass nearby. Estimates based on recorded radar data indicate that the two aircraft had 50 to 100 feet of vertical separation as they passed each other approximately 1500 feet above the ground.

The US Airways aircraft was equipped with a Traffic Alert and Collision Avoidance System (TCAS) that issued climb instructions to the crew to avert collision. The Beech 99 was not equipped with TCAS and the pilot was unaware of the proximity of the Airbus. There were no reports of damage or injuries as a result of the incident.

NTSB and FAA investigators conducted a preliminary investigation at the Minneapolis airport traffic control tower on September 18th and 19th and are continuing to review the circumstances of this incident.


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NTSB: No Rush to Judge

George’s Point of View

As urgent as the idea of an NTSB recommendation sounds, there is apparently no rush. The latest NTSB safety recommendation to EASA is rooted in a 2001 crash: American Airlines Airbus Flight 587. (see narrative below)

Probable cause of this accident was the in-flight separation of the vertical stabilizer as a result of the loads beyond ultimate design that were created by the first officer’s unnecessary and excessive rudder pedal inputs. (i.e. The pilot used the rudder and it fell off.)

(To put this into simplistic car terms, your car just skidded on some ice. You did some fancy and extreme steering which may or may not have been necessary. And the steering wheel just came off in your hands. Pretty much all you can do now is spectate and die.)

The pilot’s unnecessary and excessive rudder pedal input was based on a violent wake turbulence encounter. The pilot’s “unnecessary and excessive” rudder pedal input broke the rudder.

Isn’t this a dubious conclusion? Isn’t this like blaming a car crash on a driver hitting brakes too hard? The airbus had just taken off and encountered turbulence. Since when do flight controls not handle “aggressive input”?

Initial suggestions included pilot retraining. (I.E. don’t fix the problem, train the pilots to work around it.) This month, the NTSB encouraged modification of European certification standards. In other words, the NTSB wants to physically limit the rudder movement to what the design can safely manage. Maybe that makes more sense than expecting a pilot engaged in a desperate struggle to save a failing plane to have to make accommodations for flighty flight controls.

Some take the angle that the problem lies in the rudder design and/or composition. In 2001, the FAA was one of those so inclined.

On November 16, 2001, the FAA issued emergency AD 2001-23-51 warning of failure of the vertical stabilizer-to-fuselage attachment fittings, transverse (side) load fittings, or rudder-to-vertical stabilizer attachment fittings, if not corrected, could result in loss of the vertical stabilizer and/or rudder and consequent loss of control of the airplane. The FAA considers that, before structural failure, it may be possible to detect indications of possible failure modes that could result in separation of the vertical stabilizer from the airplane. These indications include edge delaminations, cracked paint, surface distortions, other surface damage, and failure of the transverse (side) load fittings. Similarly, indications of failure of the rudder assembly, which could lead to failure of the vertical stabilizer, may also be detectable with such an inspection.

This failure has happened more than once.

In the Air Transat flight 961 incident (also a 300 series Airbus) out of Varadero, Cuba, the rudder disintegrated. The pilot in that flight questions the integrity of the rudder design and composition.

Here another point that has been commonly made. Aircraft have had rudders made of aluminum for 70 years without them disintegrating. With high tech composites, planes are falling out of the sky.

In March 2006, US safety investigators recommended rudder inspections on Airbus A300-600 jets because a FedEx A300-600 rudder damaged during maintenance.

Tested on the ground by Fed Ex engineers, in the Fed-Ex A300 cargo plane, the hydraulic system which actuates the rudder tore a hole around the hinges exactly where the rudders of both flight 961 and flight 587 did. Coincidence? I think not.

Does the certification process need an overhaul? I think so.

Have a couple of dead pilots again become convenient scapegoats for/by using the very computer controlled flight control system that they believed protected them? I bet I know what the pilots think.

Flight 587, Official NTSB narrative of the crash
On November 12, 2001, about 0916:15 eastern standard time, American Airlines flight 587, an Airbus Industrie A300-605R, N14053, crashed into a residential area of Belle Harbor, New York, shortly after takeoff from John F. Kennedy International Airport (JFK), Jamaica, New York. Flight 587 was a regularly scheduled passenger flight to Las Americas International Airport, Santo Domingo, Dominican Republic, with 2 flight crewmembers, 7 flight attendants, and 251 passengers aboard the airplane. The airplane’s vertical stabilizer and rudder separated in flight and were found in Jamaica Bay, about 1 mile north of the main wreckage site. The airplane’s engines subsequently separated in flight and were found several blocks north and east of the main wreckage site. All 260 people aboard the airplane and 5 people on the ground were killed, and the airplane was destroyed by impact forces and a postcrash fire. Flight 587 was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.

The accident airplane arrived at JFK about 2231 on the night before the accident. The airplane had been flown from San Jose, Costa Rica, to JFK with an intermediate stop in Miami International Airport, Miami, Florida. During postaccident interviews, the pilots of the flight leg from MIA to JFK indicated that the flight was smooth and uneventful.

Flight 587 was the first leg of a 1-day roundtrip sequence for the flight crew. American Airlines records indicated that the captain checked in for the flight about 0614 and that the first officer checked in about 0630. The gate agent working the flight arrived at the departure gate about 0645. She stated that the flight attendants were already aboard the airplane at that time and that the captain and the first officer arrived at the gate about 0700.

About 0710, the airplane fueling process began. The airplane fueler indicated that, during the fueling process, he saw one of the pilots perform an exterior inspection of the airplane. He finished the fueling process about 0745 and stated that he saw nothing unusual regarding the airplane.

Statements provided to the Port Authority of New York and New Jersey Police Department by American Airlines maintenance and avionics personnel indicated that, sometime between 0730 and 0800, the captain reported that the number 2 pitch trim and yaw damper system would not engage. Two avionics technicians were sent to the airplane to investigate the problem. They performed an auto flight system (AFS) check, which indicated a fault with the number 2 flight augmentation computer. The circuit breaker was then reset, another AFS check was performed, and no fault was detected. In addition, an autoland system check was performed, and that test also did not detect a fault. The avionics technicians estimated that they were in the cockpit for 5 to 7 minutes.

The cockpit voice recorder (CVR) recording began about 0845:35. The CVR indicated that, about 0859:58, the airplane was cleared to push back from the gate. About 0901:33, the ground controller provided the flight crew with taxi instructions to runway 31L, and the first officer acknowledged these instructions. About 0902:05, the captain told the first officer, “your leg, you check the rudders.” (The first officer was the flying pilot, and the captain was the nonflying pilot.) Data from the flight data recorder (FDR) showed that, about 0902:07, the rudder pedal check began. The FDR data also showed that a maximum right rudder pedal deflection of about 3.7 inches was recorded about 0902:11 and that a maximum left rudder pedal deflection of 3.6 inches was recorded about 0902:19. About 0902:23, the first officer responded, “rudders check.” The FDR data showed that the rudder pedals returned to their neutral position about 0902:25.

About 0906:53, the ground controller provided the pilots of Japan Air Lines flight 47, a Boeing 747-400, with taxi instructions to runway 31L. About 0908:01, the ground controller instructed the Japan Air Lines pilots to contact the local (tower) controller. About 0908:58, the ground controller instructed the flight 587 pilots to follow the Japan Air Lines airplane and to contact the local controller. The first officer acknowledged this instruction.

About 0911:08, the local controller cleared the Japan Air Lines airplane for takeoff. About 0911:36, the local controller cautioned the flight 587 pilots about wake turbulence and instructed the pilots to taxi into position and hold for runway 31L. The first officer acknowledged the instruction. About 0913:05, the local controller instructed the Japan Air Lines pilots to fly the bridge climb and to contact the departure controller at the New York Terminal Radar Approach Control (TRACON). About 0913:21, the flight 587 captain said to the first officer, “you have the airplane.”

About 0913:28, the local controller cleared flight 587 for takeoff, and the captain acknowledged the clearance. About 0913:35, the first officer asked the captain, “you happy with that [separation] distance?” About 3 seconds later, the captain replied, “we’ll be all right once we get rollin’. He’s supposed to be five miles by the time we’re airborne, that’s the idea.” About 0913:46, the first officer said, “so you’re happy.”

The National Transportation Safety Board’s airplane performance study for this accident0 determined that flight 587 started its takeoff roll about 0913:51 and lifted off about 0914:29, which was about 1 minute 40 seconds after the Japan Air Lines airplane. About 0914:43, the local controller instructed the flight 587 pilots to turn left, fly the bridge climb, and contact the New York TRACON departure controller. About 5 seconds later, the captain acknowledged this instruction. Radar data indicated that the airplane climbed to 500 feet above mean sea level (msl) and then entered a climbing left turn to a heading of 220º. About 0915:00, the captain made initial contact with the departure controller, informing him that the airplane was at 1,300 feet msl and climbing to 5,000 feet msl. About 0915:05, the departure controller instructed flight 587 to climb to and maintain 13,000 feet msl, and the captain acknowledged this instruction about 5 seconds later. About 0915:29, the CVR recorded the captain’s statement “clean machine,” indicating that the gear, flaps, and slats had all been retracted.

About 0915:35, flight 587 was climbing through 1,700 feet msl with its wings approximately level. About 1 second later, the departure controller instructed flight 587 to turn left and proceed direct to the WAVEY navigation intersection (located about 30 miles southeast of JFK). About 0915:41, the captain acknowledged the instruction. The controller did not receive any further transmissions from flight 587.

FDR data indicated that, about 0915:36, the airplane experienced a 0.04 G drop in longitudinal load factor, a 0.07 G shift to the left in lateral load factor, and about a 0.3 G drop in normal (vertical) load factor. The airplane performance study found that these excursions were consistent with a wake turbulence encounter. Between 0915:36 and 0915:41, the FDR recorded movement of the control column, control wheel, and rudder pedals. Specifically, the control column moved from approximately 0º (neutral) to 2º nose up, 2º nose down, and back to 0º; the control wheel moved a total of seven times, with peaks at 18º right, 30º left, 37º right, 34º left, 5º left, 21º left, and 23º right, before moving to between 5º and 6º left; and the rudder pedals moved from about 0.1 inch left (the starting point for the pedals) to about 0.1 inch right and 0.2 inch left before moving to 0.1 inch left. The airplane performance study indicated that, during this time, the rudder moved from 0º (neutral) to about 2º left, about 0.6º right, and back to 0º.

During the wake turbulence encounter, the airplane’s pitch angle increased from 9º to 11.5º, decreased to about 10º, and increased again to 11º. The airplane’s bank angle moved from 0º (wings level) to 17º left wing down, which was consistent with the turn to
the WAVEY navigation intersection.

At 0915:44.7, the captain stated, “little wake turbulence, huh?” to which the first officer replied, at 0915:45.6, “yeah.” At 0915:48.2, the first officer indicated that he wanted the airspeed set to 250 knots, which was the maximum speed for flight below 10,000 feet msl. At that point, the airplane was at an altitude of about 2,300 feet msl.

FDR data indicated that, about 0915:51, the load factors began excursions that were similar to those that occurred about 0915:36: the longitudinal load factor dropped from 0.20 to 0.14 G, the lateral load factor shifted 0.05 G to the left, and the normal load factor dropped from 1.0 to 0.6 G. The airplane performance study found that these excursions were also consistent with a wake turbulence encounter. According to the FDR, the airplane’s bank angle moved from 23º to 25º left wing down at 0915:51.5, the control wheel moved to 64º right at 0915:51.5, and the rudder pedals moved to 1.7 inches right at 0915:51.9.

At 0915:51.8, 0915:52.3, and 0915:52.9, the CVR recorded the sound of a thump, a click, and two thumps, respectively. At 0915:54.2, the first officer stated, in a strained voice, “max power.” At that point, the airplane was traveling at 240 knots. About 0915:55, the captain asked, “you all right?” to which the first officer replied, “yeah, I’m fine.” One second later, the captain stated, “hang onto it. Hang onto it.” The CVR recorded the sound of a snap at 0915:56.6, the first officer’s statement “let’s go for power please” at 0915:57.5, and the sound of a loud thump at 0915:57.7. According to the airplane performance study, the vertical stabilizer’s right rear main attachment fitting fractured at 0915:58.4, and the vertical stabilizer separated from the airplane immediately afterward. At 0915:58.5, the CVR recorded the sound of a loud bang. At that time, the airplane was traveling at an airspeed of about 251 knots.

According to the FDR, the rudder pedals moved from 1.7 inches right to 1.7 inches left, 1.7 inches right, 2.0 inches right, 2.4 inches left, and 1.3 inches right between 0915:52 and 0915:58.5. Also, the FDR showed that the control wheel moved 64º to the right at 0915:51.5, 78º (full) to the left at 0915:53.5, 64º to the right at 0915:55.5, and 78º to the left at 0915:56.5.

The airplane performance study estimated that, at 0915:53.2, the rudder was deflected 11º to the left, and the sideslip angle at the airplane’s center of gravity (cg) was about 4º to the left (after peaking temporarily at 5º to the left).21 At 0915:56.8, the rudder was deflected 10.2º to the left, and the sideslip angle was about 7º to the left. At 0915:58.4 (the time that the right rear main attachment fitting fractured), the rudder was deflected between 10º and 11º to the right, the sideslip angle was between 11º and 12º to the right, and the airplane experienced a 0.2 G shift to the right in lateral load factor.

The CVR recorded, at 0916:00.0, a sound similar to a grunt and, 1 second later, the first officer’s statement, “holy [expletive].” At 0916:04.4, the CVR recorded a sound similar to a stall warning repetitive chime, which lasted for 1.9 seconds. At 0916:07.5, the first officer stated, “what the hell are we into…we’re stuck in it.” At 0916:12.8, the captain stated, “get out of it, get out of it.” The CVR recording ended 2 seconds later. The airplane was located at 40º 34′ 37.59″ north latitude and 73º 51′ 01.31″ west longitude. The accident occurred during the hours of daylight.


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NTSB Safety Recommendation

Mr. Patrick Goudou
Executive Director
European Aviation Safety Agency
Postfach 10 12 53
D-50452 Cologne, Germany

The National Transportation Safety Board (NTSB) is an independent U.S. Federal Government agency charged by the U.S. Congress with investigating transportation accidents, determining their probable cause, and making recommendations to prevent similar accidents from occurring. We are providing the following information in support of the safety recommendations in this letter. The NTSB is making these recommendations because they are designed to prevent accidents and save lives.

On November 12, 2001, about 0916 eastern standard time, an Airbus A300-605R,1 N14053, operated as American Airlines flight 587, crashed into a residential area of Belle Harbor, New York, shortly after takeoff from John F. Kennedy International Airport, Jamaica, New York.2 Following an encounter with wake turbulence from a preceding Boeing 747 (747), the first officer made a series of full alternating rudder pedal inputs before the airplane’s vertical stabilizer and rudder separated in flight; both were found in Jamaica Bay about 1 mile north of the main wreckage site.

The NTSB determined that the probable cause of the American Airlines flight 587 accident was the in-flight separation of the vertical stabilizer as a result of the loads beyond ultimate design3
that were created by the first officer’s unnecessary and excessive rudder pedal inputs. Contributing to these rudder pedal inputs were characteristics of the Airbus A300-600
rudder system design and elements of the American Airlines Advanced Aircraft Maneuvering Program (AAMP).4
1 The Airbus A300-605R is one of several variants of the A300-600 series airplane. The “5” refers to the type of engine installed on the airplane, and the “R” refers to the airplane’s ability to carry fuel in the horizontal stabilizer.
2 For more information, see In-Flight Separation of Vertical Stabilizer, American Airlines Flight 587, Airbus Industrie A300-605R, N14053, Belle Harbor, New York, November 12, 2001, Aircraft Accident Report NTSB/AAR-04/04 (Washington, DC: National Transportation Safety Board, 2004).
3 The ultimate design load is the maximum load to be expected in service multiplied by a safety factor of 1.5.
4 According to American Airlines, AAMP was “advanced training for experienced aviators involving upsets in aircraft attitude” that consisted of ground school and simulator flight training.
5 The leading 747, United Airlines flight 896, was en route from Hong Kong to Chicago O’Hare International Airport. The 747 was eastbound at FL370. At the time of the upset, both flights were under Seattle Air Route Traffic Control Center control, and when Air Canada flight 190 was cleared from FL350 to FL370, the 747 was ahead of and above Air Canada flight 190. The Transportation Safety Board of Canada calculated that, at the time of the upset, United Airlines flight 896 was 10.7 nautical miles ahead of Air Canada flight 190. According to postaccident interviews and cockpit voice recorder data, although the flight crewmembers of Air Canada flight 190 knew they were following a 747, they were unaware of their trailing distance to United Airlines flight 896.
6 Encounter with Wake Turbulence, Air Canada Airbus A319-114 C-Gbhz, Washington State, United States, 10 January 2008, Aviation Investigation Report A08W0007 (Gatineau, Quebec, Canada: Transportation Safety Board of Canada, 2010). .
7 In the Airbus A319, a side-stick controller is used to control pitch and roll.
8 The vertical stabilizer is attached to the airplane’s aft fuselage. The vertical stabilizer provides supporting structure for the rudder, which is an aerodynamic control surface that is used to make the airplane yaw, or rotate, about its vertical axis. An airplane cannot be flown without its vertical stabilizer.
9 According to 14 Code of Federal Regulations (CFR) 25.301(a), the limit load is the highest load that the airplane structure is expected to experience while in service. According to 14 CFR 25.305(a), the airplane must be designed to withstand this load without detrimental permanent deformation, and the deformation may not interfere with safe operation.
10 For more information, see table 4 of NTSB/AAR-04/04.
11 APC excursions occur when the dynamics of the airplane and the dynamics of the pilot combine to produce an unstable system. For more information, see National Research Council, Aviation Safety and Pilot Control—Understanding and Preventing Unfavorable Pilot-Vehicle Interactions (Washington, DC: National Academy Press, 1997).
12 This change in pedal sensitivity is not characteristic of a variable ratio control system, such as employed on other airplanes, which retains a relatively uniform aircraft response throughout the airspeed envelope.
13 On September 13, 2005, the NTSB acknowledged that, on behalf of France, the European Aviation Safety Agency (EASA) would perform the functions and tasks of the State of Design with respect to International Civil Aviation Organization Annex 8 in the field of airworthiness; therefore, EASA would be responsible for responding to Safety Recommendation A-04-63.

The circumstances of the American Airlines flight 587 accident are similar to a more recent accident involving an Airbus model A319. On January 10, 2008, about 0848 central standard time, an Airbus Industrie A319, Canadian registration C-GBHZ, operated as Air Canada flight 190, experienced an in-flight upset after encountering wake turbulence from a 747 while climbing from flight level (FL) 360 to FL370.5 The flight crew declared an emergency and diverted the flight to Calgary, where it landed uneventfully. Of the 5 crewmembers and 83 passengers on board, 2 crewmembers and 8 passengers sustained minor injuries, and 3 passengers sustained serious injuries. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the scheduled domestic passenger flight from Victoria International Airport, British Columbia, Canada, to Toronto Pearson International Airport, Ontario, Canada. The Transportation Safety Board of Canada investigated this accident;6 the NTSB and Bureau d’Enquêtes et d’Analyses provided accredited representatives and technical advisors to the investigati

Data from the flight data recorder (FDR) indicate that, during the upset, the airplane experienced several roll and vertical load factor oscillations and lost about 1,000 feet of altitude. Although the autopilot was engaged during the start of the wake vortex encounter, after about 3 seconds, the autopilot was disengaged, and there was a series of large oscillatory inputs on the left side-stick controller.7 In addition, the FDR recorded a series of three to four alternating rudder pedal inputs (right pedal, then left pedal) over the next 15 seconds. During these inputs, the airplane continued to oscillate in roll, reaching a maximum roll of 55º. At the same time, the recorded acceleration was also oscillating, with peaks of -0.46 G to +0.49 G of lateral load factor and peaks of -0.76 G to +1.57 G of vertical load factor.

Because of the severity of the upset, following the emergency landing at Calgary, the airplane was grounded pending an inspection by Airbus engineers. During an extensive inspection, the vertical stabilizer8 was removed from the airplane and scanned ultrasonically to inspect for damage to the stabilizer’s composite components. No damage was found, and the stabilizer was reattached and the airplane returned to service.
Although no damage to the stabilizer was found, an analysis of the accident performed by Airbus indicated that the rear vertical stabilizer attachment fitting sustained loads 29 percent above its design limit load.9 Simulation work performed by Airbus revealed that these high loads were primarily the result of the flight crew’s series of alternating rudder pedal inputs and were not the result of the wake turbulence. Information and animations provided by Airbus showed that if the pilots had not made any control inputs after the wake encounter, the airplane would have righted itself with minimum altitude loss and g-loading.

Prevention of High Loads Resulting From Pilot Rudder Pedal Inputs

The rudder system design for the Airbus A320 airplane family, which includes the A319, is functionally similar to the design for the Airbus A300/A310 airplane family. Both families use a variable-stop rudder travel limiter, which mechanically limits available rudder pedal deflection as airspeed increases. Consequently, at high airspeeds, these systems require lighter pedal forces and smaller pedal displacements to obtain maximum available rudder than at low airspeeds.10 Investigation of the American Airlines flight 587 accident revealed that variable-stop systems produce dramatically larger aircraft responses to the same rudder input at higher airspeeds than at lower airspeeds, which can surprise a pilot and serve as a trigger for an aircraft-pilot coupling (APC)11 event.12

As a result of findings from the American Airlines flight 587 investigation, the NTSB issued Safety Recommendation A-04-63, which asked the French Direction Générale de l’Aviation Civile13 to do the following:

Review the options for modifying the Airbus A300-600 and the Airbus A310 to provide increased protection from potentially hazardous rudder pedal inputs at high airspeeds and, on the basis of this review, require modifications to the A300-600 and A310 to provide increased protection from potentially hazardous rudder pedal inputs at high airspeeds.

In the same report, the NTSB issued a companion recommendation, A-04-58, to the Federal Aviation Administration (FAA). On September 13, 2005, the NTSB classified Safety
Recommendation A-04-63 “Open—Acceptable Response.” On April 6, 2009, the European Aviation Safety Agency (EASA) responded that Airbus had analyzed several modifications, and a reduced pedal travel limiting unit (PTLU) was identified as the most promising solution to address this recommendation. On March 19, 2010, EASA further indicated that “its previously held position on the pilot training out as being an efficient and sufficient measure to avoid any new hazardous situations has to be reconsidered following more recent service experience which confirms that crew use of rudder pedal inputs in upset encounters cannot be ‘trained out.’” EASA therefore indicated that it plans to require the PTLU on Airbus A310 and A300-600 aircraft models. The NTSB will consider how the proposed changes are responsive to Safety Recommendation A-04-63 when EASA provides further details about the PTLU. In the meantime, the NTSB still believes that the changes called for in this recommendation are necessary. Therefore, the NTSB reiterates Safety Recommendation A-04-63.

Yaw Axis Certification and Rudder Pedal Sensitivity

The similarities between the Air Canada flight 190 and American Airlines flight 587 crewmembers’ responses to wake encounters indicate that the Airbus A320 family is also susceptible to potentially hazardous rudder pedal inputs at higher airspeeds. In both events, the vertical stabilizer limit loads were exceeded by a large margin as a result of the alternating rudder inputs. In the American Airlines flight 587 accident, the pilot applied four full alternating rudder inputs; after the fourth input, the aerodynamic loads on the vertical stabilizer exceeded the vertical stabilizer’s ultimate design load (at about twice the maximum load), and it separated from the airplane. In the Air Canada flight 190 accident, the pilot applied three alternating rudder inputs and exceeded the limit load by 29 percent.

Rudder control systems with a variable ratio rudder travel limiter may provide better protection against high loads from sustained rudder pedal inputs at high airspeeds than systems with a variable-stop rudder travel limiter because variable ratio rudder travel limiter systems retain a relatively uniform aircraft response throughout the airspeed envelope and require more physical effort from a pilot (in terms of force and displacement) to produce cyclic full rudder inputs at high speeds. There is no certification standard regarding rudder pedal sensitivity or any requirement for the sensitivity to remain constant at all airspeeds. As discussed above, the Airbus A320 rudder control system design characteristics are comparatively similar to those of the Airbus A300-600 and A310 and may serve as a trigger for an APC event at high airspeeds. The NTSB concludes that, as demonstrated by the American Airlines flight 587 and Air Canada flight 190 accidents, certification standards for transport-category aircraft regarding yaw sensitivity to rudder pedal inputs must ensure that airplane designs minimize the potential for APC susceptibility and better protect against high loads in the event of large rudder inputs.

As a result of the American Airlines flight 587 accident investigation, the NTSB issued Safety Recommendations A-04-56 and -57, which asked the FAA to do the following:

Modify 14 Code of Federal Regulations Part 25 to include a certification standard that will ensure safe handling qualities in the yaw axis throughout the flight envelope, including limits for rudder pedal sensitivity. (A-04-56)

After the yaw axis certification standard recommended in Safety Recommendation A-04-56 has been established, review the designs of existing airplanes to determine if they meet the standard. For existing airplane designs that do not meet the standard, the FAA should determine if the airplanes would be adequately protected from the adverse effects of a potential [APC] after rudder inputs at all airspeeds. If adequate protection does not exist, the FAA should require modifications, as necessary, to provide the airplanes with increased protection from the adverse effects of a potential APC after rudder inputs at high airspeeds. (A-04-57)

On March 1, 2005, the FAA indicated that the current standards governing the performance and design of yaw control systems may need to be redefined. The FAA added that it was evaluating the existing standards and conducting a study to identify critical rudder control system parameters and human interaction with those controls. The FAA further indicated that, based on the results of the study, it would determine whether the current standards need to be updated and would work with industry to develop rudder control standards. On August 3, 2005, the NTSB classified Safety Recommendations A-04-56 and -57 “Open—Acceptable Response.” As a result of the investigation of the Air Canada flight 190 accident, the NTSB reiterated Safety Recommendations A-04-56 and -57. The NTSB concludes that the yaw axis handling qualities standards envisioned in Safety Recommendations A-04-56 and -57 would increase the safety of all aircraft, not just those whose initial airworthiness certificate is issued by the FAA. Therefore, the NTSB recommends that EASA modify EASA Certification Specifications for Large Aeroplanes CS-25 to ensure safe handling qualities in the yaw axis throughout the flight envelope, including limits for rudder pedal sensitivity. Further, the NTSB recommends that, after the yaw axis certification standard recommended in Safety Recommendation A-10-119 has been established, EASA review the designs of existing airplanes to determine if they meet the standard. For existing airplane designs that do not meet the standard, EASA should determine if the airplanes would be adequately protected from the adverse effects of a potential APC after rudder inputs at all airspeeds. If adequate protection does not exist, EASA should require modifications, as necessary, to provide the airplanes with increased protection from the adverse effects of a potential APC after rudder inputs at high airspeeds.

Therefore, the National Transportation Safety Board recommends that the European Aviation Safety Agency:
Modify European Aviation Safety Agency Certification Specifications for Large Aeroplanes CS-25 to ensure safe handling qualities in the yaw axis throughout the flight envelope, including limits for rudder pedal sensitivity. (A-10-119)
After the yaw axis certification standard recommended in Safety Recommendation A-10-119 has been established, review the designs of existing airplanes to determine if they meet the standard. For existing airplane designs that do not meet the standard, the European Aviation Safety Agency (EASA) should determine if the airplanes would be adequately protected from the adverse effects of a potential aircraft-pilot coupling (APC) after rudder inputs at all airspeeds. If adequate protection does not exist, EASA should require modifications, as
necessary, to provide the airplanes with increased protection from the adverse effects of a potential APC after rudder inputs at high airspeeds. (A-10-120)
In addition, the National Transportation Safety Board reiterates the following recommendation to the European Aviation Safety Agency:
Review the options for modifying the Airbus A300-600 and the Airbus A310 to provide increased protection from potentially hazardous rudder pedal inputs at high airspeeds and, on the basis of this review, require modifications to the A300-600 and A310 to provide increased protection from potentially hazardous rudder pedal inputs at high airspeeds. (A-04-63)

The National Transportation Safety Board reiterated three safety recommendations (A-04-56 through -58) and reiterated and reclassified one safety recommendation (A-02-01) to the Federal Aviation Administration.

In response to the recommendations in this letter, please refer to Safety Recommendations A-10-119 and -120 and A-04-63. If you would like to submit your response electronically rather than in hard copy, you may send it to the following e-mail address: correspondence@ntsb.gov. If your response includes attachments that exceed 5 megabytes, please e-mail us asking for instructions on how to use our secure mailbox. To avoid confusion, please use only one method of submission (that is, do not submit both an electronic copy and a hard copy of the same response letter).

Chairman HERSMAN, Vice Chairman HART, and Members SUMWALT, ROSEKIND, and WEENER concurred with these recommendations.

By: Deborah A.P. Hersman
Chairman


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LIMITATIONS OF “SEE AND AVOID” CONCEPT AND DISTRACTED AIR TRAFFIC CONTROLLER LED TO MID-AIR COLLISION OVER HUDSON RIVER, NTSB DETERMINES

National Transportation Safety Board
Washington, DC 20594
FOR IMMEDIATE RELEASE: September 14, 2010
SB-10-37

The National Transportation Safety Board today determined that the probable cause of last year’s midair collision over the Hudson River that resulted in the deaths of all nine persons aboard the two aircraft were the inherent limitations of “see-and-avoid” concept and a Teterboro Airport air traffic controller’s nonpertinent telephone conversation at the time of the collision. The see-and-avoid technique of averting mid-air collisions was not effective because of the difficulty the airplane pilot had in seeing the helicopter until the final seconds before the collision. In addition, the Teterboro Airport local controller engaged in a personal telephone conversation, which distracted him from his air traffic control duties, including the timely transfer of communications for the accident airplane to the Newark Liberty International Airport (EWR) tower and correcting the airplane pilot’s incorrect read-back of the EWR tower frequency.

The Safety Board met today in a five-hour public meeting to determine the probable cause of the accident and issued five recommendations to the Federal Aviation Administration for improving the safety of the national airspace, and in particular, the airspace over the Hudson River near New York City. The Safety Board noted that contributing to the cause of the accident were the ineffective use by both pilots of their aircrafts’ electronic advisory system to maintain awareness of other air traffic, FAA’s procedures for transfer of communications among air traffic facilities near the Hudson River, and FAA regulations that did not provide for adequate vertical separation of aircraft operating over the Hudson River.

On August 8, 2009, a Piper PA-32R-300 airplane, N71MC, and a Eurocopter AS350BA helicopter, N401LH, operated by Liberty Helicopters, collided over the Hudson River near Hoboken, New Jersey. The airplane flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 91, with a pilot and two passengers. The helicopter flight, which carried a pilot and five passengers, was conducting an air tour of the area under the provisions of 14 CFR Parts 135 and 136. No flight plans were filed or were required for either flight, and visual meteorological conditions prevailed at the time of the accident.

“This collision could have been prevented,” NTSB Chairman Deborah A.P. Hersman said. “While traffic alerts go a long way in helping pilots “see and avoid” other aircraft, these technologies are not, in and of themselves, enough to keep us safe. Strong operating procedures, professionalism, and commitment to the task at hand – these are all essential to safety.”

As a result of the accident investigation, the NTSB made recommendations to the FAA regarding changes within the special flight rules area (SFRA) surrounding the Hudson River corridor; vertical separation among aircraft operating in the Hudson River SFRA; see-and-avoid guidance; and helicopter electronic traffic advisory systems.

A synopsis of the Board’s report, including the probable cause, conclusions, and recommendations, is available on the NTSB’s website, at http://ntsb.gov/Publictn/2010/AAR1005.html.

The Board’s full report will be available on the website in several weeks.


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NTSB TO HOLD PUBLIC FORUM ON CHILD PASSENGER SAFETY IN AUTOMOBILES AND ON AIRPLANES

FOR IMMEDIATE RELEASE: September 13, 2010
SB-10-35

Washington, DC – The National Transportation Safety Board will address the safety of children traveling in airplanes or in cars when it holds a public forum on child passenger safety on Thursday, December 9, 2010.

“American families are on the go, and children today are frequent travelers almost from the time they are born,” said NTSB Chairman Deborah A.P. Hersman. “Much more should be done to reduce fatalities and injuries of our smallest travelers, whether they are in a jumbo jet or their family’s car.”

The forum will be geared to providing parents and care givers information they can use immediately to protect their children while traveling. The forum will explore current education and other safety advocacy efforts by non-profit groups and government, as well as the continuing problem of nonuse of child seats and seat belts by a significant portion of the traveling public.

Safety experts from the transportation industry, trade associations, unions, advocacy groups, and federal government will be asked to discuss the best approaches for keeping children safe while flying and riding in cars, how to increase the use of child seats and seat belts, and the importance of government data collection on the issue of nonuse.

The NTSB has issued 33 safety recommendations addressing child passenger safety; 12 of these safety recommendations have been or currently are on the NTSB’s Most Wanted List of Transportation Safety Improvements.

The forum, titled “Child Passenger Safety in the Air and in Automobiles”, will be held at the NTSB’s Board Room and Conference Center, located at 429 L’Enfant Plaza, S.W., Washington, D.C. Parents, care givers, and others interested in child safety are encouraged to view the forum in person or by webcast on the NTSB’s website, www.ntsb.gov. Additional information about the forum can be found at www.ntsb.gov/children.


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NTSB TO HOLD BOARD MEETING ON MID-AIR COLLISION OVER HUDSON RIVER NEAR HOBOKEN, NEW JERSEY

The National Transportation Safety Board will hold a public
Board meeting on Tuesday, September 14, at 9:30 a.m., in its
Board Room and Conference Center, 429 L’Enfant Plaza, S.W.,
Washington, DC.

On August 8, 2009, a Piper PA-32R-300 airplane, N71MC, and a
Eurocopter AS350BA helicopter, N401LH, operated by Liberty
Helicopters, collided over the Hudson River near Hoboken,
New Jersey. All 9 people aboard the two aircraft died in the
accident. The airplane flight was operating under the
provisions of 14 Code of Federal Regulations (CFR) Part 91,
and the helicopter flight was operating under the provisions
of 14 CFR Parts 135 and 136. No flight plans were filed or
were required for either flight, and visual meteorological
conditions prevailed at the time of the accident.

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

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

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

###


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NTSB ASSISTS GOVERNMENT OF THE UNITED ARAB EMIRATES IN AVIATION ACCIDENT

National Transportation Safety Board
Washington, DC 20594

September 3, 2010

The National Transportation Safety Board will dispatch an aviation investigator to assist the government of United Arab Emirates in its investigation of the crash of a United Parcel Service (UPS)-operated cargo plane, a Boeing 747-400.

On September 3, the aircraft, en route to Cologne, Germany, crashed near the international airport in the emirate of Dubai shortly after takeoff.

NTSB Chairman Deborah A.P. Hersman has designated senior air safety investigator Bill English as the U.S. Accredited Representative. His team will include NTSB specialists in
the areas of human performance, fire, operations, and systems. The team will also include technical advisors from the Federal Aviation Administration, Boeing, UPS, GE and
Independent Pilots Association.

The investigation is being conducted by the General Civil Aviation Authority of the United Arab Emirates, which will release all information on the progress of the investigation. The agency’s phone number in Abu Dhabi is (971) 2 405-4501/4445 and the agency’s email address is:
accid@gcaa.ae.


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Symposium Announced: Airline Code-Sharing Arrangements and Their Role in Aviation Safety


Date and Location:
October 26 – 27, 2010
NTSB Conference Center

Short Description:
The goals of the symposium are to (1) elicit information on the structures, practices, and oversight of domestic and international code-sharing arrangements; (2) gain insight into best practices regarding the sharing of safety information between airlines and their code-sharing partners; and (3) to explore the role that a major airline would have in the family disaster assistance response for an accident involving a code-sharing partner. These areas will be explored through presentations from major and regional airlines, industry organizations, and representatives of the traveling public.


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NTSB SENDING TEAM TO ASSIST GOVERNMENT OF COLUMBIA WITH TODAY’S 737 ACCIDENT

National Transportation Safety Board
Washington, DC 20594

August 16, 2010

The National Transportation Safety Board is dispatching a
team of investigators to assist the government of Columbia
with its investigation of today’s airplane accident on San
Andreas Island.

At about 1:50 a.m. local time today, an Aires Airlines B737-
700 (HK-4682), crashed during landing at the San Andreas
Island airport. Flight #8250 originated in Bogota.

NTSB Chairman Deborah A.P. Hersman has designated Senior Air
Safety Investigator Lorenda Ward as the U.S. Accredited
Representative. The U.S. team will also include three other
NTSB investigators (specialists in flight operations, human
performance, and airworthiness) and technical advisors from
the Federal Aviation Administration and Boeing.


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ALFONSO J. MONTANO APPOINTED NTSB ADMINISTRATIVE LAW JUDGE

National Transportation Safety Board
Washington, DC 20594

FOR IMMEDIATE RELEASE: August 16, 2010
SB-10-31

Washington, DC – National Transportation Safety Board Chairman Deborah A.P. Hersman today announced the appointment of Alfonso J. Montano as an Administrative Law Judge for the agency.

Judge Montano has been an Administrative Law Judge for 15 years with the Department of Health and Human Services and the Social Security Administration. During that time he heard adversarial cases dealing with Medicare nursing home compliance issues, fraudulent or abusive practices involving Social Security disability programs, and the exclusion or debarment of individuals or companies from participation in federal health care programs.

Before becoming an Administrative Law Judge, Judge Montano served as a trial attorney for the U.S. Department of Justice.

Judge Montano is a graduate of New Mexico Highlands University and earned his law degree at the University of San Francisco School of Law. He is a licensed private aircraft pilot.

Judge Montano resides in Prince William County, Virginia with his wife. He has two adult children.

Administrative Law Judges at the NTSB hear appeals from airmen, mechanics or companies that have had adverse action taken against their authority by the Federal Aviation Administration.


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NTSB TO HOLD SYMPOSIUM ON AIRLINE CODE-SHARING ARRANGEMENTS AND THEIR ROLE IN AVIATION SAFETY

National Transportation Safety Board
Washington, DC 20594
August 16, 2010

The National Transportation Safety Board will hold a two-day symposium on the role that airline code-sharing arrangements play in aviation safety. The event, chaired by NTSB Chairman Deborah A.P. Hersman, will be held on October 26-27, 2010, in Washington, DC.

Code-sharing is a marketing arrangement in which one airline places its designator code on a flight operated by another airline, then sells and issues tickets for that flight.

Recent NTSB investigations of accident flights operated under code-sharing arrangements include the February 2009 accident near Buffalo, New York, in which a Colgan Air flight was operated as Continental Connection; a 2007 accident in Traverse City, Michigan, in which a Pinnacle Airlines flight was operated as Northwest Airlink; a 2007 accident in Cleveland, Ohio, in which a Shuttle America flight was operated as Delta Connection; and a 2006 accident in Lexington, Kentucky, in which a Comair flight was operated as Delta Connection.

Today, most airlines participate in some type of code- sharing arrangement, either with domestic or international partners. More than half of passenger enplanements in the U.S. this year are on regional airlines, almost all of which are involved in code-sharing arrangements.

“In the past twenty years, code-sharing arrangements have so proliferated within commercial aviation that today the vast majority of airlines are involved in what are often complex business and operational arrangements.” said NTSB Chairman Deborah A.P. Hersman. “We have investigated many accidents in which passengers bought tickets on a major carrier and flew all or part of their trip on a different carrier – one that may have been operating to different safety standards than the carrier that issued the ticket. While all carriers are required to meet minimum standards, a clearer picture and deeper understanding of the best safety practices for code-sharing arrangements are the goals of this symposium.”

The symposium will be organized to elicit information on the following three issue areas: (1) structures, practices, and oversight of domestic and international code-sharing arrangements; (2) best practices regarding the sharing of safety information between airlines and their code-sharing partners; and (3) the role that a major airline would have in the family disaster assistance response for an accident involving a code-sharing partner.

These areas will be explored through presentations from major and regional airlines, industry organizations, and representatives of the traveling public.

The symposium, “Airline Code-Sharing Arrangements and Their Role in Aviation Safety” will be held at the NTSB Board Room and Conference Center, located at 429 L’Enfant Plaza, S.W., Washington, DC. A detailed agenda will be released closer to the date of the event.


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NTSB RELEASES PHOTOS OF AIRCRAFT ACCIDENT IN ALASKA

The National Transportation Safety Board has released three
photographs of the aircraft accident site near Aleknagik,
Alaska that took the lives of 5 of the 9 persons aboard.

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