NTSB Advisory

National Transportation Safety Board
Washington, DC 20594

May 22, 2010

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

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

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

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

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

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

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

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

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

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

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

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

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

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

National Transportation Safety Board
Washington, DC 20594

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

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

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

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

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

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

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

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

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

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

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

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

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

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

National Transportation Safety Board
Washington, DC 20594

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

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

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

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

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

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

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

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

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

NTSB TO HOLD A PUBLIC FORUM ON PROFESSIONALISM IN AVIATION

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

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

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

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

FOR IMMEDIATE RELEASE: April 8, 2010

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

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

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

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

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

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

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

ON-DEMAND ACCIDENTS AT LOWEST LEVEL IN LAST 20 YEARS

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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