Aviation News, Headlines & Alerts
 
Category: <span>Official Report</span>

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Oslo: October 31, 2013, Near Miss

We wrote about two Norwegian Air Shuttle planes that suffered a near miss when two planes followed the same instruction from ATC. The Accident Investigation Board Norway (AIBN) report on the event is below.

Report (Translation)
Description
The 31 October 2012, two airliners from English too close together under a simultaneous missed approach (NAX741) and departure (NAX740) at Oslo Airport. There was strong tailwind on final. The AIBN believes that the flight crew on NAX741 had unrealistic expectations of the ability to be stabilized later in 1000 ft above the airport elevation. The decision to initiate the missed approach was taken at a late stage. Expectations of final-controller and tower controller that the speed of the landing would be reduced sufficiently during the approach, was not met. The missed approach for NAX741 came into conflict with the simultaneous departure of NAX740.

Visibility conditions were such that the tower controller could not maintain visual separation between aircraft. Planes were for each other and both were rising. Tower air traffic controller instructed NAX741 to swing west. A mixture of callsign originated and led to NAX740 initiated clearance given to NAX741. The minimum horizontal distance between the aircraft was about. 0.2 NM (370 m) while the vertical height difference was 500 ft (152 m). AIBN considers that there was real danger of collision in the incident. When the situation first arose, prevented the situation awareness and good reviews from the flight crew and tower controller further escalation of the conflict.

AIBN considers that established and practiced procedures will help to ensure that situations are recognized and averted before they become critical. Data from the cockpit voice recorder (Cockpit Voice Recorder CVR) was not secured. CVR data is important to understand the sequence of events, and AIBN therefore it is unfortunate that CVR data is not guaranteed. AIBN no new safety recommendation in this report, but refers to a previously issued safety recommendation (SL no 2012/06T) not closed.

Type of report: Full report
Location: Oslo Airport Gardermoen ENGM
Event Date: 31/10/2012
ICAO Location indicator: ENGM
Aircraft: Boeing 737-600/700/800 / Boeing 737-600/700/800
Operator: Norwegian Air Shuttle / Norwegian Air Shuttle
Reg notice: LN-DYC / LN-NOM
Flight conditions: IMC
County: Akershus
Type of event: Serious incident
Type of flight: Commercial, scheduled / Commercial, scheduled
Category Aviation: Tung, aircraft (> 10 000kg) / Tung, aircraft (> 10 000kg)
Flykategori: Land plane, multi-engine, turbofan / turbojet
FIR / AOR: ENOS (Oslo ATCC)


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FAA Pilot Training

In George’s Point of View

The Federal Aviation Administration’s new pilot training rule has been a long time coming, like the recommendation for simulator training for pilots in using TCAS that dates back to 1993, remedial training from 2005 for pilots with bad track records and training in aerodynamic stall recovery from the Colgan accident, and pilot monitoring. Just read FAA Administrator Michael Huerta’s discussion of the new Pilot training rule.

I look forward to safer skies from the implementation of this additional training. Hopefully operators in foreign countries will follow the FAA’s suit and ramp up their pilot training. It will be interesting to hear what pilots think of the new pilot training rule.


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FAA Issues Final Rule on Pilot Training


As part of its ongoing efforts to enhance safety and put the best qualified and trained pilots in the flight decks of U.S. airplanes, the Department of Transportation’s Federal Aviation Administration (FAA) today issued a final rule that will significantly advance the way commercial air carrier pilots are trained.

In addition, FAA Administrator Michael Huerta is inviting the nation’s commercial aviation safety leaders to Washington, D.C. on November 21, to discuss additional voluntary steps that can be taken to further boost safety during airline operations, including pilot training.

“Today’s rule is a significant advancement for aviation safety and U.S. pilot training,” said U.S. Transportation Secretary Anthony Foxx. “One of my first meetings as Transportation Secretary was with the Colgan Flight 3407 families, and today, I am proud to announce that with their help, the FAA has now added improved pilot training to its many other efforts to strengthen aviation safety.”

The final rule stems in part from the tragic crash of Colgan Air 3407 in February 2009, and addresses a Congressional mandate in the Airline Safety and Federal Aviation Administration Extension Act of 2010 to ensure enhanced pilot training. Today’s rule is one of several rulemakings required by the Act, including the requirements to prevent pilot fatigue that were finalized in December 2011, and the increased qualification requirements for first officers who fly U.S. passenger and cargo planes that were issued in July 2013.

The final rule requires:

  • ground and flight training that enables pilots to prevent and recover from aircraft stalls and upsets. These new training standards will impact future simulator standards as well;
  • air carriers to use data to track remedial training for pilots with performance deficiencies, such as failing a proficiency check or unsatisfactory performance during flight training;
  • training for more effective pilot monitoring;
  • enhanced runway safety procedures; and
  • expanded crosswind training, including training for wind gusts.

“This pivotal rule will give our nation’s pilots the most advanced training available,” said FAA Administrator Michael Huerta. “While the rule marks a major step toward addressing the greatest known risk areas in pilot training, I’m also calling on the commercial aviation industry to continue to move forward with voluntary initiatives to make air carrier training programs as robust as possible.”

The FAA is focusing on pilot training for events that, although rare, are often catastrophic. Focusing on these events will provide the greatest safety benefit to the flying public. The recent rule to boost pilot qualifications for first officers has raised the baseline knowledge and skill set of pilots entering air carrier operations. Many air carriers have also voluntarily begun developing safety management systems (SMS), which will help air carriers identify and mitigate risks unique to their own operating environments.

The FAA proposed to revise the training rules for pilots in 2009, one month prior to the Colgan Flight 3407 accident. The FAA issued a supplemental proposal on May 20, 2011, to address many of the NTSB’s recommendations resulting from the accident, and incorporate congressional mandates for stick pusher, stall recovery and remedial training. A stick pusher is a safety system that applies downward elevator pressure to prevent an airplane from exceeding a predetermined angle of attack in order to avoid, identify, or assist in the recovery of a stall.

On Aug. 6, 2012, the FAA issued Advisory Circular (AC) Stall and Stick Pusher Training to provide best practices and guidance for training, testing, and checking for pilots to ensure correct and consistent responses to unexpected stall events and stick pusher activations. A copy of the AC is available at online.

Air carriers will have five years to comply with the rule’s new pilot training provisions, which will allow time for the necessary software updates to be made in flight simulation technology. The cost of the rule to the aviation industry is estimated to be $274.1 to $353.7 million. The estimated benefit is nearly double the cost at $689.2 million. The final rule is available online.


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Associated Plane Crash Was Due to Human Error

The report on the Associated Plane crash is based on a study of the flight data recorder (FDR) which contained 47 hours of data, and 32.5 minutes of cockpit voice recording of internal conversation of the two pilots, radio calls and cockpit noise. Sixteen people were killed when the Embraer 120 plane on a Lagos-Akure trajectory crashed shortly after takeoff outside Lagos airport’s domestic terminal. Four people survived.

The crew had concerns about the plane before they took off; and after they took off, there were more concerns. The crew ignored the plane’s warnings, then the First Officer complained that since the aircraft was not climbing, the Captain should not stall the aircraft. ATC expressed concern of the plane’s orientation.

The flight data shows the characteristics of an aerodynamic stall thirty one seconds before the crash. The failed engine was a Pratt & Whitney Canada model.

This is still the preliminary report, but it does point to facts that seem to show that the Lagos crash was caused by engine failure and human error.


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FAA Orders Inspections of Honeywell Emergency Locator Transmitters


The FAA is issuing an Airworthiness Directive (AD) identical to the August 26 Transport Canada Civil Aviation (TCCA) directive which requires airlines to inspect Honeywell emergency locator transmitters (ELTs) by January 14, 2014 to prevent an electrical short and possible ignition source. The FAA AD has the same deadline for the U.S. fleet and will impact approximately 4,000 airplanes at a total cost of approximately $325,720. The investigation of the July 12, 2013 Ethiopian Airlines Boeing 787 fire at Heathrow Airport continues under the leadership of the United Kingdom Air Accident Investigation Branch (AAIB).

In George’s Point of View

Good for Transport Canada Civil Aviation beating us to the punch. Too bad that the deadline is January 14, 2014. Seems like they could behave with a bit more urgency with a potential fire hazard. Does this mean that–if one of these Honeywell emergency locator transmitters happens to cause a fire between now and January 14, 2014, the TCCA and the FAA are responsible? By setting a date months away, aren’t these agencies downplaying the hazard potential?


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NTSB ISSUES SECOND INVESTIGATIVE UPDATE ON SOUTHWEST AIRLINES ACCIDENT IN NEW YORK

August 6, 2013
WASHINGTON – In its continuing investigation of the July 22 accident in which Southwest Airlines flight 345, a B-737-700, landed hard at New York’s LaGuardia Airport (LGA), the National Transportation Safety Board has developed the following factual information:

• The captain has been with Southwest for almost 13 years and has been a captain for six of those years. The captain has over 12,000 total flight hours, over 7,000 of which are as pilot-in-command. In 737s, the captain has over 7,900 hours, with more than 2,600 as the pilot-in-command.

• The first officer has been with Southwest for about 18 months. The pilot has about 5,200 total flight hours, with 4,000 of those as pilot-in-command. In 737s, the first officer has about 1,100 hours, none of which are as the pilot-in-command.

• This was the first trip the flight crew had flown together and it was the second leg of the trip. The first officer had previous operational experience at LGA, including six flights in 2013. The captain reported having flown into LGA twice, including the accident flight, serving as the pilot monitoring for both flights.

• The en route phase of the flight, which originated in Nashville, was characterized by the flight crew as routine. On approach into LGA, the first officer was the pilot flying and the captain was the pilot monitoring. SWA 345 was cleared for the ILS Runway 04 approach.

• The weather in the New York area caused the accident flight to enter a holding pattern for about 15 minutes. The crew reported that they saw the airport from about 5-10 miles out and that the airplane was on speed, course and glideslope down to about 200-400 feet.

• The crew reported that below 1,000 feet, the tailwind was about 11 knots. They also reported that the wind on the runway was a headwind of about 11 knots.

• SWA 345 proceeded on the approach when at a point below 400 feet, there was an exchange of control of the airplane and the captain became the flying pilot and made the landing.

• The jetliner touched down on the runway nose first followed by the collapse of the nose gear; the airplane was substantially damaged.

At this point in the investigation, no mechanical anomalies or malfunctions have been found. A preliminary examination of the nose gear indicated that it failed due to stress overload.

Investigators have collected five videos showing various aspects of the crash landing. The team will be analyzing these recordings in the coming months.

Parties to the investigation are the Federal Aviation Administration, Boeing Commercial Airplanes, Southwest Airlines, and the Southwest Airlines Pilots Association.


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Least safe commercial jets

An Airline Ratings study points out these planes as the least safe commercial jets to fly: LET 410, Ilyushin 72, Antonov AN-12, Twin Otter, CASA. This might be one of those cases where certain facts can’t be separated. How can statistics separate the effect of the planes being flown in third world countries with the least safe airports? How can one separate the fact of the Twin Otter’s heavy usage in Nepal, home of some of the worlds most dangerous airports?

The same study indicates Boeing’s 777, 717, 787 and 767/757, the Airbus A380 and A340, the Embraer 135/145, and CRJ 700/1000 as the safest planes.

While 137 airlines were deemed safest, only these carriers score top marks for both safety and service: Air New Zealand, Asiana Airlines, Cathay Pacific, Emirates, Etihad, EVA Air, Korean Air, Qantas, Royal Jordanian, Singapore Airlines and Virgin Atlantic.

British Airways, Flybe, Virgin Atlantic, Lufthansa and Aer Lingus were considered safe but had lesser marks for service. The full spectrum of the rated airlines is located here: http://www.airlineratings.com/ratings.php


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TWA Flight 800 report Questioned

James Kallstrom, who headed up the investigation into the 1996 crash for the FBI says the original report is legitimate.

But six retired investigators from TWA, the National Transportation Safety Board, and the Air Line Pilots Association say the final report of the 1996 accident, “TWA Flight 800” was falsified. They say the accident was either a terrorist attack or a failed military operation. The cadre of retired investigators are calling for a new investigation by the feds. Others argue that there’s no question the explosion was an accident. 230 people died after Flight 800 took off from JFK.

Originally there were several theories put forward: a missile theory ,a bomb-on-the-plane theory, a meteor strike theory. All of these theories were discarded when an exploding fuel tank was concluded to be the cause.

The retirees have appealed to families to ask for the case to be reinvestigated. Many family members are disturbed by the idea of renewal of the case which they believe is simply hype to push a new documentary “TWA Flight 800.”


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NTSB Issues 9 New Safety Recommendations

NTSB Issues Nine New Safety Recommendations as a Result of Its Investigation of the 8/26/2011 Crash of a Eurocopter AS350 B2 Near Mosby, Missouri

May 6, 2013 The National Transportation Safety Board Issues the Following Recommendations to the Following Organizations:

  • Prohibit flight crewmembers in 14 Code of Federal Regulations Part 135 and 91 subpart K operations from using a portable electronic device for nonoperational use while at their duty station on the flight deck while the aircraft is being operated. (A-13-007)
  • Require all 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to incorporate into their initial and recurrent pilot training programs information on the detrimental effects that distraction due to the nonoperational use of portable electronic devices can have on performance of safety-critical ground and flight operations. (A-13-008)
  • Require all 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to review their respective general operations manuals to ensure that procedures are in place that prohibit the nonoperational use of portable electronic devices by operational personnel while in flight and during safety-critical preparatory and planning activities on the ground in advance of flight. (A-13-009)
  • Inform pilots of helicopters with low inertia rotor systems about the circumstances of this accident, particularly emphasizing the findings of the simulator flight evaluations, and advise them of the importance of simultaneously applying aft cyclic and down collective to achieve a successful autorotation entry at cruise airspeeds. (A-13-010)
  • Revise the Helicopter Flying Handbook to include a discussion of the entry phase of autorotations that explains the factors affecting rotor rpm decay and informs pilots that immediate and simultaneous control inputs may be required to enter an autorotation. (A-13-011)
  • Require the installation of a crash-resistant flight recorder system on all newly manufactured turbine-powered, nonexperimental, nonrestricted-category aircraft that are not equipped with a flight data recorder and a cockpit voice recorder and are operating under 14 Code of Federal Regulations Parts 91, 121, or 135. The crash-resistant flight recorder system should record cockpit audio and images with a view of the cockpit environment to include as much of the outside view as possible, and parametric data per aircraft and system installation, all as specified in Technical Standard Order C197, “Information Collection and Monitoring Systems.” (A-13-012)
  • Require all existing turbine-powered, nonexperimental, nonrestricted-category aircraft that are not equipped with a flight data recorder or cockpit voice recorder and are operating under 14 Code of Federal Regulations Parts 91, 121, or 135 to be retrofitted with a crash-resistant flight recorder system. The crash-resistant flight recorder system should record cockpit audio and images with a view of the cockpit environment to include as much of the outside view as possible, and parametric data per aircraft and system installation, all as specified in Technical Standard Order C197, “Information Collection and Monitoring Systems.” (A-13-013)

    To Air Methods Corporation:

  • Expand your policy on portable electronic devices to prohibit their nonoperational use during safety-critical ground activities, such as flight planning and preflight inspection, as well as in flight. (A-13-014)
  • Revise company procedures so that pilots are no longer solely responsible for nonroutine operational decisions but are required to consult with the Air Methods Operational Control Center for approval to accept or continue a mission when confronted with elevated risk situations, such as fuel-related issues and unplanned deviations. (A-13-015)

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Flying Tigers Inspection Fraud Scheme

Joel Stout at Flying Tigers, Inc forged the signature of a certified mechanic claiming to have performed inspections he had not done.

Stout pleaded guilty to seven counts of conspiracy and mail fraud.

His sentencing will be June 24.

See CRIMINAL NO. 12-394 below:

NTSB Reports on Dreamliner Battery Fire in Boston

briefing
Briefing March 7, 2013

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

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

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

Interim Report on Battery


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Final Report on Sikorsky Incident

When a Bristow S-76 Helicopter with eight passengers and two crew fishtailed as it was flying from from Humberside Airport to a gas platform in the North Sea, the helicopter made a precautionary landing. The crew smelled smoke in the cockpit at the time.

The investigation concluded that an electrical short had occurred in a wiring loom.

The incident occurred on Sept 26, 2012.

The report is below:


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Safety recommendations

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

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

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

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

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


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IMPROPER MAINTENANCE LED TO Vegas AIR TOUR HELICOPTER CRASH

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

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

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

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

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

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

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

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


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FAA Issues Battery Statement. And Me Too…Attention, Boeing…

My experts are telling me that it looks like Boeing is all alone on these 787 battery fires. The FAA issued 31 ‘Special Conditions’ (you can read that to mean that the FAA gave Boeing a whole lot of slack) but this battery problem is not getting a free ride, or any favors.

SAFETY is the top priority. Make no mistake. The sooner the Dreamliner and its battery is grounded, the sooner the fix will be found and it will be safe to fly again. Well. While you’re at it fixing the battery problem, get that team of pilots who fly this thing to go over all areas of failure thus far, including the engines. Look at ALL of these…

  • Nov 6 2010: Boeing flight Texas: electrical problems in the aft electronics bay which disabled the primary flight displays in the cockpit.
  • Nov 6 2011: ANA Flight Okayama forced to deploy the landing gear using the alternate extension backup system, after an active warning light, which said that the wheels were not properly down.
  • July 28 2012: Boeing Flight Charleston: contained engine failure during a taxi test at Charleston International Airport PRE Delivery Taxi test. Debris fell from engine
  • Dec 4, 2012: United over Mississippi: “multiple messages” regarding flight-system errors, and diverted to New Orleans (KMSY). The problems occurred when one of the plane’s generators failed. Power was supplied to the aircraft with the five functioning generators.
  • Jan 7, 2013: JAL Boston: fire was discovered in a battery and electrical compartment of the aircraft.
  • Jan 8, 2013: JAL Boston: 40 gallons of fuel had spilled from one of its wing tanks at the gate. The plane was contacted before takeoff and it returned to the terminal without incident. Probably a case of overfilling the tank.
  • Jan 9, 2013: ANA Yamaguchi: Brake problems
  • Jan 16, 2013: ANA Takamatsu: instrument indications of smoke in the forward electrical compartment. No fire was found.

Boeing? Are you listening? I fly everywhere, all over the world but at the moment, I’m not comfortable getting on this great plane that I really want to love for future travel. I’m am confident you can do it, even if all of these wrinkles are going to mean you need to bring in the really big iron. We need all the finders and fixers on this! The world has places to go and things to do, and you’re holding their safety in the palm of your hand.

The Emergency Airworthiness Directive has been issued. Issued Jan 16, 2013
and here is their announcement:

As a result of an in-flight, Boeing 787 battery incident earlier today in Japan, the FAA will issue an emergency airworthiness directive (AD) to address a potential battery fire risk in the 787 and require operators to temporarily cease operations. Before further flight, operators of U.S.-registered, Boeing 787 aircraft must demonstrate to the Federal Aviation Administration (FAA) that the batteries are safe.
The FAA will work with the manufacturer and carriers to develop a corrective action plan to allow the U.S. 787 fleet to resume operations as quickly and safely as possible.
The in-flight Japanese battery incident followed an earlier 787 battery incident that occurred on the ground in Boston on January 7, 2013. The AD is prompted by this second incident involving a lithium ion battery. The battery failures resulted in release of flammable electrolytes, heat damage, and smoke on two Model 787 airplanes. The root cause of these failures is currently under investigation. These conditions, if not corrected, could result in damage to critical systems and structures, and the potential for fire in the electrical compartment.

Last Friday, the FAA announced a comprehensive review of the 787’s critical systems with the possibility of further action pending new data and information. In addition to the continuing review of the aircraft’s design, manufacture and assembly, the agency also will validate that 787 batteries and the battery system on the aircraft are in compliance with the special condition the agency issued as part of the aircraft’s certification.

United Airlines is currently the only U.S. airline operating the 787, with six airplanes in service. When the FAA issues an airworthiness directive, it also alerts the international aviation community to the action so other civil aviation authorities can take parallel action to cover the fleets operating in their own countries.

See Directive:


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NTSB Reports Uncertified Pilot in December Crash

According to the NtSB Preliminary report of the Beech crash on December 18, 2012, about 0002 mountain standard time (MST), a Beech B100, N499SW, collided with trees at Libby, Montana. Stinger Welding was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The noncertificated pilot and one passenger sustained fatal injuries; the airplane sustained substantial damage from impact forces. The cross-country personal flight departed Coolidge, Arizona, about 2025 MST on December 17th, with Libby as the planned destination. Visual meteorological conditions prevailed at the nearest official reporting station of Sandpoint, Idaho, 264 degrees at 46 miles, and an instrument flight rules (IFR) flight plan had been filed.

Read the preliminary report


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Sukhoi plane crash Caused by Pilot Error

The National Commission on Safety Transportation announced that the Russian Sukhoi Superjet 100 that crashed into a mountain in Indonesia seven months did so as a result of pilot error. All 45 Aboard were fatalities.

Indonesian authorities claimed that the plane functioned adequately and there were no malfunctions of safety gear.

The fact that the pilot digressed from the route, and that the (foreign) pilots were not well aware of the mountainous terrain may be behind part of the decision. As a demonstration flight, the pilots were probably encouraged to make dramatic maneuvers at a terrible price.

Thirty-eight seconds prior to the impact, cockpit instruments issued a warning saying “pull up, terrain ahead”. Later the warning “avoid terrain” was issued six times, but the instruments were turned off because the crew assumed there was a problem with the database.

Officials said that “The crew was not aware of the mountainous area surrounding the flight path,”

The Jakarta radar service was incapable of informing flight crews of minimum safe altitudes.

The Russian pilots, while experts, were not intimate with the Indonesian topography.
Six minutes after takeoff, the pilot and co-pilot requested Jakarta ATC for permission to drop from 3,000 meters to 1,800 meters on the scheduled half-hour flight. Six minutes later, the plane struck Mount Salak.

READ MORE:

Sukhoi SuperJet-100 Demo Disaster Final Report In October

Russian Pilots Bail out of Sukhoi Jet

The Investigation of Sukhoi Superjet’s Crash holds Answers to Many Questions

Black Boxes Located and in Indonesian Custody

Continuing Search for Sukhoi Superjet Wreckage Indicates Probable Black Box Location Buried Under Debris

Joy Flight Steals Joy

Superjet Wreckage Found

Sukhoi-Superjet Goes Missing on Demo Flight over Indonesian Mountains

Airbus A318-A321 Hydraulic Power System Airworthiness Bulletin


This Special Airworthiness Information Bulletin advises registered owners and operators, repair stations, and mechanics holding inspection authorizations, of all Airbus Model A318, A319, A320 and A321 series airplanes of an airworthiness concern regarding overheating of the power transfer unit (PTU) of the hydraulic system.

Hydraulic Power System: Power Transfer Unit
There have been several reports of loss of a single hydraulic system due to leakage, and subsequent failure of a second hydraulic system from overheating. Airbus determined that overheating of the second hydraulic system is caused when the PTU is not de-activated by the flight crew within two minutes after the fault annunciation (AMBER CAUTION) alert on the electronic centralized aircraft monitoring (ECAM) system. Consequently the airplane is left with only one functional hydraulic system. The subject airplanes require at least one functional hydraulic system for continuous safe flight and landing.
Read More


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NTSB Safety Recommendations


The NTSB issued 10new recommendations, including five to the FederalAviation Administration, three to the Flight Test Safety Committee, and the following two recommendations to Gulfstream
Aerospace Corporation:

A-12-62
Commission an audit by qualified independent safety experts, before the start of the next major certification flight test program, to evaluate the company’s flight test safety management system, with special attention given to the areas of weakness identified in this
report, and address all areas of concern identified by the audit.

A-12-63
Provide information about the lessons learned from the implementation of its flight test safety management system to interested manufacturers, flight test industry groups, and other appropriate parties.

Safety Recommendations


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NTSB Says Aggressive Test Flight Schedule, Overlooked Errors Led to Stall and Crash

Oct. 10, 2012
The National Transportation Safety Board determined today that the probable cause of the crash of an experimental Gulfstream G650 on April 2, 2011, in Roswell, N.M., was the result of an aerodynamic stall and uncommanded roll during a planned takeoff test flight conducted with only one of the airplane’s two engines operating.
The Board found that the crash was the result of Gulfstream’s failure to properly develop and validate takeoff speeds and recognize and correct errors in the takeoff safety speed that manifested during previous G650 flight tests; the flight test team’s persistent and aggressive attempts to achieve a takeoff speed that was erroneously low; and Gulfstream’s inadequate investigation of uncommanded roll events that occurred during previous flight tests, which should have revealed incorrect assumptions about the airplane’s stall angle of attack in ground effect.

Contributing to the accident, the NTSB found, was Gulfstream’s pursuit of an aggressive flight test schedule without ensuring that the roles and responsibilities of team members were appropriately defined, sufficient technical planning and oversight was performed, and that hazards had been fully identified and addressed with appropriate, effective risk controls.

“In this investigation we saw an aggressive test flight schedule and pressure to get the aircraft certified,” said NTSB Chairman Deborah A.P. Hersman. “Deadlines are essential motivators, but safety must always trump schedule.”

At approximately 9:34 a.m. Mountain Time, during takeoff on the accident flight, the G-650 experienced a right wing stall, causing the airplane to roll to the right with the right wingtip contacting the runway. The airplane then departed the runway, impacting a concrete structure and an airport weather station, resulting in extensive structural damage and a post-crash fire. The two pilots and two flight engineers on board were fatally injured and the airplane was substantially damaged.

The NTSB made recommendations to the Flight Test Safety Committee and the Federal Aviation Administration to improve flight test operating policies and encourage manufacturers to follow best practices and to coordinate high-risk flight tests. And the Board recommended that Gulfstream Aerospace Corporation commission an independent safety audit to review the company’s progress in implementing a flight test safety management system and provide information about the lessons learned from its implementation to interested manufacturers, flight test safety groups and other appropriate parties.

“In all areas of aircraft manufacturing, and particularly in flight testing, where the risks are greater, leadership must require processes that are complete, clear and include well-defined criteria,” said Chairman Deborah A.P. Hersman. “This crash was as much an absence of leadership as it was of lift.”

The preliminary synopsis of the report is below:

NATIONAL TRANSPORTATION SAFETY BOARD
Public Meeting of October 10, 2012
(Information subject to editing)
Aircraft Accident Report:
Crash During Experimental Test Flight
Gulfstream Aerospace Corporation GVI (G650), N652GD
Roswell, New Mexico
April 2, 2011

NTSB/AAR-12/02

This is a synopsis from the National Transportation Safety Board’s report and does not include the NTSB’s rationale for the conclusions, probable cause, and safety recommendations. Safety Board staff is currently making final revisions to the report from which the attached conclusions and safety recommendations have been extracted. The final report and pertinent safety recommendation letters will be distributed to recommendation recipients as soon as possible. The attached information is subject to further review and editing.

Executive Summary

On April 2, 2011, about 0934 mountain daylight time, an experimental Gulfstream Aerospace Corporation GVI (G650), N652GD, crashed during takeoff from runway 21 at Roswell International Air Center Airport, Roswell, New Mexico. The two pilots and the two flight test engineers were fatally injured, and the airplane was substantially damaged by impact forces and a postcrash fire. The airplane was registered to and operated by Gulfstream as part of its G650 flight test program. The flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time of the accident.

The accident occurred during a planned one-engine-inoperative (OEI) takeoff when a stall on the right outboard wing produced a rolling moment that the flight crew was not able to control, which led to the right wingtip contacting the runway and the airplane departing the runway from the right side. After departing the runway, the airplane impacted a concrete structure and an airport weather station, resulting in extensive structural damage and a postcrash fire that completely consumed the fuselage and cabin interior.

The National Transportation Safety Board’s (NTSB) investigation of this accident found that the airplane stalled while lifting off the ground. As a result, the NTSB examined the role of “ground effect” on the airplane’s performance. Ground effect refers to changes in the airflow over the airplane resulting from the proximity of the airplane to the ground. Ground effect results in increased lift and reduced drag at a given angle of attack (AOA) as well as a reduction in the stall AOA. In preparing for the G650 field performance flight tests, Gulfstream considered ground effect when predicting the airplane’s takeoff performance capability but overestimated the in ground effect stall AOA. Consequently, the airplane’s AOA threshold for stick shaker (stall warning) activation and the corresponding pitch limit indicator (on the primary flight display) were set too high, and the flight crew received no tactile or visual warning before the actual stall occurred.

The accident flight was the third time that a right outboard wing stall occurred during G650 flight testing. Gulfstream did not determine (until after the accident) that the cause of two previous uncommanded roll events was a stall of the right outboard wing at a lower-than-expected AOA. (Similar to the accident circumstances, the two previous events occurred during liftoff; however, the right wingtip did not contact the runway during either of these events.) If Gulfstream had performed an in-depth aerodynamic analysis of these events shortly after they occurred, the company could have recognized before the accident that the actual in-ground-effect stall AOA was lower than predicted.

During field performance testing before the accident, the G650 consistently exceeded target takeoff safety speeds (V2). V2 is the speed that an airplane attains at or before a height above the ground of 35 feet with one engine inoperative. Gulfstream needed to resolve these V2 exceedances because achieving the planned V2 speeds was necessary to maintain the airplane’s 6,000-foot takeoff performance guarantee (at standard sea level conditions). If the G650 did not meet this takeoff performance guarantee, then the airplane could only operate on longer runways. However, a key assumption that Gulfstream used to develop takeoff speeds was flawed and resulted in V2 speeds that were too low and takeoff distances that were longer than anticipated.

Rather than determining the root cause for the V2 exceedance problem, Gulfstream attempted to reduce the V2 speeds and the takeoff distances by modifying the piloting technique used to rotate the airplane for takeoff. Further, Gulfstream did not validate the speeds using a simulation or physics-based dynamic analysis before or during field performance testing. If the company had done so, then it could have recognized that the target V2 speeds could not be achieved even with the modified piloting technique. In addition, the difficulties in achieving the target V2 speeds were exacerbated in late March 2011 when the company reduced the target pitch angle for some takeoff tests without an accompanying increase in the takeoff speeds.

Gulfstream maintained an aggressive schedule for the G650 flight test program so that the company could obtain Federal Aviation Administration (FAA) type certification by the third quarter of 2011. The schedule pressure, combined with inadequately developed organizational processes for technical oversight and safety management, led to a strong focus on keeping the program moving and a reluctance to challenge key assumptions and highlight anomalous airplane behavior during tests that could slow the pace of the program. These factors likely contributed to key errors, including the development of unachievable takeoff speeds, as well as the superficial review of the two previous uncommanded roll events, which allowed the company’s overestimation of the in-ground-effect stall AOA to remain undetected.

After the accident, Gulfstream suspended field performance testing through December 2011 while the company examined the circumstances of the accident. In March 2012, Gulfstream reported that company field performance testing had been repeated and completed successfully. In June 2012, the company reported that FAA certification field performance testing had been successfully completed. Gulfstream obtained FAA type certification for the G650 on September 7, 2012.

Conclusions

1. The test team’s focus on achieving the takeoff safety speeds for the flight tests and the lack of guidance specifying precisely when the pitch angle target and pitch limit applied during the test maneuver contributed to the team’s decision to exceed the initial pitch target and the pitch angle at which a takeoff test was to be discontinued.

2. A stall on the right outboard wing produced a right rolling moment that the flight crew was not able to control, which led to the right wingtip contacting the runway and the airplane departing the runway from the right side.

3. Given the airplane’s low altitude, the time-critical nature of the situation, and the ambiguous stall cues presented in the cockpit, the flight crew’s response to the stall event was understandable.

4. The impact forces from the accident were survivable, but the cabin environment deteriorated quickly and became unsurvivable because of the large amount of fuel, fuel vapor, smoke, and fire entering the cabin through the breaches in the fuselage.

5. The airplane stalled at an angle of attack (AOA) that was below the in ground effect stall AOA predicted by Gulfstream and the AOA threshold for the activation of the stick shaker stall warning.

6. If Gulfstream had performed an in-depth aerodynamic analysis of the cause of two previous G650 uncommanded roll events, similar to the analyses performed for roll events during previous company airplane programs, the company could have recognized that the actual in-ground-effect stall angle of attack for the accident flight test was significantly lower than the company predicted.

7. Gulfstream’s decision to use a takeoff speed development method from a previous airplane program was inappropriate and resulted in target takeoff safety speed values that were too low to be achieved.

8. By not performing a rigorous analysis of the root cause for the ongoing difficulties in achieving the G650 takeoff safety speeds (V2), Gulfstream missed an opportunity to recognize and correct the low target V2 speeds.

9. Before the accident flight, Gulfstream had sufficient information from previous flight tests to determine that the target takeoff safety speeds (V2) could not be achieved with a certifiable takeoff rotation technique and that the V2 speeds needed to be increased.

10. Deficiencies in Gulfstream’s technical planning and oversight contributed to the incorrect speeds used on the day of the accident.

11. Because Gulfstream did not clearly define the roles and responsibilities for on site test team members, critical safety-related parameters were not being adequately monitored and test results were not being sufficiently examined during flight testing on the day of the accident.

12. Gulfstream’s focus on meeting the G650’s planned certification date caused schedule related pressure that was not adequately counterbalanced by robust organizational processes to prevent, identify, and correct the company’s key engineering and oversight errors.

13. Gulfstream’s flight test safety program at the time of the accident was deficient because risk controls were insufficient and safety assurance activities were lacking.

14. The inherent risks associated with field performance flight testing, and minimum unstick speed testing in particular, could be reduced if airplane manufacturers considered the potential for a lower maximum lift coefficient in ground effect when estimating the stall angle of attack in ground effect.

15. Effective flight test standard operating policies and procedures that are fully implemented by manufacturers would help reduce the inherent risks associated with flight testing.

16. Flight test safety management system guidance specifically tailored to the needs of manufacturers would help promote the development of effective flight test safety programs.

17. External safety audits would help Gulfstream monitor the implementation of safety management principles and practices into its flight test operations and sustain long-term cultural change.

18. Flight test safety would be enhanced if manufacturers and flight test industry groups had knowledge of the lessons learned from Gulfstream’s implementation of its flight test safety management system.

19. Advance coordination between flight test operators and airport operations and aircraft rescue and firefighting personnel for high-risk flight tests could reduce the response time to an accident site in the event of an emergency.

Probable Cause

The National Transportation Safety Board determines that the cause of this accident was an aerodynamic stall and subsequent uncommanded roll during a one engine-inoperative takeoff flight test, which were the result of (1) Gulfstream’s failure to properly develop and validate takeoff speeds for the flight tests and recognize and correct the takeoff safety speed (V2) error during previous G650 flight tests, (2) the G650 flight test team’s persistent and increasingly aggressive attempts to achieve V2 speeds that were erroneously low, and (3) Gulfstream’s inadequate investigation of previous G650 uncommanded roll events, which indicated that the company’s estimated stall angle of attack while the airplane was in ground effect was too high. Contributing to the accident was Gulfstream’s failure to effectively manage the G650 flight test program by pursuing an aggressive program schedule without ensuring that the roles and responsibilities of team members had been appropriately defined and implemented, engineering processes had received sufficient technical planning and oversight, potential hazards had been fully identified, and appropriate risk controls had been implemented and were functioning as intended.

Recommendations

To the Federal Aviation Administration:

1. Inform domestic and foreign manufacturers of airplanes that are certified under 14 Code of Federal Regulations Parts 23 and 25 about the circumstances of this accident and advise them to consider, when estimating an airplane’s stall angle of attack in ground effect, the possibility that the airplane’s maximum lift coefficient in ground effect could be lower than its maximum lift coefficient in free air.

2. Work with the Flight Test Safety Committee to develop and issue detailed flight test operating guidance for manufacturers that addresses the deficiencies documented in this report regarding flight test operating policies and procedures and their implementation.

3. Work with the Flight Test Safety Committee to develop and issue flight test safety program guidelines based on best practices in aviation safety management.

4. After the Flight Test Safety Committee has issued flight test safety program guidelines, include these guidelines in the next revision of Federal Aviation Administration Order 4040.26, Aircraft Certification Service Flight Test Risk Management Program.

5. Inform 14 Code of Federal Regulations Part 139 airports that currently have (or may have in the future) flight test activity of the importance of advance coordination of high risk flight tests with flight test operators to ensure adequate aircraft rescue and firefighting resources are available to provide increased readiness during known high risk flight tests.

To the Flight Test Safety Committee:

6. In collaboration with the Federal Aviation Administration, develop and issue flight test operating guidance for manufacturers that addresses the deficiencies documented in this report regarding flight test operating policies and procedures and their implementation, and encourage manufacturers to conduct flight test operations in accordance with the guidance.

7. In collaboration with the Federal Aviation Administration, develop and issue flight test safety program guidelines based on best practices in aviation safety management, and encourage manufacturers to incorporate these guidelines into their flight test safety programs.

8. Encourage members to provide notice of and coordinate high-risk flight tests with airport operations and aircraft rescue and firefighting personnel.

To Gulfstream Aerospace Corporation:

9. Commission an audit by qualified independent safety experts, before the start of the next major certification flight test program, to evaluate the company’s flight test safety management system, with special attention given to the areas of weakness identified in this report, and address all areas of concern identified by the audit.

10. Provide information about the lessons learned from the implementation of its flight test safety management system to interested manufacturers, flight test industry groups, and other appropriate parties.

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Release: NTSB Urges Changes

The National Transportation Safety Board today issued two urgent safety recommendations to the Federal Aviation Administration (FAA) regarding two recent occurrences in which the fan midshaft on General Electric GEnx-1B engines fractured or exhibited crack indications; and a GEnx -2B incident that appears similar in nature. The recommendations are: (1) Issue an airworthiness directive to require, before further flight, the immediate ultrasonic inspection of the fan midshaft in all GEnx-1B and -2B engines that have not undergone inspection, and (2) Require repetitive inspections of the fan midshaft at a sufficiently short interval that would permit multiple inspections and detection of a crack before it could reach critical length and the fan midshaft fractures.

On July 28, 2012, the NTSB initiated an investigation of an engine failure that occurred on a Boeing 787 during a pre-delivery taxi test in Charleston, South Carolina. This investigation is ongoing.

“The parties to our investigation — the FAA, GE and Boeing — have taken many important steps and additional efforts are in progress to ensure that the fleet is inspected properly,” said NTSB Chairman Deborah A.P. Hersman. “We are issuing this recommendation today because of the potential for multiple engine failures on a single aircraft and the urgent need for the FAA to act immediately.”

In addition, on August 31, 2012, a GEnx-1B engine installed on a Boeing 787 that had not yet flown was found to have an indication of a similar crack on the fan midshaft. The fan midshaft was removed from the engine for further inspection and examination. As a result of the investigative work to date, the NTSB has determined that the fan midshafts on the GEnx engines fractured or cracked at the forward end of the shaft where the retaining nut is installed.

GE developed a field ultrasonic inspection method to inspect the fan midshaft in the area where the fracture and crack occurred that can be accomplished with the engine still installed on the airplane. To date, all in-service and spare GEnx-1B engines have been inspected. In addition, all GEnx-2B engines on passenger airplanes have been inspected. However, the NTSB is aware of approximately 43 GEnx-2B engines on 747-8F cargo airplanes that have not yet been inspected and is concerned that they are potentially susceptible to a fan midshaft failure.

More recently, a Boeing 747-8F cargo flight, operated by Air Bridge Cargo, equipped with General Electric GEnx-2B turbofan engines, experienced a loss of power in one of the engines during the takeoff roll in Shanghai, China. The airplane had accelerated through 50 knots when the engine’s low pressure rotor speed dropped. The pilot rejected the takeoff and returned to the ramp. Photographs of the low pressure turbine show damage similar to the GEnx-1B engine from the Charleston incident. The NTSB will continue to coordinate with our investigative counterparts in China.

Read the Recommendation Letter:


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DETERIORATED PARTS ALLOWED FLUTTER WHICH LED TO FATAL CRASH AT 2011 RENO AIR RACES


August 27, 2012
WASHINGTON – The National Transportation Safety Board determined today that deteriorated locknut inserts found in the highly modified North American P-51D airplane that crashed during the 2011 National Championship Air Races in Reno, Nevada, allowed the trim tab attachment screws to become loose, and even initiated fatigue cracking in one screw. This condition, which resulted in reduced stiffness in the elevator trim system, ultimately led to aerodynamic flutter at racing speed that broke the trim tab linkages, resulting in a loss of controllability and the eventual crash.

On September 16, 2011, as the experimental single-seat P-51D airplane “The Galloping Ghost,” traveling about 445 knots, or 512 mph, in the third lap of the six-lap race, passed pylon 8, it experienced a left-roll upset and high-G pitch up. During the upset sequence, the airplane’s vertical acceleration peaked at 17.3 G, causing incapacitation of the pilot. Seconds later, a section of the left elevator trim tab separated in flight. The airplane descended and impacted the ramp in the spectator box seating area, killing the pilot and 10 spectators and injuring more than 60 others.

“In Reno, the fine line between observing risk and being impacted by the consequences when something goes wrong was crossed,” said NTSB Chairman Deborah A. P. Hersman. “The pilots understood the risks they assumed; the spectators assumed their safety had been assessed and addressed.”

Contributing to the accident were the undocumented and untested major modifications made to the airplane, as well as the pilot’s operation of the airplane in the unique air racing environment without adequate flight testing.

The nearly 70-year-old airplane had undergone numerous undocumented modifications. The modifications, designed to increase speed, included shortening of the wings, installation of a boil-off cooling system for the engine, increasing the elevator counterweights, modification of the pitch trim system, and changing the incidence of the horizontal and vertical stabilizers.

Although the Federal Aviation Administration required that a flight standards district office be notified in writing of any major changes made to The Galloping Ghost before it could be flown, investigators could find no records that such notifications were made except for the installation of the boil-off cooling system. The undocumented major modifications were identified through wreckage examinations, photographic evidence, and interviews with ground crewmembers.

In April, while the investigation was ongoing and after the NTSB’s investigative hearing in January on air race and air show safety, the NTSB issued 10 safety recommendations to the Reno Air Racing Association, the National Air racing Group Unlimited Division, and the FAA. These recommendations addressed:

  • requiring engineering evaluations for aircraft with major modifications;
  • raising the level of safety for spectators and personnel near the race course;
  • improving FAA guidance for air race and course design;
  • providing race pilots with high-G training and evaluating the feasibility of G-suit requirements for race pilots; and
  • tracking the resolution of race aircraft discrepancies identified during prerace technical inspections.

Although no additional safety recommendations were issued today, the Board reclassified nine existing recommendations as described below:

  • Eligibility Requirements for Aircraft with Major Modifications – recommendations A 12 9 and A-12-13 classified “Open—Acceptable Response”
  • Prerace Technical Inspection Discrepancy Tracking – recommendation A 12 10, classified “Closed—Acceptable Action”
  • Spectator Safety – recommendations A 12 14 and 15, classified “Closed—Acceptable Action”
  • High G Training, G-Suit Feasibility for Pilots – recommendations A 12 11, -12, -16, and -17, classified “Closed—Acceptable Action”

A tenth safety recommendation, issued to the FAA, which addressed air race and course design guidance was reclassified as “Open—Acceptable Response” on July 25, 2012.

“It’s good news for the air races that so many of our recommendations have been addressed,” said Chairman Hersman. “We will continue to push for the full implementation of all of our safety recommendations.”


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Final Report on Helicopter Crash

What: DAVCRON PTY LTD Bell 206
Where: South Turramurra near the Canoon Rd netball courts
When: July 20121
Who: 2 fatalities
Why: The pilot had picked his passenger to take him to Sydney Adventist Hospital apparently without checking weather reports which resulted in the Bell helicopter crashing in a cliff. Inclement weather and hazardous conditions in Lane Cove National Park led to the decision to call off the recovery operation on July 22, 2012, the same inclement conditions which caused the accident. Businessman Bruce Campbell, 65, and freelance pilot Colin Greenwood died in the crash at the foot of 15m cliff in Lane Cove National Park.

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