Official Report

  • NTSB Chairman Opens Child and Youth Transportation Safety Initiative at Safety Seat Check Event

    National Transportation Safety Board
    Washington, DC 20594

    FOR IMMEDIATE RELEASE: January 24, 2011

    National Transportation Safety Board Chairman Deborah A.P. Hersman recently launched the agency’s initiative to promote child and youth safety across alltransportation modes, with a particular focus on educating parents and
    caregivers about ways to keep children safe when traveling. The yearlong effort was first announced at the NTSB’s forum on Child Passenger Safety in the Air and in Automobiles in December.

    At a child safety seat check event in Bristow, Virginia sponsored by the Prince William County Fire and Rescue, Chairman Hersman spoke about child passenger safety and her own plans to renew her certification as a CPS technician.

    “These community-sponsored seat checks give parents peace of mind,” Hersman said. “Every parent wants their child to be safe, so knowing that trained and knowledgeable CPS technicians are available to make sure that their child safety seats have been installed properly is invaluable to them.”

    To view the video that captured highlights of the event, please visit: www.ntsb.gov/children.

    Chairman Hersman noted that not all states have adequate child passenger safety laws. “As state legislatures begin their 2011 sessions, the NTSB is calling upon legislators to pass laws that ensure that all children up to 8 years old are using child safety and booster seats.”

    Florida, the most lenient in child passenger safety laws, requires child safety seats only for children age 3 years or younger. The laws in Arizona, South Dakota, American Samoa and Puerto Rico are only slightly more
    protective, covering children age 4 years or younger. Twelve states (Alabama, Arkansas, California, Georgia, Iowa, Louisiana, Montana, Nebraska, Nevada, New Hampshire, Oklahoma, and South Carolina) mandate child restraints for children age 5 or younger and six states (Connecticut, Idaho, Kentucky, Mississippi, New Mexico, and North Dakota) only cover children age 6 or younger.

    The issue of improving child occupant protection has been on the NTSB’s Most Wanted List of Transportation Safety Improvements since 1997.

  • Reportlinker Adds World Commercial Avionics Markets

    NEW YORK, Jan. 20, 2011 /PRNewswire/ — Reportlinker.com announces that a new market research report is available in its catalogue:

    World Commercial Avionics Markets
    http://www.reportlinker.com/p0236790/World-Commercial-Avionics-Markets.html

    This research service examines the commercial air transport and general aviation avionics markets. Included in this research service is a detailed avionics market forecast from 2009 to 2014. The service also includes market share and revenues for avionics manufacturers, including the overall share and shares for both the air transport and general aviation markets. Within the individual markets it contains a segment-specific analysis for each of the individual technology segments, and an analysis of the retrofit and post sales service markets segments.

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    NTSB STUDY SHOWS THAT AIRBAGS CAN PROVIDE OCCUPANT PROTECTION IN GENERAL AVIATION ACCIDENTS

    National Transportation Safety Board
    Washington, DC 20594

    FOR IMMEDIATE RELEASE: January 11, 2011
    SB-11-03

    Today the National Transportation Safety Board adopted a study that concluded that general aviation (GA) airplanes equipped with airbags provide additional protection to occupants in accidents involving survivable forward impacts.

    Airbags are designed to mitigate head and upper body injuries and are installed in the lap belt or shoulder harness portions of the restraint system. They were first approved for use in the pilot and co-pilot seats in GA aircraft in 2003. Currently, there are nearly 18,000 airbag- equipped seats in over 7,000 of the 224,000 GA aircraft in the United States.

    “Although airbags have been mandated in automobiles for over a decade, the aviation industry has no such requirement for small aircraft,” said NTSB Chairman Deborah A.P. Hersman. “The good news is that over 30 manufacturers have stepped up to the plate and offer airbags as standard or optional equipment.”

    The study, which examined 88 accidents involving airbag- equipped airplanes that occurred between 2006 and 2009, found no instances where the airbag caused harm in properly restrained occupants. In addition, the study found 10 survivable accidents in which the crash forces were severe enough to cause injury and/or to deploy the airbag.

    Within the group of 10 accidents, 12 occupants experienced airbag deployments, and the study found that the airbag likely mitigated injuries for two of the occupants.

    The study also noted that there were no negative consequences as a result of airbag deployments. For instance, there were no cases in which the airbags were expected to deploy but did not. Nor were there any cases that involved airbags deploying under unexpected circumstances, hindering egress, fueling post-crash fires or interfering with rescue attempts. Yet investigators did uncover some safety issues with restraint systems.

    One such issue involved the incorrect usage or adjustment of seat belts. In certain aircraft types, the seat belts in the left and right seats can become reversed, which could result in the wrong airbag being activated if only one of the seats is occupied.

    There were also concerns with optimal airbag protection for occupants whose body mass indexes (BMI) classified them as either overweight or obese (BMIs of 25 or higher). The NTSB questions whether the airbag-equipped restraints were designed and tested with the high-BMI population in mind.

    An additional finding of this study was the strong affirmation that correctly installed shoulder harness/lap belt combinations provide significantly greater protection in GA accidents than that offered by a lap belt alone. Based on an analysis of over 37,000 GA accidents, the Board concluded that the risk of fatal or serious injury was 50 percent higher when an occupant was only restrained by a lap belt as compared to the combination lap belt and shoulder harness.

    “The simplest and cheapest improvement to the safety of general aviation aircraft occupants is the mandatory installation of shoulder harnesses,” said Hersman.

    The five-Member Board voted to adopt six safety recommendations, all directed to the Federal Aviation Administration:

    1. Require manufacturers to modify restraint systems vulnerable to being used incorrectly in newly built GA airplanes and to modify restraints in existing airplanes.

    2. Revise the guidance and certification standards for restraint systems to reduce the likelihood of misuse.

    3. Modify the guidance to GA airbag manufacturers as to how they should demonstrate that an airbag design provides adequate protection for a greater range of body sizes, including very small and very large individuals.

    4. Require the retrofitting of shoulder harnesses on all general aviation airplanes that are not currently equipped with such restraints.

    5. Evaluate the feasibility of requiring airbag-equipped aircraft to capture and record crash dynamics data to determine whether the system performed as designed.

    6. Develop a system to track safety equipment, such as restraint systems, airbags, and aircraft parachutes, designed to improve crash outcomes.

    The complete safety study will be available at www.ntsb.gov in several weeks.

  • 2011 SAFO: The Importance of Properly Inflated Aircraft Tires

    SAFO 11001 DATE: 11/6/11
    Flight Standards Service Washington, DC
    http://www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/safo

    A SAFO contains important safety information and may include recommended action. SAFO content should be especially valuable to air carriers in meeting their statutory duty to provide service with the highest possible degree of safety in the public interest. Besides the specific action recommended in a SAFO, an alternative action may be as effective in addressing the safety issue named in the SAFO.

    Subject: The Importance of Properly Inflated Aircraft Tires

    Purpose: This SAFO stresses the importance of ensuring properly inflated tires and the potential consequences improper tire pressure can have on the performance of aircraft operations during Taxi, Takeoff and Landing.
    Background: The probable causes of numerous accidents have highlighted the importance of ensuring proper aircraft tire pressure. For instance, a Douglas DC-8-61 crashed shortly after takeoff from Jeddah, Saudi Arabia killing all 261 on board. The probable cause of the crash was under-inflated tires, which in turn caused an overheated tire to explode during taxi, which then caused other tires to catch on fire during the takeoff role. The fire continued as the wheels were retracted into the wheel well, eventually causing a loss of hydraulic control and finally an in-flight break-up which destroyed the aircraft. This accident also revealed numerous human factor issues that contributed to the underinflated tire.
    Recently, the National Transportation Safety Board (NTSB) determined that inadequate maintenance of the airplane’s tires was the probable cause of an accident where a Learjet 60 overran the runway in Columbia, South Carolina. The inadequate maintenance of tires resulted in multiple tire failures during the takeoff roll due to severe under inflation. This accident took the lives of both flightcrew members and two passengers; two other passengers were seriously injured.

    Discussion: Aircraft tires are designed to carry specified loads during a variety of temperatures and wheel speeds. When aircraft tires are improperly serviced as illustrated in the background paragraph above, they are severely compromised and catastrophic consequences can occur. The Federal Aviation Administration (FAA) suggests any individual associated with the operation of aircraft under Title 14 Code of Federal Regulations (14 CFR) part 121, 125, 129, 135 and 91 subpart K (91K), including those who perform servicing and maintenance functions at a certificated or non certificated repair facility (maintenance providers), make certain their procedures ensure tire pressure checks frequently to ensure tires remain inflated to within the maintenance manual-specified inflation range.
    Research has shown that transport-category airplanes can lose as much as five percent of tire pressure per day under typical operations. At a pressure rate loss of five percent per day, it would only take a few days before they require servicing. Tires not serviced within an acceptable range may require tire replacement due to under inflation limitations specified in the maintenance manual. Additionally, servicing of underinflated tires without proper protection such as a tire screen or other protective devices may cause damage to the aircraft or injury to the individual servicing an underinflated tire.

    Distributed by: AFS-200 OPR: AFS-330

    Recommended Action: Air Carrier Certificate Holders, Fractional Ownership Program Managers, Training Center Managers, Directors of Maintenance, Accountable Managers, Maintenance Providers and others with responsibility for maintenance should become familiar with the contents of this SAFO. This SAFO’s intent is to ensure appropriate personnel are made aware of the importance of proper tire pressures, appropriately calibrated tire pressure gauges and servicing safety precautions. The maintenance manual tire pressure interval checks are followed to ensure proper tire pressure is accurately maintained. Failure to follow the published procedures with aircraft tires could result in personal injury or catastrophic aircraft loss.

    Contact: Questions or comments concerning this SAFO can be directed to Aircraft Maintenance Divisions Air Carrier Maintenance Branch, AFS-330 at (202) 385-6426.

  • Qantas Airbus Failure: Australian investigation report


    src australian safety board

    Inflight engine failure – Qantas, Airbus A380, VH-OQA, overhead Batam Island, Indonesia, 4 November 2010

    Safety Recommendation AO-2010-089-SR-012
    On 4 November 2010, at 0157 Universal Coordinated Time (UTC), an Airbus A380 aircraft, registered VH-OQA (OQA), being operated as Qantas flight 32, departed from runway 20 centre (20C) at Changi Airport, Singapore for Sydney, New South Wales. On board the aircraft were five flight crew, 24 cabin crew and 440 passengers (a total of 469 persons on board).

    Following a normal takeoff, the crew retracted the landing gear and flaps. The crew reported that, while maintaining 250 kts in the climb and passing 7,000 ft above mean sea level, they heard two almost coincident ‘loud bangs’, followed shortly after by indications of a failure of the No 2 engine.

    The crew advised Singapore Air Traffic Control of the situation and were provided with radar vectors to a holding pattern. The crew undertook a series of actions before returning the aircraft to land at Singapore. There were no reported injuries to the crew or passengers on the aircraft. There were reports of minor injuries to two persons on Batam Island, Indonesia.

    A subsequent examination of the aircraft indicated that the No 2 engine had sustained an uncontained failure of the Intermediate Pressure (IP) turbine disc. Sections of the liberated disc had penetrated the left wing and the left wing-to-fuselage fairing, resulting in structural and systems damage to the aircraft. The No 2 engine was removed from the aircraft and disassembled in an authorised engine workshop for examination, under the supervision of the Australian Transport Safety Bureau. In addition, a large section of liberated IP turbine disc was also recovered from Batam Island for examination. Those examinations are ongoing.

    As a result of this occurrence, a number of safety actions were immediately undertaken by Qantas, the Australian Civil Aviation Safety Authority, Airbus, Rolls-Royce plc, and the European Aviation Safety Agency.
    The Australian Transport Safety Bureau has prepared a Preliminary Factual Report on the investigation of the occurrence. That report will be publicly released on 3 December 2010.

    Recent developments

    Recent examination of components removed from the failed engine at the Rolls-Royce plc facility in Derby, United Kingdom, has identified the presence of fatigue cracking within a stub pipe that feeds oil into the High Pressure (HP) / Intermediate Pressure (IP) bearing structure. While the analysis of the engine failure is ongoing, it has been identified that the leakage of oil into the HP/IP bearing structure buffer space (and a subsequent oil fire within that area) was central to the engine failure and IP turbine disc liberation event.
    \
    Further examination of the cracked area has identified the axial misalignment of an area of counter?boring within the inner diameter of the stub pipe; the misalignment having produced a localised thinning of the pipe wall on one side. The area of fatigue cracking was associated with the area of pipe wall thinning (Figure 1).

    Figure 1: Detail of stub pipe showing misaligned counter-bore

    Critical Safety Issue
    Misaligned stub pipe counter-boring is understood to be related to the manufacturing process. This condition could lead to an elevated risk of fatigue crack initiation and growth, oil leakage and potential catastrophic engine failure from a resulting oil fire.

    As a result of the identified critical safety issue, the Australian Transport Safety Bureau issues the following safety recommendation:

    Safety Recommendation AO-2010-089-SR-012

    The Australian Transport Safety Bureau recommends that Rolls-Royce plc address the safety issue and take actions necessary to ensure the safety of flight operations in transport aircraft equipped with Rolls-Royce plc Trent 900 series engines.

    On 4 November 2010, at 0157 Universal Coordinated Time (UTC), an Airbus A380 aircraft, registered VH-OQA (OQA), being operated as Qantas flight 32, departed from runway 20 centre (20C) at Changi Airport, Singapore for Sydney, New South Wales. On board the aircraft were five flight crew, 24 cabin crew and 440 passengers (a total of 469 persons on board).

    Following a normal takeoff, the crew retracted the landing gear and flaps. The crew reported that, while maintaining 250 kts in the climb and passing 7,000 ft above mean sea level, they heard two almost coincident ‘loud bangs’, followed shortly after by indications of a failure of the No 2 engine.

    The crew advised Singapore Air Traffic Control of the situation and were provided with radar vectors to a holding pattern. The crew undertook a series of actions before returning the aircraft to land at Singapore. There were no reported injuries to the crew or passengers on the aircraft. There were reports of minor injuries to two persons on Batam Island, Indonesia.

    A subsequent examination of the aircraft indicated that the No 2 engine had sustained an uncontained failure of the Intermediate Pressure (IP) turbine disc. Sections of the liberated disc penetrated the left wing and the left wing-to-fuselage fairing, resulting in structural and systems damage to the aircraft.

    As a result of this occurrence, a number of safety actions were immediately undertaken by Qantas, Airbus, Rolls-Royce plc and the European Aviation Safety Agency. On 1 December 2010, the ATSB issued a safety recommendation to Rolls-Royce plc in respect of the Trent 900 series engine high pressure/intermediate pressure bearing structure oil feed stub pipes. In addition, the Civil Aviation Safety Authority issued a Regulation 38 maintenance direction that addressed the immediate safety of flight concerns in respect of Qantas A380 operations with the Trent 900 series engine. On 2 December 2010, Qantas advised that the requirements of Rolls-Royce plc Service Bulletin RB211-72-G595 would take place within the next 24 hours on engines in place on A380 aircraft currently in service, and before further flighton engines on aircraft not yet returned to service.

    The investigation is continuing.




    Date: 04 Nov 2010 Investigation Status: Active
    Time: 0201 UTC Investigation Type: Occurrence Investigation
    Location: overhead Batam Island, Indonesia Occurrence Type: Powerplant / Propulsion
    State: International Occurrence Class: Mechanical
    Release Date: 03 Dec 2010 Occurrence Category: Accident
    Report Status: Preliminary Highest Injury Level: None

    Aircraft Details

    Aircraft Manufacturer: Airbus
    Aircraft Model: A380
    Aircraft Registration: VH-OQA
    Serial Number: 0014
    Type of Operation: Air Transport High Capacity
    Damage to Aircraft: Serious
    Departure Point: Singapore
    Destination: Sydney, NSW
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    NTSB MEETS TO CONSIDER SAFETY STUDY ON THE USE OF AIRBAGS IN GENERAL AVIATION AIRCRAFT

    National Transportation Safety Board
    Washington, DC 20594

    January 6, 2011

    The National Transportation Safety Board will hold a public
    Board meeting to consider a safety study on the
    effectiveness of airbags in general aviation (GA) aircraft.

    The NTSB initiated the safety study to 1) examine the
    effectiveness of airbags in mitigating occupant injury in a
    survivable GA accident, 2) identify any unintended
    consequences of airbag deployments, and 3) develop
    procedures to assist investigators in documenting airbag
    systems in future investigations.

    During the course of the study, investigators became aware
    of several potential issues that could compromise occupant
    safety associated with the use, adjustment and design of
    restraint systems. All of these findings will be presented
    to the five-Member Board for their consideration.

    The meeting will be held on Tuesday, January 11, at 9:30
    a.m., in its Board Room and Conference Center, 429 L’Enfant
    Plaza, S.W., Washington, D.C.

    A live and archived webcast of the proceedings will be
    available on the Board’s website at
    http://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 safety study, which will include its
    findings and safety recommendations, will appear on the
    website shortly after the conclusion of the meeting. The
    entire study will appear on the website several weeks later.

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    NTSB ISSUES RECOMMENDATIONS DEALING WITH EMERGENCY LOCATOR TRANSMITTERS IN GENERAL AVIATION AIRCRAFT FOLLOWING CRASH INVOLVING SENATOR STEVENS

    FOR IMMEDIATE RELEASE: January 5, 2011
    SB-11-02

    The National Transportation Safety Board today issued two safety recommendations to the Federal Aviation Administration requiring a detailed inspection of all emergency locator transmitters (ELT) installed on general aviation aircraft to ensure that their mountings maintain their retention capabilities during an accident sequence.

    An ELT is designed to broadcast a signal through an externally mounted antenna that contains the aircraft’s registration information and the global positioning system coordinates of the original signal. Also, the “homing signal” can be detected locally by other aircraft, air traffic control facilities, or rescue personnel who use a compatible receiver.

    “In this case, the airplane was equipped with a functioning 406 megahertz ELT, which can be a tremendous aid to search and rescue operations,” said NTSB Chairman Deborah A.P. Hersman. “But this vital life-saving technology won’t do anyone any good if it doesn’t stay connected to the antenna.”

    On August 9, 2010, a de Havilland turbine Otter airplane crashed in mountainous tree-covered terrain approximately 10 miles from Aleknagik, Alaska. Nearly five hours after the crash, volunteer airborne search personnel located the aircraft approximately 19 miles from where the flight originated. The pilot and four passengers, including former U.S. Senator Ted Stevens, sustained fatal injuries. The other four passengers were seriously injured.

    Aircraft involved in the search and rescue efforts and satellites did not detect any ELT signals. Following the discovery of the airplane, a pararescuer found the ELT loose on the floor of the airplane. The ELT had activated but had separated from its mounting bracket and antenna.

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    NTSB ISSUES RECOMMENDATIONS DEALING WITH EMERGENCY LOCATOR TRANSMITTERS IN GENERAL AVIATION AIRCRAFT FOLLOWING CRASH INVOLVING SENATOR STEVENS

    National Transportation Safety Board
    Washington, DC 20594

    FOR IMMEDIATE RELEASE: January 5, 2011

    Washington, DC – The National Transportation Safety Board
    today issued two safety recommendations to the Federal
    Aviation Administration requiring a detailed inspection of
    all emergency locator transmitters (ELT) installed on
    general aviation aircraft to ensure that their mountings
    maintain their retention capabilities during an accident
    sequence.

    An ELT is designed to broadcast a signal through an
    externally mounted antenna that contains the aircraft’s
    registration information and the global positioning system
    coordinates of the original signal. Also, the “homing
    signal” can be detected locally by other aircraft, air
    traffic control facilities, or rescue personnel who use a
    compatible receiver.

    “In this case, the airplane was equipped with a functioning
    406 megahertz ELT, which can be a tremendous aid to search
    and rescue operations,” said NTSB Chairman Deborah A.P.
    Hersman. “But this vital life-saving technology won’t do
    anyone any good if it doesn’t stay connected to the
    antenna.”

    On August 9, 2010, a de Havilland turbine Otter airplane
    crashed in mountainous tree-covered terrain approximately 10
    miles from Aleknagik, Alaska. Nearly five hours after the
    crash, volunteer airborne search personnel located the
    aircraft approximately 19 miles from where the flight
    originated. The pilot and four passengers, including former
    U.S. Senator Ted Stevens, sustained fatal injuries. The
    other four passengers were seriously injured.

    Aircraft involved in the search and rescue efforts and
    satellites did not detect any ELT signals. Following the
    discovery of the airplane, a pararescuer found the ELT loose
    on the floor of the airplane. The ELT had activated but had
    separated from its mounting bracket and antenna.

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    NTSB ISSUES UPDATE ON JACKSON HOLE B-757 RUNWAY OVERRUN INCIDENT

    NTSB Advisory
    National Transportation Safety Board
    Washington, DC 20594
    December 31, 2010

    In its continuing investigation of the runway overrun of a jetliner in Jackson Hole, Wyo., the National Transportation Safety Board has developed the following factual information:

    At about 11:38 am MT on Wednesday, December 29, American Airlines flight 2253, a B-757-200 (N668AA) inbound from Chicago O’Hare International Airport, ran off the end of runway 19 in snowy conditions while landing at Jackson Hole Airport. No injuries were reported among the 181 passengers and crew on board.

    The aircraft came to rest in hard packed snow about 350 feet beyond the runway overrun area. An initial inspection did not reveal any structural damage to the aircraft. Shortly after the aircraft came to a stop, in accordance with American Airlines’ procedures, the pilots pulled the circuit breaker to the cockpit voice recorder (CVR) to preserve all of the recorded information for investigators.

    The CVR and DFDR (digital flight data recorder) arrived at the Safety Board’s recorder laboratory on Thursday evening, Dec. 30, where investigators were standing by to download the contents of both recorders. The CVR provided a two-hour recording of excellent quality audio; the voices of each of the pilots on the flight deck were clearly audible. The DFDR provided 1200 recorded parameters of flight data and captured the entire incident.

    The crew, who were interviewed on Thursday evening, indicated that they saw the runway prior to reaching the minimum descent altitude before touchdown. Both crewmembers characterized the flight and approach to landing as uneventful prior to the runway overrun. The first officer was the flying pilot.

    The accident docket, which will contain additional factual information, is expected to be opened in 60-90 days. It will be available on the docket section of the NTSB website at http://go.usa.gov/rjR

    PROTOCALS FOR TRANSPORTING AIRCRAFT RECORDERS IN INCIDENT INVESTIGATIONS

    The Safety Board has long-established protocols for the handling and transportation of CVRs and DFDRs that contain recorded information from a commercial aviation incident, which by definition is one where no serious injuries or substantial damage to the aircraft or other property has occurred.

    In such incident investigations, the Safety Board frequently asks the airline involved to transport the recorders on their own aircraft as such an arrangement often provides the most expeditious means of conveying the devices to Safety Board labs in Washington. The airline is instructed to transport the recorders without delay and without accessing the information contained within them by any means. This practice has worked efficiently and without complication for more than 40 years.

    During this incident investigation, the Safety Board learned that the recorders were flown to Tulsa, Okla., where American Airlines technicians downloaded information from the DFDR; the CVR was not accessed by American.

    “Although a thorough examination by our investigators determined that no information from the DFDR was missing or altered in any way, the breach of protocol by American Airlines personnel violates the Safety Board’s standards of conduct for any organization granted party status in an NTSB investigation,” said NTSB Chairman Deborah A.P. Hersman. “Because maintaining and enforcing strict investigative protocols and procedures is vital to the integrity of our investigative processes, we have revoked the party status of American Airlines and excused them from further participation in this incident investigation.”

    American Airlines has assured the Safety Board that a full review of proper procedures and internal controls would be undertaken to ensure that such an occurrence is not repeated.

    Despite their removal from party standing, the NTSB will provide American Airlines with any and all information needed to ensure a timely response to operational safety deficiencies identified in the course of the investigation.

  • SPECIAL AIRWORTHINESS INFORMATION BULLETIN: Main Landing Gear – Tires and Wheels

    SAIB: CE-11-06 Date: December 15, 2010

    Introduction

    SPECIAL AIRWORTHINESS INFORMATION BULLETIN

    SAIB: CE-11-06 Date: December 15, 2010

    This Special Airworthiness Information Bulletin (SAIB) alerts you, registered owners and operators of small airplanes, to follow established safety criteria, guidance, and data when modifying your aircraft with tires that are oversized compared to the original equipment Federal Aviation Administration- (FAA-) approved type design. Oversized tires have been FAA approved by supplemental type certificates (STC) and field approvals on numerous small aircraft types for an assortment of reasons, such as maintaining ground clearance when installing larger propellers or improving landing performance for unique conditions. These oversized tires have customarily been referred to as “Tundra” tires.

    At this time, the FAA has determined that this airworthiness concern is not an unsafe condition that would warrant airworthiness directive (AD) action under Title 14 of the Code of Federal Regulations (14 CFR) part 39. Investigation of a recent accident highlights the need for reminding operators of part 23 certificated airplanes that oversized tire modifications require analysis and substantiation as well as periodic inspections to prevent unsafe conditions. This SAIB reiterates the criteria to apply when evaluating the use of oversized tires and for determining the appropriate requirements to obtain necessary FAA approval.

    Background

    Recently, there was a non-fatal accident involving an Allied Ag Cat Productions, Inc. (Ag-Cat) (also known as Schweizer) Model G-164B airplane (Type Certificate Data Sheet 1A16) equipped with the larger 29×11-10 tires. The aircraft encountered a wheel failure that caused a wheel brake to lock up, which resulted in the aircraft departing the runway, coming to rest in a ditch.

    An investigation determined the likely failure sequence of the accident was due to an initial crack of unknown origin in the inner flange. The weakened flange allowed the larger pressurized tire to fail the flange at the crack. The wheel flange broke into several pieces 360 degrees around the wheel assembly circumference. The broken flange pieces pressed inward by the existing tire/tube pressure, contacted the calipers, and caused the wheel brakes to lock up. The aircraft subsequently left the runway and came to rest in a ditch. The facts provided from the initial on-site investigation were insufficient to determine the precise failure scenario.

    Some G-164B aircraft have been modified with “Geared” Pratt & Whitney R-1340 engines having larger diameter propellers. With the reduced ground clearance these propellers tended to siphon up debris on unimproved airstrips when at flight attitude during take-off, thereby damaging the propellers. To improve ground clearance, some operators replaced the standard 8.50×10 tires with the larger 29×11-10 tires on the original Cleveland Wheel and Brake wheel part number 40-101. This practice subsequently continued with the turbo propeller configured aircraft. The larger tires on the 40-101 wheels reduced the running clearance between the tire sidewalls and the wheel brake calipers.

    1We have not been able to identify a documented FAA approval to install these larger tires on the G-164B aircraft. However, an STC that authorizes the larger tire approval on similar aircraft (Air Tractor) has been issued. This STC has been used by operators and repair stations as a basis for field installations for the G-164B aircraft.

    Recommendations

    All operators of 14 CFR part 21, section 21.25 Restricted Category and 14 CFR part 23 Normal Category certificated airplanes that are currently operating with or may modify their aircraft to operate with oversized tires different from the aircraft’s approved type design, should acquire an STC or field approval supported by FAA-approved data with similar original equipment manufacturer (OEM) restrictions for installation, pressure, etc. before doing so. The approved data should include flight test requirements and their results as well as system design and structural analysis. Guidance for replacing OEM tires with oversized tundra tires is provided in FAA Advisory Circular (AC) AC 23-17B. The AC summarizes the results of flight tests recommended by National Transportation Safety Board and conducted by the FAA for evaluation of tundra tires installed on a Piper PA-18. In addition, the AC provides information of these tires as well as testing of their installation. Although the guidance in the AC is based specifically on the Piper Aircraft, Inc. PA-18, it identifies issues and guidance that can be extended to other airplane types equipped with oversized tires. The AC also identifies the possible performance effects and flight and ground handling characteristics that may be altered with the installation of the tundra tires. Potential propulsion system effects such as unusable fuel may be affected by changes in normal flying attitude. Review of all these potential effects as identified in AC 23-17B should be evaluated.

    Before

    installation of larger tires operators should do the following as a minimum:

    1. Initially inspect wheels for cracks using an industry standard fluorescent penetrant process with annual inspections thereafter.

    2. Install only approved vendor supplied tires. 3. Install new tubes. 4. Determine the appropriate tire pressure for your specific tire, aircraft, and aircraft operations

    in consultation with the approved tire manufacturer and FAA Advisory Circular, AC 23-17B. 5. Check for clearance between the tire and brake components. 6. Check the tire pressure and abnormal wear at 2 week intervals or less.

    Additional safety information to the public of potential problems associated with aircraft with oversized tires is also provided in Safety Alert for Operations (SAFO) 10007, dated 5/24/10. The SAFO provides recommended actions for persons interested in operating aircraft with oversized tundra tires as well as with skis, or wheel/ski installations.

    Owners and operators of Restricted Category and Normal Category airplanes who intend to modify their aircraft with oversized tires should review the above documents for guidance and the issues to consider and evaluate when replacing the manufacturer’s recommended main landing gear wheels and/or tires with oversized replacements.

    For Further Information Contact

    Werner Koch, Aerospace Engineer, FAA, Airplane Certification Office, ASW-150, 2601 Meacham Blvd, Fort Worth, TX 76137; phone: (817) 222-5133; fax: (817) 222-5960; e-mail: werner.g.koch@faa.gov.

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    NTSB Safety Recommendations A-10-159 through -168

    the National Transportation Safety Board recommends that the U.S. Forest Service:

    Develop mission-specific operating standards for firefighter transport operations that include procedures for completing load calculations and verifying that actual aircraft performance matches predicted performance, require adherence to aircraft operating limitations, and detail the specific 14 Code of Federal Regulations Part 135 regulations that are to be complied with by its contractors. (A-10-159)

    Require its contractors to conduct firefighter transport operations in accordance with the mission-specific operating standards specified in Safety Recommendation A-10-159. (A-10-160)

    Create an oversight program that can reliably monitor and ensure that contractors comply with the mission-specific operating requirements specified in Safety Recommendation A-10-159. (A-10-161)

    Provide specific training to inspector pilots on performance calculations and operating procedures for the types of aircraft in which they give evaluations. (A-10-162)

    Require a hover-out-of-ground-effect power check to be performed before every takeoff carrying passengers from helispots in confined areas, pinnacles, and ridgelines. (A-10-163)

    Review and revise policies regarding the type and use of gloves by firefighting personnel during transport operations, including but not limited to, compatibility with passenger restraints and opening emergency exits. (A-10-164) Review and revise your contract requirements for passenger transport by aircraft so that the requirement to install shoulder harnesses on passenger seats provides improved occupant crashworthiness protection consistent with the seat design. (A-10-165)

    Require that helispots have basic weather instrumentation that has the capability to measure wind speed and direction, temperature, and pressure and provide training to helitack personnel in the proper use of this instrumentation. (A-10-166) Modify your standard manifest form to provide a place to record basic weather information and require that this information be recorded for each flight. (A-10-167)

    Require all contracted transport-category helicopters to be equipped with a cockpit voice recorder and a flight data recorder or a cockpit image recorder with the capability of recording cockpit audio, crew communications, and aircraft parametric data. (A-10-168)

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    NTSB SAFETY RECOMMENDATION

    The National Transportation Safety Board recommends that the Federal Aviation Administration:

    Require that the hover performance charts published by helicopter manufacturers reflect the true performance of the helicopter in all conditions for which the charts are applicable, including light and variable wind conditions. (A-10-148)

    Develop and implement a surveillance program specifically for 14 Code of Federal Regulations (CFR) Part 135 operators with aircraft that can operate both as public aircraft and as civil aircraft to maintain continual oversight ensuring compliance with 14 CFR Part 135 requirements. (A-10-149)

    Take appropriate actions to clarify Federal Aviation Administration (FAA) authority over public aircraft, as well as identify and document where such oversight responsibilities reside in the absence of FAA authority. (A-10-150)

    Require the installation of fuel tanks that meet the requirements of 14 Code of Federal Regulations 29.952 on S-61 helicopters that are used for passenger transport. (A-10-151) Require that S-61 helicopters that are used for passenger transport be equipped with passenger seats and seat mounting structures that provide substantial improvement over the requirements of Civil Air Regulations 7.260, such as complying with portions of 14 Code of Federal Regulations 29.561 and 29.562. (A-10-152)

    Require operators of transport-category helicopters to equip all passenger seats with restraints that have an appropriate release mechanism that can be released with minimal difficulty under emergency conditions. (A-10-153)

    Require that Advisory Circular 21-34 be used to evaluate all shoulder harness retrofit installations and to determine that the installations reduce the risk of occupant injury. (A-10-154)

    Require operators of Sikorsky S-61 helicopters with General Electric model CT58-140 engines to install 10-micron airframe fuel filters. (A-10-155)

    Require Carson Helicopters, Inc., to put a conspicuous notification on the title page of the Instructions for Continuing Airworthiness that accompany its supplemental type certificate for installing side-mounted seats indicating that the installation does not provide enhanced occupant protection over that provided by the originally installed seats and meets Civil Air Regulations 7.260 standards. (A-10-156)

    Require all applicants for supplemental type certificate (STC) seat installations in any type of aircraft to put a conspicuous notification on the title page of the Instructions for Continuing Airworthiness that accompany the STC indicating whether the installation provides enhanced occupant protection over that provided by the originally installed seats and the certification standard level met by the seating system. (A-10-157)

    Require supplemental type certificate (STC) applicants to improve the crashworthiness design of the seating system, such as complying with portions of 14 Code of Federal Regulations 29.561 and 29.562, when granting STC approval for older transport-category rotorcraft certificated to Civil Air Regulations 7.260 standards. (A-10-158)

    Also, the National Transportation Safety Board reiterates the following previously issued recommendation to the Federal Aviation Administration:

    Do not permit exemptions or exceptions to the flight recorder regulations that allow transport-category rotorcraft to operate without flight recorders, and withdraw the current exemptions and exceptions that allow transport-category rotorcraft to operate without flight recorders. (A-06-18)

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    NTSB INVESTIGATING TODAY’S JETLINER RUNWAY EXCURSION IN WYOMING

    The National Transportation Safety Board has opened an investigation into an incident in which a passenger jetliner departed the runway while landing at Jackson Hole Airport in Wyoming.

    At about 11:38 am MT today, American Airlines flight 2253, a B-757 (N668AA) inbound from Chicago O’Hare International Airport, ran off the end of runway 19 while landing at Jackson Hole Airport. No injuries were reported among the 181 passengers and crew on board.

    The aircraft came to rest in hard packed snow about 350 feet beyond the runway overrun area. The weather was reported to be snowing at the time of the incident. No damage to the aircraft has been reported.

    Senior NTSB Air Safety Investigator Joseph Sedor has been designated as the Investigator-In-Charge.

    At this time, parties to the investigation are American Airlines, Boeing, the Allied Pilots Association, and the Federal Aviation Administration.

    Improving runway safety has been on the NTSB’s Most Wanted List of Safety Improvements since its inception in 1990: http://go.usa.gov/rTn

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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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    FAA Needs To Improve Risk Assessment Processes For Its Air Transportation Oversight System

    On December 16, 2010, we (the FAA) issued our report on the Federal Aviation Administration’s (FAA) Air Transportation Oversight System (ATOS). FAA uses ATOS to conduct surveillance of nearly 100 airlines that transport more than 90 percent of U.S. airline passenger and cargo traffic. While ATOS is conceptually sound, our prior reports have found that FAA needs to strengthen national oversight of the system. Following safety lapses at a major airline in 2008, the Senate Committee on Science, Commerce, and Transportation and the House Committee on Transportation and Infrastructure asked us to assess weaknesses systemwide. Accordingly, our audit objectives were to determine (1) whether FAA has completed timely ATOS inspections of air carriers’ policies and procedures for their most critical maintenance systems; (2) how effective ATOS performance inspections have been in testing and validating that these critical maintenance systems are working properly; and (3) how well FAA implemented ATOS for the remaining Part 121 air carriers and what, if any, oversight challenges FAA inspection offices face.

    While FAA has worked to continuously improve ATOS, we found that FAA inspectors did not complete ATOS inspections of air carriers’ maintenance policies and procedures or systems performance on time. In addition, FAA transitioned all of its Part 121 inspection offices to ATOS at the end of 2007, but–due in part to training gaps–some inspectors for smaller air carriers had difficulty adapting ATOS to those carriers’ operations. We made seven recommendations to FAA to improve its data, training, and risk assessment processes for ATOS. FAA concurred with four of our seven recommendations and partially concurred with three.

  • 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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    SAFO: Maintenance of Night Vision Imaging Systems (NVIS)

    Purpose: This SAFO alerts operators of aircraft equipped with a Night Vision Imaging System (NVIS) of
    potential deficiencies in the configuration and condition of installed NVIS equipment.

    Background: Recent Federal Aviation Administration (FAA) assessments of NVIS-equipped aircraft have shown that the likelihood of configuration and maintenance problems increases as aircraft continue in service after NVIS modifications. This means that operators of NVIS-equipped aircraft may not be adequately meeting the inspection and maintenance requirements of NVISs.

    The assessment also concluded that operators are installing light-emitting or light-reflecting equipment, which affects the NVIS compatibility of the aircraft, without ensuring that the equipment is properly evaluated.

    Discussion: The FAA’s Aviation Safety (AVS) organization recently directed a nation-wide sampling of NVIS- equipped aircraft. FAA teams, made up of Flight Standards Service (AFS) inspectors and Aircraft Certification Service (AIR) inspectors/engineers, conducted the sampling and discovered that NVIS-equipped aircraft were frequently out of compliance with NVIS requirements for three primary reasons:
    ? Operators installed light-emitting or light-reflecting equipment that caused the aircraft to no longer be properly configured for use with Night Vision Goggles (NVG);
    ? Operators failed to properly maintain the installed NVIS equipment; and
    ? Flightcrews were aware of conditions that reduced the ability to see necessary instruments/equipment during day, night, NVG-aided, or NVG-unaided flights. Another common problem was improperly filtered light-emitting equipment. Flightcrews did not communicate these discrepancies to the maintenance department or maintenance personnel.

    After assessing and analyzing the data collected, the FAA has determined it is likely that other NVIS-equipped aircraft may not be properly configured or maintained for NVG operations. The term night vision device was intended to include all necessary equipment that is installed or modified as part of the entire NVIS, which includes NVGs. Failure to properly maintain an aircraft’s NVIS configuration and equipment can degrade NVG acuity (i.e., blind spots for flight crewmembers using NVG) and prevent the flightcrew from clearly seeing aircraft instrumentation.
    Distributed by: AFS-200 OPR: AFS-300

    Recommended Action: Directors of Maintenance, Directors of Safety, Directors of Operations, Chief Pilots, mechanics, and pilots operating or maintaining NVIS-equipped aircraft should take appropriate action to confirm the following:
    1. Instructions for Continued Airworthiness (ICA) are current, correct, applicable by serial number, and are being properly applied by maintenance departments and personnel. If the ICA has been incorporated into an inspection program, confirm that all the additional ICA requirements are being met;
    2. Installed NVIS equipment are properly maintained;
    3. Maintenance personnel are appropriately trained on the maintenance and inspection of NVIS installations;
    4. Flightcrews fully understand the importance of reporting NVIS-related problems to maintenance personnel;
    5. Aircraft configuration/conformity is periodically checked to ensure that installed NVIS equipment complies with the Supplemental Type Certificate (STC); and
    6. Current and complete data is available to maintenance personnel to support the NVIS equipment.
    NOTE: An aircraft that does not comply with the STC and/or ICA requirements, or that has inoperative or improperly maintained equipment, should not be operated until corrective action has been taken. Operators may use or apply for Minimum Equipment List (MEL) relief as applicable. MEL information is contained in FAA Order 8900.1, Flight Standards Information Management System (FSIMS), Volume 4, Chapter 4, Minimum Equipment Lists (MEL) and Configuration Deviation Lists (CDL), as well as MMEL Policy Letter 127.

    Please visit http://www.faa.gov/aircraft/air_cert/design_approvals/rotorcraft/nvis/ for additional information on NVIS-equipped aircraft.
    Contact: Questions or comments concerning this SAFO can be directed to your Certificate Holding District Office (CHDO).

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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.

  • SAFO: Adverse Levels of Porous Coke for All Engine and Oil Combinations

    A SAFO contains important safety information and may include recommended action. SAFO content should be especially valuable to air carriers in meeting their statutory duty to provide service with the highest possible degree of safety in the public interest. Besides the specific action recommended in a SAFO, an alternative action may be as effective in addressing the safety issue named in the SAFO.

    Subject: Adverse Levels of Porous Coke for All Engine and Oil Combinations

    Purpose: This SAFO provides safety information related to engine problems associated with potentially hazardous porous-coke conditions to airplane operators in general and with emphasis to Title 14 Code of Federal Regulations (14 CFR) part 121 Extended-Range Operations (ETOPS) airplane operators.

    Background: The Federal Aviation Administration (FAA) issued Airworthiness Directive (AD) 2007-02-05 requiring initial and repetitive borescope inspections of the high pressure and intermediate pressure turbine internal and external oil vent tubes for coking and carbon buildup, and cleaning or replacing the vent tubes if necessary. The AD resulted from an incident where an RB211 Trent 700 series turbofan engine had an oil vent tube rupture as a result of blockage, leading to significant loss of engine oil and uncontained engine failure. Contributing to the cause was the absence of measures to adequately monitor and evaluate risk of in service performance of engine/oil combinations.

    Discussion: An engine borescope inspection revealed that the HP/IP turbine bearing chamber internal vent tube was obstructed with porous coke. An airflow check of the vent tube revealed that the air passage was not completely blocked. Although coke formations within oil tubes are not uncommon, the type, amount, and location of the carbon deposits found in the vent tube of the engine were unusual and inconsistent with coke formation seen on other Trent engines or from other service experiences. Investigation revealed that the operator had switched from Mobile jet oil II to MJO 291 after two months of engine in-service operation.

    Recommended Action: Operators should review their Continuous Analysis and Surveillance System (CASS) measures for all engine and oil combinations currently in service, with particular emphasis on the evaluation of airplanes approved for ETOPS with two engines, to determine that they have gathered and evaluated sufficient data, including operational experience and engine hardware disassembly inspection findings, to ensure that these combinations are not at risk of producing potentially hazardous porous-coke conditions. If such data is insufficient, develop and implement appropriate CASS measures, including periodic inspections, to collect and evaluate the necessary data until the risk associated with the presence of porous coke is either ruled out or properly controlled.

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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.

  • 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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    Safety Alert for Operators: 14 CFR, parts 91, 133, and 137 and Helicopter hot fueling/loading

    U.S. Department of Transportation
    Federal Aviation Administration
    SAFO
    Safety Alert for Operators
    SAFO 10020

    Flight Standards Service Washington, DC

    A SAFO contains important safety information and may include recommended action. SAFO content should be especially valuable to air carriers in meeting their statutory duty to provide service with the highest possible degree of safety in the public interest. Besides the specific action recommended in a SAFO, an alternative action may be as effective in addressing the safety issue named in the SAFO.
    Subject: 14 CFR, parts 91, 133, and 137 and hot fueling/loading

    Purpose: This SAFO highlights current guidance and best-practices for Title 14 Code of Federal Regulations (14 CFR) parts 91, 133, and 137 operators that conduct fueling or chemical loading with the engines running (hot fueling/loading).

    Background: On May 30, 2009, a Bell 47G-2 helicopter operating under part 137 was being refueled with the engine running (hot fueling) when the ground crew spilled fuel onto the engine while trying to untangle a kink in the hose. The helicopter quickly caught fire and the pilot sustained serious injuries as a result. Additionally, on September 9, 2008, a Bell 206-B helicopter, operating under part 137, sustained substantial damage while conducting hot fueling and chemical loading simultaneously. After fueling was complete, but with the chemical hose still attached, the ground crew mistakenly gave an “all clear” hand signal to the pilot. As the pilot ascended, the chemical hose caused the helicopter to pitch nose down and roll to the right, contacting the ground.

    Recommended Action: Hot fueling/loading can be extremely hazardous and is not recommended except when absolutely necessary due to the nature of the operation. Operators who conduct hot fueling/loading should develop standard operating procedures (SOP) for flight and ground crew personnel. The operator’s procedures should address the following guidelines:

    • The Federal Aviation Administration (FAA) recommends that hot fueling be conducted only by aircraft utilizing JET A or JET A-1 fuel types. If strict operating procedures are not followed, hot fueling of aircraft utilizing AvGas can be extremely hazardous due to its low flash point. Aircraft being fueled while an engine is operating should have all potential ignition sources located above the fuel inlet port(s) and above fuel vent or tank openings. Sources of ignition include, but are not limited to: engines, exhausts, auxiliary power units (APU), and combustion-type cabin heater exhausts. In accordance with 14 Code of Federal Regulations (14 CFR) section 91.9, hot fueling is not permitted if the Airplane or Rotorcraft Flight Manual contains an associated operating limitation.
    • An appropriately certificated and rated pilot should be at the flight controls during the entire hot fueling/loading process with controls appropriately adjusted to prevent aircraft movement. The pilot should unbuckle all restraints, and be prepared to immediately shut-down the engine and egress the aircraft, if necessary. The pilot should not conduct any extraneous duties during hot fueling/loading. Other personnel should not be on-board the aircraft during hot fueling/loading.
    • Only designated personnel, with proper training in hot fueling/loading operations, should operate fueling or chemical loading equipment. The operator’s written procedures should include: precautions for safe handling of the fuel or chemical, emergency shutoff procedures, fire extinguisher use, hand signal use, and precautions regarding moving propeller and rotor blades.
    • At least two ground personnel should be present during hot fueling/loading. One person conducts the fueling/loading, while the other stands by prepared to activate the fuel/chemical emergency shutoff and handle fire extinguishers if necessary. The aircraft should remain well clear of the fuel source, and at no time should the aircraft wing or helicopter blades extend over the fueling source
    • Before fueling, the aircraft must be bonded to the fuel source to equalize static electricity between the fuel source and the aircraft. Grounding of the aircraft and/or fuel truck is no longer recommended because it does not prevent sparks at the fuel source, and the grounding cable may not be sufficient to discharge the electrical current.
    • All doors, windows, and access points allowing entry to the interior of the aircraft that are adjacent to, or in the immediate vicinity of, the fuel inlet ports should be closed and should remain closed during fueling operations.
    • Fuel should be dispensed into an open port only from approved deadman-type nozzles, with a flow rate not to exceed 10 gallons per minute (38 liters per minute). Close port pressure fueling ports are preferable because the potential for spillage is reduced.
    • A fire extinguisher of an appropriate type and size for the fueling operation must be within easy reach of ground personnel at all times during hot fueling operations. Operators who conduct hot fueling should also equip the aircraft with a fire extinguisher in the cockpit, if possible.
    • When fueling/loading is complete, the pilot must ensure that the seatbelt and shoulder harness are properly re-secured as necessary prior to any aircraft movement.
    • Operators should include this SAFO in initial and recurrent training programs for pilots and ground personnel.

    References:

      ? Aeronautical Information Manual (AIM) – Helicopter Rapid Refueling
      ? AC 00-34A, Aircraft Ground Handling and Servicing
      ? National Fire Prevention Association (NFPA) 407 Standard for Aircraft Fuel Servicing
      ? Include review of this SAFO in initial and recurrent training, and flight reviews.
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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.