Official Report

NTSB Advisory
National Transportation Safety Board
Washington, DC 20594

The National Transportation Safety Board is investigating yesterday’s turbulence event experienced by United Airlines Flight #967 (N773UA).

The airplane, a Boeing 777-200, en route from Washington, D.C. (Dulles) to Los Angeles, Calif.(LAX), encountered severe turbulence at approximately 6:14 p.m. (MDT) about 60 miles southeast of Kansas City, Missouri and about 40 miles north of Springfield, Missouri, at approximately 34,000 feet. The aircraft diverted and landed in Denver, Colorado.

The airplane had 255 passengers and 10 crew members onboard. Seventeen passengers and four flight attendants reported minor injuries. Initial reports indicate minor damage to the interior of the cabin.

Information from the flight data recorder was downloaded in Denver and was received at NTSB headquarters today where it will be studied by investigators.

Senior Air Safety Investigator, Bill English, is the Investigator-in-Charge. Mr. English and the NTSB technical experts assisting him will conduct the investigation from the NTSB headquarters in Washington, D.C. and will not travel to the scene.

Crew member, passenger, and weather information will be gathered over the coming days.

The National Transportation Safety Board today dispatched a team to investigate today’s aviation event that occurred at approximately 10:05 a.m. at Reagan National Airport, in Washington, D.C.

A Boeing Stearman ST75 (N27WE) ground looped and then flipped on landing on runway 1.

Senior Aviation Safety Investigator Robert Benzon has been designated as the Investigator-in-Charge.

The National Transportation Safety Board has launched an investigation into the near midair collision of a passenger jetliner and a cargo jumbo jet.

On May 21, 2010, at about 12:10 a.m. Alaska Daylight Savings Time, an Airbus A319, operating as US Airways flight 140, and a Boeing 747-400, operating as Cargolux Airlines International flight 658, came within an estimated 100 feet vertically and a .33 mile lateral separation as the B747 was departing Anchorage International Airport (ANC) and the A319 was executing go-around procedures at ANC.

The A319, with 138 passengers and crew aboard, was inbound from Phoenix (PHX) to runway 14 and the B747, with a crew of 2, was departing Anchorage en route to Chicago (ORD) on runway 25R. The incident occurred in night visual meteorological conditions with 10 miles of visibility.

According to the TCAS report from the A319 crew, that aircraft was approaching ANC when, because of the effects of tailwinds on the aircraft’s approach path, the crew initiated a missed approach and requested new instructions from air traffic control. The tower controller instructed the A319 to turn right heading 300 and report the departing B747 in sight. After the A319 crew reported the B747 in sight, the controller instructed the A319 to maintain visual separation from the B747, climb to 3000 feet, and turn right heading 320. The A319 crew refused the right turn because the turn would have put their flight in direct conflict with the B747. The A319 crew then received a resolution advisory to “monitor vertical speed” and the crew complied with the descent command. During the descent, the A319 crew lost sight of the B747. At about 1700 feet above ground level, the A319 crew received a “clear of conflict” aural command.

There were no reported injuries or damage to either aircraft.

NTSB investigator Dan Bartlett, an air traffic control specialist based in Washington, will be traveling to Anchorage to begin the investigation.

Washington, DC – The National Transportation Safety Board today issued two urgent safety recommendations to the Federal Aviation Administration (FAA). The first recommendation asks that the FAA require operators of aircraft equipped with a particular model engine to immediately perform blade borescope inspections (BSI) of the high pressure turbine rotor at specific intervals until the current turbine disk can be redesigned and replaced with one that can withstand the unbalance vibration forces from the high pressure rotor. The second recommendation asks the FAA to require the engine manufacturer to immediately redesign the disk. The NTSB issued an additional recommendation for a requirement that operators perform a second type of inspection and another recommendation related to the engine manufacturer regarding the installation of the replacement disk.

All four recommendations apply to the low pressure turbine (LPT) stage 3 (S3) rotor disk in the General Electric (GE) CF6-45/50 series turbofan engines that can fail unexpectedly when excited by high-pressure (HP) rotor unbalance.

An uncontained engine event occurs when an engine failure results in fragments of rotating engine parts penetrating and exiting through the engine case. Uncontained turbine engine disk failures within an aircraft engine present a direct hazard to an airplane and its passengers because high-energy disk fragments can penetrate the cabin or fuel tanks, damage flight control surfaces, or sever flammable fluid or hydraulic lines. Engine cases are not designed to contain failed turbine disks. Instead, the risk of uncontained disk failure is mitigated by designating disks as safety-critical parts, defined as the parts of an engine whose failure is likely to present a direct hazard to the aircraft.

In its safety recommendations to the FAA, the NTSB cited four foreign accidents, which the NTSB is either investigating or participating in an investigation led by another nation, in which the aircraft experienced an uncontained engine failure of its GE CF6-45/50 series engine.

The date, location, and circumstances of these four events (none had injuries or fatalities) are as follows:

On July 4, 2008, a Saudi Arabian Airlines (Saudia) Boeing 747-300 experienced an engine failure during initial climb after takeoff from Jeddah, Kingdom of Saudi Arabia. This investigation has been delegated to the NTSB.

On March 26, 2009, an Arrow Cargo McDonnell Douglas DC-10F, about 30 minutes after takeoff from Manaus, Brazil, experienced loss of oil pressure in one engine. The pilots shut down the engine and diverted to Medellin, Columbia. This investigation has been delegated to the NTSB.

On December 17, 2009, a Jett8 Cargo Boeing 747-200F airplane was passing through 7,000 feet above ground level (agl) when the flight crewmembers heard a muffled explosion and immediately applied left rudder. With one engine losing oil pressure, the airplane returned to land at Changi, Singapore. The NTSB is participating in the investigation that is being led by the Air Accident Investigation Bureau of Singapore.

On April 10, 2010, an ACT Cargo Airbus A300B4 experienced an engine failure while accelerating for takeoff at Manama, Bahrain. The crew declared an emergency, rejected the takeoff, activated the fire suppression system, and evacuated the airplane. The NTSB is participating in the investigation that is being led by the Bahrain Ministry of Transportation – Civil Aviation.

The four recommendations to the FAA are as follows:

Immediately require operators of CF6-45/50-powered airplanes to perform high pressure turbine rotor blade borescope inspections every 15 flight cycles until the low pressure turbine stage 3 disk is replaced with a redesigned disk that can withstand the unbalance vibration forces from the high pressure rotor. (Urgent)
Require operators of CF6-45/50-powered airplanes to perform fluorescent penetrant inspections of CF6-45- 50- low pressure turbine stage 3 disks at every engine shop visit until the low pressure turbine stage 3 disk is replaced with a redesigned disk that can withstand the unbalance vibration forces from the high pressure rotor.
Immediately require General Electric Company to redesign the CF6-45/50 low pressure turbine stage 3 disk so that it will not fail when exposed to high pressure rotor unbalance forces. (Urgent)
Once General Electric Company has redesigned the CF6- 45/50 low pressure turbine (LPT) stage 3 disk in accordance with Safety Recommendation [3], require all operators of CF6-45/50-powered airplanes to install the newly designed LPT S3 at the next maintenance opportunity.

The National Transportation Safety Board has launched an
investigation into the near midair collision of a passenger
jetliner and a cargo jumbo jet.

On May 21, 2010, at about 12:10 a.m. Alaska Daylight Savings
Time, an Airbus A319, operating as US Airways flight 140,
and a Boeing 747-400, operating as Cargolux Airlines
International flight 658, came within an estimated 100 feet
vertically and a .33 mile lateral separation as the B747 was
departing Anchorage International Airport (ANC) and the A319
was executing go-around procedures at ANC.

The A319, with 138 passengers and crew aboard, was inbound
from Phoenix (PHX) to runway 14 and the B747, with a crew of
2, was departing Anchorage en route to Chicago (ORD) on
runway 25R. The incident occurred in night visual
meteorological conditions with 10 miles of visibility.

According to the TCAS report from the A319 crew, that
aircraft was approaching ANC when, because of the effects of
tailwinds on the aircraft’s approach path, the crew
initiated a missed approach and requested new instructions
from air traffic control. The tower controller instructed
the A319 to turn right heading 300 and report the departing
B747 in sight. After the A319 crew reported the B747 in
sight, the controller instructed the A319 to maintain visual
separation from the B747, climb to 3000 feet, and turn right
heading 320. The A319 crew refused the right turn because
the turn would have put their flight in direct conflict with
the B747. The A319 crew then received a resolution advisory
to “monitor vertical speed” and the crew complied with the
descent command. During the descent, the A319 crew lost
sight of the B747. At about 1700 feet above ground level,
the A319 crew received a “clear of conflict” aural command.

There were no reported injuries or damage to either
aircraft.

NTSB investigator Dan Bartlett, an air traffic control
specialist based in Washington, will be traveling to
Anchorage to begin the investigation.

A preliminary report of the incident will be available on
the Board’s website within 10 business days.

# # #

Notice Number: NOTC2314
New Automatic Dependent Surveillance – Broadcast (ADS-B) Rule
On May 27, 2010, the FAA published new rules (contained in 14 CFR §92.225 and §91.227) mandating airspace and avionics performance requirements after January 1, 2020. The avionics perform a function that is generally known as “ADS-B Out” which transmits precise location and other information about the aircraft to ground stations and other ADS-B equipped aircraft.

The ADS-B rule mandates ADS-B Out avionics performance when operating within the designated airspace, giving aircraft owners approximately 10 years to equip.

The ADS-B rule, like current transponder operating requirements, requires operators to have ADS-B Out avionics installed and operating in order to fly their aircraft in the busiest airspace, as described below:

Class A, B, and C airspace.

All airspace at and above 10,000 feet MSL (mean sea level) over the 48 contiguous United States and the District of Columbia.

Within 30 nautical miles of airports listed in 14 CFR §91.225, from the surface up to 10,000 feet MSL.

Class E airspace over the Gulf of Mexico from the coastline of the United States out to 12 nautical miles, at and above 3,000 feet MSL.
FAA Technical Service Orders (TSOs) describe the equipment approved for ADS-B operations. The ADS-B rule states that avionics must meet the standards of either TSO-C166b (for 1090ES link equipment) or TSO-C154c (for UAT link equipment). TSO-C166b is required in Class A airspace and either link can be used in all other airspace.

For more information about the FAA’s ADS-B program, visit www.adsb.gov.

The National Transportation Safety Board today issued two
urgent safety recommendations to the Federal Aviation
Administration (FAA). The first recommendation asks that the
FAA require operators of aircraft equipped with a particular
model engine to immediately perform blade borescope
inspections (BSI) of the high pressure turbine rotor at
specific intervals until the current turbine disk can be
redesigned and replaced with one that can withstand the
unbalance vibration forces from the high pressure rotor. The
second recommendation asks the FAA to require the engine
manufacturer to immediately redesign the disk. The NTSB
issued an additional recommendation for a requirement that
operators perform a second type of inspection and another
recommendation related to the engine manufacturer regarding
the installation of the replacement disk.

All four recommendations apply to the low pressure turbine
(LPT) stage 3 (S3) rotor disk in the General Electric (GE)
CF6-45/50 series turbofan engines that can fail unexpectedly
when excited by high-pressure (HP) rotor unbalance.

An uncontained engine event occurs when an engine failure
results in fragments of rotating engine parts penetrating
and exiting through the engine case. Uncontained turbine
engine disk failures within an aircraft engine present a
direct hazard to an airplane and its passengers because
high-energy disk fragments can penetrate the cabin or fuel
tanks, damage flight control surfaces, or sever flammable
fluid or hydraulic lines. Engine cases are not designed to
contain failed turbine disks. Instead, the risk of
uncontained disk failure is mitigated by designating disks
as safety-critical parts, defined as the parts of an engine
whose failure is likely to present a direct hazard to the
aircraft.

In its safety recommendations to the FAA, the NTSB cited
four foreign accidents, which the NTSB is either
investigating or participating in an investigation led by
another nation, in which the aircraft experienced an
uncontained engine failure of its GE CF6-45/50 series
engine.

The date, location, and circumstances of these four events
(none had injuries or fatalities) are as follows:

On July 4, 2008, a Saudi Arabian Airlines (Saudia) Boeing
747-300 experienced an engine failure during initial climb
after takeoff from Jeddah, Kingdom of Saudi Arabia. This
investigation has been delegated to the NTSB.

On March 26, 2009, an Arrow Cargo McDonnell Douglas DC-10F,
about 30 minutes after takeoff from Manaus, Brazil,
experienced loss of oil pressure in one engine. The pilots
shut down the engine and diverted to Medellin, Columbia.
This investigation has been delegated to the NTSB.

On December 17, 2009, a Jett8 Cargo Boeing 747-200F airplane
was passing through 7,000 feet above ground level (agl) when
the flight crewmembers heard a muffled explosion and
immediately applied left rudder. With one engine losing oil
pressure, the airplane returned to land at Changi,
Singapore. The NTSB is participating in the investigation
that is being led by the Air Accident Investigation Bureau
of Singapore.

On April 10, 2010, an ACT Cargo Airbus A300B4 experienced an
engine failure while accelerating for takeoff at Manama,
Bahrain. The crew declared an emergency, rejected the
takeoff, activated the fire suppression system, and
evacuated the airplane. The NTSB is participating in the
investigation that is being led by the Bahrain Ministry of
Transportation – Civil Aviation.

The four recommendations to the FAA are as follows:
1. Immediately require operators of CF6-45/50-powered
airplanes to perform high pressure turbine rotor blade
borescope inspections every 15 flight cycles until the
low pressure turbine stage 3 disk is replaced with a
redesigned disk that can withstand the unbalance
vibration forces from the high pressure rotor.
(Urgent)
2. Require operators of CF6-45/50-powered airplanes to
perform fluorescent penetrant inspections of CF6-45-
50- low pressure turbine stage 3 disks at every engine
shop visit until the low pressure turbine stage 3 disk
is replaced with a redesigned disk that can withstand
the unbalance vibration forces from the high pressure
rotor.
3. Immediately require General Electric Company to
redesign the CF6-45/50 low pressure turbine stage 3
disk so that it will not fail when exposed to high
pressure rotor unbalance forces. (Urgent)
4. Once General Electric Company has redesigned the CF6-
45/50 low pressure turbine (LPT) stage 3 disk in
accordance with Safety Recommendation [3], require all
operators of CF6-45/50-powered airplanes to install
the newly designed LPT S3 at the next maintenance
opportunity.

The National Transportation Safety Board today issued a
Safety Alert to advise parents of the dangers to young
children on aircraft when not restrained in an approved
child restraint system or device. The Safety Alert notes
that preventable injuries and deaths have occurred in
children younger than 2 years who were unrestrained.

Specific child passenger safety issues on aircraft include
the likelihood that parents and caregivers may not be able
to maintain a secure hold on a lap-held child during
turbulence and survivable accidents. Additionally,
unrestrained children have become separated from their
parents during survivable crashes and parents were unable to
locate them during the evacuation.

“As the summer travel season gets underway, the NTSB would
like to remind families traveling with children that child
restraints are the best way to keep youngsters safe –
whether traveling by car or air,” said NTSB Chairman Deborah
A.P. Hersman. “While the NTSB would still like to see a
federal regulation requiring the use of child restraints on
aircraft, we continue to recommend that, when traveling by
air, all parents purchase an airline ticket for every child
in the family and place each child in a size-appropriate
restraint system to ensure that everyone travels safely.”

The National Transportation Safety Board makes the following
recommendations to the Federal Aviation Administration:
Work with the military, manufacturers, and National
Aeronautics and Space Administration to complete the
development of a technology capable of informing pilots
about the continuing operational status of an engine. (A-10-
62)

Once the development of the engine technology has been
completed, as asked for in Safety Recommendation A-10-62,
require the implementation of the technology on transport-
category airplane engines equipped with full-authority
digital engine controls. (A-10-63)

Modify the 14 Code of Federal Regulations 33.76(c) small and
medium flocking bird certification test standard to require
that the test be conducted using the lowest expected fan
speed, instead of 100-percent fan speed, for the minimum
climb rate. (A-10-64)

During the bird-ingestion rulemaking database (BRDB) working
group’s reevaluation of the current engine bird-ingestion
certification regulations, specifically reevaluate the 14
Code of Federal Regulations (CFR) 33.76(d) large flocking
bird certification test standards to determine whether they
should 1) apply to engines with an inlet area of less than
3,875 square inches and 2) include a requirement for engine
core ingestion. If the BRDB working group’s reevaluation
determines that such requirements are needed, incorporate
them into 14 CFR 33.76(d) and require that newly
certificated engines be designed and tested to these
requirements. (A-10-65)

Require manufacturers of turbine-powered aircraft to develop
a checklist and procedure for a dual-engine failure
occurring at a low altitude. (A-10-66)

Once the development of the checklist and procedure for a
dual-engine failure occurring at a low altitude has been
completed, as asked for in Safety Recommendation A-10-66,
require 14 Code of Federal Regulations Part 121, Part 135,
and Part 91 Subpart K operators of turbine-powered aircraft
to implement the checklist and procedure. (A-10-67)

Develop and validate comprehensive guidelines for emergency
and abnormal checklist design and development. The
guidelines should consider the order of critical items in
the checklist (for example, starting the auxiliary power
unit), the use of opt outs or gates to minimize the risk of
flight crewmembers becoming stuck in an inappropriate
checklist or portion of a checklist, the length of the
checklist, the level of detail in the checklist, the time
needed to complete the checklist, and the mental workload of
the flight crew. (A-10-68)

Require 14 Code of Federal Regulations Part 121, Part 135,
and Part 91 Subpart K operators to include a dual-engine
failure scenario occurring at a low altitude in initial and
recurrent ground and simulator training designed to improve
pilots? critical-thinking, task-shedding, decision-making,
and workload-management skills. (A-10-69)

Require 14 Code of Federal Regulations Part 121, Part 135,
and Part 91 Subpart K operators to provide training and
guidance to pilots that inform them about the visual
illusions that can occur when landing on water and that
include approach and touchdown techniques to use during a
ditching, with and without engine power. (A-10-70)

Work with the aviation industry to determine whether
recommended practices and procedures need to be developed
for pilots regarding forced landings without power both on
water and land. (A-10-71)

Require applicants for aircraft certification to demonstrate
that their ditching parameters can be attained without
engine power by pilots without the use of exceptional skill
or strength. (A-10-72)

Require Airbus operators to amend the ditching portion of
the Engine Dual Failure checklist and any other applicable
checklists to include a step to select the ground proximity
warning system and terrain alerts to OFF during the final
descent. (A-10-73)

Require Airbus operators to expand the angle-of-attack-
protection envelope limitations ground-school training to
inform pilots about alpha-protection mode features while in
normal law that can affect the pitch response of the
airplane. (A-10-74)

Require all 14 Code of Federal Regulations Part 139-
certificated airports to conduct wildlife hazard assessments
(WHA) to proactively assess the likelihood of wildlife
strikes, and, if the WHA indicates the need for a wildlife
hazard management plan (WHMP), require the airport to
implement a WHMP into its airport certification manual. (A-
10-75)

Work with the U.S. Department of Agriculture to develop and
implement innovative technologies that can be installed on
aircraft that would reduce the likelihood of a bird strike.
(A-10-76)
Require Airbus to redesign the frame 65 vertical beam on
A318, A319, A320, and A321 series airplanes to lessen the
likelihood that it will intrude into the cabin during a
ditching or gear-up landing and Airbus operators to
incorporate these changes on their airplanes. (A-10-77)

Conduct research to determine the most beneficial passenger
brace position in airplanes with nonbreakover seats
installed. If the research deems it necessary, issue new
guidance material on passenger brace positions. (A-10-78)

Require, on all new and in-service transport-category
airplanes, that cabin safety equipment be stowed in
locations that ensure that life rafts and/or slide/rafts
remain accessible and that sufficient capacity is available
for all occupants after a ditching. (A-10-79)

Require quick-release girts and handholds on all evacuation
slides and ramp/slide combinations. (A-10-80)

Require 14 Code of Federal Regulations Part 121, Part 135,
and Part 91 Subpart K operators to provide information about
life lines, if the airplane is equipped with them, to
passengers to ensure that the life lines can be quickly and
effectively retrieved and used. (A-10-81)

Require that aircraft operated by 14 Code of Federal
Regulations Part 121, Part 135, and Part 91 Subpart K
operators be equipped with flotation seat cushions and life
vests for each occupant on all flights, regardless of the
route. (A-10-82)

Require 14 Code of Federal Regulations Part 121, Part 135,
and Part 91 Subpart K operators to brief passengers on all
flotation equipment installed on an airplane, including a
full demonstration of correct life vest retrieval and
donning procedures, before all flights, regardless of route.
(A-10-83)

Require modifications to life vest stowage compartments or
stowage compartment locations to improve the ability of
passengers to retrieve life vests for all occupants. (A-10-
84)

Revise the life vest performance standards contained in
Technical Standard Order-C13f to ensure that they result in
a life vest that passengers can quickly and correctly don.
(A-10-85)

Conduct research on, and require 14 Code of Federal
Regulations Part 121, Part 135, and Part 91 Subpart K
operators to implement, creative and effective methods of
overcoming passengers? inattention and providing them with
safety information. (A-10-86)