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Gol Goes On and On

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    Cerritos: Aeromexico Shattered Lives

    In George’s Point of View

    It is a strange, sad phenomenon how tragedies live on.

    On August 31, 1986, a Piper and a Douglas DC-9-32 collided over Cerritos California. The Piper, carrying the pilot and two passengers was going from Torrence to Big Bear. They departed Torrence at 11:46. The DC-9 from Mexico City was approaching Los Angeles with 58 passengers and 6 crew aboard. At 11:52 am, the DC-9’s left horizontal stabilizer sheared through the Piper’s cockpit like a can-opener.

    The Piper crashed in the Cerritos Elementary School playground; the DC-9 in a Cerritos neighborhood destroying five houses, damaging seven more and killing an additional 15 on the ground.

    Descriptions of the collision still fill me with horror.

    The accident predates some of the precautionary measures we have now. Now, the Piper would have a Mode C transponder, which would indicate that it was too high, breeching LAX Terminal Control area; LAX was not at that time equipped with automatic warning systems.

    It has been twenty-five years since that accident happened. A memorial ceremony now is being held commemorating the tragedy in the Cerritos Sculpture Garden, and another in Loreto, Mexico. The tragedy is being remembered by at least 30 US families, 20 Mexican families, in at least one home in Colombia, and one in El Salvador. It is being remembered in the neighborhood the wreckage demolished, where families neither need nor want a plaque to remind them of their loss.

    There is a reminder of this crash in every light plane, and every jet. In fact, everyone who flies now, everyone who has flown and not died in a crash owes a debt to the victims of this senseless tragedy, because this was the event that spurred the FAA to require “Mode C” transponders that could report three-dimensional positioning on light aircraft. This was the event that spurred the FAA to require TCAS on airliners.

    I still live to breathe the smoggy air of Los Angeles. And as long as I still have the breath of life, I will remember the day when these 82 souls breathed their last.

    Aviation tragedies shatters lives like broken glass, and there is no lawsuit, no settlement, no “all the kings horses, nor all the kings men” who can ever put families back together again.

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    Tam Air Crash Lawsuit

    A complaint filed by his family on behalf of Ricardo Tazoe, in the U.S. District Court for the Southern District of Florida, also names European jet manufacturer Airbus, the Goodrich Corp, and International Aero Engines (IAE) as defendants. The Miami resident died in an Airbus crash in Sao Paulo.

    198 other people who were killed when the Tam Airbus A320 skidded off a rainy runway at Sao Paulo’s Congonhas Airport.

    TAM is charged with negligence. The plane should have been grounded because one of its thrust reversers was not working. Defendants include Goodrich, the manufacturer of the aircraft’s braking system and IAE, which assembled the plane’s engine.

    “From the evidence gathered so far, it’s clear that TAM knew there were problems with the aircraft,” Steven C. Marks, an attorney at Miami law firm Podhurst Orseck, said in the statement. “Had (the thrust reverser) been operational, it may have prevented this accident.”

    The lawsuit seeks unspecified financial damages.

    IAE is United Technologies Corp. Pratt & Whitney, Britain’s Rolls-Royce Plc, Japan’s Aero Engines Corp. and Germany’s MTU Aero Engones.

    The firm that filed the suit is also representing several families in a suit concerning an earlier crash in the Amazon this year.

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  • DOT: Airworthiness Directives; Airbus Model A330-300, A340-200, A340-300

    [Federal Register: March 26, 2009 (Volume 74, Number 57)]
    [Proposed Rules]
    [Page 13148-13152]
    From the Federal Register Online via GPO Access [wais.access.gpo.gov]
    [DOCID:fr26mr09-30]

    ———————————————————————–

    DEPARTMENT OF TRANSPORTATION

    Federal Aviation Administration

    14 CFR Part 39

    [Docket No. FAA-2009-0264; Directorate Identifier 2008-NM-174-AD]
    RIN 2120-AA64

    Airworthiness Directives; Airbus Model A330-300, A340-200, and
    A340-300 Series Airplanes

    AGENCY: Federal Aviation Administration (FAA), DOT.

    ACTION: Notice of proposed rulemaking (NPRM).

    ———————————————————————–

    SUMMARY: We propose to adopt a new airworthiness directive (AD) for the
    products listed above. This proposed AD results from mandatory
    continuing airworthiness information (MCAI)

    [[Page 13149]]

    originated by an aviation authority of another country to identify and
    correct an unsafe condition on an aviation product. The MCAI describes
    the unsafe condition as:

    One Long Range operator experienced a failure of one spoiler
    servo-control, associated with surface deflection in flight and
    hydraulic leak. On ground, this servo-control Part Number (P/N)
    MZ4306000-02X was found with the maintenance cover broken.
    Investigations showed that the rupture of the maintenance cover was
    due to pressure pulse fatigue.
    * * * The rupture of the maintenance cover in flight may result
    in the deflection of the associated spoiler surface up to the null-
    hinge position (loss of the hydraulic locking). It may also result
    in the loss of the associated hydraulic system (external leakage).
    In the worst case, the three hydraulic systems may be affected,
    which constitutes an unsafe condition.

    * * * * *
    Loss of the three hydraulic systems could result in reduced
    controllability of the airplane. The proposed AD would require actions
    that are intended to address the unsafe condition described in the
    MCAI.

    DATES: We must receive comments on this proposed AD by April 27, 2009.

    ADDRESSES: You may send comments by any of the following methods:
    Federal eRulemaking Portal: Go to http://
    www.regulations.gov. Follow the instructions for submitting comments.
    Fax: (202) 493-2251.
    Mail: U.S. Department of Transportation, Docket
    Operations, M-30, West Building Ground Floor, Room W12-140, 1200 New
    Jersey Avenue, SE., Washington, DC 20590.
    Hand Delivery: U.S. Department of Transportation, Docket
    Operations, M-30, West Building Ground Floor, Room W12-40, 1200 New
    Jersey Avenue, SE., Washington, DC, between 9 a.m. and 5 p.m., Monday
    through Friday, except Federal holidays.
    For service information identified in this proposed AD, contact
    Airbus SAS–Airworthiness Office–EAL, 1 Rond Point Maurice Bellonte,
    31707 Blagnac Cedex, France; telephone +33 5 61 93 36 96; fax +33 5 61
    93 45 80, e-mail airworthiness.A330-A340@airbus.com; Internet http://
    www.airbus.com. You may review copies of the referenced service
    information at the FAA, Transport Airplane Directorate, 1601 Lind
    Avenue, SW., Renton, Washington. For information on the availability of
    this material at the FAA, call 425-227-1221 or 425-227-1152.

    Examining the AD Docket

    You may examine the AD docket on the Internet at http://
    www.regulations.gov; or in person at the Docket Operations office
    between 9 a.m. and 5 p.m., Monday through Friday, except Federal
    holidays. The AD docket contains this proposed AD, the regulatory
    evaluation, any comments received, and other information. The street
    address for the Docket Operations office (telephone (800) 647-5527) is
    in the ADDRESSES section. Comments will be available in the AD docket
    shortly after receipt.

    FOR FURTHER INFORMATION CONTACT: Vladimir Ulyanov, Aerospace Engineer,
    International Branch, ANM-116, Transport Airplane Directorate, FAA,
    1601 Lind Avenue, SW., Renton, Washington 98057-3356; telephone (425)
    227-1138; fax (425) 227-1149.

    SUPPLEMENTARY INFORMATION:

    Comments Invited

    We invite you to send any written relevant data, views, or
    arguments about this proposed AD. Send your comments to an address
    listed under the ADDRESSES section. Include “Docket No. FAA-2009-0264;
    Directorate Identifier 2008-NM-174-AD” at the beginning of your
    comments. We specifically invite comments on the overall regulatory,
    economic, environmental, and energy aspects of this proposed AD. We
    will consider all comments received by the closing date and may amend
    this proposed AD based on those comments.
    We will post all comments we receive, without change, to http://
    www.regulations.gov, including any personal information you provide. We
    will also post a report summarizing each substantive verbal contact we
    receive about this proposed AD.

    Discussion

    The European Aviation Safety Agency (EASA), which is the Technical
    Agent for the Member States of the European Community, has issued EASA
    Airworthiness Directive 2008-0160, dated August 22, 2008 (referred to
    after this as “the MCAI”), to correct an unsafe condition for the
    specified products. The MCAI states:

    One Long Range operator experienced a failure of one spoiler
    servo-control, associated with surface deflection in flight and
    hydraulic leak. On ground, this servo-control Part Number (P/N)
    MZ4306000-02X was found with the maintenance cover broken.
    Investigations showed that the rupture of the maintenance cover was
    due to pressure pulse fatigue.
    The maintenance cover allows switching the servo-control from
    “Operational” to “Maintenance” modes. The same cover is
    installed on all standard MZ spoiler servo-controls except on P/N
    MZ4339390-12 and MZ4306000-12, which have a reinforced maintenance
    cover. The rupture of the maintenance cover in flight may result in
    the deflection of the associated spoiler surface up to the null-
    hinge position (loss of the hydraulic locking). It may also result
    in the loss of the associated hydraulic system (external leakage).
    In the worst case, the three hydraulic systems may be affected,
    which constitutes an unsafe condition.
    For the reasons described above, this EASA AD requires the
    identification and the modification of all standard MZ spoiler
    servo-controls with initial maintenance cover (P/N MZ4339390-01X, –
    02X, -10X for position 1 and P/N MZ4306000-01X, 02X, -10X for
    positions 2 to 6) into standard MZ servo-controls with reinforced
    maintenance cover (P/N MZ4339390-12 for position 1 and P/N
    MZ4306000-12 for positions 2 to 6).

    Loss of the three hydraulic systems could result in reduced
    controllability of the airplane. You may obtain further information by
    examining the MCAI in the AD docket.

    Relevant Service Information

    Airbus has issued the service information described in the
    following table. The actions described in this service information are
    intended to correct the unsafe condition identified in the MCAI.

    Service Information
    ————————————————————————
    Service Bulletin Revision level Date
    ————————————————————————
    Airbus Mandatory Service 01……………. July 25, 2008.
    Bulletin A330-27A3154.
    Airbus Service Bulletin A330-27- 02……………. March 2, 2007.
    3110.
    Airbus Mandatory Service 01……………. July 25, 2008.
    Bulletin A340-27A4154.
    Airbus Service Bulletin A340-27- 01……………. March 2, 2007.
    4115.
    ————————————————————————

    [[Page 13150]]

    FAA’s Determination and Requirements of This Proposed AD

    This product has been approved by the aviation authority of another
    country, and is approved for operation in the United States. Pursuant
    to our bilateral agreement with the State of Design Authority, we have
    been notified of the unsafe condition described in the MCAI and service
    information referenced above. We are proposing this AD because we
    evaluated all pertinent information and determined an unsafe condition
    exists and is likely to exist or develop on other products of the same
    type design.

    Differences Between This AD and the MCAI or Service Information

    We have reviewed the MCAI and related service information and, in
    general, agree with their substance. But we might have found it
    necessary to use different words from those in the MCAI to ensure the
    AD is clear for U.S. operators and is enforceable. In making these
    changes, we do not intend to differ substantively from the information
    provided in the MCAI and related service information.
    We might also have proposed different actions in this AD from those
    in the MCAI in order to follow FAA policies. Any such differences are
    highlighted in a NOTE within the proposed AD.

    Costs of Compliance

    Based on the service information, we estimate that this proposed AD
    would affect 16 products of U.S. registry. We also estimate that it
    would take between 1 work-hour per product to comply with the basic
    requirements of this proposed AD. The average labor rate is $80 per
    work-hour. Based on these figures, we estimate the cost of the proposed
    AD on U.S. operators to be $1,280, or $80 per product.

    Authority for This Rulemaking

    Title 49 of the United States Code specifies the FAA’s authority to
    issue rules on aviation safety. Subtitle I, section 106, describes the
    authority of the FAA Administrator. “Subtitle VII: Aviation
    Programs,” describes in more detail the scope of the Agency’s
    authority.
    We are issuing this rulemaking under the authority described in
    “Subtitle VII, Part A, Subpart III, Section 44701: General
    requirements.” Under that section, Congress charges the FAA with
    promoting safe flight of civil aircraft in air commerce by prescribing
    regulations for practices, methods, and procedures the Administrator
    finds necessary for safety in air commerce. This regulation is within
    the scope of that authority because it addresses an unsafe condition
    that is likely to exist or develop on products identified in this
    rulemaking action.

    Regulatory Findings

    We determined that this proposed AD would not have federalism
    implications under Executive Order 13132. This proposed AD would not
    have a substantial direct effect on the States, on the relationship
    between the national Government and the States, or on the distribution
    of power and responsibilities among the various levels of government.
    For the reasons discussed above, I certify this proposed
    regulation:
    1. Is not a “significant regulatory action” under Executive Order
    12866;
    2. Is not a “significant rule” under the DOT Regulatory Policies
    and Procedures (44 FR 11034, February 26, 1979); and
    3. Will not have a significant economic impact, positive or
    negative, on a substantial number of small entities under the criteria
    of the Regulatory Flexibility Act.
    We prepared a regulatory evaluation of the estimated costs to
    comply with this proposed AD and placed it in the AD docket.

    List of Subjects in 14 CFR Part 39

    Air transportation, Aircraft, Aviation safety, Incorporation by
    reference, Safety.

    The Proposed Amendment

    Accordingly, under the authority delegated to me by the
    Administrator, the FAA proposes to amend 14 CFR part 39 as follows:

    PART 39–AIRWORTHINESS DIRECTIVES

    1. The authority citation for part 39 continues to read as follows:

    Authority: 49 U.S.C. 106(g), 40113, 44701.

    Sec. 39.13 [Amended]

    2. The FAA amends Sec. 39.13 by adding the following new AD:

    Airbus: Docket No. FAA-2009-0264; Directorate Identifier 2008-NM-
    174-AD.

    Comments Due Date

    (a) We must receive comments by April 27, 2009.

    Affected ADs

    (b) None.

    Applicability

    (c) This AD applies to Airbus Model A330-300, A340-200, and
    A340-300 series airplanes; certificated in any category, except
    those identified in paragraph (c)(1) and (c)(2) of this AD.
    (1) Airbus Model A330-301, -302, -303, -321, -322, -323, -341, –
    342, and -343 airplanes, manufacturer serial numbers (MSNs) up to
    and including MSN 588, except those on which Airbus Service Bulletin
    A330-27-3110 has been embodied in service.
    (2) Airbus Model A340-211, -212, -213, -311, -312, and -313
    airplanes, MSNs up to and including MSN 598, except those on which
    Airbus Service Bulletin A340-27-4115 has been embodied in service.

    Subject

    (d) Air Transport Association (ATA) of America Code 27: Flight
    controls.

    Reason

    (e) The mandatory continuing airworthiness information (MCAI)
    states:
    One Long Range operator experienced a failure of one spoiler
    servo-control, associated with surface deflection in flight and
    hydraulic leak. On ground, this servo-control Part Number (P/N)
    MZ4306000-02X was found with the maintenance cover broken.
    Investigations showed that the rupture of the maintenance cover was
    due to pressure pulse fatigue.
    The maintenance cover allows switching the servo-control from
    “Operational” to “Maintenance” modes. The same cover is
    installed on all standard MZ spoiler servo-controls except on P/N
    MZ4339390-12 and MZ4306000-12, which have a reinforced maintenance
    cover. The rupture of the maintenance cover in flight may result in
    the deflection of the associated spoiler surface up to the null-
    hinge position (loss of the hydraulic locking). It may also result
    in the loss of the associated hydraulic system (external leakage).
    In the worst case, the three hydraulic systems may be affected,
    which constitutes an unsafe condition.
    For the reasons described above, this EASA AD requires the
    identification and the modification of all standard MZ spoiler
    servo-controls with initial maintenance cover (P/N MZ4339390-01X, –
    02X, -10X for position 1 and P/N MZ4306000-01X, 02X, -10X for
    positions 2 to 6) into standard MZ servo-controls with reinforced
    maintenance cover (P/N MZ4339390-12 for position 1 and P/N
    MZ4306000-12 for positions 2 to 6).
    Loss of the three hydraulic systems could result in reduced
    controllability of the airplane.

    Actions and Compliance

    (f) Unless already done, do the following actions.
    (1) For airplanes that have accumulated more than 8,500 total
    flight cycles since first flight as of the effective date of this
    AD: Do the actions required by paragraphs (f)(1)(i) and (f)(1)(ii)
    of this AD, as applicable.
    (i) Within 3 months after the effective date of this AD:
    Identify the part number of spoiler servo-controls installed on the
    airplane at all positions in order to determine the number of
    affected hydraulic circuits in accordance with the Accomplishment
    Instructions of Airbus Mandatory Service Bulletin A330-27A3154,
    Revision 01; or Airbus Mandatory Service Bulletin A340-27A4154,
    Revision 01; both dated July 25, 2008, as applicable. If there is no
    spoiler servo-control installed with a part number

    [[Page 13151]]

    identified in Table 1 of this AD, no further action is required by
    this paragraph.
    (ii) If there is any spoiler servo-control installed with a part
    number identified in Table 1 of this AD, do all applicable actions
    required by paragraph (f)(2), (f)(3), or (f)(4) of this AD.

    Table 1–Spoiler Servo-Control Part Numbers
    ————————————————————————
    Position 1 Positions 2 through 6
    ————————————————————————
    MZ4339390-01X……………………….. MZ4306000-01X.
    MZ4339390-02X……………………….. MZ4306000-02X.
    MZ4339390-10X……………………….. MZ4306000-10X.
    ————————————————————————

    (2) If three affected hydraulic circuits are identified during
    the inspection required by paragraph (f)(1) of this AD, do the
    actions required by paragraphs (f)(2)(i), (f)(2)(ii), and
    (f)(2)(iii) of this AD, at the time specified.
    (i) Before the accumulation of 10,400 total flight cycles since
    first flight, or within 3 months after accomplishing the
    requirements of paragraph (f)(1)(i) of this AD, whichever occurs
    later: Modify the affected spoiler servo-controls on one hydraulic
    circuit in accordance with the Accomplishment Instructions of Airbus
    Service Bulletin A330-27-3110, Revision 02; or Airbus Service
    Bulletin A340-27-4115, Revision 01; both dated March 2, 2007, as
    applicable.
    (ii) Before the accumulation of 10,800 total flight cycles since
    first flight, or within 6 months after accomplishing the
    requirements in paragraph (f)(1)(i) of this AD, whichever occurs
    later: Modify the affected spoiler servo-controls on the second
    hydraulic circuit in accordance with the Accomplishment Instructions
    of Airbus Service Bulletin A330-27-3110, Revision 02; or Airbus
    Service Bulletin A340-27-4115, Revision 01; both dated March 2,
    2007, as applicable.
    (iii) Within 18 months after the effective date of this AD:
    Modify the remaining affected spoiler servo-controls in accordance
    with the Accomplishment Instructions of Airbus Service Bulletin
    A330-27-3110, Revision 02; or Airbus Service Bulletin A340-27-4115,
    Revision 01; both dated March 2, 2007, as applicable.
    (3) If two affected hydraulic circuits are identified during the
    inspection required by paragraph (f)(1) of this AD, do the actions
    required by paragraphs (f)(3)(i) and (f)(3)(ii) of this AD, at the
    time specified:
    (i) Before the accumulation of 10,800 total flight cycles since
    first flight, or within 6 months after accomplishing the
    requirements in paragraph (f)(1)(i) of this AD, whichever occurs
    later: Modify the affected spoiler servo-controls on one hydraulic
    circuit in accordance with the Accomplishment Instructions of Airbus
    Service Bulletin A330-27-3110, Revision 02; or Airbus Service
    Bulletin A340-27-4115, Revision 01; both dated March 2, 2007, as
    applicable.
    (ii) Within 18 months after the effective date of this AD:
    Modify the remaining affected spoiler servo-controls in accordance
    with the Accomplishment Instructions of Airbus Service Bulletin
    A330-27-3110, Revision 02; or Airbus Service Bulletin A340-27-4115,
    Revision 01; both dated March 2, 2007, as applicable.
    (4) If one affected hydraulic circuit is identified during the
    inspection required by paragraph (f)(1) of this AD: Within 18 months
    after the effective date of this AD, modify the affected spoiler
    servo-controls in accordance with the Accomplishment Instructions of
    Airbus Service Bulletin A330-27-3110, Revision 02; or Airbus Service
    Bulletin A340-27-4115, Revision 01; both dated March 2, 2007, as
    applicable.
    (5) For airplanes that have accumulated less than or equal to
    8,500 total flight cycles since first flight as of the effective
    date of this AD: Do the actions required by paragraphs (f)(5)(i) and
    (f)(5)(ii) of this AD, as applicable.
    (i) Within 9 months after the effective date of this AD: Do the
    actions specified in paragraph (f)(1)(i) of this AD. If there is no
    spoiler servo-control installed with a part number identified in
    Table 1 of this AD, no further action is required by this paragraph.
    (ii) If there is any spoiler servo-control installed with a part
    number identified in Table 1 of this AD: Within 18 months after the
    effective date of this AD, modify all the affected spoiler servo-
    controls in accordance with the Accomplishment Instructions of
    Airbus Service Bulletin A330-27-3110, Revision 02; or Airbus Service
    Bulletin A340-27-4115, Revision 01; both dated March 2, 2007, as
    applicable.
    (6) As of the effective date of this AD, no person may install
    any spoiler servo-control with a part number identified in Table 1
    of this AD on any aircraft as a replacement part, unless the part
    has been modified in accordance with the Accomplishment Instructions
    of Airbus Service Bulletin A330-27-3110, Revision 02; or Airbus
    Service Bulletin A340-27-4115, Revision 01; both dated March 2,
    2007, as applicable.
    (7) Actions accomplished before the effective date of this AD in
    accordance with the service bulletins specified in Table 2 of this
    AD are considered acceptable for compliance with the corresponding
    requirements of this AD.

    Table 2–Credit Service Information
    ————————————————————————
    Service Bulletin Revision level Date
    ————————————————————————
    Airbus Service Bulletin A330-27- Original………. November 28, 2003.
    3110.
    Airbus Service Bulletin A330-27- 01……………. March 26, 2004.
    3110.
    Airbus Service Bulletin A340-27- Original………. November 28, 2003.
    4115.
    ————————————————————————

    FAA AD Differences

    Note 1: This AD differs from the MCAI and/or service information
    as follows: No differences.

    Other FAA AD Provisions

    (g) The following provisions also apply to this AD:
    (1) Alternative Methods of Compliance (AMOCs): The Manager,
    International Branch, ANM-116, Transport Airplane Directorate, FAA,
    has the authority to approve AMOCs for this AD, if requested using
    the procedures found in 14 CFR 39.19. Send information to ATTN:
    Vladimir Ulyanov, Aerospace Engineer, International Branch, ANM-116,
    Transport Airplane Directorate, FAA, 1601 Lind Avenue, SW., Renton,
    Washington 98057-3356; telephone (425) 227-1138; fax (425) 227-1149.
    Before using any approved AMOC on any airplane to which the AMOC
    applies, notify your principal maintenance inspector (PMI) or
    principal avionics inspector (PAI), as appropriate, or lacking a
    principal inspector, your local Flight Standards District Office.
    (2) Airworthy Product: For any requirement in this AD to obtain
    corrective actions from a manufacturer or other source, use these
    actions if they are FAA-approved. Corrective actions are considered
    FAA-approved if they are approved by the State of Design Authority
    (or their delegated agent). You are required to assure the product
    is airworthy before it is returned to service.
    (3) Reporting Requirements: For any reporting requirement in
    this AD, under the provisions of the Paperwork Reduction Act, the
    Office of Management and Budget (OMB) has approved the information
    collection requirements and has assigned OMB Control Number 2120-
    0056.

    Related Information

    (h) Refer to European Aviation Safety Agency Airworthiness
    Directive 2008-0160, dated August 22, 2008, and the service
    bulletins specified in Table 3 of this AD, for related information.

    Table 3–Service Information
    —————————————————————————————————————-
    Revision
    Service Bulletin level Date
    —————————————————————————————————————-
    Airbus Mandatory Service Bulletin A330-27A3154. 01 July 25, 2008.

    [[Page 13152]]

    Airbus Service Bulletin A330-27-3110……….. 02 March 2, 2007.
    Airbus Mandatory Service Bulletin A340-27A4154. 01 July 25, 2008.
    Airbus Service Bulletin A340-27-4115……….. 01 March 2, 2007.
    —————————————————————————————————————-

    Issued in Renton, Washington, on March 18, 2009.
    Ali Bahrami,
    Manager, Transport Airplane Directorate, Aircraft Certification
    Service.
    [FR Doc. E9-6734 Filed 3-25-09; 8:45 am]

    BILLING CODE 4910-13-P

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  • | | |

    When Lady Luck Turns Away

    Incidents and Accidents.

    Behind every accident, there are many incidents. Accidents may be defined as involving fatalities and incidents as those many smaller events seemingly unconnected from any others. The importance of incidents has gotten little respect but for two obscure references. The industry recognized Heinrich Pyramid says “…. for every accident that causes a major injury, there are 29 accidents that cause minor injuries and 300 accidents that cause no injuries.”

    A 2005 Rand Report drawing attention to NTSB databases said “…(there is) poor control of information, part of resolving more complex accidents depends upon a thorough knowledge of prior incidents, the number of major airline incidents the FAA reported in 1997 was ten times the number of major accidents, (there is) neither oversight nor an emphasis on accuracy in the collection and maintenance of NTSB records, as a result, the accuracy of most of the NTSB data sources was rated as “poor” and although the NTSB does examine a significant number of major incidents, only a small portion of the NTSB’s aviation resources are focused on incident events.”

    Rand report Link >
    http://www.rand.org/content/dam/rand/pubs/monograph_reports/2005/MR1122.pdf

    See page 38 –40.

    Key Public Databases – NTSB and FAA. Gaps Compromising Safety Assessments.

    The NTSB’s most public source of records is the accident/incident database.

    It is cited in the FAA Accident/Incident Data System (AIDS), Airworthiness Directives (ADs), risk/analysis studies, and in DOT/GAO Reports to congress.

    In my various surveys along major safety issues (uncontained engine explosions, un-commanded rudder movements, shutdowns due to engine main bearing failures, or smoke/fire incidents, the NTSB data contains about 20 % of what is found in SDR data or other counterpart investigative agencies.

    Gaps in NTSB data are further compounded by similar gaps in SDR data. From
    1992 to 2002 four NTSB Safety Reccommendation Letters and the GAO had complained of such gaps. In 2010 and regarding data on windshield fires, an article said the “FAA said it was aware of 11 cases of fires in the planes over the past 20 years. However, Boeing has said it is aware of 29 incidents involving fire or smoke over the past eight years.’ Source link >
    http://www.news24.com/World/News/FAA-orders-Boeing-inspection-20100710 – bottom of article.

    1994. In 1994, The Department of Transportation Inspector General reported that between “46 and 98 percent of the data fields of inflight ‘service difficulty’ records are missing data.” From GAO/AIMD-95-27. 02/08/95. Data
    Problems Threaten FAA Strides on Safety Analysis
    Source Link >
    http://www.gao.gov/archive/1995/ai9527.pdf

    From the House Hearing Electrical Safety. (Ref report 106-112, Thursday, October 5, 2000, Testimony of Alexis M. Stefani, assistant IG for auditing), said; “Third, of most concern to us is the health of this SDR system, itself. While the new rule (coding for wire issues) was intended to improve the data in the system, FAA must also insure that the reports that are provided to it are timely, and follow the guidance. We found, however, that the SDR system is not robust, and over the years, it has suffered from budget cuts with staffing going from twelve full-time to three full-time people. Weakness in this system reduces the reliability and usefulness of the data, and can impact FAA’s ability to do trend analysis.”
    Source Link >
    http://commdocs.house.gov/committees/Trans/hpw106-112.000/hpw106-112_1.HTM
    Page 47

    From a June 8, 2006 U.S./Europe International Aviation Safety Conference, FAA’s Flight Standards Service, Jim Ballough.spoke of “FAA’s growing concern over numerous reports of smoke/fumes in cockpit/cabin and that FAA data analysis indicates numerous events not being reported.” Source Link >
    http://www.faa.gov/news/conferences/2006_us_europe_conference/ See ‘Presentation
    ’ by Jim Ballough.
    650 Records Of “Smoke In The Cockpit” A Lack of Concern.

    Gary Stoller at USA Today did a good piece on “smoke in the cockpit”
    reports. Of some 650 records, the FAA/NTSB has but a fraction. The story highlights included; (that the) “issue happens roughly four times a month.

    Some experts say the problem is under-reported. FAA says there is “no safety benefit” to requiring systems to remove cockpit smoke. Smoke in a plane’s cockpit from electrical or other failures is reported an average of four times each month, a USA TODAY analysis finds.” Further that “In-flight fires left unattended “may lead to catastrophic failure and have resulted in the complete loss of airplanes,” the FAA warned. A flight crew “may have as few as 15-20 minutes to get an aircraft on the ground if the crew allows a hidden fire to progress without intervention.” USA Today

    Source http://www.usatoday.com/story/news/nation/2013/10/30/cockpit-smoke-airline-faa/3316429/

    33 records Of Insulation Blankets Fires. – How They Start.

    From my catalog of 78 Records of fire from 1983 to 2012 sourced from the NTSB, AAIB (Danish & UK), French BEA, FAA’s SDR databases, and a few media reports of records of accidents and incidents of fire. There is no central repository. There are 33 records where acoustic insulation (blankets) were specifically mentioned are listed. The issues of self-igniting and flammable wire insulations and of flammable blankets were now are co-mingled.

    Three modes of ignition are seen here: wire shorting/arcing, molten metal sprayed from faulting electrical relays and heating tapes. Most reports lack necessary detail, but seven incidents were seen from wires shorting/arcing.
    Some involved only a few wires; one powering coal closet lights. Molten Metal (spatter) comprised another 8. More importantly, within those reports were references to another 19 (but without details) and that the NTSB said; the relays involved were not “substantially different from the receptacles used on other transport-category airplanes.”

    Ignition from faulting heating tapes/ribbons was seen in another 4 reports – but there were more. In a November 14, 2002 Letter to the FAA, the Canadian Transport Safety Board (TSB) advised that; “heater ribbons are used extensively in transport category aircraft, including Boeing 707, 727, 737, 747, 757 and 767 series and Boeing (Douglas) DC-9, DC-10, and MD-11 aircraft. ” From a TSB report of such fires on 747s and a 767, four other reports were disclosed. The TSB added; “The standard Boeing 767 incorporates 26 heater ribbons. Between June 1985 and June 2002, operators of Boeing aircraft made a total of 67 reports to Boeing of heater ribbon failures where thermal degradation was evident.” From one Delta MD-88 fire in 1999, the NTSB said; “DAL conducted a fleet wide examination of their MD-88/MD-90 fleet to ascertain the condition of their static port heaters. Eight heaters were found with evidence of thermal damage on their wires and or connectors.” There are 8 ADs, and 24 additional SDRs describing burn marks or fire damage. (ref King Survey ‘History Heater Blanket/Tape Fires’.)

    In 2002, the FAA concluded that “in-flight Fires In Hidden Areas are a risk to aviation safety – most hidden fires are caused by electrical problems – non-compliance with Safety Regulations have been uncovered. Fire safety problems and improvements are in various stages of correction and study” and that “it is impossible to predict the relative risk of serious fires occurring in Hidden Areas or Locations”. Source Link >
    http://www.caasd.org/atsrac/meeting_minutes/2002/2002_01_Fire-Safety-in-Hidden-Inaccessible-Areas.pdf

    Dense, Continuous Smoke in the Cockpit.

    In June 2013 a GAO Report to Congress cited but one record of ‘Dense, Continuous Smoke in the Cockpit’ (in 1973). The input came from the NTSB and the FAA. Contrary to that, a Specialist Paper by the Royal Aeronautical Society detailed seven. Only two were in the NTSB databases – but with no mention of ‘continuous smoke.’

    Links > GAO-13-551R, Jun 4, 2013. FAA Oversight of Procedures and Technologies to Prevent and Mitigate the Effects of Dense, Continuous Smoke in the Cockpit.
    http://www.gao.gov/products/GAO-13-551R

    Link > Royal Aeronautical Society – Smoke, Fire and Fumes in Transport Aircraft. Second Edition 2013, Part 1, Past History, Current Risk, And Recommended Mitigations. A Specialist Paper prepared by the Flight
    Operations Group of the Royal Aeronautical Society. March 2013

    http://flightsafety.org/files/RAESSFF.pdf

    In Lady Luck We Trust ? – Those ‘Lucky’ Ground Incidents.
    Often heard whenever the safety of our air transportation system is questioned is that we have an enviable safety record due to the industry, the FAA and the NTSB’s efforts. That is true if only actual deaths are counted.

    This boiler-plate response comes whenever issues of safety are raised, but something else is left unspoken: its conditional nature. It includes just the U.S. carriers, and is based on the records kept. However, there have been no less than 6 events where fires occurred on the ground and caused significant damage, or loss of the airframes. Fire departments intervened in five.

    What if, instead, over 900 lives had been lost over the past 12 years ?
    For example:

    (1) Aug 8, 2000, AirTran DC-9-32 – fire and blistering of aircraft skin, 63 on board.

    (2) Nov 29, 2000, a DC-9-32 by AirTran (97 on board).

    (3) Same Day, Nov 29, 2000, a DC-9-82, American Airlines (66 on board) ,
    blankets burned, emergency evacuation on taxiways – 97 on board”.

    (4) June 28, 2008, ABX 767 freighter burned through the fuselage and was destroyed at the gate, (“The risk of an in-flight fire and the propagation of a fire in those areas is essentially the same whether the airplane is equipped to fly passengers or cargo” says the FAA). Approximate 767 capacity is 190 people.

    (5) July 29 2011, Egypt Air 777, fire erupted and burned a cockpit-widow
    sized hole through the fuselage. Emergency services put the fire out – 291 passengers were evacuated.

    (6) On October 14, 2012, a Corendon Airlines 737-800 had “substantial damage” from fire in the cockpit on the gate. 196 on board were evacuated. Had these fires broken at altitude or during the trans-oceanic crossing, all on board may have been lost.

    For the sum each of these fires found in the NTSB’s accident/incident database, over 900 lives were not lost. A more honest assessment and the credit for this remarkable safety record of no fatalities was not the FAA and industry abilities to manage and ‘mitigate risks’ – but rather the kindness of Lady Luck. But what can happen when lady Luck turns away ?

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    MH17 Crash: Mother of German Victim Sues Ukrainian Government

    Malaysia AirlinesMother of a German victim of the Malaysia Airlines flight MH17 has sued the Ukrainian government for keeping the airspace open during military conflict.

    The MH17, en-route from Amsterdam to Kuala Lumpur, crashed on July 17 in the Ukrainian airspace. It is presumed that the plane crashed after it was shot by a surface-to-air missile fired from Donetsk region of Ukraine. All 298 people aboard the plane were killed in the crash.

    According to media reports, the mother of a German victim has claimed that the government of Ukraine did not close the airspace during military conflict because of millions of dollars which the country makes through foreign commercial flights. She has filed the case in the European Court of Human Rights, asking for about $1 million as a compensation for the suffering she had to endure.

    Renowned German lawyer Elmar Giemula, who is a professor of aviation law, will be presenting the case in court.

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