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

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    NTSB Directive Contradicts Boeing Statement

    On April 25, the NTSB released information about the April 1 Southwest Airlines Boeing 737-300 fuselage incident where the rupture in the fuselage caused depressurization and forced pilots to make an emergency landing in Yuma.

    From the release

    The NTSB Materials Laboratory work is actively conducting additional inspections and examinations in the following areas:

    1. Removal of rivets and examination of rivet hole dimensions, rivet dimensions, and rivet hole alignment between upper and lower skins.
    2. Detailed fractographic analysis of the skin fractures emanating from the rivet holes using optical and scanning electron microscopes.
    3. Fatigue striation analysis using a scanning electron microscope of specific skin fractures to determine the rate of crack propagation.
    4. Additional portions of the lap joints from the accident aircraft.

    Of 136 airplanes inspected worldwide four had crack indications at a single rivet and one plane was found to have crack indications at two rivets.

    In spite of these findings, Boeing Chief Executive Jim McNerney told Reuters“I think the initial data that I think we’re all seeing is suggesting a possible workmanship issue on an airplane, rather than a design issue across a fleet of airplanes.”

    If Boeing believes that the problem was workmanship on a single plane, then how did other planes reveal conditions precursing the same type of rupture incident as was incurred on Southwest Airlines Flight 812?

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    NTSB Safety Recommendation A-11-7 through -11

    National Transportation Safety Board
    Washington, DC 20594

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

    Require Boeing to develop a method to protect the elevator power control unit input arm assembly on 737-300 through -500 series airplanes from foreign object debris. (A-11-7)

    Once Boeing has developed a method to protect the elevator power control unit input arm assembly on 737-300 through -500 series airplanes from foreign object debris as requested in
    Safety Recommendation A-11-7, require operators to modify their airplanes with this method of protection. (A-11-8)

    Require Boeing to redesign the 737-300 through -500 series airplane elevator control system such that a single-point jam will not restrict the movement of the elevator control system and prevent continued safe flight and landing. (A-11-9)

    Once the 737-300 through -500 series airplane elevator control system is redesigned as requested in Safety Recommendation A-11-9, require operators to implement the new design. (A-11-10)

    Require Boeing to develop recovery strategies (for example, checklists, procedures, or memory items) for pilots of 737 airplanes that do not have a mechanical override feature for a jammed elevator in the event of a full control deflection of the elevator system and incorporate those strategies into pilot guidance. Within those recovery strategies, the consequences of removing all hydraulic power to the airplane as a response to any uncommanded control surface should be clarified. (A-11-11)

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    Taxi and Ground Movement

    NOTICE U.S. DEPARTMENT OF TRANSPORTATION
    FEDERAL AVIATION ADMINISTRATION N JO
    Air Traffic Organization Policy
    Effective Date:
    June 30, 2010
    Cancellation Date:
    March 10, 2011
    SUBJ: Taxi and Ground Movement Operations
    1. Purpose of This Notice. This notice amends Federal Aviation Administration (FAA)Order JO 7110.65, Air Traffic Control, Paragraph 3-7-2, Taxi and Ground Movement Operations, by deleting the phraseology and procedure of issuing “taxi to” when authorizing an aircraft to taxi to an assigned takeoff runway, thus allowing an aircraft to cross all runways/taxiways which the taxi route intersects except the assigned runway.

    2. Audience. This notice applies to the Terminal Services organization and all associated air traffic control facilities.

    3. Where Can I Find This Notice? This notice is available on the MYFAA employee Web site at https://employees.faa.gov/tools_resources/orders_notices/ and on the air traffic publications Web site at http://www.faa.gov/air_traffic/publications.

    4. Explanation of Policy Change. This change establishes the requirement that an explicit runway crossing clearance be issued for each runway (active/inactive or closed) crossing and requires an aircraft/vehicle to have crossed the previous runway before another runway crossing clearance may be issued. At airports where the taxi route between runway centerlines is less than 1,000 feet apart, multiple runway crossings may be issued after receiving approval by the Terminal Services Director of Operations.

    5. Procedures. Change FAA Order JO 7110.65, paragraph 3-7-2, to read as follows:
    3-7-2. TAXI AND GROUND MOVEMENT OPERATIONS Issue the route for the aircraft/vehicle to follow on the movement area in concise and easy to understand terms. The taxi clearance must include the specific route to follow. When a taxi clearance to a runway is issued to an aircraft, confirm the aircraft has the correct runway assignment.
    NOTE-
    1. A pilot’s read back of taxi instructions with the runway assignment can be considered confirmation of runway assignment.
    2. Movement of aircraft/vehicles on nonmovement areas is the responsibility of the pilot, the aircraft operator, or the airport management.
    a. When authorizing an aircraft/vehicle to proceed on the movement area, or to any point other than assigned takeoff runway, specify the route/taxi instructions. If it is the intent to hold the aircraft/vehicle short
    of any given point along the taxi route, issue the route and then state the holding instructions.
    NOTE-
    1. The absence of holding instructions authorizes an aircraft/vehicle to cross all taxiways that intersect the taxi route.
    2. Movement of aircraft/vehicles on nonmovement areas is the responsibility of the pilot, the aircraft operator, or the
    airport management.
    Phraseology, no change.
    06/30/10 N JO 7110.528
    2
    EXAMPLE-
    “Cross Runway Two Eight Left, hold short of Runway Two Eight Right.”
    “Taxi/continue taxiing/proceed to the hangar.”
    “Taxi/continue taxiing/proceed straight ahead then via ramp to the hangar.”
    “Taxi/continue taxiing/proceed on Taxiway Charlie, hold short of Runway Two Seven.”
    or
    “Taxi/continue taxing/proceed on Charlie, hold short of Runway Two Seven.”
    b. When authorizing an aircraft to taxi to an assigned takeoff runway, state the departure runway
    followed by the specific taxi route. Issue hold short restrictions when an aircraft will be required to hold short
    of a runway or other points along the taxi route.
    PHRASEOLOGY-
    “Runway (number) taxi via (route as necessary).”
    or
    “Runway (number) taxi via (route as necessary)(hold short instructions as necessary).”
    EXAMPLE-
    “Runway Three Six Left, taxi via taxiway Alpha, hold short of taxiway Charlie.”
    or
    “Runway Three Six Left, taxi via Alpha, hold short of Charlie.”
    or
    “Runway Three Six Left, taxi via taxiway Alpha, hold short of Runway Two Seven Right.”
    or
    “Runway Three Six Left, taxi via Charlie, cross Runway Two Seven Left, hold short of Runway Two Seven Right.”
    or
    “Runway Three Six Left, taxi via Alpha, Charlie, cross Runway One Zero.”
    c. Aircraft/vehicles must receive a runway crossing clearance for each runway that their taxi route
    crosses. An aircraft/vehicle must have crossed a previous runway before another runway crossing clearance
    may be issued.
    NOTEA
    runway crossing clearance is required to cross or operate on any active/inactive or closed runway.
    EXAMPLE-
    “Cross Runway One Six Left, hold short of Runway One Six Right.”
    06/30/10 N JO 7110.528
    3
    d. When an aircraft/vehicle is instructed to “follow” traffic and requires a runway crossing, issue a
    runway crossing clearance in addition to the follow instructions and/or hold short instructions, as applicable.
    EXAMPLE-
    “Follow (traffic), cross Runway Two Seven Right.”
    or
    “Follow (traffic), cross Runway Two Seven Right, hold short Runway Two Seven Left.”
    e. At those airports where the taxi distance between runway centerlines is less than 1,000 feet, multiple
    runway crossings may be issued with a single clearance. The air traffic manager must submit a request to the
    appropriate Terminal Services Director of Operations for approval before authorizing multiple runway
    crossings.
    REFERENCEFAAO
    JO 7210.3, Para 10-3-10 MULTIPLE RUNWAY CROSSINGS
    Renumber subparagraphs d thru f as f thru h.
    6. Distribution. This notice is distributed to the following Air Traffic Organization (ATO) service
    units: Terminal, En Route and Oceanic, and System Operations Services; the ATO Office of Safety;
    Office of the Service Center; the Air Traffic Safety Oversight Service; the William J. Hughes Technical
    Center; and the Mike Monroney Aeronautical Center.
    7. Background. The FAA Runway Safety Call to Action Committee issued several recommendations
    to address improving runway safety across the NAS. In response to the Committee’s recommendations,
    the ATO convened a Safety Risk Management Panel to evaluate the safety of the Committee
    recommendations. These are two of the recommended changes from the Call to Action Committee.
    Changes will also be made to the AIM and AIP. Title14 Code of Federal Regulations, Part 91.129(i),
    will be changed after the completion of the rulemaking period.

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    Kotaite Lecture on the Future of Aviation Safety

    National Transportation Safety Board Chairman Deborah A. P. Hersman delivered the 8th Annual Assad Kotaite Lecture last evening at the International Civil Aviation Organization (ICAO) Headquarters in Montreal, Quebec, Canada. Hosted by the Montreal Branch of the Royal Aeronautical Society, the annual lecture is a tribute to Dr.Assad Kotaite, former Secretary General of ICAO and President of the Council of ICAO.

    Chairman Hersman’s talk, “Assuring Safety in Aviation’s Second Century,” highlighted the past, present, and future of accident investigation and addressed how accident investigation must adapt to play an even more pivotal rolein creating civil aviation’s safer and stronger future. Citing examples from recent accident investigations, Hersman said that it’s clear that future accident investigations will depend far more on data and cooperation than in the past.

    “While traditional tin-kicking will never go away, it is increasingly being joined by sophisticated data analysis,” Hersman said. “In this era of dynamic growth and greater complexity, data is more important than ever.”

    Hersman applauded the agreement reached last year at the 37th ICAO Assembly to foster data sharing through the creation of the Global Safety Information Exchange. This information can be vital to investigators as they seek to learn what really happened and determine what can be done to
    improve safety.

    “Data and cooperation is how the aviation community will maintain – and enhance – its strong safety record into the second century of powered flight,” Hersman said.

    See Speech Here

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    CAPTAIN’S INAPPROPRIATE ACTIONS LED TO CRASH OF FLIGHT 3407 IN CLARENCE CENTER, NEW YORK, NTSB SAYS

    NTSB PRESS RELEASE

    National Transportation Safety Board
    Washington, DC 20594

    FOR IMMEDIATE RELEASE: February 2, 2010
    SB-10-02

    CAPTAIN’S INAPPROPRIATE ACTIONS LED TO CRASH OF FLIGHT 3407 IN CLARENCE CENTER, NEW YORK, NTSB SAYS

    The National Transportation Safety Board determined that the
    captain of Colgan Air flight 3407 inappropriately responded
    to the activation of the stick shaker, which led to an
    aerodynamic stall from which the airplane did not recover.
    In a report adopted today in a public Board meeting in
    Washington, additional flight crew failures were noted as
    causal to the accident.

    On February 12, 2009, a Colgan Air, Inc., Bombardier DHC-8-
    400, N200WQ, operating as Continental Connection flight
    3407, was on an instrument approach to Buffalo-Niagara
    International Airport, Buffalo, New York, when it crashed
    into a residence in Clarence Center, New York, about 5
    nautical miles northeast of the airport. The 2 pilots, 2
    flight attendants, and 45 passengers aboard the airplane
    were killed, one person on the ground was killed, and the
    airplane was destroyed by impact forces and a postcrash
    fire. The flight was a 14 Code of Federal Regulations (CFR)
    Part 121 scheduled passenger flight from Newark, New Jersey.
    Night visual meteorological conditions prevailed at the
    time of the accident.

    The report states that, when the stick shaker activated to
    warn the flight crew of an impending aerodynamic stall, the
    captain should have responded correctly to the situation by
    pushing forward on the control column. However, the
    captain inappropriately pulled aft on the control column and
    placed the airplane into an accelerated aerodynamic stall.

    Contributing to the cause of the accident were the
    Crewmembers’ failure to recognize the position of the
    low-speed cue on their flight displays, which indicated that
    the stick shaker was about to activate, and their failure to
    adhere to sterile cockpit procedures. Other contributing
    factors were the captain’s failure to effectively manage the
    flight and Colgan Air’s inadequate procedures for airspeed
    selection and management during approaches in icing
    conditions.

    As a result of this accident investigation, the Safety Board
    issued recommendations to the Federal Aviation
    Administration (FAA) regarding strategies to prevent flight
    crew monitoring failures, pilot professionalism, fatigue,
    remedial training, pilot records, stall training, and
    airspeed selection procedures. Additional recommendations
    address FAA’s oversight and use of safety alerts for
    operators to transmit safety-critical information, flight
    operational quality assurance (FOQA) programs, use of
    personal portable electronic devices on the flight deck, and
    weather information provided to pilots.

    At today’s meeting, the Board announced that two issues that
    had been encountered in the Colgan Air investigation would
    be studied at greater length in proceedings later this year.
    The Board will hold a public forum this Spring exploring
    pilot and air traffic control high standards. This
    accident was one in a series of incidents investigated by
    the Board in recent years – including a mid-air collision
    over the Hudson River that raised questions of air traffic
    control vigilance, and the Northwest Airlines incident last
    year where the airliner overflew its destination airport in
    Minneapolis because the pilots were distracted by non-flying
    activities – that have involved air transportation
    professionals deviating from expected levels of performance.
    In addition, this Fall the Board will hold a public forum
    on code sharing, the practice of airlines marketing their
    services to the public while using other companies to
    actually perform the transportation. For example, this
    accident occurred on a Continental Connection flight,
    although the transportation was provided by Colgan Air.

    A summary of the findings of the Board’s report are
    available on the NTSB’s website at:
    http://www.ntsb.gov/Publictn/2010/AAR1001.htm
    -30-

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    NTSB Issues 9 New Safety Recommendations

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

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

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

      To Air Methods Corporation:

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