NTSB Hudson River Docket Opened

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    NTSB Safety Recommendations A-10-44 and -45

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

    Require repetitive inspections for fatigue cracking of the
    nose landing gear actuator attachment foot areas on all
    Piper PA-46-310 and -350P engine mounts and require
    replacement, if necessary. (A-10-44)

    Require Piper to redesign the PA-46-310 and -350P engine
    mounts so that they are not susceptible to fatigue cracking
    in the attachment foot areas. (A-10-45)

    The National Transportation Safety Board (NTSB) has investigated two accidents involving Piper PA-46-350P airplanes that resulted from fatigue cracking in the attachment between the nose landing gear (NLG) actuator and the engine mount. Such fatigue cracks can lead to the collapse of the NLG, which could cause a serious or catastrophic accident if the separation occurred at a critical point during takeoff or landing or if the aircraft collided with parked aircraft or aircraft waiting at taxiways.

    On August 16, 2009, about 1130 eastern daylight time,1 a Piper PA-46-350P, N548C, experienced an NLG collapse during landing at the Orlando-Sanford International Airport, Sanford, Florida.2 The private pilot and passenger were uninjured, and the airplane sustained substantial damage. No flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 personal flight, nor was one required to be filed by the Federal Aviation Administration (FAA). Visual meteorological conditions (VMC) prevailed at the time of the accident.

    On May 19, 2007, about 1305, a Piper PA-46-350P, N411MD, experienced an NLG collapse during landing at the Indianapolis Metropolitan Airport near Fishers, Indiana.3 The pilot and passenger were uninjured, and the airplane sustained substantial damage. No flight plan was filed for the 14 CFR Part 91 personal flight, nor was one required to be filed by the FAA. VMC prevailed at the time of the accident.

    The NLG actuator on Piper PA-46-350P airplanes is bolted via two attachment feet to the lower aft engine mount, which is constructed of welded tubes (see figure 1). The NLG actuator extends down and forward from the attachment feet and attaches to the NLG. During taxi, takeoff, and landing, the attachment feet transmit loads from the NLG to the engine mount, thus creating repetitive tensile stress in the engine mount attachment feet areas and, in some cases, leading to fatigue cracking.

    Piper PA-46-310 and -350P airplanes have either an original engine mount or a redesigned engine mount (see figure 2).5 In the original design, each attachment foot is a two-piece part consisting of a metal disk welded to the end of a metal tube, which is then welded to the engine mount support tubes. In the redesigned engine mount, each attachment foot is a one-piece machined part made from a single piece of steel, eliminating the welding within the feet themselves. However, on both the original and redesigned engine mounts, the attachment feet are welded to the engine mount support tubes, which is where fatigue cracking has been identified by the NTSB.

    The airplane in the Sanford, Florida, accident was equipped with a redesigned engine mount that was installed at the time of manufacture. The NTSB’s postaccident examination of N548C revealed that the right attachment foot had fractured at the engine mount support tube. The NTSB materials laboratory’s examination of the fractured foot revealed a fatigue crack emanating from multiple origins at the exterior of the joint where the attachment foot was welded to the support tube. At the time of the accident, the airplane was 8 years old and had accumulated 711 flight hours with 878 cycles since new (CSN).

    The airplane in the Fishers, Indiana, accident had a redesigned engine mount that was installed on March 21, 2003. The airplane had accumulated 542 flight hours and an estimated 1,400 cycles since then. At the time of the accident, the airplane was 7 years old and had accumulated a total of 772 flight hours.6 The NTSB’s postaccident examination of N411MD revealed that the right attachment foot had separated from the rest of the engine mount due to fatigue cracking7 where the attachment foot was welded to the support tube.
    The NTSB also notes that a similar incident of fatigue cracking of an NLG attachment foot was found on September 29, 2009, during a routine inspection of a Piper PA-46-350P airplane. The airplane was 5 years old and had accumulated a total of 678 flight hours with 600 CSN and was equipped with the redesigned engine mount.

    On April 22, 2002, Piper issued mandatory Service Bulletin (SB) 1103, recommending that operators of PA-46-310P, -350P, and -500TP8 airplanes inspect the NLG actuator attachment foot area of the original engine mounts for evidence of fatigue cracking. The SB indicated that such cracking had been found in this area of some original engine mounts.

    The inspection included visual and liquid penetrant inspection at the next regular scheduled maintenance event and each 100 hours in service or at the annual inspection, whichever occurred first. If cracks were found, the original engine mounts were to be replaced with the redesigned engine mounts before returning to service. SB 1103 does not subject the airplanes with redesigned engine mounts to repetitive inspections, and replacing the original engine mount with the redesigned engine mount relieves the need for repetitive inspections. Piper issued several inspections.

    The NTSB is concerned that the redesigned engine mounts on Piper P
    A-46-310 and -350P model airplanes have attachment foot areas susceptible to fatigue cracking similar to the fatigue cracks identified by Piper on the original engine mounts. The NTSB concludes that the tensile stresses applied to the redesigned engine mounts could lead to fatigue fractures in the NLG actuator attachment foot areas. However, redesigned engine mounts are not currently subject to the inspection provisions of SB 1103, nor is compliance with SB 1103 required.10 Although the NTSB is not aware of incidents or accidents involving original engine mounts that have not been inspected, the NTSB believes that inspections of the original engine mounts should also be mandatory in order to detect fatigue cracking.

    Therefore, the NTSB recommends that the FAA require repetitive inspections for fatigue cracking of the NLG actuator attachment foot areas on all Piper PA-46-310 and -350P engine mounts and require replacement, if necessary.

    As previously noted, Piper redesigned the engine mounts on the PA-46-310 and -350P in an effort to prevent fatigue cracking at the attachment foot areas. However, based on the accidents discussed above, this redesign does not appear to have been successful since fatigue cracking has also occurred in the redesigned engine mounts. Therefore, the NTSB recommends that the FAA require Piper to redesign the PA-46-310 and -350P engine mounts so that they are not susceptible to fatigue cracking in the attachment foot areas.
    Therefore, the National Transportation Safety Board recommends that the Federal Aviation Administration:

    Require repetitive inspections for fatigue cracking of the nose landing gear actuator attachment foot areas on all Piper PA-46-310 and -350P engine mounts and require replacement, if necessary. (A-10-44)

    Require Piper to redesign the PA-46-310 and -350P engine mounts so that they are not susceptible to fatigue cracking in the attachment foot areas. (A-10-45)

    In response to the recommendations in this letter, please refer to Safety Recommendations A-10-44 and -45. If you would like to submit your response electronically rather than in hard copy, you may send it to the following e-mail address: correspondence@ntsb.gov.

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    NTSB SAFETY RECOMMENDATION

    National Transportation Safety Board
    Washington, DC 20594
    July 30, 2010

    The National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration:

    Conduct research into and document the effects of mountain wave and downslope conditions at airports, such as Denver International Airport, that are located downwind of
    mountainous terrain (including, for example, airports in or near Colorado Springs, Colorado; Anchorage, Alaska; Salt Lake City, Utah; and Reno, Nevada), identify potential
    mountain-wave-related hazards to ground operations at those airports, and disseminate the results to pilots and airport air traffic control personnel to allow for more informed
    runway selection decisions. (A-10-105)

    Archive all low-level windshear alert system (LLWAS) data obtained from Denver International Airport and other airports that experience similar wind conditions and make these data available for additional research and the potential future development of an improved LLWAS algorithm for crosswind and gusty wind alerts on air traffic control tower ribbon display terminals. (A-10-106)

    Modify Federal Aviation Administration Order 7110.65 to require air traffic controllers at airports with multiple sources of wind information to provide pilots with the maximum wind component, including gusts, that the flight could encounter. (A-10-107)

    Review the required documentation for all low-level windshear alert system (LLWAS)-equipped air traffic control towers to ensure that a letter to airmen has been published
    and is easily accessible describing the location and designation of the remote sensors, the capabilities and limitations of the system, and the availability of current LLWAS remote sensor wind information on the request of a pilot, in compliance with Federal Aviation Administration Order 7210.3. (A-10-108)

    Require air traffic control towers to locally develop and implement written runway selection programs that proactively consider current and developing wind conditions and include clearly defined crosswind components, including wind gusts, when considering operational advantage with respect to runway selection. (A-10-109)

    Gather data on surface winds at a sample of major U.S. airports (including Denver International Airport) when high wind conditions and significant gusts are present and use these data to develop realistic, gusty crosswind profiles for use in pilot simulator training programs. (A-10-110)

    Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to incorporate the realistic, gusty crosswind profiles developed as a result of Safety Recommendation A- 10-110 into their pilot simulator training programs. (A-10-111)

    Once realistic, gusty crosswind profiles as asked for in Safety Recommendation A-10-110 are developed, develop a standard methodology, including pilot-in-the-loop testing, for transport-category airplane manufacturers to establish empirically based, type-specific maximum-gusting-crosswind limitations for transport-category airplanes that account for wind gusts. (A-10-112)

    Once a methodology as asked for in Safety Recommendation A- 10-112 has been developed, require manufacturers of transport-category airplanes to develop type-specific, maximum-crosswind takeoff limitations that account for wind gusts. (A-10-113)

    Until the actions described in Safety Recommendation A-10-113 are accomplished, require manufacturers of transport- category airplanes to provide operators with interim crosswind takeoff guidelines that account for wind gusts. (A-10-114)

    Work with U.S. airline operators to review and analyze operational flight data to identify factors that contribute to encounters with excessive winds and use this information to develop and implement additional strategies for reducing the likelihood of wind-related runway excursions. (A-10-115)

    Require cockpit crew seats installed in newly manufactured airplanes that were type certificated before 1988 to meet the crashworthiness standards contained in 14 Code of Federal Regulations 25.562. (A-10-116)

    Require operators to perform periodic inspections on the Burns Aerospace model 2501-5 jumpseats for fatigue cracks within the jumpseat structure and replace the jumpseat if fatigue cracks are found. (A-10-117)

    Require that operators of transport-category airplanes that use galley latches or latch plates secured solely by adhesives that may degrade over time modify the latches to include mechanical fasteners. (A-10-118)

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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.

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    NTSB TO OFFER TRAINING ON EMERGENCY COMMUNICATIONS INVOLVED IN MAJOR AIRCRAFT ACCIDENTS AND INCIDENTS

    National Transportation Safety Board
    Washington, DC 20594

    August 5, 2010

    The National Transportation Safety Board is devoting two
    days at its Training Center to offer guidance to aviation
    public affairs professionals on how to most effectively
    manage emergency communications following a major aircraft
    accident or incident.

    The training will be offered on October 7-8, 2010, at the
    NTSB Training Center in Ashburn, Virginia, (near Washington,
    D.C.) and is aimed at communications professionals working
    with airports, airlines and corporations with aviation
    departments.

    Representatives from the NTSB Office of Public Affairs will
    explain the process by which investigation-related
    information is verified and released to the news media and
    the family members of those affected by a major accident.

    Members of the national news media will be there to discuss
    how previous accidents have been covered and to talk about
    how social media is changing how breaking news is
    disseminated and consumed. Airport and airline
    communications professionals will provide case studies on
    how communications during previous aircraft incidents and
    accidents were handled.

    Those interested in learning more should see the complete
    description of the training, registration information, and
    cost to attend at:
    http://www.ntsb.gov/TC/CourseInfo/PA302_2010.htm

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    CHARLESTON, WEST VIRGINIA RUNWAY OVERRUN

    NTSB TO OPEN PUBLIC DOCKET ON JANUARY 2010 CHARLESTON, WEST VIRGINIA RUNWAY OVERRUN

    As part of the Safety Board’s investigation into the runway overrun at Yeager Airport, Charleston, West Virginia, the NTSB will open the public accident docket on Thursday, April 8, 2010.

    On January 19, 2010, PSA Airlines d.b.a. US Airways Express flight 2495, a Bombardier CL600-2B19, registration N246PS, rejected the takeoff and ran off the end of the runway at Yeager Airport, Charleston, West Virginia. The airplane stopped in the engineered materials arresting system (EMAS).

    There were no injuries to the 31 passengers or 3 crew members onboard and the airplane received minor damage. The flight was operating under the provisions of 14 CFR Part 121 and its intended destination was Charlotte/Douglas International Airport, Charlotte, North Carolina.

    The Transportation Safety Board of Canada has assigned an Accredited Representative to assist the investigation under the provisions of ICAO Annex 13 as the State of the Manufacturer of the airplane.

    The information being released is factual in nature and does not provide any analysis. It will include investigative group factual reports, photographs, and other documents from the investigation. Additional material will 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.

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    NTSB Warns Old Weather Data on Pilot Displays Can Contribute to Plane Crashes

    The NTSB has sent out a safety alert concerning weather information that is up to twenty minutes old, although it may be advertised as real time data. The discrepancy in time can be fatal when weather conditions are in rapid flux. The NTSB has related this old weather information to two recent crashes that occurred at night:

    • March 2010 med-evac helicopter Tennessee crash where the pilot was racing to home base trying to beat a storm
    • December 2011 Piper PA-32 Bryan Texas where the plane broke up in stormy weather.

    In both these crashes, “the time stamps indicated the one-minute time interval used to create the image, and not the actual age of the data used to create the image.”

    The Tennessee crash involved information five minutes old; the Texas crash involved information six to eight minutes old.

    The night crashes in particular are affected by old data. Pilots need to be aware that the data can be old, and not use the weather display to navigate around bad weather.

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