NTSB INVESTIGATING TURBULENCE EVENT OVER MISSOURI

NTSB Holding Family Assistance Symposium
Panel discussions during the March 28-29 event will help the transportation industry, the media, and investigative agencies learn how families are helped after accidents around the world.

The National Transportation Safety Board will hold a two-day conference March 28-29 for family members, transportation accident investigation agencies, transportation industry representatives, government agencies, and the media to discuss family assistance after transportation accidents in an international context. The event coincides with the 15th anniversary of the Aviation Disaster Family Assistance Act and the 10th anniversary of ICAO Circular 285 and will give those who attend the chance to learn firsthand from those involved worldwide in family assistance, according to NTSB.

Day one features four panel discussions and will be webcast. Day two includes training by the NTSB Transportation Disaster Assistance staff, who will give an overview of the NTSB model for family assistance operations.

The tentative agenda shows the panel discussions will be:

Family Members: Perspectives from those affected by accidents, a discussion of their needs, and how those needs are met through family assistance programs.
Transportation industry, vendors, and non-governmental organizations: Responsibilities of the industry, their vendors, and non-governmental organizations.

Government transportation accident investigation agencies: How investigative agencies provide information about accident investigations and their role in family assistance.

Media: How the media report on family members following accidents and how family assistance has affected such reporting.

The event will take place at the NTSB Conference Center, 429 L’Enfant Plaza SW, Washington, DC 20594. Registration is free and is being conducted separately for each day. Visit this page to register and for links to transportation family assistance resources.

Tentative Agenda

Perspectives from Family Members, Industry, Government, and Media

Welcome and Introductions: The Honorable Deborah A.P. Hersman
Commemoration of the 15th Anniversary of the Aviation Disaster Family Assistance Act
Four high-level panel discussions designed to share best practices and lessons learned in the provision of family assistance in transportation accidents internationally.
Family Members: Perspectives from those impacted by accidents, a discussion of their needs, and ways in which those needs are met through family assistance programs.
Transportation industry, vendors, and non-governmental organizations: Perspectives on the responsibilities of the industry, their vendors, and non-governmental organizations in providing assistance.
Government transportation accident investigation agencies: How investigative agencies provide information about the accident investigation and their role in family assistance.
Media: How the media reports on family members following accidents and how family assistance has impacted such reporting.
March 29, 2011

The NTSB Family Assistance Model: An Introduction

NTSB family assistance legislation overview; information flow and timelines; family assistance operations; conducting effective family briefings; personal effects best practices; victim identification concerns; site visits, memorials, anniversaries.

SEE AGENDA

FOR IMMEDIATE RELEASE
April 6, 2010
SB-10-10

POOR MAINTENANCE STARTED ACCIDENT CHAIN THAT RESULTED IN HIGH-SPEED RUNWAY EXCURSION THAT KILLED FOUR IN 2008, NTSB DETERMINES

Washington, DC – A chartered business jet crashed at a South Carolina airport 18 months ago because of the operator’s inadequate maintenance of the airplane’s tires and the decision by the captain to attempt a high-speed rejected takeoff, which went against standard operating procedures and training, the NTSB determined today.

On September 19, 2008, at 11:53 p.m. EDT, a Bombardier Learjet Model 60 (N999LJ) operated by Global Exec Aviation and destined for Van Nuys, California, overran runway 11 during a rejected takeoff at Columbia Metropolitan Airport. After the airplane left the departure end of runway 11, it struck airport lights, crashed through a perimeter fence, crossed a roadway and came to rest on a berm. The captain, the first officer, and two passengers were killed; two other passengers were seriously injured.

The investigation revealed that prior to the accident the aircraft was operated while the main landing gear tires were severely underinflated because of Global Exec Aviation’s inadequate maintenance. The underinflation compromised the integrity of the tires, which led to the failure of all four of the airplane’s main landing gear tires during the takeoff roll.

Shortly after the first tire failed, which occurred about 1.5 seconds after the airplane passed the maximum speed at which the takeoff attempt could be safely aborted, the first officer indicated that the takeoff should be continued but the captain decided to reject the takeoff and deployed the airplane’s thrust reversers. Pilots are trained to avoid attempting to reject a takeoff at high-speed unless the pilot concludes that the airplane is unable to fly; the investigation found no evidence that the accident airplane was uncontrollable or unable to become airborne.

The tire failure during the takeoff roll damaged a sensor, which caused the airplane’s thrust reversers to return to the stowed position. While the captain was trying to stop the airplane by commanding reverse thrust, forward thrust was being provided at near-takeoff power because the thrust reversers were stowed. The Safety Board determined that the inadvertent forward thrust contributed to the severity of the accident.

The Safety Board also found that neither the Federal Aviation Administration nor Learjet adequately reviewed the Airplane’s design after a similar uncommanded forward thrust accident that occurred during landing in Alabama in 2001. While the modifications put into place after the Alabama accident provided additional protection against uncommanded forward thrust upon landing, no such protection was provided for a rejected takeoff.

“This accident chain started with something as basic as inadequate tire inflation and ended in tragedy,” said NTSB Chairman Deborah A.P. Hersman. “This entirely avoidable crash should reinforce to everyone in the aviation community that there are no small maintenance items because every time a plane takes off, lives are on the line.”

The safety recommendations that the NTSB made to the Federal Aviation Administration as a result of this investigation are: provide pilots and maintenance personnel with information on the hazards associated with tire underinflation, including the required intervals for tire pressure checks, and allow pilots to perform pressure checks in air taxi operations to ensure that tires remain safely inflated at all times; require tire pressure monitoring systems for all transport category airplanes; identify and correct deficiencies in both Learjet’s thrust reverser system safety analysis and the FAA’s design certification process to ensure that hazards encountered in all phases of flight are mitigated; require that simulator training for pilots who conduct turbojet operations include opportunities to practice responding to events other than engine failures near takeoff speeds; require that pilots who fly air taxi turbojet operations have a minimum level of pilot operating experience in an airplane type before acting as pilot-in- command in that type; and require that airplane tire testing criteria reflect the loads that may be imposed on tires both during normal operating conditions and after the loss of one tire.

National Transportation Safety Board
Washington, DC 20594
August 6, 2010

NTSB Safety Recommendation A-10-119 and -120
and Reiteration of NTSB Safety Recommendation A-04-63

The National Transportation Safety Board recommends that the European Aviation Safety Agency:

Modify European Aviation Safety Agency Certification Specifications for Large Aeroplanes CS-25 to ensure safe handling qualities in the yaw axis throughout the flight envelope, including limits for rudder pedal sensitivity. (A-10-119)

After the yaw axis certification standard recommended in Safety Recommendation A-10-119 has been established, review the designs of existing airplanes to determine if they meet the standard. For existing airplane designs that do not meet the standard, the European Aviation Safety Agency (EASA) should determine if the airplanes would be adequately protected from the adverse effects of a potential aircraft-pilot coupling (APC) after rudder inputs at all airspeeds. If adequate protection does not exist, EASA should require modifications, as necessary, to provide the airplanes with increased protection from the adverse effects of a potential APC after rudder inputs at high airspeeds. (A-10-
120)

In addition, the National Transportation Safety Board reiterates the following recommendation to the European Aviation Safety Agency:

Review the options for modifying the Airbus A300-600 and the Airbus A310 to provide increased protection from potentially hazardous rudder pedal inputs at high airspeeds and, on the basis of this review, require modifications to the A300-600 and A310 to provide increased protection from potentially hazardous rudder pedal inputs at high airspeeds. (A-04-63

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

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

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

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

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

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

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

PROTOCALS FOR TRANSPORTING AIRCRAFT RECORDERS IN INCIDENT INVESTIGATIONS

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

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

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

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

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

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