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NTSB SAFETY RECOMMENDATION

National Transportation Safety Board
Washington, DC 20594

July 7, 2011
http://www.ntsb.gov/doclib/recletters/2011/A-11-056-059.pdf
The National Transportation Safety Board makes the following recommendations to the Airborne Law Enforcement Association:

Revise your standards to define pilot rest and ensure that pilots receive protected rest periods that are sufficient to minimize the likelihood of pilot fatigue during aviation operations. (A-11-56)

Revise your accreditation standards to require that all pilots receive training in methods for safely exiting inadvertently encountered instrument meteorological conditions for all aircraft categories in which they operate. (A-11-57)

Encourage your members to install 406-megahertz emergency locator transmitters on all of their aircraft. (A-11-58)

Encourage your members to install flight-tracking equipment on all public aircraft that would allow for near-continuous flight tracking during missions. (A-11-59)

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    NTSB reports on Clear Air Turbulence



    Scheduled 14 CFR Part 121: Air Carrier operation of UNITED AIR LINES INC
    Accident occurred Friday, February 19, 2010 in Anchorage, AK
    Probable Cause Approval Date: 02/23/2017
    Aircraft: BOEING 747, registration: N173UA
    Injuries: 1 Serious, 25 Minor, 236 Uninjured.
    NTSB investigators used data provided by various entities, including, but not limited to, the Federal Aviation Administration and/or the operator and did not travel in support of this investigation to prepare this aircraft accident report.

    On February 19, 2010, about 1452 Alaska standard time (AKST) (2352 UTC), United Airlines flight 897, a Boeing 747-400, N173UA, encountered severe turbulence during cruise descent between FL310 and FL300 about 100 miles west of Anchorage, Alaska. Of the 243 passengers and 19 crew members on board, 17 passengers and eight flight attendants (FA) received minor injuries and one FA received a serious injury. The airplane received minor damaged. The flight was operating under 14 Code of Federal Regulations (CFR) part 121 as a regularly scheduled international passenger flight from Dulles International Airport (IAD), Washington, DC, to Narita International Airport (NRT), Narita, Japan.

    Prior to the turbulence encounter, the flight crew received pilot reports (PIREPs) of moderate to severe turbulence above FL340 and that it was less at FL300. According to the flight crew, about one hour late, the flight began to encounter a few “light bumps” or intermittent light “chop.” The sky conditions were clear with good visibility. The captain turned on the “fasten seat belt” sign and made a public address (PA) announcement to fasten seat belts. The flight crew requested a descent to FL300 and began to encounter moderate turbulence after starting the descent. The first officer then made a PA announcement directing the flight attendants to “take your seats.” The autopilot remained engaged throughout the turbulence encounter, which lasted less than one minute.

    After encountering the turbulence, the crew assessed airplane damage and checked the number and severity of injuries to passengers and crew. The crew was assisted in assessing passenger and crew injuries by a U.S. Army Special Forces medic who stated that all of the injuries were considered minor. All the FAs indicated that they were able to perform their required emergency duties for the remainder of the flight.

    After discussing the injuries and the available diversion airports with the FAs, company dispatch and the medic, the flight crew decided to continue on to NRT since there were sufficient diversion airports along the route if the situation worsened.

    Upon arrival in NRT, 16 passengers and one FA were transported to hospitals for medical evaluation. All were released with only minor injuries, however, the FA was re-evaluated by her personal physician when she returned home with the further diagnosis of a fractured rib.

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    IMPROPER CONTRACTOR ACTIONS AND INSUFFICENT FEDERAL OVERSIGHT LED TO 2008 FATAL FIREFIGHTING HELICOPTER CRASH NEAR WEAVERVILLE, CALIFORNIA, NTSB SAYS

    FOR IMMEDIATE RELEASE:
    December 7, 2010

    The National Transportation Safety Board today determined that a series of improper actions by the contractor and insufficient oversight by the U.S. Forest Service (USFS) and the Federal Aviation Administration (FAA) led to the August 5, 2008, fatal crash of a Sikorsky S-61N helicopter near Weaverville, California. The contractor’s actions included the intentional alteration of weight documents and performance charts and the use of unapproved performance calculations.

    Contributing to the accident was the failure of flight crewmembers to address issues related to operating the helicopter at its maximum performance capability. Contributing to the fatalities and survivors’ injuries were the immediate and intense fire that resulted from fuel spillage from the fuel tanks that were not crash resistant, the separation from the floor of the cabin seats that were not crash resistant, and the use of an inappropriate mechanism on the cabin seat restraints. The pilot-in- command, the safety crewmember, and seven firefighters were fatally injured; the copilot and three firefighters were seriously injured.

    On August 5, 2008, a Sikorsky S-61N helicopter (N612AZ), which was being operated by the USFS as a public flight to transport firefighters battling forest fires, impacted trees and terrain during the initial climb after takeoff at a location about 6,000 feet above sea level in mountainous terrain near Weaverville. The USFS had contracted with Carson Helicopters, Inc. (CHI) of Grants Pass, Oregon, for the services of the helicopter, which was registered to CHI and leased to Carson Helicopter Services, Inc. (CHSI), also of Grants Pass.

    “The probable cause of this accident had to do with Carson’s actions and the oversight entities’ inactions,” said NTSB Chairman Deborah A.P. Hersman. “Carson engaged in a bargain that violated the trust of their crewmembers, the firefighters that they carried onboard, and the aviation industry. But the FAA and the Forest Service did not hold up their end of the deal to oversee Carson’s actions. Public aircraft have been made the orphans of the aviation
    industry. It’s now time for the FAA and other government agencies to step up and take responsibility.”

    In order to prevent similar accidents and to improve the survivability of such accidents when they do occur, the NTSB issued 11 new recommendations to the FAA and reiterated one from 2006. Ten recommendations were issued to the USFS.

    Recommendations to the FAA include oversight of 14 Code of Federal Regulations Part 135 operators with aircraft that can operate part of the time as public aircraft and part of the time as civil, clarification of oversight responsibilities for public aircraft, accuracy of hover performance charts, pilot performance, fuel tank crashworthiness, and occupant protection.

    To the USFS, the NTSB recommended the development of mission-specific operating standards for firefighter transport operations, a requirement that its contractors adhere to these standards, and the creation of an oversight program that can monitor and ensure contractor compliance with all standards and requirements. Other issue areas for the USFS recommendations included pilot training, occupant protection, weather instrumentation, and onboard recorders.

    A synopsis of the NTSB report, including the probable cause conclusions and safety recommendations, will be available on the NTSB website.

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  • NTSB INVESTIGATING NEAR MIDAIR COLLISION OF US AIRWAYS A319 AND CARGOLUX AIRLINES INTERNATIONAL 747 IN ALASKA

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

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

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

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

    There were no reported injuries or damage to either aircraft.

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

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    NTSB ANNOUNCES AGENDA FOR AIRLINE CODE-SHARING SYMPOSIUM

    The National Transportation Safety Board has published the agenda for the symposium on airline code-sharing, which will take place on October 26-27 in the NTSB Board Room and Conference Center (429 L’Enfant Plaza, SW, Washington, DC 20594). The symposium is open to all and free to attend (there is no registration). The event will also be webcast live on www.ntsb.gov.

    A description of the symposium, a detailed agenda, and biographies of the presenters, panelists and moderator are all available at http://go.usa.gov/aZ6

    The media advisory announcing the symposium is available athttp://go.usa.gov/aZF

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