The National Transportation Safety Board makes the following recommendation to the Federal Aviation Administration:
Require repetitive inspection of Engine Components, Inc. cylinder assemblies produced between May 2003 and October 2009 (serial numbers 7709 through 52884) installed on Teledyne Continental Motors model 520 and 550 engines and removal of these cylinder assemblies once they reach the engine manufacturer’s recommended normal time (hours) in service between overhauls. (A-12-7)
National Transportation Safety Board
Washington, DC 20594
FOR IMMEDIATE RELEASE: November 24, 2010
SB-10-45
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.
National Transportation Safety Board
Washington, DC 20594
January 6, 2011
The National Transportation Safety Board will hold a public
Board meeting to consider a safety study on the
effectiveness of airbags in general aviation (GA) aircraft.
The NTSB initiated the safety study to 1) examine the
effectiveness of airbags in mitigating occupant injury in a
survivable GA accident, 2) identify any unintended
consequences of airbag deployments, and 3) develop
procedures to assist investigators in documenting airbag
systems in future investigations.
During the course of the study, investigators became aware
of several potential issues that could compromise occupant
safety associated with the use, adjustment and design of
restraint systems. All of these findings will be presented
to the five-Member Board for their consideration.
The meeting will be held on Tuesday, January 11, at 9:30
a.m., in its Board Room and Conference Center, 429 L’Enfant
Plaza, S.W., Washington, D.C.
A live and archived webcast of the proceedings will be
available on the Board’s website at
http://www.ntsb.gov/Events/Boardmeeting.htm. Technical
support details are available under “Board Meetings.” To
report any problems, please call 703-993-3100 and ask for
Webcast Technical Support.
A summary of the safety study, which will include its
findings and safety recommendations, will appear on the
website shortly after the conclusion of the meeting. The
entire study will appear on the website several weeks later.
A twin-engine plane crashed in San Juan Mountains, in the north of Silverton, Colorado, at around 4:15 P.M on September 6.
The immediate cause of Cessna 310 crash is not yet known.
At least 5 people lost their lives in the crash.
San Juan County Sheriff’s office and NTSB are investigating.
Air India Airlines did not single-handedly inspire the newly formed Indian separate body to investigate air accidents, but as the committee was formed immediately after the Air India Express crash in Mangalore that claimed 158 lives, it certainly was a major catalyst. It remains to be seen if the new investigatory committee will be as efficient or reliable as the US’s NTSB/FAA which investigates all major air events in the US and some outside of the US (when requested by foreign agencies or when American pilots, citizens, service or goods are involved).
Certainly the DGCA needs help. We have already pointed out in a prior editorial that the DGCA’s report on the Mangalore crash is overdue. The Times of India quoted the DGCA’s own statutes:
According to Civil Aviation Requirement (CAR) Section 5 (Air Safety), Series C, Part I issued on 13 October 2006, “preliminary report by the inspector of accidents/inquiry officer should be finalized within 10 days of the accident.”
We have also located a source that claims that * all of Air India Express managerial positions are “part-time.” Does this mean that the company was deliberately set up to have no key personnel who can be targeted as decision-makers? Though why should that matter? Air India Express is the budget branch of a larger company; Air India Express is a wholly owned subsidiary of Air India which is now part of National Aviation Company of India Limited (a merger between Air India and Indian Airlines.) Someone is in control.
Those who fly India and have high expectations of the new safety committee being effective may be in for a let down while the newly formed body finds its footing. The new, separate Civil Aviation Safety Advisory Council which has been set up to handle air crashes has no experts from Air Traffic Control (ATC) nor expert pilots. Along with the Directorate General of Civil Aviation (DGCA) chief, Dr Nasim Zaidi, the 28 member body includes Aviation CEOs including Air India Chairman Arvind Jadav, Spicejet CEO Sanjay Aggarwal, managing editor of Centre for Asia Pacific Aviation, Kapil Kaul.
If you take a look at how the NTSB handles an investigation, you will see that a team of experts are engaged and all interested parties, including pilots, are represented, including some you might not expect. Without such input, investigation is a waste of time.
The NTSB team of investigators handle individual aspects of the individual investigation, allocated by expertise. Each expert is responsible for a specific and sometimes overlapping portion of the investigation. Specialization like this helps develop and apply expertise in each area and prevents key points from being overlooked. Also, bear in mind that the experts involved in investigating each crash will differ, depending on the parties involved; and most of these parties are on site within hours of the crash.
SomeAreas of investigation/investigators
Plane manufacturers have their own investigative teams experienced in this type of analysis, and they stand ready to work on any event that needs their expertise. And the investigation is networked so that if and when they need additional specialists, they can tap into their own company resources.
One should note that in the case of the Mangalore Crash investigation, the wreckage sat out in the elements for 50+ days before being collected and warehoused. In my opinion, this is carelessness; and furthermore, this carelessness is just one visible aspect demonstrating where the existing procedures are obviously not up to par. While I am sure that experts combed the wreckage, including Boeing, (they always dispatch a team when one of their planes is in a crash,) leaving the wreckage out in the elements is not a best practice for conservation/preservation of evidence. One can only wonder how all other aspects of procedure including those behind closed doors-stand up to Aviation Industry’s internationally expected best practices.
The industry calls this massive joint investigation the “party system.”
The parties involved include all parties affected. The more parties involved, the faster the investigation may go.
Chairmen of each group make their report; and any groups who discover any failures or unusual effects of machinery make note in the final report given to the primary investigator. The investigator invites the individual groups to provide their angle on what caused the crash and how it might be prevented.
If all the probable causes line up neatly, then it is a simple thing to complete the final report. When theories conflict, the final report takes longer, and tension develops.
All of this information is supposed to remain confidential until the final report is published.
In this “party system,” the various opposing parties tend to keep each other “honest”. Unfounded attempts at blame by one party will be met with rebuttal by another–so it is obvious that if there is no pilot representation in this new committee, pilots may end up the “dumping ground.” Let’s say, for example, that a pilot in a crash went in with bad input like an outdated map. Is this committee set up to pursue the investigation to the source of the bad input? A pilot’s association representative would be instrumental in getting to the cause, whether it might be inadequate training, or materials.
The international community and the people of India are waiting to see how this new committee manages to regulate and oversee all aspects of civil aviation in India, and whether it helps keep India’s DGCA and the safety of India’s aviation systems on track.
* Need separate body to probe air crashes: Patel; Economic Times, The (India), May 25, 2010
NTSB Advisory
National Transportation Safety Board
Washington, DC 20594
February 10, 2011
NTSB SENDING TEAM TO ASSIST IRELAND IN METROLINER INVESTIGATION
The National Transportation Safety Board is sending three investigators to assist the Government of Ireland as it investigates the crash of an airliner this morning.
At about 9:45 a.m. local time today, a Swearingen SA-227 Metroliner (Spanish registration EC-ITP), operated by Flightline/Manx2 Air as flight 7100 from Belfast, Northern Ireland, crashed after attempting a landing at Cork Airport, Cork, Ireland. Twelve people were aboard the aircraft, and there are reports of both fatalities and survivors.
NTSB senior air safety investigator Dan Bower has been designated the U.S. Accredited Representative and is being assisted by an NTSB systems investigator and an NTSB operations investigator. A Federal Aviation Administration investigator is also joining the team.
Information about the progress of the investigation will be released by the Air Accident Investigation Unit of Ireland, +353 (0) 1-604-1293.
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Officials of Reali were not immediately available for comment on the crash of the Learjet 35 on Sunday. It was raining at the time, but not badly; the cause of the crash is unknown.
The private jet can carry up to 10 passengers. The first three victims identified were not passengers.
