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NTSB Safety Recommendations A-11-1 through -6

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    NTSB Release: Probable Cause of Denver Runway Accident Cited

    National Transportation Safety Board
    Washington, DC 20594

    FOR IMMEDIATE RELEASE: July 13, 2010

    Lack of Rules Requiring Dissemination of Wind Condition Data and Pilot’s Insufficient Rudder Control Cited as Probablye Cause of 2008 Denver Runway Accident

    Washington, DC – The National Transportation Safety Board today determined that the probable cause of the 2008 Continental Airlines flight 1404 runway excursion accident was the captain’s cessation of rudder input, which was needed to maintain directional control of the airplane, about 4 seconds before the aircraft departed the runway, when the airplane encountered a strong and gusty crosswind that exceeded the captain’s training and experience.

    Contributing to the accident was the air traffic control system that did not require or facilitate the dissemination of key available wind information to air traffic controllers and pilots, and inadequate cross wind training in the airline industry due to deficient simulator wind gust modeling.

    On December 20, 2008, Continental Airlines flight 1404 veered off the left side of runway 34R during a takeoff from Denver International Airport. As a result, the captain initiated a rejected takeoff and the airplane came to rest between runways 34R and 34L. There was a post-crash fire.
    All 110 passengers and 5 crewmembers evacuated the airplane immediately after it came to rest. The captain and five passengers were seriously injured.

    At the time of the accident, mountain wave and downsloping wind conditions existed in the Denver area and the strong localized winds associated with these conditions resulted in pulses of strong wind gusts at the surface that posed a threat to operations at Denver International Airport.

    “This aircraft happened to be in the direct path of a perfect storm of circumstances that resulted in an unexpected excursion in an airport with one of the most sophisticated wind sensing systems in the country,” said NTSB Chairman Deborah A.P. Hersman. “It is critical that pilots receive training to operate aircraft when high wind conditions and significant gusts are present, and that sufficient airport-specific wind information be provided to ATC controllers and pilots as well.”

    As a result of this accident the NTSB issued 14 recommendations to the Federal Aviation Administration regarding mountain waves, wind dissemination to flightcrews, runway selection, pilot training for crosswind takeoffs, and crashworthiness.

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    NTSB INVESTIGATING OPERATIONAL ERROR NEAR NEW YORK

    The National Transportation Safety Board has been investigating an operational error that occurred near New York City in January.

    The Safety Board was notified of a Traffic Collision and Alerting System (TCAS) resolution advisory that occurred due to a near midair collision involving American Airlines flight 951 on January 20, 2011, at about 10:30 p.m. Eastern Standard Time. The American Airlines aircraft, a Boeing 777-200 (N7CA), had taken off from John F. Kennedy International Airport en route to Sao Paulo, Brazil and was flying southeast. A flight of two U.S. Air Force C-17s was heading northwest toward McGuire Air Force Base, New Jersey. There were no injuries in the incident.

    The NTSB has interviewed air traffic controllers on duty at the time of the incident, and is gathering information from American Airlines and the Air Force.

    The air traffic controllers talking to each of the aircraft received conflict alerts, and immediately provided traffic advisories and turned their aircraft to resolve the conflict. In addition, the American Airlines crew responded to directions provided by TCAS. Radar data indicate that the aircraft came within a mile of each other at their closest point. The incident occurred about 80 miles southeast of New York City.

    Betty Koschig has been designated the NTSB’s Investigator-in-Charge for this incident. Further information will be released as it becomes available.

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    DR. EARL F. WEENER SWORN IN AS NTSB MEMBER

    National Transportation Safety Board
    Washington, DC 20594

    FOR IMMEDIATE RELEASE: June 30, 2010
    SB-10-25

    Earl F. Weener, Ph.D., took the oath of office today as a
    Member of the National Transportation Safety Board.

    Dr. Weener is a licensed pilot who has dedicated his entire
    career to the field of aviation safety. He most recently has
    been a consultant and fellow for the Flight Safety
    Foundation, where he worked to reduce accidents through
    coordinated industry programs.

    From 1984 to 1999, Dr. Weener held a series of positions
    with The Boeing Company, including three Chief Engineer
    positions, in Airworthiness, Reliability and
    Maintainability, and Safety; in System Engineering; and in
    Safety Technology Development. He also served four years as
    Boeing’s Manager of Government Affairs.

    He has served as a general aviation flight instructor and
    Part 135 pilot.

    Dr. Weener earned all three of his academic degrees in
    Aerospace Engineering at the University of Michigan – his
    bachelor’s, master’s and doctorate.

    Among his awards are a 1994 Laurel Award from Aviation Week
    and Space Technology magazine and, in 2005, the Honeywell
    Bendix Trophy for Aviation Safety.

    Dr. Weener’s term as a Member of the NTSB expires December
    31, 2015.

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    FAA Release: Speech – “Respect and Consideration”

    “Respect and Consideration”
    Michael Huerta, Indianapolis, IN
    September 15, 2010

    National Black Coalition of FAA Employees National Convention

    Good morning, and thanks for inviting me.

    You’re holding this conference at an important juncture for our society. And you’re holding it in a place that’s been a lightning rod for the very things that are perplexing our nation at this time.

    I’m going to raise some hot button issues today, and I by no means am poising myself as the One Who Holds the Answer. But what I am doing – and what I’m hoping that you’ll do alongside me – is to discuss these issues – the ones that are turning up the heat on the kettle we call America.

    As everybody knows, all last week there was a horrendous display of religious, ethical and cultural intolerance in Florida. No one can say that terrorism is the answer. But burning a holy book – a book held near and dear by millions of Americans – well, that did nothing to bring about healing, much less win an argument. Pouring salt into an open wound is not, in my opinion, the springboard to intelligent discourse.

    Instead of raising a concern, they raised the temperature – put fuel to the fire – agitated – whatever you want to call it.

    And in New York City, we have another situation of equal tension. The plans to build a mosque near Ground Zero have both sides in an uproar.

    So here’s my question to you: we are indeed the land of the free and the home of the brave. We are a land of religious tolerance. We’re a land where equality is supposed to be the law of the land.

    So if all this is true, why is it that we’re having the same argument over and over and over again?

    It comes down to respect. And by “respect,” I mean consideration – thinking about something from someone else’s point of view.

    As far as both of those issues are concerned, I must say that just because you have a right doesn’t make you right; that just because you can, doesn’t mean you should.

    If you remember the movie, you know that this is what caused the problem in Jurassic Park. One of the more memorable lines from the movie was delivered by an eccentric mathematician who thought cloning dinosaurs was a bad idea. He said, “You were so busy wondering whether or not you could create these things that you never stopped to wonder if you should.” In the haste to make a buck – or a statement – they plowed ahead without thinking about long-term consequences. Or maybe even short-term consequences.

    That’s a fictional example, but it fits. We’re talking about something that is scary, and has really, really big teeth. Both sides on these issues – the books and the mosque, not the dinosaurs – are raising points that are at the very core of our freedoms.

    But, and this is unfortunate for us, there’s more time spent slinging mud than there is building a bridge.

    You can build a bridge with brick and mortar, with concrete and steel.

    But the bridge between opposing sides must be built with respect. You must be considerate of what the other person has to say.

    Everyone here who’s faced discrimination of any kind knows this to be true. Screaming an epithet at someone who just screamed one at you is not the answer. But it’s our nature to say, You hurt me, I hurt you. An eye for an eye. A tooth for a tooth.

    All of which leaves you with a bunch of one-eyed guys trying to gum each other to death.

    At the agency, we’re not necessarily facing things that are quite that blatant, but we are indeed in an era of change – not just for our work place, but for the entire NAS. The things that we’ve grown comfortable with, like ground-based radar – well, they’re changing as new technology comes along. We’re obligated to change along with them. We’re obligated to see things from a different perspective.

    There was a time, I’m sure, that the idea of horseless carriages seemed pretty strange. And cable TV? Why on earth would anyone pay for cable when you can get TV for free with an antenna? I’ve heard more than once about moms and grandmas who said, “Don’t even take that microwave oven out of the box. I don’t need it, and I won’t use it. And you shouldn’t either.”

    Those examples make us smile, but there are others in our workplace that grate against the grain. For those of you who are used to filling out the paperwork with an actual piece of paper, you’re butting heads with a new generation that can’t figure out why anyone would use paper when you can do it on-line.

    And what about tracking systems that are leading us to cost accounting? We never had to do that before, why should we do it now? Don’t you trust me? Don’t you think I’m doing my job?

    Those are just a couple of things rolling our way. As we know, in an era where the budget isn’t getting any bigger and the work we’re being asked to do isn’t getting any smaller, well, change is upon us.

    It’s a NextGen workplace, and I’m not just talking about satellites. Randy says, “Be ready for Destination 2025,” and he’s right. It’s time for us to recognize that we must adapt to new scenarios, even ones that make us a little uncomfortable – maybe a lot uncomfortable. If we’re going to provide safe, efficient, secure, environmentally friendly service, there’s no other way. We know that the approach we’ve taken has worked so far, but it is indeed time for a change.

    And just like the larger social issues I raised at the beginning, some of the changes we’ll agree with and some we won’t. Some we’ll like and some we might even despise. But at the core of this must be respect – consideration for co-workers, colleagues, friends, supervisors, managers, even – even someone who works for a different line of business. We laugh at that one, but we’re not going to get to Destination 2025 unless and until we learn to work across organizational boundaries.

    I’m looking to you for the support that will make it happen. The kind of support that ripples through an organization and energizes it. Raising the level of those around you is one of the strong themes I see at this conference, and that is definitely the right way to go, definitely the right thing to do.

    So let me close with this. I know where I stand on these issues, but where I stand is not as important right now as it is for us to remember that what makes us great is that we allow differing opinions, differing views, differences of race and creed; and that while we might not respect the opinion on the other side of the argument, we still have respect for that person.

    This is a time for us to show ourselves for what it is we are supposed to be: the land of the free, and a land big enough to have room for ideas with which we disagree, even ideas that we despise with the very essence of our being.

    Let me close again by saying thank you for the invitation. Thank you for holding a conference where important ideas can be raised. You have my respect and my best wishes for success. Thank you.

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    Press: FAA Issues Cape Wind Determination

    The Federal Aviation Administration (FAA) today issued a “Does Not Exceed (DNE)” determination for the proposed construction of 130 wind turbines in Nantucket Sound.
    The FAA completed an aeronautical study and has determined that the proposed construction of the 130 wind turbines, individually and as a group, has no effect on aeronautical operations. Therefore, the FAA concludes that the project, if constructed as proposed, poses no hazard to air navigation.
    The FAA makes obstruction evaluations based on safety considerations and the available solutions to mitigate potential risks.

    Form 7460-1 for ASN: 2012-WTE-322-OE

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    NTSB IDENTIFIES ORIGIN OF JAL BOEING 787 BATTERY FIRE


    NTSB IDENTIFIES ORIGIN OF JAL BOEING 787 BATTERY FIRE; DESIGN, CERTIFICATION AND MANUFACTURING PROCESSES COME UNDER SCRUTINY
    February 7, 2013
    WASHINGTON – At a news conference today, NTSB Chairman Deborah A.P. Hersman identified the origin of the Jan. 7 battery fire that occurred on a Japan Airlines 787 parked at Boston Logan Airport, and said that a focus of the investigation will be on the design and certification requirements of the battery system.

    “U.S. airlines carry about two million people through the skies safely every day, which has been achieved in large part through design redundancy and layers of defense,” said Hersman. “Our task now is to see if enough – and appropriate – layers of defense and adequate checks were built into the design, certification and manufacturing of this battery.”

    After an exhaustive examination of the JAL lithium-ion battery, which was comprised of eight individual cells, investigators determined that the majority of evidence from the flight data recorder and both thermal and mechanical damage pointed to an initiating event in a single cell. That cell showed multiple signs of short circuiting, leading to a thermal runaway condition, which then cascaded to other cells. Charred battery components indicated that the temperature inside the battery case exceeded 500 degrees Fahrenheit.

    As investigators work to find the cause of the initiating short circuit, they ruled out both mechanical impact damage to the battery and external short circuiting. It was determined that signs of deformation and electrical arcing on the battery case occurred as a result of the battery malfunction and were not related to its cause.

    Chairman Hersman said that potential causes of the initiating short circuit currently being evaluated include battery charging, the design and construction of the battery, and the possibility of defects introduced during the manufacturing process.

    During the 787 certification process, Boeing studied possible failures that could occur within the battery. Those assessments included the likelihood of particular types of failures occurring, as well as the effects they could have on the battery. In tests to validate these assessments, Boeing found no evidence of cell-to-cell propagation or fire, both of which occurred in the JAL event.

    The NTSB learned that as part of the risk assessment Boeing conducted during the certification process, it determined that the likelihood of a smoke emission event from a 787 battery would occur less than once in every 10 million flight hours. Noting that there have been two critical battery events on the 787 fleet with fewer than 100,000 flight hours, Hersman said that “the failure rate was higher than predicted as part of the certification process and the possibility that a short circuit in a single cell could propagate to adjacent cells and result in smoke and fire must be reconsidered.”

    As the investigation continues, which will include testing on some of the batteries that had been replaced after being in service in the 787 fleet, the NTSB will continue to share its findings in real time with the FAA, Boeing, the Japan Transport Safety Board, and the French investigative agency, the Bureau d’Enquêtes et d’Analyses.

    “The decision to return the fleet to flight will be made by the FAA, which underscores the importance of cooperation and coordination between our agencies,” Hersman said.

    She also announced that the NTSB would release an interim report of factual findings within 30 days.

    Additional information, including a video of the today’s media briefing, the PowerPoint presentation, the FAA’s Special Conditions for the B-787 battery system, and related documents, can be accessed at http://go.usa.gov/4K4J.

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