News
01 DEC - ATSB action to be taken against accident operator for failing to report safety i 02 DEC - Irish AAIU: serious incident due to non-briefed and non-configured approach
04 DEC - NTSB releases report on Afghanistan CASA 212 CFIT accident
05 DEC - Aviation groups issue safety plan to ICAO
05 DEC - Romanian plane hits horse on takeoff
06 DEC - TSB Report: Canadian Caravan crash at Winnipeg due to in-flight icing
07 DEC - NTSB urges airlines to change runway stopping calculations
08 DEC - Near collision with equipment on runway - Boeing 737-800 at Manchester
12 DEC - NTSB issues safety recommendations in wake of Lexington crash
13 DEC - AAIB issues Special Bulletin on Airbus 319 generator problems
13 DEC - EU gives Bulgarian airlines three more months for safety comliancy
20 DEC - Nigeria may sanction Sosoliso over alleged certificate forgery
21 DEC - Swiss BFU report issued on airprox near Zurich
25 DEC - Lion Air Boeing 737 skidds off runway at Makassar
01 DEC 2006 ATSB action to be taken against accident operator for failing to report safety i [to table of contents]
The ATSB has announced that it will refer Lessbrook Pty Ltd to the Director of Public Prosecutions for its failure over several years to report aviation safety occurrences to the bureau as required by legislation. Lessbrook Pty Ltd operates under the name Transair and was the operator of the aircraft in which two pilots and 13 passengers lost their lives on 7 May 2005. Despite the accident, it is only in recent weeks that Lessbrook has provided the Australian Transport Safety Bureau with evidence which our analysis has shown includes 25 safety incidents which should have been reported immediately or within 72 hours depending on their severity. The unreported occurrences include 7 immediately reportable matters (IRMs) that occurred between 1 July 2003 and the accident. They include a gear failure on departure from Bamaga, a cabin pressurisation warning near Cairns, a burning smell near Inverell, and a problem with flaps leading to a flapless takeoff and associated flight issues from Gunnedah to Sydney. Under the Transport Safety Investigation Act 2003 (TSI Act) and Regulations such IRMs must be reported immediately by responsible persons (eg the airline operator) in accordance with the regulations and failure to do so has a maximum penalty of imprisonment for six months (Section 18 of the TSI Act). Failure to report the more routine matters or to make a written report of IRMs carries a maximum penalty of 60 penalty units, a very steep fine.
While in accordance with international requirements and domestic law, ATSB investigations do not seek to assign blame or liability, a serious breach of the TSI Act with respect to the investigations or reporting requires action to deter people from failing to comply with its safety objectives.
The failure to report these occurrences, which were reported by relevant pilots to the operator, is indicative of a poor safety culture and poor safety system within the operator. However, the reports are a separate safety issue compared with the fatal accident. (ATSB)
Media Release
On March 26, 2006 a Ryanair Boeing 737-800 (EI-DHX) was involved in a serious incident at Knock, Ireland. This was precipitated by both pilot`s becoming involved in manually programming the FMC during descent, thus diverting their attention from safety-critical tasks contrary to the Operator`s SOP`s and leading to a non-briefed and non-configured high speed approach to RWY 27, followed by a non-procedural overshoot from a height of just 400 ft AGL. (AAIU)
AAIU Report No 2006-028
04 DEC 2006 NTSB releases report on Afghanistan CASA 212 CFIT accident [to table of contents] The NTSB concluded that the probable cause of the November 2004 CFIT accident involving a CASA 212 was: "The captain`s inappropriate decision to fly a nonstandard route and his failure to maintain adequate terrain clearance, which resulted in the inflight collision with mountainous terrain. Factors were the operator`s failure to require its flight crews to file and to fly a defined route of flight, the operator`s failure to ensure that the flight crews adhered to company policies and FAA and DoD Federal safety regulations, and the lack of in-country oversight by the FAA and the DoD of the operator. Contributing to the death of one of the passengers was the operator`s lack of flight-locating procedures and its failure to adequately mitigate the limited communications capability at remote sites." (NTSB)
NTSB/AAB-06/07
05 DEC 2006 Aviation groups issue safety plan to ICAO [to table of contents] The ICAO took delivery of the second and final part of a Global Aviation Safety Roadmap developed by members of the air transport industry, in consultation with ICAO safety specialists, and designed to establish one level of aviation safety worldwide. This marks the first time that governments and industry have jointly developed a unified and coordinated approach to reducing accident rates, particularly in developing regions of the world, in accordance with ICAO’s Global Aviation Safety Plan. (ICAO)
Implementing the Global Aviation Safety Roadmap - report (PDF)
05 DEC 2006 Romanian plane hits horse on takeoff [to table of contents] A Saab 2000 operated by Carpatair struck a horse on take-off from Bacau airport, Romania. The airplane continued to its destination Timisoara where a fly-by was made to allow a visual inspection of the landing gear. No problems were noted and a safe landing was made. It appears that three horses had wandered onto the runway at Bacau. (Adevarul OnLine) 06 DEC 2006 TSB Report: Canadian Caravan crash at Winnipeg due to in-flight icing [to table of contents]
The Transportation Safety Board of Canada (TSB) released its final investigation report into the fatal accident that occurred in Winnipeg, on October 6, 2005 involving a Cessna 208 Caravan. Although the aircraft took off clean, the performance diminished as ice built up on its critical surfaces. While encouraged that significant safety actions have been taken by regulatory authorities to date, the Board believes that it would be safer still if Cessna 208 pilots never take off or continue flight into anything more than light icing. (TSB)
Media Release
07 DEC 2006 NTSB urges airlines to change runway stopping calculations [to table of contents] The NTSB is urging airlines to voluntarily adopt changes in the way they calculate stopping distances on contaminated runways, in accordance with Federal Aviation Administration (FAA) guidance issued in response to an urgent NTSB recommendation. (NTSB)
press release
08 DEC 2006 Near collision with equipment on runway - Boeing 737-800 at Manchester [to table of contents] Investigation report released on the July 2003 serious incident at Manchester, UK: G-XLAG with seven crew and 190 passengers on board, was undertaking a flight from Manchester Airport to Kos, Greece. Runway 06L was in use but the flight crew were not aware that this runway was being operated at reduced length. This was due to work-in-progress to remove rubber deposits at the far end of the runway, which was out of sight from the 06L threshold end as the runway was built over a slight rise in the ground. Due to a difference in interpretation of information passed between Air Traffic Control (ATC) and the flight crew, the aircraft entered the runway from holding point AG, rather than the expected holding point A, and the takeoff was conducted using a reduced thrust setting calculated for the assumed normal runway length. As the aircraft passed the crest of the runway, the flight crew became aware of vehicles at its far end but, as they were now close to their rotation speed, they continued and carried out a normal takeoff. The aircraft passed within 56 ft of a 14 ft high vehicle. (AAIB)
AAIB AAR 03/2006
12 DEC 2006 NTSB issues safety recommendations in wake of Lexington crash [to table of contents] The National Transportation Safety Board recommends that the Federal Aviation Administration: 1) Require that all 14 Code of Federal Regulations Part 121 operators establish procedures requiring all crewmembers on the flight deck to positively confirm and cross-check the Airplane's location at the assigned departure runway before crossing the hold-short line for takeoff. (A-06-83); and 2) Require that all 14 Code of Federal Regulations Part 121 operators provide specific guidance to pilots on the runway lighting requirements for takeoff operations at night. (A- 06-84) (NTSB)
Safety Recommendation A-06-83 and -84
13 DEC 2006 AAIB issues Special Bulletin on Airbus 319 generator problems [to table of contents] An easyJet Airbus A.319 (G-EZAC) was dispatched under the provisions of the operator`s MEL with the APU generator on line, substituting for the No 1 main generator which had been selected off after a fault on the previous flight had caused it to trip off line. During the cruise, the APU generator disconnected from the system, probably because of a reccurrence of the original fault. This caused the loss of a substantial number of aircraft services, including some flight instruments and all means of RTF communication. Manual reconfiguration of the electrical system should have recovered many of the services but the flight crew was not able to achieve this. Since they were without RTF communications, the crew considered that the best option was to select the emergency transponder code and continue the flight in accordance with the flight plan. In the light of the initial findings of the investigation, four safety recommendations are made. The investigation is continuing. (AAIB)
Special Bulletin S9/2006
13 DEC 2006 EU gives Bulgarian airlines three more months for safety comliancy [to table of contents] Eight Bulgarian airlines currently comply with the standards of the European Aviation Safety Agency (EASA). Hemus Air will receive the first EASA certificate within a week, to be followed by Bulgaria Air Charter. EASA's latest report singled out several areas of serious concern, triggering a three-month delay in the requirement for Bulgarian aviation to comply with its standards, Transport Minister Peter Mutafchiev announced. (SNA) 20 DEC 2006 Nigeria may sanction Sosoliso over alleged certificate forgery [to table of contents]
The Nigerian federal government said it might institute a criminal prosecution against Sosoliso Airlines if the report from DGAC France indicting the airline of alleged safety certificate forgery were found to be true. A Sosoliso DC-9 was ferried to France for maintenance at EAS Industries. There it was discovered that the airplane had four unapproved parts with with falsified `Authorised Release Certificate` FAA Form 8130-3. (Daily Trust) 21 DEC 2006 Swiss BFU report issued on airprox near Zurich [to table of contents]
Report issued on the Feb 2005 near miss with an altitude difference of 300 ft and a lateral separation of 1.5 NM between a Tu-154 and an Airbus A.319. This incident is attributable to the fact that the crew of the Tu-154M did not follow the instruction of air traffic control to descend to FL 150 and continued its descent for reasons unknown. (BFU Switz.)
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25 DEC 2006 Lion Air Boeing 737 skidds off runway at Makassar [to table of contents] A Lion Air Boeing 737-400 skidded off the runway at Makassar, Indonesia. Flight JT 792 carried 156 passengers and six crew. The airplane skidded at about 20:35 local time on runway 31, which remained closed for four hours. The airplane reportedly suffered damages to the right main landing gear, left wing and both engines. (The Jakarta Post)
