News
02 DEC - Cessna 208 forced landing on highway: no injuries 03 DEC - An overview of spatial disorientation as a factor in aviation accidents and inci
04 DEC - CAA UK issues Aircraft Maintenance Incident Analysis Paper
05 DEC - U.S. GAO issues report runway and ramp safety
06 DEC - Lion Air MD-90 loses three-metre-long part on takeoff
06 DEC - NTSB recommends fire suppression systems on all cargo airplanes
06 DEC - BEA France releases preliminary factual report on Moorea DHC-6 accident
10 DEC - Chinese chemical firm ordered to pay US$65m in plane damage case
11 DEC - CRM tests for foreign pilots in Thailand
12 DEC - TSB issues final report on Airbus A340 runway overrun and fire - Toronto
17 DEC - US Navy grounds 39 P-3 Orions due to structural fatigue concerns
17 DEC - UK will increase foreign aircraft checks
19 DEC - ATSB releases CFIT accidents study
19 DEC - EASA will be granted power to fine safety violators
19 DEC - Turkey suspends flights of Tarhan Tower Airlines and Golden Airlines
19 DEC - Final report: bird strike caused loss of AN-12 near Moscow
19 DEC - NTSB seeks components lost over Texas in uncontained engine failure
20 DEC - ATSB analysis of increased accident and incident data
23 DEC - Canada: SMS required for airports and ATS
31 DEC - Japan to boost foreign plane safety checks
02 DEC 2007 Cessna 208 forced landing on highway: no injuries [to table of contents]
A Cessna 208B Grand Caravan (OB-1740) of the Peruvian airline Aerocondor made a forced landing on the Panamericana Sur highway. The pilot was forced to return to the airport because of technical problems, but was forced to carry out a forced landing. The aircraft was not damaged and the pilot and twelve tourists were not injured. (El Comercio)
The Australian Transportation Safety Board (ATSB) released a research report examining the problem of spatial disorientation. The report explains that the chances of a spatial disorientation event occurring in flight can be reduced by a series of simple preventive measures, many of which can be attended to before flight. These include flying when fit and well to do so, not flying under the influence of alcohol or medications, avoiding visual flight rules into instrument meteorological conditions, increasing awareness of spatial disorientation illusions and planning for their possible appearance at different stages of flight in the pre-flight planning process. The ATSB report encourages pilots who have had a spatial disorientation event to share their experiences with their aviation colleagues, either informally, or through magazines, journals and web-based forums. A more open approach to acknowledging and discussing spatial disorientation and its various causes will make a valuable contribution to a better understanding of this common human factor. (ATSB)
Aviation Research and Analysis Report – B2007/0063
04 DEC 2007 CAA UK issues Aircraft Maintenance Incident Analysis Paper [to table of contents] The U.K. CAA released the results of an analyses of a selection of maintenance related events on jet aircraft above 5,700kg MTOW, captured and stored under the requirements of the CAA’s Mandatory Occurrence Reporting (MOR). The data showed that the vast majority of MORs were related to Equipment and Furnishings, escape slides in particular. The study concludes that the number of maintenance related MORs as a percentage of the total number of MORs submitted to the CAA appears to decrease steadily from 2000 to 2005. This reduction may, in part, be attributable to the extensive efforts of the CAA to promote human factors awareness training, guidance and policy within the industry. Recommendations include improving the consistency and comprehensiveness of data captured to facilitate future trend analysis, and identification of the underlying causes of maintenance error. (CAA)
CAA Paper 2007/04
05 DEC 2007 U.S. GAO issues report runway and ramp safety [to table of contents] The U.S. Government Accountability Office (GAO) issued a report on their evaluation of: (1) the progress being made by the FAA in addressing runway safety and what additional measures, if any, could be taken and (2) the factors affecting progress in improving ramp safety and what is being done by FAA and others to address those factors. FAA and aviation stakeholders have taken steps to address runway and ramp safety, including deploying and testing technology designed to prevent runway incursions and overruns; helping to change airport layout, markings, signage, and lighting; and providing training for pilots and air traffic controllers. In addition, FAA has made progress in addressing runway overruns and reports that 70 percent of the runways at U.S. commercial airports substantially comply with runway safety area standards, up from 55 percent in 2000. However, the rate of runway incursions has not decreased over the last 5 years. In addition, FAA has not prepared a national runway safety plan since 2002, despite agency policy that it be updated every 2 to 3 years, resulting in uncoordinated efforts within the agency. Runway safety technology currently being installed is experiencing some operational difficulties with its alerting function, while additional technology to prevent runway collisions is years away from deployment. FAA also lacks data on runway overruns that could be used to analyze the causes and circumstances of such incidents. Air traffic controller fatigue, which may result from regularly working overtime, continues to be a matter of concern for the National Transportation Safety Board (NTSB), which investigates transportation accidents, and other aviation stakeholders. Efforts to improve safety in airport ramp areas are hindered by a lack of complete accident data and standards for ground handling, but the aviation industry is taking steps to address these problems with the goal of reducing ramp accidents. Data from 2001 through 2006 from the Occupational Safety and Health Administration (OSHA), which investigates occupational accidents, NTSB, and FAA indicated that these agencies had investigated 29 fatal ramp accidents during that time. The majority of the fatalities in these accidents were ramp workers. GAO found no comprehensive nonfatal injury data on ramp accidents and neither federal nor industrywide standards for ramp operations. The federal government has generally taken an indirect role overseeing ramp safety; airlines and airports typically control the ramp areas using their own policies and procedures. Meanwhile, some airlines and airports have initiated their own efforts to address ramp safety, and aviation organizations have begun collecting ramp accident data. (GAO)
GAO-08-29
06 DEC 2007 Lion Air MD-90 loses three-metre-long part on takeoff [to table of contents] An MD-90 operated by Indonesia`s Lion Air has been grounded after the airline admitted that a three-metre-long part found on a runway belonged to it. The airplane lost the part on takeoff from Jakarta-Sukarno Hatta airport, December 4. Lion Air`s operational director told the Detikcom online news service the part was from the exhaust system and not vital for flight. He reportedly said it fell off the plane because of `a mistake of the workshop`. (Straits Times) 06 DEC 2007 NTSB recommends fire suppression systems on all cargo airplanes [to table of contents]
The U.S. NTSB has recommended that the FAA require that all cargo airplanes operating under Part 121 install fire suppression systems. This recommendation is a result of the Board`s investigation of a UPS DC-8 cargo fire in Philadelphia last year. As a result of its investigation, the Safety Board made recommendations in the following areas including: guidance and checklists relating to in-flight fire and smoke, certification requirements for smoke and fire detection system tests, fire suppression system requirements, aircraft rescue and firefighting training, cargo airplane emergency exit requirements, hazardous materials information and dissemination procedures, and transport of lithium batteries on board aircraft. (NTSB)
press release
06 DEC 2007 BEA France releases preliminary factual report on Moorea DHC-6 accident [to table of contents] BEA France released a preliminary factual report of the investigation into the DHC-6 Twin Otter which crashed shortly after takeoff from Moorea, French Polynesia. BEA discovered a.o. some problems relating to the elevator control cables. Two stainless steel cables were found to be severely worn due to friction. (BEA)
BEA Rapport d`étape f-oi070809e
10 DEC 2007 Chinese chemical firm ordered to pay US$65m in plane damage case [to table of contents] A Chinese chemical company has been ordered to pay more than US$65 million in compensation to five overseas insurers over an incident in 2000, when a leak of corrosive chemicals destroyed a Malaysian cargo plane. The Dalian company, affiliated with China National Chemical Construction Corporation (CNCCC), was brought before the Beijing High Court in 2002 by Malaysian Airlines and the insurers. The plaintiffs contended that Dalian company had mislabeled a consignment of chemicals that were aboard the Airbus A330 plane. The airplane was badly corroded and considered damaged beyond repair. (Xinhua)
Accident description
11 DEC 2007 CRM tests for foreign pilots in Thailand [to table of contents] In the wake of the Phuket air crash, the Thai Civil Aviation Department will require all foreign pilots working in Thailand to cooperate better with their Thai co-pilots. The foreign pilots' working culture was different from that of the Thais, according to the CAD. The department is about to issue a new regulation requiring all foreign pilots working in Thailand to pass a Crew Resource Management (CRM) test and a test about the Thai aviation laws. (Bankok Post) 12 DEC 2007 TSB issues final report on Airbus A340 runway overrun and fire - Toronto [to table of contents]
The Transportation Safety Board of Canada (TSB) released its final report into the runway overrun of an Air France Airbus A340 at Toronto/Lester B. Pearson International Airport on August 2, 2005. The aircraft approached Toronto in a severe and rapidly changing thunderstorm with shifting winds and limited visibility. It came in too high and too fast. Touching down almost halfway along the wet and slippery runway, it ran out of room and overran the runway. The first five TSB recommendations focus on crews and the need for mandatory standards, training, and procedures. The TSB is also making two recommendations aimed at reducing the risk of injury following an accident. (TSB)
TSB Report Number A05H0002
17 DEC 2007 US Navy grounds 39 P-3 Orions due to structural fatigue concerns [to table of contents] The U.S. Naval Air Systems Command announced the grounding of 39 Lockheed P-3C Orion aircraft due to structural fatigue concerns. The concerns are the result of continuing P-3 fatigue life analysis and validation by physical findings. Program officials determined that these aircraft are beyond known structural limits on the lower section of the P-3 wing. Analysis and corrective measures are expected to take between 18 to 24 months per aircraft to complete. The Navy has a total of 161 P-3C aircraft in its inventory. Of the 39 aircraft being grounded, ten are currently deployed. (Naval Air Systems Command) 17 DEC 2007 UK will increase foreign aircraft checks [to table of contents]
U.K. Aviation Minister Jim Fitzpatrick announced that the number of safety checks carried out on foreign aircraft will more than double in 2008, from 250 to 600, and rise to 1000 inspections a year in 2009. The increased number of safety checks, known as ramp inspections, will ensure that the UK plays its full part in maintaining the safety of the skies over Europe, as part of the pan-European, Safety Assessment of Foreign Aircraft (SAFA) Programme. (Department for Transport) 19 DEC 2007 ATSB releases CFIT accidents study [to table of contents]
The Australian Transport Safety Bureau's (ATSB) released a report on CFIT accidents. It examines accidents from an international perspective, current and potential CFIT preventative strategies, and identifies those characteristics associated with CFIT in Australia. Australian data shows 25 CFIT accidents and two CFIT incidents in the period 1996 to 2005. General aviation accounted for the greatest proportion of CFIT accidents, fatal accidents and fatalities. Only one CFIT occurrence over the reporting period (VH-TFU, Lockhart River, Queensland, 7 May 2005) involved regular public transport operations, but this accident accounted for nearly one-third of all CFIT fatalities. In line with international experience, nearly two-thirds of CFIT accidents and incidents in Australia occurred in the approach phase of flight, of which half of these were during an instrument approach. When compared with the total number of accidents recorded by the ATSB over the 10-year period, the results of the study indicate that CFIT in Australia is a rare event. However, when CFIT does occur, the likelihood of it resulting in fatalities is high. (ATSB)
ATSB Report B20060352
19 DEC 2007 EASA will be granted power to fine safety violators [to table of contents] European lawmakers have approved a compromise deal on handing over more powers to Europe's Aviation Safety Agency (EASA), including the possibility of imposing fines on unworthy aircraft manufacturers, in a bid to tighten variable air safety standards across the 27 nation bloc. According to the text adopted, EASA will take over from national authorities as regards regulating airline companies` operations, licensing pilots and certifying third-country aircraft. In an important amendment, the agency will also be able to ask the Commission to impose `fines and periodic penalty payments` on aircraft manufacturers and equipment suppliers to which it has awarded certificates if they are "intentionally or negligently" in breach of EU safety provisions. (Euractiv) 19 DEC 2007 Turkey suspends flights of Tarhan Tower Airlines and Golden Airlines [to table of contents]
Turkey`s civil aviation administration SHGM has suspended the flights of charter airline Tarhan Tower Airlines after discovering technical issues with the operator`s maintenance department. It has cancelled the carrier`s JAR-145 maintenance certificate and ordered a three-month suspension of the airline`s flight services. TT Airlines is planning to reorganise its operations and regain its permits. Start-up Golden Airlines has also had its operations suspended for three months after the carrier failed to introduce a second aircraft within the set time limits. The airline has a single Boeing 757 leased from ILFC but, under Turkish regulations, start-up carriers must bring in a second aircraft within three months. (Flightglobal) 19 DEC 2007 Final report: bird strike caused loss of AN-12 near Moscow [to table of contents]
Russia`s Interstate Aviation Committee (MAK) concluded that an Antonov 12 crashed shortly after takeoff from Moscow-Domodedovo Airport in July 2007, was caused by bird strike. The two right hand engines autofeathered and the airplane lost altitude and airspeed. The crew could not maintain control as the aircraft banked 100 degrees to the right. It crashed in a forest and broke up. (MAK)
MAK Report on RA-93912
19 DEC 2007 NTSB seeks components lost over Texas in uncontained engine failure [to table of contents] In its investigation of an uncontained engine failure that occurred on a Southwest Airlines flight from Dallas, Texas (Love Field), to Little Rock (LIT), on November 17, the National Transportation Safety Board is searching for engine components that fell to the ground in a sparsely populated rural area of Texas. The incident, in which pieces of the fan blades and the spinner separated from the #2 (right) engine, occurred at 2:54 pm over Hunt County, Texas, at an altitude of 25,000 feet during the climb phase of flight. None of the 133 passengers or 5 crewmembers on board the B-737-300 (N676SW) aircraft were injured. The crew shut down the damaged engine and returned safely to Dallas on power from the #1 (left) engine. In addition to the damage to the engine and its housing components, the aircraft sustained minor damage to the fuselage. NTSB engineers developed a Ballistic Trajectory Analysis using data such as the aircraft ground track, speed, prevailing winds and other factors, to create an area where the engine pieces are most likely to be found. The area is approximately 0.4 miles wide and 1.7 miles long and is located on private property. The owners of the property whose land is in the identified area will be contacted by the Hunt County sheriff`s office and will be asked to notify the sheriff if an aircraft engine part is discovered. Because these engine parts and the exact location of discovery are essential to the investigation, parts should not be handled by the public, but instead should be marked in place. If found, please contact the Hunt County sheriff`s office at (903) 453-6800. The NTSB asks anyone volunteering to search for these items to respect private property rights and get permission of the landowner before searching on anothe`s property. (NTSB) 20 DEC 2007 ATSB analysis of increased accident and incident data [to table of contents]
ATSB analysis shows that an increase in reported airline accident and incident data since 2001 is mainly due to industry expansion, and the rates of many types of occurrence have fallen. The Australian Transport Safety Bureau research report covered more serious airline Immediately Reportable Matters in the 5 years from mid 2001 to mid 2006. Despite the increased activity in scheduled public transport operations, the number of Immediately Reportable Matters has generally either remained stable or declined. When measured in relation to airline activity, the trend rate is generally downwards. Violations of controlled airspace involve aircraft entering controlled or restricted airspace without appropriate clearances from air traffic control. There was a total of 82 airspace violations recorded over 5 years, and the ATSB found a downward trend for these incidents. A breakdown of separation occurs when the distance between aircraft is less than that required. In many cases where separation breaks down the aircraft will still be some considerable distance apart. Of the 462 incidents recorded, only two per cent were serious enough to warrant further investigation by the ATSB. Breakdown of separation events have become more common, but only at about the same rate that airline activity has increased. Other incidents examined by the ATSB include reports of crew incapacitation and cabin fumes. Serious crew injury or illness was rare, supporting the findings from an earlier study by the ATSB. The ATSB also received 140 notifications of fumes. Sources of fumes included oil or solvent residues following maintenance activities, failed or overheated electrical or mechanical components, or passenger's luggage. Smoke or fumes from burning food in the galley was also common. The ATSB confirmed that accidents in Australian regular public transport operations are extremely rare. Only one accident involved fatalities, with the loss of all 15 people on board a regional airliner near Lockhart River. All other accidents were limited to damage to the aircraft, including damage to aircraft by service vehicles before flight, or injury to crew or passengers, including from unexpected turbulence during a flight. (ATSB)
ATSB report b20070107_001
23 DEC 2007 Canada: SMS required for airports and ATS [to table of contents] The Canadian Aviation Regulations will be amended to increase accountability in the aviation sector. These amendments require airports and organizations providing air traffic services to implement safety management systems in their organizations and appoint executives who are accountable for safety. These systems will make organizations more accountable for day-to-day operations while allowing them flexibility to determine the most effective means of improving safety performance within the regulatory framework. (Transport Canada)
News release
31 DEC 2007 Japan to boost foreign plane safety checks [to table of contents] The Japanese Construction and Transport Ministry has decided to strengthen monitoring of foreign airlines operating in Japan with a view to improving safety and preventing accidents. The tighter monitoring will start next fiscal year and is a major change in the ministry`s current safety policy, under which it depends on foreign aviation authorities to supervise airlines based in their countries. The ministry judged that it is necessary to conduct its own safety guidance ahead of an expected increase in the number of foreign airlines serving this country. According to the sources, the ministry will appoint `safety control officers` who will specialize in monitoring the safety of overseas airlines. When a foreign airline is classified as `caution necessary,` the officers will step up monitoring of the company and call on the aviation authorities in the relevant country to instruct the company to improve its safety standards. (The Yomiuri Shimbun)
