News
06 MAR - AAIU (Ireland): final report on airprox off Ireland 06 MAR - FAA issues final rule, revising CVR and DFDR regulations
06 MAR - FAA proposes USD10.2 Million civil penalty against Southwest Airlines
06 MAR - NTSB issues recommendations on GE Regional Jet engines
10 MAR - SAS receives compensation after DHC-8-Q400 incidents
10 MAR - AAIB releases final report of Airbus A320 hard landing at Bristol
12 MAR - Breakthrough in simulation of aircraft wake turbulence
13 MAR - Southwest acts on alleged safety violations
18 MAR - Indonesia grounds AdamAir
18 MAR - FAA audits U.S. airlines on AD compliancy
21 MAR - Reports calls for ATSB - CASA co-operation (Australia)
24 MAR - Indonesia releases final report of AdamAir Boeing 737-400 accident
27 MAR - ATSB releases preliminary report into Boeing 717 hard landing
29 MAR - U.S. Airways finds seven aircraft with wing problems following incident
31 MAR - ICAO publishes safety 'white-list' of aviation states
06 MAR 2008 AAIU (Ireland): final report on airprox off Ireland [to table of contents]
The Irish AAIU released their investigation report regarding a serious incident in the Irish controlled airspace near Reporting Point BANBA at high level off the South East coast of Ireland.
Aircraft involved were an MD-83 routing northwards towards Dublin from Faro, and the a B737 routing westwards towards Cork from Stansted. The former was maintaining FL280, while the latter, which was cruising at FL300, was cleared initially by the Shannon Radar Controller to descend to FL290 and subsequently to FL100. This ATC clearance conflicted with the path of the northern bound aircraft, and, in spite of at least four warnings, one verbal and three electronic, the Radar Controller appeared not to comprehend the closing speeds of the two aircraft and allowed the higher one to descend and lose the required minimum vertical and lateral separation from the other. Each aircrafts on board TCAS automatically activated. The pilot of each aircraft reacted correctly to this TCAS warning, one climbed his aircraft as instructed by the system and the other descended his aircraft as instructed by the system. A potential mid-air collision was thus narrowly avoided due to the TCAS activation and the correct response of the pilots. They came within 600 feet of each other on the vertical plane. With separation subsequently re-established by ATC, both aircraft continued onwards and landed at their respective destinations. (AAIU)
AAIU Report No 2008-004
The U.S. FAA issued a final rule, amending cockpit voice recorder (CVR) and digital flight data recorder (DFDR) regulations affecting certain air carriers, operators, and aircraft manufacturers. This final rule increases the duration of certain CVR recordings, increases the data recording rate for certain DFDR parameters, requires physical separation of the DFDR and CVR, improves the reliability of the power supplies to both the CVR and DFDR, and requires that certain datalink communications received on an aircraft be recorded if datalink communication equipment is installed. This final rule is based on recommendations issued by the NTSB following its investigations of several accidents and incidents, and includes other revisions the FAA has determined are necessary. These changes to CVR and DFDR systems are intended to improve the quality and quantity of information recorded, and increase the potential for retaining important information needed for accident and incident investigations. (FAA)
final rule
06 MAR 2008 FAA proposes USD10.2 Million civil penalty against Southwest Airlines [to table of contents] The U.S. FAA initiated an action to collect a $10.2 million civil penalty from Southwest Airlines for operating 46 airplanes without performing mandatory inspections for fuselage fatigue cracking. Subsequently, the airline found that six of the 46 airplanes had fatigue cracks. From June 18, 2006 to March 14, 2007, the FAA alleges that Southwest Airlines operated 46 Boeing 737 airplanes on 59,791 flights while failing to comply with a September 8, 2004 FAA Airworthiness Directive (AD) that required repetitive inspections of certain fuselage areas to detect fatigue cracking. The FAA alleges that after Southwest Airlines discovered that it had failed to accomplish the required repetitive inspections, between March 15, 2007 and March 23, 2007, it continued to operate those same 46 airplanes on an additional 1,451 flights. The amount of the civil penalty reflects the serious nature of those deliberate violations. In this case, the FAA’s AD mandated repetitive external detailed and eddy-current inspections at intervals of no more than 4,500 flight cycles to detect fatigue cracking in areas of the fuselage skin on some Boeing 737 models. Southwest Airlines has 30 days from receipt of the FAA’s civil penalty letter to respond to the agency. (FAA) 06 MAR 2008 NTSB issues recommendations on GE Regional Jet engines [to table of contents]
The U.S. NTSB issued recommendations to the FAA to address a safety concern raised by two engine failures on Bombardier Canadair Regional Jet CRJ-200 aircraft. A flaw during the manufacturing process for fan blades led to the two engine failures, and the Board wants procedures set up to remove these blades before another incident occurs. A companion recommendation was sent to the Canadian government. In both instances - a July 27, 2006 engine failure on an Air Nostrum CRJ shortly after takeoff from Barcelona, Spain, and a May 24, 2007 engine failure on an Atlantic Southeast airlines CRJ while in cruise flight from Syracuse to Atlanta - a fan blade on a General Electric CF34-3B1 turbofan engine fractured, causing a loud bang, severe vibration and in one case an engine fire. Both flight crews declared emergencies and landed safely with no injuries. Examination of the blades showed that they failed due to a material defect introduced during the manufacturing process. The Board issued six recommendations to the FAA, including that it require GE Aviation to define a reasonable maximum time frame below 4,717 cycles since new for these Teleflex fan blades and require that the blades be removed from service before that limit is exceeded, to require GE to include additional testing in the manufacturing process for those blades, and to require GE to make modifications in its CF34-1/-3 engine design to ensure that high engine vibrations (such as can happen when a fan blade fractures) will not cause the engine to catch fire. The Board also issued a recommendation to Transport Canada to require Bombardier to redesign the retention feature of the CRJ 100/-200 engine throttle gearbox to ensure that it can withstand the loads generated by a fan blade separation or similar event. (NTSB)
Safety recommendations
10 MAR 2008 SAS receives compensation after DHC-8-Q400 incidents [to table of contents] SAS has agreed a settlement with Bombardier and Goodrich regarding the incidents involving the Dash 8-Q400 aircraft in the autumn of 2007. The details of the agreement are confidential but SAS Group confirms the total financial compensation is slightly more than USD164 million in the form of a cash payment and credits for future firm and optional aircraft orders. As part of the agreement, the Board of Directors of SAS AB has approved an order for 27 aircraft, with an option for a further 24 aircraft. The new aircraft to be delivered by Bombardier will be jet aircraft of the type CRJ900 NextGen and turboprop aircraft of the type DHC-8-Q400 NextGen. (SAS) 10 MAR 2008 AAIB releases final report of Airbus A320 hard landing at Bristol [to table of contents]
The UK AAIB released the report of their investigation into an incident involving an A320 hard landing in November 2006. The Thomas Cook A320 diverted to to Manchester Airport on 16 November 2006. The diversion resulted from a landing gear malfunction after takeoff from Bristol Airport. Subsequent enquiries revealed that the landing gear had been damaged during the previous landing at Bristol on 15 November. The A320 aircraft had landed at Bristol Airport in a strong crosswind, with associated turbulence. During the shutdown procedure the crew were presented with an automatically generated aircraft warning indicating that certain parameters had been exceeded during the landing. The crew recorded the exceedence in the Technical Log. A type-qualified engineer met the aircraft on arrival and complied with his understanding of the technical checks required after the generation of such a warning. Substantial damage had occurred to the landing gear, but this damage was not detected before the aircraft was cleared for a further flight. On that flight the crew experienced landing gear problems after takeoff, together with other warnings, and diverted to Manchester Airport. Following further engineering activity, the aircraft was again released for flight without the damage being detected; this resulted in a repeat of the gear problems and other warnings after takeoff. The damage to the landing gear was eventually discovered after the subsequent landing at Manchester. The investigation identified the following contributory factors: 1. The A320 aircraft landed at Bristol Airport in a strong crosswind with associated turbulence; the landing was classified as 'hard' because specified parameters were exceeded at touchdown. 2. The autopilots were disconnected about 100 ft above the runway threshold. In the prevailing turbulent conditions, this allowed insufficient time to separate the piloting tasks of taking control of the aircraft and flaring the aircraft to land. 3 The engineers maintaining the aircraft at Bristol had not received adequate training in the use of the computer software supporting the operator’s aircraft manuals. 4. The Airbus aircraft manuals did not differentiate, in their effectivity coding, how the implementation of Service Bulletins affected specific aircraft. 5. No connection was made between the previous LOAD <15> report and the subsequent 20GA sensor failure, indicating the internal damage to the landing gear. 6. Guidance provided in the aircraft manuals required to interpret the LOAD<15> report was unclear and differences existed between sections, particularly with regards to corrective action. (AAIB)
AAIB Report No: 4/2008
12 MAR 2008 Breakthrough in simulation of aircraft wake turbulence [to table of contents] Researchers made a breakthrough in the simulation of aircraft wake turbulence. Post-docs Philippe Chatelain and Michael Bergdorf, doctoral student Diego Rossinelli, Petros Koumoutsakos, Professor at the Institute of Computational Science of ETH Zurich, and Alessandro Curioni and Wanda Andreoni of the Department of Computational Sciences at the IBM Zurich Research Laboratory in Rüschlikon used high-resolution calculations to simulate, with an accuracy two to three orders of magnitude higher than previously, the vortexes generated when an aircraft takes off or lands. The simulation also visibly revealed how the wake turbulence vortexes become unstable. (ETHZ)
press release
13 MAR 2008 Southwest acts on alleged safety violations [to table of contents] On March 6, the U.S. FAA initiated an action to collect a $10.2 million civil penalty from Southwest Airlines for operating 46 airplanes without performing mandatory inspections for fuselage fatigue cracking. The airline is taking action on preliminary findings of its own internal investigation. According to a press statment, Southwest has placed three employees on administrative leave. Those Employees are cooperating with the investigation. Southwest hired a respected outside consultant with proven experience to help review its maintenance program controls, especially Airworthiness Directive (AD) compliance. And Southwest is fully engaged with the FAA on its current audit and committed to FAA leadership that it will investigate and address any deficiencies in its maintenance controls. During a review by Southwest of its maintenance records, the airline discovered an ambiguity related to required testing. Southwest immediately began ground and reinspecting 44 aircraft. (Southwest Airlines) 18 MAR 2008 Indonesia grounds AdamAir [to table of contents]
Indonesian authorities have withdrawn the Operation Specification (OSPEC) of PT Adam Air Sky Connection (dba AdamAir). The carrier is grounded as of March 19 and has three months to make safety improvements or it will have its AOC revoked. Shortcomings noted by the Ministry of Transport include that the airline carried out operations not in accordance with their AOM. Also, personnel training was not carried out in accordance with the company training program. And maintenance was carried out, not in accordance with the Maintenance Manual. (Ministry of Transport) 18 MAR 2008 FAA audits U.S. airlines on AD compliancy [to table of contents]
Acting U.S. Federal Aviation Administrator Robert Sturgell today directed the federal aviation inspectors to reconfirm that commercial carriers operating within the United States have complied with all airworthiness directives. Sturgell noted that one recent failure to comply with one such directive prompted him to validate that all other carriers were in full compliance. Sturgell said an initial review would be completed by March 28 and that the full audit would be completed no later than June 30. (FAA press release) 21 MAR 2008 Reports calls for ATSB - CASA co-operation (Australia) [to table of contents]
The Australian ATSB and CASA must work more closely, a report commissioned after one of Australia's worst air crashes recommends. The Miller Report on Aviation Safety Agency Relations contained 19 recommendations. Amongst others, "the agencies should negotiate a new MOU (Memorandum of Understanding) and include matters such as a means of encouraging more day-to-day interaction between the agencies when serious accidents and incidents occur." Comments on the report's recommendations should be provided to the by 30 April. (Australian Government)
press release
24 MAR 2008 Indonesia releases final report of AdamAir Boeing 737-400 accident [to table of contents] The Indonesian accident investigstion board, KNKT, released the final report of their investigation into the January 1, 2007 accident of an AdamAir Boeing 737 in which all 102 occupants were killed. They found that, during the flight from Surabaya to Manado, the Inertial Reference System (IRS) malfunctioned. Both pilots became engrossed with trouble shooting the IRS anomalies for at least the last 13 minutes of the flight, with minimal regard to other flight requirements. The pilots selected Attitude in the IRS, which disengaged the autopilot. After the autopilot disengaged and the aircraft rolled right and exceeded 35 degrees right bank, the pilots appeared to have become spatially disoriented. Control was lost and the airplane broke up and crashed into the sea. CAUSES: 1) Flight crew coordination was less than effective. The PIC did not manage the task sharing; crew resource management practices were not followed. 2) The crew focused their attention on trouble shooting the Inertial Reference System (IRS) failure and neither pilot was flying the aircraft. 3) After the autopilot disengaged and the aircraft exceeded 30 degrees right bank, the pilots appeared to have become spatially disoriented. 4) The AdamAir syllabus of pilot training did not cover complete or partial IRS failure. 5) The pilots had not received training in aircraft upset recovery, including spatial disorientation. OTHER CAUSAL FACTORS: 1) At the time of the accident, AdamAir had not resolved the airworthiness problems with the IRS that had been reoccurring on their Boeing 737 fleet for more than 3 months. 2) The AdamAir maintenance engineering supervision and oversight was not effective and did not ensure that repetitive defects were rectified. (KNKT)
KNKT/07.01/08.01.36
27 MAR 2008 ATSB releases preliminary report into Boeing 717 hard landing [to table of contents] The Australian ATSB released a preliminary report of their investigation into the February 7, 2008 accident involving a Boeing 717. During an ILS approach to runway 29 at Darwin Airport, the aircraft touched down on the runway at a high rate of descent which resulted in a hard landing. The aircraft then bounced before settling onto the runway. The crew completed the landing rollout and taxied the aircraft to the terminal without further incident. (ATSB)
ATSB AO-2008-007
29 MAR 2008 U.S. Airways finds seven aircraft with wing problems following incident [to table of contents] US Airways has found problems on seven of its Boeing 757 aircraft during inspections prompted by the loss of a wing part from another company plane en route from Orlando. Seventeen Boeing 757s with similar wing specifications were inspected. During the inspections, maintenance crews found problems on seven planes. They performed minor repairs before returning them to service. (WITN) 31 MAR 2008 ICAO publishes safety 'white-list' of aviation states [to table of contents]
All but six of the International Civil Aviation Organisation's 190 member states have agreed that ICAO may publish the results of the organisation's universal safety oversight audit programme (USOAP) revealing standards at their national aviation authorities. (Flight International)
