News
15 AUG - Taiwan ASC issues final report on TCAS event 15 AUG - FAA seeks penalties against American Airlines for deferred maintenance, other vi
21 AUG - AAIB: final report issued on HS-748 runway overrun at Guernsey
21 AUG - FAA conducts special certification review of Eclipse 500 jet
25 AUG - ICAO safety audit gives U.S. high mark
29 AUG - ATSB releases preliminary report into Boeing 747 depressurisation
15 AUG 2008 Taiwan ASC issues final report on TCAS event [to table of contents]
The Taiwanese Aviation Safety Council conluded their investigation into the near collision between a Boeing 757 and a Boeing 777 off Jeju Island, Korea.
They concluded that:
ICN control made a non-standard call and gave a confusing instruction to the EF306 during its descent when passing FL340. EF306 flight crew did not fully comprehend the ATC instructions, failed to confirm the instructions and stopped descending at 33,800 ft. Both parties did not apply standard radiotelephony procedures and phraseologies. These anomalies contributed to the TCAS event between EF306 and TG659. The EF306 flight crew did not complete the TCAS RA standard operation procedures and commenced an excessive high rate descent. The induced negative G-force resulted in the occupants’ injury.
There are other 8 findings related to risk which include : The EF306 flight crew did not adequately exhibit good CRM performance in this occurrence, South Sector Radar Control(SSRC) momentarily missed monitoring the approaching situations developed between EF306 and TG659 while concentrating on the radar identification of other aircraft, SSRC did not comply with ATC/TCAS operating procedures and the limited human capability during a sudden occurrence of abnormal situation who was paying attention continuously to a large number of aircraft in a relatively broad service area which was B576 that applying Reduced Vertical Separation Method(RVSM) operations. In addition, most of the injured passenger did not have their seat belts fastened and lost their protection while the fasten seat best sign was still on, the cabin crewmembers did not provide timely injury information to the flight crew, that would have allowed the flight crew to request sufficient medical assistance before landing and the controllers did not aware the importance of the number of injuries and the need for more ambulances to meet the flight upon landing. This caused the necessary number of ambulances to arrive at the airport with delay.
(ASC)
ASC final report
The U.S. FAA announced actions totaling $7.1 million in civil penalties against American Airlines for improperly deferring maintenance on safety-related equipment and deficiencies with its drug and alcohol testing programs and exit lighting inspections. The FAA asserts that in December 2007, American used the wrong provisions of its Minimum Equipment List (MEL) to return two MD-83 aircraft to service after pilots had reported problems, and flew the planes 58 times in violation of FAA regulations. The MEL contains components and systems without which the aircraft may operate safely under specific limitations, as proven by the operator or manufacturer. On December 11 and 12, American operated the first MD-83 on eight flights in airspace it should have been restricted from after maintenance on part of the autopilot system was improperly deferred. An FAA inspector discovered the improper deferral and informed the airline, however American flew the plane on 10 more revenue flights until the problem was fixed on December 17. In another incident, the autopilot disconnected during a landing by the same aircraft on December 21. American technicians did not check for the actual problem, and instead deferred maintenance using an inappropriate MEL item. The plane flew another 36 passenger-carrying flights during December 21-31. Airline maintenance later discovered the fault was in a radio altimeter – not the autopilot. For the violations involving this MD-83, the FAA is proposing a $4.1 million civil penalty. A different MD-83 experienced an autopilot disconnect on December 27. Although American mechanics correctly diagnosed the problem, they again deferred maintenance under the wrong item of the MEL. As a result, the aircraft operated on four revenue flights without a fully functioning autopilot. The FAA is proposing a $325,000 civil penalty in this instance. The FAA believes the large total amount of the fine for these violations is appropriate because American Airlines was aware that appropriate repairs were needed, and instead deferred maintenance. In intentionally continuing to fly the aircraft, the carrier did not follow important safety regulations intended to protect passengers and crew. Also, in May of this year the FAA proposed civil penalties in the amount of $2.7 million in civil penalties against American for alleged past deficiencies in its drug and alcohol testing programs and for allegedly operating aircraft in past years without timely inspections of emergency escape path lighting systems. The amount included $1.7 million civil penalty for the testing program violations and $1 million for the lighting inspection violations. American Airlines will have the opportunity to respond to the proposed civil penalties. (FAA)
press release
21 AUG 2008 AAIB: final report issued on HS-748 runway overrun at Guernsey [to table of contents] The U.K. AAIB released the final report of their investigation into a serious incident at Guernsey Airport in March 2006. The HS-748 aircraft was landing at Guernsey at the end of a two-sector cargo service from Coventry and Jersey. The Category I ILS approach on Runway 27 at Guernsey was flown in weather conditions that were poor but acceptable for making the approach and there was ample fuel on board for a diversion. The aircraft was seen to touch down between 400 and 550 metres from the 'stop' end of the runway and overran by some 145 metres onto the grass beyond the paved surface. There were no injuries. Investigation by the AAIB revealed no aircraft or runway deficiencies to account for the overrun. During the final approach and landing there were substantial divergences from the company Operations Manual. This operator had previously been the subject of close monitoring by the CAA over a sustained period and its Air Operator’s Certificate (AOC) was later suspended. The investigation identified the following causal factors: (i) The flight crew did not comply with the Standard Operating Procedures for a Category I ILS. (ii) The commander’s decision to land or go around was delayed significantly beyond the intersection of the Decision Altitude and the ILS glideslope. (iii) After landing, the crew did not immediately apply maximum braking or withdraw the flight fine pitch stops, as advised in the Operations Manual. (iv) The operator’s training staff lacked knowledge of the Standard Operating Procedures. The investigation identified the following contributory factor: (i) Close monitoring by the CAA had not revealed the depth of the lack of knowledge of Standard Operating Procedures within the operator’s flight operations department until after this incident. (AAIB)
AAIB Report No: 6/2008
21 AUG 2008 FAA conducts special certification review of Eclipse 500 jet [to table of contents] On August 11, the U.S. Federal Aviation Administration (FAA) began a 30-day review of Eclipse Aviation’s Very Light Jet, the Eclipse 500. Jerry Mack, a former Boeing safety executive, is leading an oversight team of seven FAA experts with specialties such as flight testing, avionics, and certification. The team members are independent of the original certification group. The FAA convened this Special Certification Review (SCR) team to look at: aircraft safety, certification of aircraft trim, flaps, screen blanking, and stall speeds. These issues were the subject of Service Difficulty Reports (SDRs) that have been filed by operators since the aircraft was certificated on September 30, 2006. The team will look at whether or not any of these issues were raised during the certification process and if any of the issues are currently a threat to safety. Special reviews are regularly used by the FAA. In the past 10 years, the agency has conducted special reviews on the Liberty XL-2 (2008), Mitsubishi MU-2B (2005), Cessna 208 (2005), Twin Cessna 400 Series Models (2004), Raytheon 390 (2004), and the Beechcraft T34 (2003). (FAA) 25 AUG 2008 ICAO safety audit gives U.S. high mark [to table of contents]
The U.S. aviation system received a score of 91 out of 100 in a new safety audit released by the International Civil Aviation Organization (ICAO). The U.S. score, which was well above the global average of 56, reflected U.S. compliance with over 9,500 international safety standards. The FAA led U.S. preparations for the audit, which also included the National Transportation Safety Board, the U.S. Coast Guard and the Pipeline and Hazardous Materials Safety Administration. The team of ICAO auditors conducted a comprehensive audit of all aspects of civil aviation in the United States, including aircraft operations and airworthiness, accident investigation, navigation services, airports, personnel licensing and legislation and regulations. The auditors interviewed technical experts and conducted site visits to government and industry facilities to assess overall safety oversight. The Universal Safety Oversight Audit Program was established by ICAO in 1995 at the urging of the United States. It provides civil aviation authorities throughout the world with valuable information on the overall health and effectiveness of their airspace systems. (FAA) 29 AUG 2008 ATSB releases preliminary report into Boeing 747 depressurisation [to table of contents]
The Australian Transport Safety Bureau (ATSB) released its Preliminary Factual report on the depressurisation of Boeing 747-438, VH-OJK, 475 km northwest of the Philippines. On the basis of the physical damage to the aircraft's forward cargo hold and cabin, it was evident that the number-4 passenger oxygen cylinder sustained a failure that allowed a sudden and complete release of the pressurised contents. The rupture and damage to the aircraft's fuselage was consistent with being produced by the energy associated with that release of pressure. Furthermore, it was evident that as a result of the cylinder failure, the vessel was propelled upward, through the cabin floor and into the cabin space. Damage and impact witness marks found on the structure and fittings around the R2 cabin door showed the trajectory of the cylinder after the failure. (ATSB)
ATSB AO-2008-053
