News
02 MAR - Indonesian air traffic controllers leave in fear of prosecution 02 MAR - EASA issues emergency AD on BAe 146/Avro RJ NLG inspections
03 MAR - Southwest agrees to pay USD 7.5 million safety fine
04 MAR - AAIB: prelim report on control problems during maintenance check flight
09 MAR - Italian Ministry of Justice will improve cooperation with ANSV
10 MAR - Indonesian authorities ground Lion Air MD-90's
10 MAR - Spanish investigators issue safety recommendation after Spanair MD-80 crash
12 MAR - NTSB issues urgent safety recommendation on B777 engine thrust rollback events
19 MAR - Study finds criminal prosecution following accidents damages flight safety
30 MAR - Report: U.K. Business Jet Safety Research
30 MAR - American Airlines, pilots union will again join air-safety program
02 MAR 2009 Indonesian air traffic controllers leave in fear of prosecution [to table of contents]
Nearly 30 experienced Indonesian air traffic controllers have left their jobs to look for work abroad amid fears they could be targeted for criminal prosecution for accidents or mishaps, the Indonesian Air Traffic Controllers Association (IATCA) says.
The association’s chairman, Adrie Gunawan said the exodus was triggered by the prosecution of Garuda Indonesia pilot, who was commanding a Boeing 737 that crashed upon landing at Yogyakarta’s Adisucipto International Airport in March 2007, killing 21 people aboard. (The Jakarta Globe )
As part of a recent accident investigation, the examination of a fractured nose landing gear (NLG) main fitting showed that a Messier-Dowty Service Bulletin (SB.146-32-150) had not been accomplished, although the records indicated that it had been. BAE Systems has determined that more NLG units could be similarly affected. These NLG units have been overhauled at Messier Services in Sterling, Virginia, in the United States. This condition, if not corrected, could result in NLG failure. The Emergency AD requires repetitive NDT inspections of each affected NLG unit and, if cracks are found, replacement with a serviceable unit. (EASA)
AD No.: 2009-0043-E
03 MAR 2009 Southwest agrees to pay USD 7.5 million safety fine [to table of contents] The Federal Aviation Administration (FAA) reached a settlement agreement with Southwest Airlines to resolve outstanding enforcement actions. Under the agreement, Southwest Airlines will pay a $7.5 million civil penalty that could double to $15 million if the airline does not accomplish specific safety improvements outlined in the settlement agreement. The agreement stems from a $10.2 million civil penalty proposed on March 6, 2008 against Southwest Airlines for operating 46 airplanes on 59,791 flights without performing mandatory inspections for fuselage fatigue cracking. Southwest Airlines will pay an additional $7.5 million if it does not accomplish 13 additional safety-related requirements related to personnel; manuals and procedures; company organization; and training. FAA inspectors will monitor Southwest Airlines’ progress on a variety of improvements for which the longest compliance time is one year. Examples include: * Within 30 days, Southwest Airlines will increase the number of on-site technical representatives for heavy maintenance vendors from 27 to 35 people. * Within 60 days, Southwest Airlines will allow FAA inspectors improved access to information used for tracking maintenance and engineering activities. * Within 90 days, Southwest Airlines will designate a management head of Quality Assurance who does not have air carrier certification responsibilities. * Within 180 days, Southwest Airlines will review its Required Inspection Item (RII) procedures to ensure compliance with FAA rules related to maintenance and identify more clearly all RII items on its maintenance work instructions, engineering authorizations, and task cards. * Within 365 days, Southwest Airlines will rewrite all FAA-approved manuals. (FAA)
press release
04 MAR 2009 AAIB: prelim report on control problems during maintenance check flight [to table of contents] The U.K. AAIB issued a preliminary report regarding their investigation into a serious incident in January 2009. A Boeing 737-73V, G-EZJK, experienced a violent pitch down during a combined maintenance check and customer demonstration flight. Vmo was exceeded by 100 knots, and a 10,000 foot loss of altitude occurred. The aircraft recovered from the maneuver and landed safely. Four flight crewmembers were on board, and there were no passengers. None of the flight crewmembers were injured. (AAIB)
AAIB Special Bulletin S2/2009
09 MAR 2009 Italian Ministry of Justice will improve cooperation with ANSV [to table of contents] The Italian flight safety board, ANSV, received a positive response from the Ministry of Justice regarding safety recommendation ANSV-10/888-06/1/A/08, issued following the accident involving a Piper PA-31 (I-POMO) on November 6th, 2006. In particular, the Ministry of Justice invited the Directors of Public Prosecutions within the Appeal Courts to stipulate that, in the case of an accident involving an aircraft and immediately following the event, in compatibility with search and rescue activities, there shall be no tampering with or alteration of evidence before the arrival of the assigned ANSV investigators, in order not to compromise acquisition of evidences necessary to determine the cause. The ministry has also stated that, following any examinations, in compatibility with public safety requirements, the subsequent recovery of wreckage is also to be coordinated with ANSV personnel. Nevertheless, the FDR/CVR data of the fatal Cessna Citation accident currently under investigation are still exclusively in the hands of the responsible judicial authority. (ANSV)
press release
10 MAR 2009 Indonesian authorities ground Lion Air MD-90's [to table of contents] The Indonesian government decided to temporarily stop the operation of all MD-90 type aircraft belonging to Lion Air as of 11 March 2009. This decision was taken following a runway excursion of an MD-90 at the Jakarta-Soekarno-Hatta Airport March 9th. The Ministry of Transportation will check all five MD-90 planes as well as the way Lion Air manages the safety of this aircraft type. (Ministry of Transportation)
press release
10 MAR 2009 Spanish investigators issue safety recommendation after Spanair MD-80 crash [to table of contents] On 20 August 2008 a McDonnell Douglas DC-9-82 operated by Spanair, was involved in an accident immediately after takeoff at Madrid-Barajas Airport (Spain). The aircraft was destroyed as a consequence of the impact with the ground and the resultant fire. There were 154 fatalities. Prior to takeoff the crew reported a problem with the RAT probe heater and returned to the stand. Once the aircraft returned to the stand, maintenance personnel verified the fault described in the ATLB, checked the Minimum Equipment List under the appropriate section for the Rat probe heating, and proceeded to open the circuit breaker that supplied electrical power to the heater of the probe. Once this was done, it was proposed and accepted that the airplane be dispatched. Upon completion of this action, the aircraft was cleared for takeoff and, once airborne, reached a height of 40 feet above the ground before descending and impacting the terrain. Although the accident investigation has not yet been concluded, all available data show that flaps and slats were not set in takeoff configuration, resulting in the failure of the airplane to climb properly after takeoff. It also shows that the cockpit crew did not receive the automated takeoff configuration warning during the takeoff roll. The RAT temperature probe has a heating system that should be inhibited while the aircraft is on ground. The way the airplane detects that it is in ground or in flight is by means of a switch connected to the nose landing gear that provides a ground signal when the strut is compressed, and a flight signal when it is extended. This ground-flight signal is sent to a set of relays. Each of these relays provides a ground-flight signal to various systems that require it for proper operation. In accordance with the manufacturer's Wiring Diagram Manual (WDM), in the case of the RAT probe heater, its associated relay is R2-5 which, in addition to heating, also supplies information to a.o. the Take Off Warning System (TOWS). Although no determination has yet been reached as to why the TOWS did not sound and/or whether there was a fault with the R2-5 relay, the investigation has focused on the relationship between the R2-5 relay, the high temperature indication while the airplane was on the ground, and the failure of the TOWS to sound during the takeoff roll. It is recommended that the FAA and EASA require the manufacturer, Boeing, to include in its Aircraft Maintenance Manual (AMM) for the DC-9 and MD-80, the Troubleshooting Manual for the MD-90 and the Fault Isolation manual for the 717 series of airplanes, specifically identified instructions to detect the cause and to troubleshoot the fault involving the heating of the RAT temperature probe while on the ground. (CIAIAC)
Safety Recommendation REC 01/09
12 MAR 2009 NTSB issues urgent safety recommendation on B777 engine thrust rollback events [to table of contents] Following two engine thrust rollback events on Boeing 777 aircraft powered by Rolls-Royce engines, the National Transportation Safety Board (NTSB) issued an urgent safety recommendation today calling for the redesign of a Rolls- Royce engine component. The Safety Board also recommended that, after the redesign is completed, the new system be installed on all affected B-777 airplanes at the next maintenance check or within six months. These recommendations are being issued in response to the findings in two investigations - an accident and an incident - involving engine thrust rollbacks on Boeing 777-200ER airplanes powered by Rolls-Royce RB211 Trent 800 Series engines. In both cases a build-up of ice (from water normally present in all jet fuel) on the fuel/oil heat exchanger (FOHE) restricted the flow of fuel to the engine, resulting in an uncommanded engine rollback. (NTSB)
Safety recommendations A09-17/20
19 MAR 2009 Study finds criminal prosecution following accidents damages flight safety [to table of contents] A new doctoral study of the criminal prosecution of pilots or air traffic controllers following aircraft accidents and incidents has concluded that they have a definite detrimental effect on flight safety, but fail to have the intended effect of deterring individuals from making mistakes. The study, carried out by two Cypriots, found controllers are particularly aware that successful prosecution could follow an unintentional error, and the resulting stress may even make mistakes more likely. (Flight International)
full article
30 MAR 2009 Report: U.K. Business Jet Safety Research [to table of contents] Describes a study of U.K. business jet safety, based on an analysis of safety data supplemented by externally contracted research that involved personal industry visits and a questionnaire sent to operators and pilots to obtain feedback on any safety related issues. The study makes a number of recommendations, some of which have already been addressed. (CAA)
CAA Paper 2009/03
30 MAR 2009 American Airlines, pilots union will again join air-safety program [to table of contents] American Airlines and its pilots union, the Allied Pilots Association, agreed to re-establish the Aviation Safety Action Program (ASAP). The voluntary reporting program will be resumed pending FAA approval. The Allied Pilots Association said the program was suspended after American threatened pilots with disciplinary action related to ASAP reports. American says those pilots faced discipline because the incidents involved willful misconduct or otherwise didn't belong within ASAP. (Dallas Morning News,)
