News
01 APR - ANSV Italy: judicial authorities share FDR, CVR data of fatal Citation crash 01 APR - All IATA airlines are now IOSA registered
01 APR - Atlantic Southeast grounds 60 CRJs for maintenance checks
06 APR - Garuda crash pilot jailed
07 APR - NTSB: Cause of MD-80 engine fire linked to maintenance and flawed SMS
08 APR - EU adds airlines from Benin, Kazakhstan, Thailand, and Ukraine to blacklist
11 APR - FAA issues emergency AD on Rolls-Royce AE 3007A series turbofan engines
14 APR - ANSV Italy investigates 737-800 landing on taxiway at Cagliari
16 APR - AAIB: final report on Boeing 777 eletrical fire event
19 APR - Seven people face criminal charges after fatal 2007 French Polynesia plane crash
23 APR - CAA publishes report on cabin crew fire training
23 APR - NTSC Indonesia releases preliminary report on BAe-146 collision with terrain
23 APR - NTSC Indonesia releases preliminary report on MD-90 runway excursion
28 APR - Dutch Safety Board releases preliminary report on Turkish B737 accident
30 APR - ATSB: preliminary report on A340-500 tail strike accident at Melbourne
01 APR 2009 ANSV Italy: judicial authorities share FDR, CVR data of fatal Citation crash [to table of contents]
The Italian aircraft accident investigation board ANSV (Agenzia Nazionale per la Sicurezza del Volo) reports that they have now received the CVR and FDR transcripts of a Cessna 650 Citation III that crashed near Rome on February 7, 2009. The Cockpit Voice Recorder (CVR) and Flight Data Recorder (FDR) were seized for a juducial inquiry, severely obstructing a thorough investigation into the cause of the accident. The judicial authorities have now sent ANSV a copy of both transcripts. (ANSV)
ANSV news release
The International Air Transport Association (IATA) announced that all 224 of its member airlines, comprising 93% of all scheduled international air traffic, are listed on the IATA Operational Safety Audit (IOSA) registry. IOSA is the global industry standard for airline operational safety management. The IOSA registry (www.iata.org/registry) now consists of 308 airlines, 224 of which are IATA members. At the 2006 Annnual General Meeting IOSA was made a condition of IATA membership with three milestones. By 31 December 2006, member airlines had to complete contractual arrangements for an IOSA audit. By 31 December 2007, all audits needed to be completed. And by 31 December 2008, all audit findings had to be closed and the carrier noted on the IOSA registry. Failure to meet any of the deadlines resulted in termination of IATA membership, with effect 90 days after the milestone. A total of 9 carriers had their memberships terminated as a result of not meeting the 2006 or 2007 milestone deadlines. A further 8 resigned their memberships at the end of 2008 as they needed more time to complete preparations for a successful audit. One airline lost its IATA membership on 31 March 2009 as a result of being unable to complete the registration process. (IATA)
press release
01 APR 2009 Atlantic Southeast grounds 60 CRJs for maintenance checks [to table of contents] Atlantic Southeast Airlines voluntarily grounded 60 of its Bombardier CRJ200 jetliners after an internal audit showed that maintenance crews might not have inspected their GE CF34 turbofans according to the manufacturer’s recommendations. The company self-reported the problem to the FAA and voluntarily grounded the planes “as a precautionary measure”, a spokeswoman told the Atlanta Journal-Constitution newspaper. ASA operates 110 CRJ200 planes. (Atlanta Journal-Constitution) 06 APR 2009 Garuda crash pilot jailed [to table of contents]
The pilot of the Garuda Boeing 737-400 that crashed in Yogyakarta in March 2007 was found guilty of criminal negligence. Prosecutors had sought a four-year jail term, but he was sentenced to two years in prison. One of the panel of five judges remarked that the sentence was about the prevention of future accidents rather than revenge. One of the judges dissented and said that he did not think the pilot should have been found guilty. (Sydney Morning Herald) 07 APR 2009 NTSB: Cause of MD-80 engine fire linked to maintenance and flawed SMS [to table of contents]
The National Transportation Safety Board determined that an engine fire on an American Airlines jetliner was probably due to an unapproved and improper procedure used by mechanics to manually start one of the engines. The fire was prolonged and the safety of the aircraft further jeopardized by how the flight crew handled the emergency. A flawed internal safety management system, which could have identified the maintenance issues that led to the accident, was cited as a contributing factor. On September 28, 2007, American Airlines flight 1400, a McDonnell Douglas DC-9-82 (MD-82), N454AA, experienced an in-flight left engine fire during departure climb from the Lambert-St. Louis International Airport (STL). During the return to STL, the nose landing gear failed to extend, and a go-around was executed. The flight crew conducted an emergency landing, and the two flight crewmembers, three flight attendants, and 138 passengers deplaned on the runway. No occupant injuries were reported, but the airplane sustained substantial damage. The investigation revealed that a component in the manual start mechanism of the engine was damaged when a mechanic used an unapproved tool to initiate the start of the #1 (left) engine while the aircraft was parked at the gate at STL. The deformed mechanism led to a sequence of events that resulted in the engine fire, to which the flight crew was alerted shortly after take-off. The Board examined how the flight crew handled the in-flight emergency and found their performance to be lacking. The captain did not adequately allocate the numerous tasks between himself and the first officer to most efficiently and effectively deal with the emergency in a timely manner. The Board was particularly concerned with how the crew repeatedly interrupted their completion of the emergency checklist items with lower priority tasks. In examining the maintenance issues, investigators found that in the 13 days prior to the accident flight, the aircraft's left engine air turbine starter valve had been replaced a total of six times in an effort to address an ongoing problem with starting the engine using normal procedures. None of valve replacements solved the engine start problem and the repeated failures to address the issue were not recognized or discovered by the airline's Continuing Analysis and Surveillance System (CASS). As a result of the investigation, the Safety Board issued a total of nine safety recommendations. The Board asked the Federal Aviation Administration (FAA) to 1) evaluate the history of air start-related malfunctions in MD-80 airplanes to determine if changes to the cockpit warning system are warranted; 2) ensure that pilots are trained to refrain from interrupting the completion of emergency checklists with nonessential tasks; 3) ensure that MD-80 operators train crews on the interaction of systems involved in engine fire suppression; 4) and 5) ensure that crews are trained to handle multiple emergencies simultaneously; 6) require that crews be trained to prepare the aircraft for an emergency evacuation after a significant event away from the gate; 7) provide flight and cabin crews with the latest guidance on effective communications during emergencies; and 8) require Boeing to establish an interval for servicing an engine component. (NTSB)
media release
08 APR 2009 EU adds airlines from Benin, Kazakhstan, Thailand, and Ukraine to blacklist [to table of contents] The European Commission today adopted the update of the so-called blacklist of airlines that are banned from flying into the European Union due to safety concerns. The Commission has imposed a ban on six airlines from Kazakhstan, one airline certified in Thailand, one additional Ukrainian air carrier and on operations of all carriers certified in Benin. The following carriers are involved: * Air Company Kokshetau, ATMA Airlines, Berkut Air, East Wing, Sayat Air and Starline KZ (Kazakhstan) * One Two Go Airlines (Thailand) * Motor Sich Airlines (Ukraine) * All airlines certified in the Republic of Benin on the basis of the negative results of an audit by the International Civil Aviation Organisation (ICAO). The Commission noted good progress in relation to the measures taken by Angola in order to improve the safety situation. In particular, it took note of the progress report drawn up by the aviation authorities of Angola on the implementation of corrective actions following the visit of a team of European experts in February 2008 and the publication of the ICAO safety audit report in October 2008. A report of the visit of a European team of experts to Indonesia in February 2009 showed considerable improvements. The Commission will continue close consultations with the aviation authorities with a view to re-assessing the safety situation at the next meeting of the Air Safety Committee. (EU)
press release
11 APR 2009 FAA issues emergency AD on Rolls-Royce AE 3007A series turbofan engines [to table of contents] The FAA issued an emergency airworthiness directive (AD)regarding Rolls-Royce AE 3007A series turbofan engines. This emergency AD results from additional reports of cracks in the HPT stage 2 wheels identified from the required inspections of previous ADs. A revised risk assessment that includes these additional reports indicated that a higher inspection rate was required. This emergency AD also addresses a group of low utilization engines above 16,350 CSN that might not yet have been inspected. This condition, if not corrected, could result in a possible uncontained failure of the HPT stage 2 wheel and damage to the airplane. The AE3007 engines are used amongst other on several Embraer RJ series aircraft. (FAA)
Emergency AD 2009-08-51
14 APR 2009 ANSV Italy investigates 737-800 landing on taxiway at Cagliari [to table of contents] The Italian accident ingvestigation board ANSV launched an investgation into a serious incident at Cagliari-Elmas Airport (CAG/LIEE). On April 12, a Boeing 737 landed on a taxiway after a flight from Girona. The airplane involved was EI-DCE, operated by Ryanair. The main runway had reopened April 8 after having been NOTAMed closed from 20 December 2007 to 8 April 2009. During that period, the taxiway was used as runway. (ANSV)
press release
16 APR 2009 AAIB: final report on Boeing 777 eletrical fire event [to table of contents] The AAIB released their final report of the invesigation into a accident involving a United Air Lines Boeing 777 at London-Heathrow in February 2007. The accident occurred during engine start after pushback from the stand. After the right generator came online an electrical failure occurred in the right main bus. The failure resulted in severe internal arcing and short circuits inside the two main power contactors of the right main bus. The heat generated during the failure resulted in the contactor casings becoming compromised, causing molten metal droplets to fall down onto the insulation blankets below. The insulation blankets ignited and a fire spread underneath a floor panel to the opposite electrical panel (P205), causing heat and fire damage to structure, cooling ducts and wiring. The flight crew responded to the bus failure and a burning smell by shutting down the right engine and taxiing to a nearby stand. The Airfield Fire Service attended the aircraft when it arrived on stand and entered the Main Equipment Centre where they discovered significant smoke but no fire. The passengers were evacuated uneventfully via steps. CAUSAL FACTORS: 1. An internal failure of the Right Generator Circuit Breaker or Right Bus Tie Breaker contactor on the P200 power panel inside the Main Equipment Centre resulted in severe internal arcing and short-circuits which melted the contactor casings. The root cause of contactor failure could not be determined. 2. The open base of the P200 power panel allowed molten metal droplets from the failed contactors to drop down onto the insulation blankets and ignite them. 3. The aircraft’s electrical protection system was not designed to detect and rapidly remove power from a contactor suffering from severe internal arcing and short-circuits. 4. The contactors had internal design features that probably contributed to the uncontained failures. (AAIB)
AAIB Report 2/2009
19 APR 2009 Seven people face criminal charges after fatal 2007 French Polynesia plane crash [to table of contents] A French prosecutor has opened a criminal case against seven people over the 2007 fatal crash of an Air Moorea DHC-6 Twin Otter in French Polynesia. Six employees of Air Moorea and the former head of French Polynesia’s civil aviation administration are to be probed for alleged involuntary homicide. A BEA accident investigation found that the pilot lost control of the plane after the rupture of the elevator pitch-up control cable.. (Radio New Zealand International) 23 APR 2009 CAA publishes report on cabin crew fire training [to table of contents]
The U.K. CAA published the findings of an independent study it commissioned to review the current and future fire training needs of cabin crew. Twenty-four recommendations are made which are subjected to a pre-regulatory impact assessment. (CAA)
CAA Paper 2009/01
23 APR 2009 NTSC Indonesia releases preliminary report on BAe-146 collision with terrain [to table of contents] According to preliminary findings released by the Indonesian NTSC, the BAe-146 aircraft crashed while on a cargo flight to Wamena, April 9, 2009. The airplane was observed to make an approach to runway 15 at Wamena and then conducted a go around from a low height over the runway. The aircraft climbed to a low height along the extended centreline to the south east, before making a right turn onto a right downwind leg of the circuit. Witnesses observed the aircraft continuing on the right downwind at a lower than normal circuit height. They lost sight of the aircraft when it was passing a late downwind position. It subsequently made a right turn, presumably onto a right base leg and flew through the extended centreline. The aircraft subsequently impacted Pikei Hill on Tengah Mountain. At the time of the accident there was haze and broken cloud; base 300 meters. (NTSC)
KNKT 09.12.04.01
23 APR 2009 NTSC Indonesia releases preliminary report on MD-90 runway excursion [to table of contents] The Indonesian NTSC released their preliminary findings of their investigation into the landing accident at Jakarta involving a MD-90 aircraft March 9, 2009. During the approach to runway 25L, the weather conditions at the airport were reported as wind 200 degrees at 20 knots, visibility 1,500 meters, and rain. Based on this information, the captain decided to take over control from the co-pilot for the landing. The captain later reported that he had the runway in sight passing through 1,000 feet on descent, so disengaged the auto pilot at 400 feet. At about 50 feet the aircraft drifted to the right and the captain initiated corrective action to regain the centreline. The aircraft touched down to the left of the runway 25 centerline and then commenced to drift to the right. The captain reported that he immediately commenced corrective action by using thrust reverser, but the aircraft increasingly crabbed along the runway with the tail to the right of runway heading. The aircraft stopped at 08:35 on the right side of runway 25L, 1,095 meters from the departure end of the runway on a heading of 152 degrees; 90 degrees from the runway 25L track. The main landing gear was off the sealed runway surface and the nose gear was on the runway. The aircraft’s right landing light was found at 45 meters from the runway 25L threshold mark, and the right outer wing had scratches that indicated that it had contacted the runway surface. (NTSC)
KNKT 09.08.03.02
28 APR 2009 Dutch Safety Board releases preliminary report on Turkish B737 accident [to table of contents] The Dutch Safety Board released their preliminary report on their investigation into the fatal accident involving a Turkish Airlines Boeing 737-800 near Amsterdam Airport. (Dutch Safety Board)
Preliminary Report
30 APR 2009 ATSB: preliminary report on A340-500 tail strike accident at Melbourne [to table of contents] The Australian Transport Safety Bureau (ATSB) released its Preliminary Factual report into the tail strike involving Airbus A340-500, A6-ERG, during takeoff at Melbourne Airport at approximately 10:31 PM on the evening of 20 March 2009. The aircraft was being operated on a scheduled passenger flight from Melbourne to Dubai in the United Arab Emirates. It was determined that during the take-off roll on runway 16, the captain called for the first officer to rotate (lift off). However, when the aircraft was slow to respond, the captain commanded and applied maximum take-off thrust (TOGA). The aircraft's tail struck the runway and the aircraft lifted off shortly afterwards. During the take-off, the aircraft's tail contacted the ground beyond the end of the runway and a number of airport landing aids came into contact with the aircraft. After becoming airborne, the flight crew received a cockpit message that a tail strike had occurred and so they contacted Air Traffic Control (ATC) and requested a return to Melbourne. The aircraft was radar vectored by ATC over Port Philip Bay to dump fuel to reduce the aircraft's weight for landing. While reviewing the aircraft's performance documentation in preparation for landing, the crew noticed that an incorrect weight had been inadvertently entered into the laptop when completing the take-off performance calculation prior to departure. The performance calculations were based on a take-off weight that was 100 tonnes below the actual take-off weight of the aircraft. The result of that incorrect take-off weight was to produce a thrust setting and take-off reference speeds that were lower than those required for the aircraft's actual weight. During the return to land at Melbourne, a cabin crew member reported smoke in the cabin. The aircraft subsequently landed safely at 11:36 PM and was able to be taxied to the terminal where the passengers were disembarked. There were no reported injuries. Damage to the aircraft included abraded skin to the rear, lower fuselage and damage to the rear pressure bulkhead. There was also damage to a fixed approach light, an instrument landing system (ILS) monitor antenna and the ILS localiser antenna. (ATSB)
ATSB AO-2009-012
