01 OCT - NTSB issues safety recommendations on bird strikes and charter ops
01 OCT - ANSV Italy issues urgent recommendation following 737NG engine flameouts
02 OCT - NTSB recommendations target on-condition maintenance programs
07 OCT - AIBN releases report on DHC-8 heavy landing accident
08 OCT - FAA announces serious runway incursions down by 50 percent
08 OCT - AAIB UK issues safety recommendations after Jetstream 41 icing incident
13 OCT - EASA issues emergency AD requiring A330/A340 hydraulic system inspection
15 OCT - FAA proposes $5.4 million civil penalty for US Airways
15 OCT - FAA proposes $3.8 million penalty against United Airlines
16 OCT - NTSC Indonesia releases preliminary report on fatal DHC-6 accident
16 OCT - NTSC Indonesia releases preliminary report on DO-328 runway excursion
26 OCT - Southwest Airlines settles lawsuit with investors for $3.5M over safety problems
28 OCT - FAA revokes pilot licenses after overflying their destination airport

01 OCT 2009 NTSB issues safety recommendations on bird strikes and charter ops [to table of contents]
On March 4, 2008, a Cessna 500 Citation entered a steep descent and crashed after colliding in flight with a flock of large birds about 2 minutes after takeoff from Oklahoma City-Wiley Post Airport (PWA). Following its investigation the National Transportation Safety Board issued ten new safety recommendations. These include recommendations for: - the revision of bird-strike certification requirements; - airports compliance with the requirements to perform wildlife hazard assessments; - aircraft-specific guidance information for minimizing the severity of aircraft damage sustained during a bird strike; - reporting of all wildlife strikes; - inclusion of the operator and operating rules in flight plans; - issuance of a written document that expressly describes the terms of carriage by Part 135 on-demand operators; - improving FAA on-site inspector surveillance to detect improper charter operations; In addition, the NTSB reiterated a safety recommendation to require all operators of aircraft equipped with a CVR make sure the CVR is functioning (A-06-23). (NTSB)
NTSB Safety Recommendations A-09-72 through -81

01 OCT 2009 ANSV Italy issues urgent recommendation following 737NG engine flameouts [to table of contents]
The Italian Air Safety Board, ANSV, issued an urgent safety recommendation to the U.S. Federal Aviation Administration (FAA) and European Aviation Safety Agency (EASA). On June 13, 2009 a Boeing 737-700 airplane suffered an engine flameout while crossing 2500 feet on approach to Firenze (Florence) Airport, Italy. The engine was restarted in-flight and the airplane landed safely. The root of the problem was identified in the bleed air check valve stuck in the open position. The valve is designed to prevent reverse flow from 9th stage into the 5th stage of the High Pressure Compressor. The investigators leared that in just over a year, the 737 NG fleet has experienced five engine shutdowns that were all caused by the 5th stage bleed air check valve stuck in the open or partially open position. The ANSV classified this as a serious incident and issued an urgent safety recommendation on October 1, 2009. ANSV based on previous considerations, recommends Federal Aviation Administration (FAA) and European Aviation Safety Agency: - to consider requesting Boeing to build-up a pro-active procedure allowing flight crews to identify and manage the event of CFM56-7B22 engines 5th stage bleed air check valve stuck in the open position (ANSV-6/625-09/1/I/09); - to verify the on-going manufacturer investigation process on the involved P/N, in order to determine if the failure is associated with the design of the part or with a production deviation occurrence which affects a limited number of Serial numbers. Furthermore to ensure that the affected parts are replaced either if they are identified to belong to a specific batch or if is a fleet wide problem (ANSV-71625-0912/1/09). (ANSV)
Safety recommendation

02 OCT 2009 NTSB recommendations target on-condition maintenance programs [to table of contents]
On November 8, 2005, an Embraer 110P1 crashed into a department store garden center shortly after takeoff from Manchester-Boston Regional Airport (MHT), NH. The airplane was destroyed, and the certificated airline transport pilot was seriously injured. The accident occurred following a loss of power to the left engine. The NTSB determined that the probable cause of this accident was the pilot’s misapplication of flight controls following an engine failure. Contributing to the accident was the failure of the sun gear, which resulted in the loss of engine power. Contributing to the sun gear failure were the engine manufacturer’s grandfathering of previously recommended, but less reliable, maintenance standards, the Federal Aviation Administration’s (FAA) acceptance of the engine manufacturer’s grandfathering, the operator’s inadequate maintenance practices, and the FAA’s inadequate oversight of the operator. As a result, the NTSB issued four safety recommendations to the FAA: - Require all operators of PT6A-34, -35, and -36 engines, including those using on- condition maintenance programs, to incorporate the reliability standards, particularly those concerning life-limited components, noted in the most current service bulletin into their engine maintenance programs. (A-09-108); - Evaluate the effectiveness of the Portland Flight Standards District Office’s surveillance of maintenance programs and implement necessary changes so that inadequate maintenance programs are identified and improved. (A-09-109); - Resolve the differences between Advisory Circular (AC) 120-17A and AC 120-16E in regard to Federal Aviation Administration philosophy and use of on-condition maintenance programs. (A-09-110); - Once the differences noted in Safety Recommendation A-09-110 are resolved, review existing on-condition maintenance programs to ensure that they are compatible with the most current accepted philosophy. (A-09-111) (NTSB)
Safety Recommendations A-09-108/-111

07 OCT 2009 AIBN releases report on DHC-8 heavy landing accident [to table of contents]
The Norwegian Accident Investigation Board released its final report following their investigation into the hard landing accident involving a DHC-8 in 2005. During the approach to Hammerfest, Norway the crew was informed about variable and occasional gusty wind from south-east. The wind direction favoured runway 23 and the crew planned the landing accordingly. The copilot was Pilot Flying (PF) and the commander was Pilot Not Flying (PNF). The copilot was newly hired and was flying under supervision. The crew was kept updated on the wind conditions by the AFIS operator, and at times the gusty wind conditions favoured runway 05. The copilot left the control to the commander who continued the approach to runway 05. Just before landing the wind direction veered to the right and increased in strength, resulting in a significant tail wind component. This resulted in a marked increase in the descent rate which the commander tried to stop by advancing to full power. However, the altitude was too low and the airplane touched down hard just inside the runway edge on runway 05. At touch down the right main landing gear leg failed. The airplane slid on the belly, right partly retracted main wheel and wing tip for some 650 m, and stopped just after the second (TWY B) turnoff to the apron. The fire and rescue vehicles were quickly at the scene and sprayed foam on the plane to prevent fire. The cabin attendant calmed the passengers who wanted to get out of the plane quickly due to smoke and burned smell in the cabin. It took 33 seconds from the commander's order to evacuate until this was actually initiated. The delay was mainly caused by the fact that the order did not get through the cabin’s Public Address (PA) system. The investigations show that Widerøe permitted landings in up to the maximum demonstrated cross wind component of 36 kt and in up to 10 kt tail wind during short field operations. (AIBN)
AIBN SL 2009/22

08 OCT 2009 FAA announces serious runway incursions down by 50 percent [to table of contents]
The U.S. Federal Aviation Administration (FAA) announced that serious runway incursions were down 50 percent for the most recent 12-month period compared to the previous year. There were 12 serious incursions in fiscal year 2009 which ended Sept. 30, with only two involving commercial carriers, compared to 25 such events in fiscal year 2008, with nine involving commercial carriers. A runway incursion occurs when something or someone intrudes on a runway without authorization. A serious incursion is one in which a collision was narrowly avoided, or there was a significant potential for collision that resulted in the need to take quick corrective action. (FAA)
press release

08 OCT 2009 AAIB UK issues safety recommendations after Jetstream 41 icing incident [to table of contents]
AAIB UK issued two safety recommendations following their investigation into an icing incident involving a Jetstream 41. The aircraft departed Aberdeen in snow and freezing conditions, but had not been de-iced and anti-iced appropriately. During the climb the elevator became jammed by ice. The crew used changes in power and higher forces on the elevator controls to gain sufficient control to descend into warmer air, where the ice melted. The investigation also identified that the commander’s fitness to fly, coupled with pressures he may have felt to operate the flight, may have been contributory factors in the incident. Safety Recommendation 2009-077 It is recommended that BAE Systems review the emergency and abnormal checklist for the Jetstream 41 aircraft to ensure that it includes adequate instruction and advice for flight crews who encounter in-flight control problems associated with airframe ice. Safety Recommendation 2009-078 It is recommended that BAE Systems review the advice contained in the emergency and abnormal checklist concerning flap extension following failure of the aircraft’s ice protection systems, or when ice is present on the airframe, to ensure that advice and instruction relating to flap extension is optimized for safety. (AAIB)
AAIB Bulletin: 10/2009

13 OCT 2009 EASA issues emergency AD requiring A330/A340 hydraulic system inspection [to table of contents]
The European Aviation Safety Agency (EASA) issued an Emergency Airworthiness Directive (AD) requiring a hydraulic power – high pressure manifold check valve inspection on Airbus A330 and A340 models. An A330 operator experienced a low level of the Yellow hydraulic circuit due to a loose of check valve part number (P/N) CAR401. During the inspection on the other two hydraulic systems, the other three CAR401 check valves were also found to be loose with their lock wire broken in two instances. A340 aeroplanes are also equipped with the same high pressure manifold check valves. Investigations are on-going to determine the root cause of this event. Additional cases of CAR401 check valve loosening have been experienced in service on aeroplanes having accumulated more than 1 000 flight cycles (FC). The check valve fitted on the Yellow hydraulic system is more affected, probably due to additional system cycles induced by cargo door operation. The loss of torque due to pressure cycles could contribute to check valve loosening, resulting in a leak and finally the loss of the associated hydraulic system and, in the worst case, of the three hydraulic systems of the aeroplane. This AD requires to perform the following inspection programme to detect any check valve loosening and, if necessary, apply the associated corrective actions: 1st Step: on yellow and blue hydraulic circuits: lock wire inspection, inspection for traces of seepage or black deposit, check valve torque and red marking application. 2nd Step: on green hydraulic circuit: same inspections as required in 1st Step and on yellow and blue hydraulic circuits: inspection of check valves for condition. Finally: on green, yellow and blue hydraulic circuits: repetitive inspection of check valves for condition. (EASA)
EASA AD No.: 2009 - 0223-E

15 OCT 2009 FAA proposes $5.4 million civil penalty for US Airways [to table of contents]
The U.S. Federal Aviation Administration (FAA) has proposed a $5.4 million civil penalty against US Airways for allegedly operating eight aircraft on a total of 1,647 flights from October 2008 to January 2009 while not in compliance with certain Airworthiness Directives (ADs) or the airline’s maintenance program. The FAA found the following AD non-compliance issues: * US Airways, Inc. operated one Embraer 190 aircraft on 19 flights from October 22, 2008 to October 26, 2008 while the aircraft was not in compliance with an AD that required inspections to prevent a cargo door from opening during flight. * The airline failed to perform inspections required by an AD for cracking of a landing gear part on one Airbus A320. The airline operated the aircraft on 26 flights from November 2, 2008 to January 20, 2009 while not in compliance with the AD. The airline also operated another A320 for 17 flights from December 3, 2008 to January 21, 2009 while not in compliance with the same AD. The FAA found the following problems with maintenance practices: * US Airways, Inc. failed to meet the requirements of its Maintenance Policies and Procedures Manual, which required inspections related to engine work on a Boeing 757 aircraft. The airplane was flown on 505 flights from May 2, 2008 to December 3, 2008. * From October 20, 2008 to November 14, 2008, US Airways, Inc. operated one Boeing 767 aircraft on 51 flights after failing to perform the inspections, tests, and samplings required by its maintenance program on that aircraft. * From October 1, 2008 to November 24, 2008, US Airways, Inc. operated one Boeing 757 aircraft on 121 flights without proper maintenance. * The airline failed to follow its maintenance program and perform a weekly maintenance check for one Boeing 767 aircraft, which was then operated from November 2, 2008 to November 6, 2008 on 53 flights. * From May 22, 2008 to January 13, 2009, US Airways, Inc. operated one Airbus A320 aircraft on 855 flights while the aircraft did not meet the airline’s maintenance program requirements for an engine repair. US Airways, Inc. could have deferred maintenance of this item for ten days under its maintenance program but failed to do so. Fifty-one of the flights occurred after the FAA, on December 31, 2008, brought the problem to the airline’s attention. US Airways, Inc. has 30 days from the receipt of the civil penalty letter to respond to the FAA. (FAA)
press release

15 OCT 2009 FAA proposes $3.8 million penalty against United Airlines [to table of contents]
The U.S. Federal Aviation Administration (FAA) is proposing a $3.8 million civil penalty against United Airlines for allegedly operating one of its Boeing 737 aircraft on more than 200 flights after the carrier had violated its own maintenance procedures on one of the plane’s engines. On April 28, 2008, a United 737 returned to Denver after shutting down an engine due to low oil pressure indications. During teardown of the engine a week later, United mechanics found that two shop towels, instead of required protective caps, had been used to cover openings in the oil sump area when maintenance was done in December 2007. As a result of United’s failure to follow its maintenance procedures, between February 10 and April 28, 2008 it flew the aircraft on more than 200 revenue flights when it was not in an airworthy condition. United’s maintenance procedures specifically require use of protective caps or covers on all components that could be adversely affected by entry of foreign materials. United has 30 days from the receipt of the civil penalty letter to respond to the FAA. (FAA)
press release

16 OCT 2009 NTSC Indonesia releases preliminary report on fatal DHC-6 accident [to table of contents]
The Indonesian accident investigating agency, NTSC, released a preliminary report on the fatal accident of a DHC-6 Twin Otter, August 2, 2009. A Merpati Nusantara Airlines DHC-6 Twin Otter passenger plane was destroyed when it flew into the side of a mountain during a domestic flight from Jayapura (DJJ) to Oksibil Airport (OKL). Merpati Flight MZ9760D took off at 10:15 with an estimated time of arrival at Oksibil of 11:05. The flight was reported missing and a search was initiated. The wreckage was located August 4 on a mountainside at an elevation of 9300 feet. (NTSC)
KNKT.09.08.21.04

16 OCT 2009 NTSC Indonesia releases preliminary report on DO-328 runway excursion [to table of contents]
The Indonesian accident investigating agency, NTSC, released a preliminary report on the non-fatal accident of a Dornier 328 on June 14, 2009. During the landing roll the aircraft diverged abruptly to the right. The aircraft left the runway and stopped on the shoulder of the runway. The right wheels sank into the soft ground of the runway shoulder. The right propeller blades fractured as they struck the ground and the propeller assembly was torn from the engine. (NTSC)
KNKT/09.16.04.05

26 OCT 2009 Southwest Airlines settles lawsuit with investors for $3.5M over safety problems [to table of contents]
Southwest Airlines has reached a $3.5 million settlement with investors who filed a lawsuit. Investors filed a lawsuit in August 2008, a few months after the FAA proposed a civil penalty for failing to comply with an Airworthiness Directive (AD) that required repetitive inspections of certain fuselage areas to detect fatigue cracking. The investors, including Carbon County, Pennsylvania, and Employee Retirement System, contended that Southwest officials breached their fiduciary duties by allowing the airline to fail to meet FAA safety standards. AboutLawsuits.com reports that a hearing is scheduled for December 9 before state District Judge Carlos Cortez for approval of the settlement. (AboutLawsuits.com)

28 OCT 2009 FAA revokes pilot licenses after overflying their destination airport [to table of contents]
The Federal Aviation Administration has revoked the licenses of two Northwest Airlines pilots who overflew their destination airport on October 21, 2009 while operating Flight 188 from San Diego to Minneapolis. The pilots were out of contact with air traffic controllers for an extended period of time and told federal investigators that they were distracted by a conversation. Air traffic controllers and airline officials repeatedly tried to reach them through radio and data contact, without success. The emergency revocations cite violations of a number of Federal Aviation Regulations. Those include failing to comply with air traffic control instructions and clearances and operating carelessly and recklessly. The revocations are effective immediately. The pilots have 10 days to appeal the emergency revocations to the National Transportation Safety Board. (FAA)
Press Release

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