News
01 NOV - Brazil releases final report on Congonhas A320 runway excursion accident 10 NOV - TSB Canada releases final report on Bombardier Global 5000 accident
11 NOV - Dutch safety commission: closer cooperation with Public Prosecutor
11 NOV - UAE to develop blacklist and new regulations for foreign airlines
13 NOV - TV stations to crash and film an empty passenger plane
13 NOV - AAIB: TOPMS recommendations after A330 takeoff performance incident
17 NOV - ATSB: investigation update on Boeing 747 depressurisation accident
18 NOV - ATSB: investigation update on A330 in-flight upset
01 NOV 2009 Brazil releases final report on Congonhas A320 runway excursion accident [to table of contents]
Brazilian investigators released the final report of their investigation into the accident of TAM Flight 3054. The Airbus A320 landed on a wet runway at Sao Paulo-Congonhas Airport in July 2007. It failed to stop and went off the wet runway, colliding with a building. All 187 occupants were killed, along with twelve people on the ground.
One of the thrust levers was in the Reverse-position, while the other lever was in the forward (thrust) position. It was deemed possible that this occurred because of a mechanical failure, but in a more like scenario the lever was inadvertently positioned forward by the crew. In any case, the crew failed to detect the problem and act accordingly. Factors identified in the report are: lack of crew coordination, co-pilot inexperience, crew pairing, the pilot's headache, pilot's perception of company pressure to avoid landing at alternate airports, crew anxiety regarding the weather and runway condition. (CENIPA)
RF A-67/CENIPA/2009
Citing ineffective oversight by the Canadian Business Aviation Association (CBAA), the Transportation Safety Board of Canada (TSB) has released its final report into the 2007 landing accident in Fox Harbour, Nova Scotia. The accident injured 10 people when the Bombardier Global 5000 private jet skidded off the runway, stopping 1000 feet from its initial touchdown point, close to neighbouring homes. In its investigation, the TSB reported that private operators regulated by the CBAA were not held to the same standard that Transport Canada (TC) implemented for commercial operators. TC regulations require commercial airline companies to implement safety management systems (SMS) in stages, on a fixed timeline, while the CBAA was free to implement SMS for its operators on its own terms with no fixed timeframe. In 2003, TC transferred regulatory responsibility for some aviation operators to the CBAA but prior to this accident failed to exercise effective oversight of the CBAA programs. In two key recommendations, the Board calls for the CBAA to set SMS implementation milestones for its certificate holders and for TC to ensure the CBAA has an effective quality assurance program in place to audit its certificate holders. In the course of the investigation, the TSB also found that many pilots were not aware of the limitations of the visual guidance systems used to conduct safe approaches and landings. These guidance systems, known as visual glide slope indicators (VGSI), use ground-based light beams to show pilots when they are too high or too low on approach but many pilots don't realize that some VGSI should not be used when flying larger aircraft. Information on the distance between the cockpit and the landing gear (eye-to-wheel height) is needed to know which VGSI to use but the Board revealed this information is not readily available to pilots. To address these issues, the Board made two additional recommendations requiring TC to make eye-to-wheel height information available to pilots, and that better training also be provided to them on VGSI so they have the information they need to land safely. (TSB)
TSB Report A07A0134
11 NOV 2009 Dutch safety commission: closer cooperation with Public Prosecutor [to table of contents] A Dutch aviation safety commission recommended a closer cooperation between aviation industry and the the Public Prosecutor. The commission evaluated the Dutch The Mandatory Occurrence Reporting (MOR) Scheme. The commission further recommended to reorganise the "Analysebureau Luchtvaartvoorvallen" (Bureau of Aviation Occurrences Analysis). This Bureau receives and analyses the occurrences. It shoud share its findings with the Dutch aviation industry on a more regular basis. This would increase the willingness to report occurrences. (Ministry of Transport)
press release
11 NOV 2009 UAE to develop blacklist and new regulations for foreign airlines [to table of contents] A strict new licensing regime is being developed by the United Arab Emirates Government to regulate foreign passenger- and cargo airlines to ensure safety and security. The new licensing law will be implemented in 2010. The law will be followed by the publication of a blacklist of airlines that are banned operating in the UAE. (Khaleej Times) 13 NOV 2009 TV stations to crash and film an empty passenger plane [to table of contents]
International tv stations are working together on a documentary "Plane Crash" in which they will deliberatly crash an empty passenger plane. The programme is a co-production between Channel 4, National Geographic Channel, ProSieben Television and ITV Studios Global Entertainment. Two top pilots will board a passenger jet, fly it out over a vast, empty desert, set it on course to crash and parachute from the plane. The plane will be loaded with cameras and sensors, as well as crash test dummies positioned throughout the aircraft. The resulting footage and data will give an insight into what happens when a plane crashes and enable experts to study how areas such as seat belt design, seat arrangement and even overhead baggage can have an impact on passenger safety. (Channel 4)
media release
13 NOV 2009 AAIB: TOPMS recommendations after A330 takeoff performance incident [to table of contents] The AAIB completed their investigation into the serious incident involving an Airbus A330 in October 2008. Due to an error in the takeoff performance calculations, incorrect takeoff speeds were used on departure. On rotation, the aircraft initially failed to become airborne as expected, causing the commander to select TOGA power. The aircraft then became airborne and climbed away safely. Whilst the investigation could not identify the exact source of the error, deficiencies were revealed in the operator’s procedures for calculating performance using their computerised performance tool. A study of previous takeoff performance events showed that the number and potential severity is sufficient to warrant additional safeguards to be identified by industry and to be required by regulators. Two Safety Recommendations are made: Safety Recommendation 2009-080 It is recommended that the European Aviation Safety Agency (EASA) develop a specification for an aircraft takeoff performance monitoring system which provides a timely alert to flight crews when achieved takeoff performance is inadequate for given aircraft configurations and airfield conditions. Safety Recommendation 2009-081 It is recommended that EASA establish a requirement for transport category aircraft to be equipped with a takeoff performance monitoring system which provides a timely alert to flight crews when achieved takeoff performance is inadequate for given aircraft configurations and airfield conditions. (AAIB)
AAIB Bulletin: 11/2009
17 NOV 2009 ATSB: investigation update on Boeing 747 depressurisation accident [to table of contents] The Australian Transport Safety Bureau (ATSB) is continuing its rigorous and comprehensive examination of the circumstances surrounding the failure of an oxygen cylinder that led to the depressurisation of a Boeing 747 on a flight from Hong Kong to Melbourne in July 2008. The ATSB's second interim factual report on this accident indicates that to date there is no evidence of systemic safety problems with oxygen bottles of the type involved in the accident. Various tests have not been able to replicate the cylinder failure that initiated the accident. The report provides details of the wide-ranging and ongoing technical examination of five oxygen cylinders obtained by the ATSB from the same manufacturing lot as the failed cylinder. The original cylinder was lost in the South China Sea in the course of the accident. Analysis of the factual information and findings as to the factors that contributed to the accident remain the subject of ongoing work. Details will be included in the final report of the investigation. To date, all pressure tests of the cylinders met or exceeded the relevant safety specifications, with recorded rupture pressures being over twice the maximum working pressure of the cylinders. Other work is being carried out to determine the minimum size of mechanical flaws that could result in cylinder failure in service. The ongoing ATSB investigation will supplement that work with a program of rupture tests on cylinders that have had various sized 'artificial' flaws machined into the shell. The ATSB expects to conclude the data gathering and analysis aspects of the investigation in early 2010, with a final report to follow. (ATSB)
ATSB AO-2008-053
18 NOV 2009 ATSB: investigation update on A330 in-flight upset [to table of contents] The Australian Transport Safety Bureau (ATSB) has released a second Interim Factual Report into the accident involving the Qantas Airbus A330-303 in-flight upset, 154 km west of Learmonth WA, on 7 October 2008. The report summarises new activities conducted since the first Interim Factual Report that was released on 6 March 2009, and it should be read in conjunction with that previous report. The aircraft was being operated on a scheduled passenger service from Singapore to Perth. While cruising at 37,000 ft, the aircraft experienced two uncommanded pitch-down events. The flight crew were able to quickly return the aircraft to level flight on each occasion and diverted to Learmonth, WA for a safe landing. One flight attendant and 11 passengers were seriously injured, and eight other crew members and at least 99 other passengers received minor injuries. The injury rate and severity of injuries was significantly greater for those passengers who were not seated or not wearing seatbelts at the time of the first in-flight upset. The investigation is still following several lines of inquiry to explain why the ADIRU started providing erroneous data (spikes). In addition, the investigation is continuing to examine various aspects of the flight control primary computer (FCPC or PRIM) software development cycle. The investigation is also continuing to examine the performance of the ECAM and its effectiveness in assisting crews to manage aircraft system problems. (ATSB)
ATSB AO-2008-070
