Aviation Safety Network News

ATSB: investigation update on A330 in-flight upset

Wed, 18 Nov 2009 08:00:00 GMT

18 NOV 2009
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: investigation update on Boeing 747 depressurisation accident

Tue, 17 Nov 2009 08:00:00 GMT

17 NOV 2009
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)

TV stations to crash and film an empty passenger plane

Fri, 13 Nov 2009 08:00:00 GMT

13 NOV 2009
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)

AAIB: TOPMS recommendations after A330 takeoff performance incident

Fri, 13 Nov 2009 08:00:00 GMT

13 NOV 2009
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)

Dutch safety commission: closer cooperation with Public Prosecutor

Wed, 11 Nov 2009 08:00:00 GMT

11 NOV 2009
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)

UAE to develop blacklist and new regulations for foreign airlines

Wed, 11 Nov 2009 08:00:00 GMT

11 NOV 2009
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)

TSB Canada releases final report on Bombardier Global 5000 accident

Tue, 10 Nov 2009 08:00:00 GMT

10 NOV 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)

Brazil releases final report on Congonhas A320 runway excursion accident

Sun, 1 Nov 2009 07:00:00 GMT

01 NOV 2009
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)

FAA revokes pilot licenses after overflying their destination airport

Wed, 28 Oct 2009 07:00:00 GMT

28 OCT 2009
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)

Southwest Airlines settles lawsuit with investors for $3.5M over safety problems

Mon, 26 Oct 2009 07:00:00 GMT

26 OCT 2009
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)

NTSC Indonesia releases preliminary report on fatal DHC-6 accident

Fri, 16 Oct 2009 07:00:00 GMT

16 OCT 2009
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)

NTSC Indonesia releases preliminary report on DO-328 runway excursion

Fri, 16 Oct 2009 07:00:00 GMT

16 OCT 2009
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)

FAA proposes $5.4 million civil penalty for US Airways

Thu, 15 Oct 2009 07:00:00 GMT

15 OCT 2009
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)

FAA proposes $3.8 million penalty against United Airlines

Thu, 15 Oct 2009 07:00:00 GMT

15 OCT 2009
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)