Aviation Safety Network News

AAIB: final report on B777 loss of engine power and crash-landing

Tue, 9 Feb 2010 08:00:00 GMT

09 FEB 2010
The UK Air Accidents Investigation Branch (AAIB) released the final report of their investigation into the accident involving a Boeing 777 at London-Heathrow Airport in January 2008. Whilst on approach to London (Heathrow) from Beijing, China, at 720 feet agl, the right engine of the B777 ceased responding to autothrottle commands for increased power and instead the power reduced to 1.03 Engine Pressure Ratio (EPR). Seven seconds later the left engine power reduced to 1.02 EPR. This reduction led to a loss of airspeed and the aircraft touching down some 330 m short of the paved surface of Runway 27L at London Heathrow. The investigation identified that the reduction in thrust was due to restricted fuel flow to both engines. It was determined that this restriction occurred on the right engine at its FOHE. For the left engine, the investigation concluded that the restriction most likely occurred at its FOHE. However, due to limitations in available recorded data, it was not possible totally to eliminate the possibility of a restriction elsewhere in the fuel system, although the testing and data mining activity carried out for this investigation suggested that this was very unlikely. Further, the likelihood of a separate restriction mechanism occurring within seven seconds of that for the right engine was determined to be very low. The investigation identified the following probable causal factors that led to the fuel flow restrictions: 1) Accreted ice from within the fuel system released, causing a restriction to the engine fuel flow at the face of the FOHE, on both of the engines. 2) Ice had formed within the fuel system, from water that occurred naturally in the fuel, whilst the aircraft operated with low fuel flows over a long period and the localised fuel temperatures were in an area described as the �sticky range�. 3) The FOHE, although compliant with the applicable certification requirements, was shown to be susceptible to restriction when presented with soft ice in a high concentration, with a fuel temperature that is below -10�C and a fuel flow above flight idle. 4) Certification requirements, with which the aircraft and engine fuel systems had to comply, did not take account of this phenomenon as the risk was unrecognised at that time. (AAIB)

Argentine: Six acquitted in LAPA crash trial

Wed, 3 Feb 2010 08:00:00 GMT

03 FEB 2010
An Argentine court acquitted the president of LAPA, three executives and two former air force officials following a two-year trial. On Aug. 31, 1999, a Boeing 737 operated by LAPA crashed on take off from Buenos Aires-Aeroparque (AEP), killing 64 people. The former director of operations and 737 line manager of LAPA received three-year suspended sentences. (Beunos Aires Herald, Clar�n)

NTSB: Captain�s inappropriate actions led to crash of flight 3407

Wed, 3 Feb 2010 08:00:00 GMT

03 FEB 2010
In February 2009, a Colgan Air DHC-8-400 crashed into a residence in Clarence Center, New York while on approach to Buffalo. Fifty people were killed. The National Transportation Safety Board (NTSB) determined that the captain of Colgan Air flight 3407 inappropriately responded to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover. In a report adopted today additional flight crew failures were noted as causal to the accident. The report states that, when the stick shaker activated to warn the flight crew of an impending aerodynamic stall, the captain should have responded correctly to the situation by pushing forward on the control column. However, the captain inappropriately pulled aft on the control column and placed the airplane into an accelerated aerodynamic stall. Contributing to the cause of the accident were the crewmembers� failure to recognize the position of the low-speed cue on their flight displays, which indicated that the stick shaker was about to activate, and their failure to adhere to sterile cockpit procedures. Other contributing factors were the captain�s failure to effectively manage the flight and Colgan Air�s inadequate procedures for airspeed selection and management during approaches in icing conditions. As a result of this accident investigation, the Safety Board issued recommendations to the Federal Aviation Administration (FAA) regarding strategies to prevent flight crew monitoring failures, pilot professionalism, fatigue, remedial training, pilot records, stall training, and airspeed selection procedures. Additional recommendations address FAA�s oversight and use of safety alerts for operators to transmit safety-critical information, flight operational quality assurance (FOQA) programs, use of personal portable electronic devices on the flight deck, and weather information provided to pilots. (NTSB)

FAA proposes nearly $2.5 million civil penalty against American Eagle Airlines

Mon, 1 Feb 2010 08:00:00 GMT

01 FEB 2010
The U.S. Federal Aviation Administration (FAA) has proposed a civil penalty totaling almost $2.5 million against American Eagle Airlines for operating flights without adequately ensuring the weight of baggage was properly calculated. The FAA alleges that between January and October 2008, American Eagle conducted at least 154 passenger-carrying flights when the baggage weight listed on airplane cargo load sheets disagreed with data entered into the company�s Electronic Weight and Balance System. Entry of erroneous data into the weight and balance system results in an incorrect computation of the weight and balance of a particular aircraft. This can potentially lead to faulty calculations for the proper control settings and reference speeds necessary for safe takeoffs and landings. The FAA alleges that after the situation was brought to the attention of American Eagle, the company operated at least 39 flights without correcting the problem. After the FAA�s initial investigation, American Eagle took corrective action by revising its Station Operating Manual to ensure that proper weight and balance information is confirmed, pending automation of its cargo load sheets. However, the violations resulted in a proposed civil penalty of $2,475,000. American Eagle has 30 days from the receipt of the FAA�s civil penalty letter to respond to the agency. (FAA)

Mutsinzi Report published on the Rwandan Presidential plane crash in 1994

Wed, 13 Jan 2010 08:00:00 GMT

13 JAN 2010
An official Rwandan committee published their findings on the crash of a Falcon 50 in 1994 that killed President Habyarimana. The "Committee of Experts Investigation of the April 6, 1994 Crash of President Habyarimana�s Dassault Falcon-�50 Aircraft" was created via prime ministerial decree in April 2007. The incident holds tremendous historical significance since it kicked off a long-planned genocide that claimed the lives of over one million people in one hundred days. It was concluded that the airplane crashed after being hit by at least one missile. The missiles were fired by the Anti�-Aircraft Battalion located near the Kigali Airport. The assassination was the work of Hutu extremists who calculated that killing their own leader would torpedo a power-sharing agreement known as the Arusha Accords. (The Mutsinzi Report)

NTSB: new accident, incident reporting rules

Tue, 12 Jan 2010 08:00:00 GMT

12 JAN 2010
The NTSB is amending its regulations concerning notification and reporting requirements regarding aircraft accidents or incidents. The final rule was published January 7, 2010 and will become effective March 8, 2010. In particular, the NTSB is adding regulations to require operators to report certain incidents to the NTSB. The NTSB is also amending existing regulations to provide clarity and ensure that the appropriate means for notifying the NTSB of a reportable incident is listed correctly in the regulation. (Federal Register)

UAE starts incident-reporting program

Mon, 4 Jan 2010 08:00:00 GMT

04 JAN 2010
The General Civil Aviation Authority (GCAA) of the UAE launched an air safety incident-reporting program, the Reporting of Safety Incident (ROSI) Program, on 1 January 2010 as part of its new mandate to centralise aviation safety incident reporting across the UAE. Ismaeil Mohammed Al Balooshi, Director Aviation Safety at the GCAA said: "Along with high levels of growth and expansion comes increased challenges that require effective regulatory responses. The introduction of a centralised air safety incident reporting program will contribute to our efforts in maintaining a successful aviation transport safety record as a country, it will also allow us to monitor trends in the reports which will help in identifying possible risks to the safety of aviation in the UAE." (GCAA)

FAA stepping up oversight of American Airlines

Sun, 3 Jan 2010 08:00:00 GMT

03 JAN 2010
Wall Street Journal reports that the U.S. FAA is intensifying the oversight of American Airlines' operations. This decision was taken following three landing mishaps over an eleven-day period. On December 13 the wingtip of an MD-82 struck the runway on landing at Charlotte (CLT). Then on December 22 a Boeing 737-800 overran the runway at Kingston, Jamaica. The latest incident involved an MD-80 whose wingtip struck the ground while landing in Austin, Texas, on December 24. (Wall Street Journal)

Interim report on SA Airlink Jetstream 41 accident after engine failure

Wed, 23 Dec 2009 08:00:00 GMT

23 DEC 2009
CAA South Africa (SACAA) released the first interim report of the investigation into the cause of an accident involving a Jetstream 41 aircraft shortly after take off from Durban International Airport on 24 September 2009. The captain died as a reslt of his injuries. Shortly before it became airborne on a positioning flight, a catastrophic failure occurred in the nr.2 (right hand) engine due to a fatigue failure of the second stage rotating air seal. It continued to climb to an altitude of about 500 feet AMSL. Immediately after raising the undercarriage, the nr.1 engine spooled down from 100% to zero within 7 seconds. The airplane then made a forced landing in a small field within the Merebank residential area. (SACAA)

Interim report on SA Airlink Embraer 135 runway excursion accident

Wed, 23 Dec 2009 08:00:00 GMT

23 DEC 2009
CAA South Africa (SACAA) released the first interim report of the investigation into the cause of an accident involving an Embraer 135 aircraft shortly on landing at George Airport on 7 December 2009. The prevailing weather conditions at the time were overcast in light rain. The aircraft touched down in the area of the fourth landing marker. At the end of the runway veered to the right and went past the ILS localizer. The aircraft collided with eleven approach lights before it burst through the aerodrome perimeter fence, with the aircraft coming to rest in a nose down attitude on a public road. (SACAA)

Report released on BN-2A Islander CFIT accident in Vanuatu

Sat, 19 Dec 2009 08:00:00 GMT

19 DEC 2009
TAIC New Zealand released the final report on their investigation into the fatal CFIT accident involving a BN-2A Islander in Vanuatu, December 2008. TAIC carried out the investigation on behalf of the Civil Aviation Authority of Vanuatu (CAAV). The aeroplane was overloaded by at least 7%, which affected its climb performance and made it unlikely that it would be able to cross the final ridge without deviating from the path flown by the pilot. (TAIC)

ATSB: investigation update on A340 tailstrike accident

Fri, 18 Dec 2009 08:00:00 GMT

18 DEC 2009
The Australian Transport Safety Bureau (ATSB) released its Interim Factual report into the tailstrike involving Airbus A340-500 aircraft, registered A6-ERG, during takeoff at Melbourne Airport, Vic. 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. The investigation has determined that the pre-flight take-off performance calculations were based on an incorrect take-off weight that was inadvertently entered into the aircraft's portable flight planning computer by the flight crew. Subsequent crosschecks did not detect the incorrect entry and its effect on performance planning, and the resulting take-off speeds and engine thrust settings that were applied by the crew were insufficient for a normal takeoff. As a result of this accident, the aircraft operator has undertaken a number of procedural, training and technical initiatives across its fleet and operations; with a view to minimising the risk of a recurrence. In addition, the aircraft manufacturer has released a modified version of its cockpit performance-planning tool and is developing a software package that automatically checks the consistency of the flight data being entered into the aircraft's flight computers by flight crews. The investigation has found a number of similar take-off performance-related incidents and accidents across a range of aircraft types, locations and operators around the world. As a result, the ATSB has initiated a safety research project to collate those events and examine the factors involved. The findings of that project will be released by the ATSB once completed. Ongoing investigation effort will include the examination of: * computer-based flight performance planning * human performance and organisational risk controls * reduced thrust takeoffs and the use of erroneous take-off performance data. (ATSB)

Ninety warthogs removed from Harare Airport, Zimbabwe after incident

Fri, 18 Dec 2009 08:00:00 GMT

18 DEC 2009
Zimbabwe�s National Parks on Tuesday rounded up 90 warthogs from the Harare International Airport (HRE) after a South African Airways airplane was forced to abort the take off run after the pilots spotted warthogs on the runway. Reportedly two warthogs were hit by the airplane. This was the second occurrence in two months time. On November 3 an Air Zimbabwe MA60 aircraft impacted with warthogs during the take-off roll. The aircraft was about to lift off the ground when it hit the five warthogs. The plane�s nose and left main landing gears collapsed after the impact. The aircraft veered off to the left side of the runway and stopped off the runway with damage on the engine propeller and on the wing tip. The warhogs were able to enter airport grounds due to vandalised parts of the perimeter fence. In other cases the animals dug their way underneath the fences. (The Zimbabwe Telegraph)

UK Ministry of Defence announces new Air Safety Authority

Fri, 18 Dec 2009 08:00:00 GMT

18 DEC 2009
U.K. Defence Secretary Bob Ainsworth announced the creation of a new military airworthiness authority to ensure aviation safety standards are of the highest order at all times. The Military Aviation Authority (MAA) has been created as part of the MOD's full response to the Nimrod Review by Charles Haddon-Cave QC following the deaths of 14 Service personnel onboard Nimrod XV230 on 2 September 2006. The MAA will include an independent body to audit and scrutinise air safety activity. The MAA will be in place by 5 April 2010. The creation of the MAA was one of two key strategic recommendations of Mr Haddon-Cave's report which have both been accepted by the MOD. The other key recommendation is a revised arrangement of safety responsibilities for those personnel charged with ensuring the safe operation of military aircraft. (UK Ministry of Defence)