Aviation Safety Network News

BEA releases interim report on Air France Airbus A330 accident

Thu, 2 Jul 2009 07:00:00 GMT

02 JUL 2009
The French Bureau d'Enqu�tes et d'Analyses (BEA) released an interim report based on the initial evidence gathered in the course of the investigation of the June 2 accident involving an Air France A330. Some of the findings are: * the meteorological situation was typical of that encountered in the month of June in the inter-tropical convergence zone; * there were powerful cumulonimbus clusters on the route of AF447. Some of them could have been the centre of some notable turbulence; * several airplanes that were flying before and after AF 447, at about the same altitude, altered their routes in order to avoid cloud masses; * twenty-four automatic maintenance messages were received between 02:10 and 02:15 via the ACARS system. These messages show inconsistency between the measured speeds as well as the associated consequences; * visual examination showed that the airplane was not destroyed in flight; it appears to have struck the surface of the sea in a straight line with high vertical acceleration. (BEA)

ANSV: premature visual descent below minima at night caused Citation CFIT accide

Thu, 2 Jul 2009 07:00:00 GMT

02 JUL 2009
The Italian ANSV accident board released the final report of their investigation into the CFIT accident involving a Cessna Citation I near Cagliari in February 2004. It was concluded that the airplane descended significantly below the area minimum altitude (AMA), insufficient to maintain the separation from the ground during a night visual approach in the absence of adequate visual reference. Possible contributory factors included: - The aircraft was not equipped with GPWS or TAWS, nor was it required to be by law; - Premature VFR descent after misidentifying lights on the ground as the Elmas runway lights (induced by "black hole approach") - Failure to use published procedures and available instruments under conditions of total darkness; - Read errors of the elevations listed in the maps consulted, facilitated by the non representation of the ground color; - Inadequate rest, which may have contributed to a reduction in the performance of the crew. (ANSV)

NTSB investigating two runway incursions at Cleveland (CLE)

Tue, 30 Jun 2009 07:00:00 GMT

30 JUN 2009
The NTSB is investigating two runway incursions that occurred at Cleveland Hopkins International Airport, OH (CLE). The most recent occurred at 08:56, June 26, 2009. Express Jet flight 2426, an Embraer ERJ-145, was cleared by the tower developmental controller to cross runway 24L at taxiway S in order to depart from runway 24R. Approximately 19 seconds later, the same controller cleared CommutAir flight 8717, a DHC-8, for takeoff on runway 24L. The Express Jet flight crew saw the departing airplane and advised the tower controller they would not cross the runway. CommutAir 8717 rotated about 1,500 feet from where Express Jet 2426 was positioned. The incident is the second of its kind at CLE in three weeks. On June 3, 2009, at 15:15, a runway incursion occurred in which a Boeing 737 was cleared by a developmental controller to taxi into position the same runway on which an Embraer ERJ145 was cleared and entering for take-off. The ERJ145 crew saw the 737 and queried the tower controller. The two flights came within 500 feet of each other on runway 6L. This was the same developmental controller involved in the June 26 incident. (NTSB)

Mexico court ruling: Aviacsa allowed to fly again

Fri, 12 Jun 2009 07:00:00 GMT

12 JUN 2009
Aviacsa resumed operations after winning a court ruling overturning a government order grounding its planes for the second time over safety concerns. The Transportation and Communications Department first grounded Aviacsa's planes June 2, 2009 following inspections. Aviacsa resumed flights four days later after a judge overturned the government's order. On June 11, 2009, the government re-grounded the airline after a federal appeals court reinstated the order. That same day the Fifth District Judge in Ciudad Valles determined that 20 airworthy aircraft of Aviacsa were allowed to resume flight operations. These aircraft are: XA-TTM, XA-TTP, XA-TUK, XA-TVD, XA-TVL, XA-TVN, XA-TWJ, XA-TWV, XA-TYC, XA-TYI, XA-TYO, XA-UAA, XA-UCG, XA-UIU, XA-UIV, XA-UJB, XA-UJC, XA-TWO, XA-NAF, XA-NAV. Meanwhile the U.S. FAA decided to no longer allow Aviacse to operate flights to the United States until safety matters are resolved. (Secretar�a de Comunicaciones y Transportes)

EASA issues emergency AD on BAe Jetstream MLG component issues

Tue, 9 Jun 2009 07:00:00 GMT

09 JUN 2009
BAe Systems have been notified by the main landing gear (MLG) radius rod manufacturer that a batch of incorrectly manufactured Buffer Springs (part number 184818) had been supplied to their parts distributor and MRO facilities in North America. There is a risk that any radius rod fitted with one of these incorrectly manufactured Buffer Springs could jam in an unlocked position. This condition, if not corrected, could result in MLG collapse. EASA thus issued an Emergency AD, requiring the replacement of each affected radius rod with a serviceable unit and allows the installation of the affected radius rods only after the accomplishment of APPH Service Bulletins 1847-32-14 and 1862-32-14. The AD covers HP-137 Jetstream Mk.1, Jetstream 200, 3100 and 3200 models. (EASA)

JTSB issues report on Boeing 767 landing mishap

Thu, 4 Jun 2009 07:00:00 GMT

04 JUN 2009
The Japan Transport Safety Board (JTSB) released their final report of their investigation into the serious incident involving a JAL Boeing 767 at Tokyo-Haneda Airport in June 2005. This incident occurred as the aircraft landed; it is estimated that it bounded on its first touchdown. The nose gear then touched down before the aircraft weight was completely placed on the main landing gears, placing an excessive load on the nose gear, and consequently, damaging the nose gear. Excessive forward operation of the control column was the most significant factor. (JTSB)

Mexican authorities suspends operations of AVIACSA

Wed, 3 Jun 2009 07:00:00 GMT

03 JUN 2009
The Mexican Ministry of Communications and Transport (SCT), through the Directorate General of Civil Aviation (DGCA) has temporarily suspended operations of 25 aircraft of AVIACSA. The measure is a result of recent inspections in which irregularities were detected which represent risks to aviation. Aviacsa will have a period of 60 days, as of June 2, 2009, to correct the deficiencies identified. (Secretar�a de Comunicaciones y Transportes)

Iran defuses homemade bomb on Kish Air plane

Sat, 30 May 2009 07:00:00 GMT

30 MAY 2009
An Iranian Kish Air plane made an emergency landing in Ahvaz after a bomb was found on board shortly after takeoff. Security personnel defused the homemade bomb. The airplane was en route to Tehran. (Reuters)

Nigeria CAA downgrades Kaduna Airport due to inadequate fire services

Fri, 29 May 2009 07:00:00 GMT

29 MAY 2009
Following the brief closure of Kaduna Airport(KAD) two days earlier due to inadequate fire services cover, the Nigeria Civil Aviation Authority (NCAA) downgraded the airport and restricted aircraft movement to the airport. Critical aircraft that are allowed to operate to the airport shall not exceed the size of HS-125-300 category aircraft. Director-General of NCAA, Dr. Harold Demuren, said that the action was taken due to inadequate fire cover at the Kaduna airport, stressing that the Agency had no option than to downgrade the airport�s status of fire service from category seven to category three. (This Day)

FAA proposes $1.3 Million civil penalty for Gulfstream International Airlines

Tue, 26 May 2009 07:00:00 GMT

26 MAY 2009
The U.S. FAA has proposed a $1.3 million civil penalty from Florida-based Gulfstream International Airlines, Inc. for violations of the Federal Aviation Regulations. The alleged violations include improper scheduling of flight crew duty time, and the installation of unapproved air conditioner compressors and improperly maintained vent blowers on the airline's fleet of 27 Beechcraft 1900D aircraft. An FAA review of the airline's electronic record-keeping system for tracking crew duty and rest time revealed that Gulfstream International did not accurately input the proper data from its manually generated hard-copy aircraft logbook records into the electronic system. The discrepancies resulted in scheduling crew members in excess of daily and weekly flight time limitations. During a June 2008 inspection, the FAA determined that the airline had installed unapproved automotive air conditioner compressors on its aircraft between September 2006 and May 2008. Following the FAA inspection, the airline grounded all of the affected aircraft and replaced the units with approved aircraft air conditioner compressors. In the course of a July 2008 inspection of Gulfstream International avionics and component shops in Fort Lauderdale, the FAA discovered that the airline had installed improperly maintained vent blowers on six planes between January 2008 and June 2008. Following that inspection, the airline replaced the blowers with properly maintained units. Gulfstream International Airlines has 30 days from the receipt of the civil penalty letter to respond to the FAA. (FAA)

AAIB: final report on Boeing 737-300 stall during a go-around

Tue, 26 May 2009 07:00:00 GMT

26 MAY 2009
The U.K. AAIB released the final report of their investigation into a serious incident involving a Boeing 737-300 in September 2007. The Boeing 737-300 was on approach to Bournemouth Airport following a routine passenger flight from Faro, Portugal. Early in the ILS approach the auto-throttle disengaged with the thrust levers in the idle thrust position. The disengagement was neither commanded nor recognised by the crew and the thrust levers remained at idle throughout the approach. Because the aircraft was fully configured for landing, the air speed decayed rapidly to a value below that appropriate for the approach. The commander took control and initiated a go-around. During the go-around the aircraft pitched up excessively; flight crew attempts to reduce the aircraft�s pitch were largely ineffective. The aircraft reached a maximum pitch of 44� nose-up and the indicated airspeed reduced to 82 kt. The flight crew, however, were able to recover control of the aircraft and complete a subsequent approach and landing at Bournemouth without further incident. Although the commander reported the event to the operator the following morning, his initial Air Safety Report (ASR) contained limited information and the seriousness of the event was not appreciated until the Quick Access Recorder (QAR) data was inspected on 4 October 2007. G-THOF was not subjected to an engineering examination to ensure its continued airworthiness and remained in service throughout this period. (AAIB)

Audit: FAA not realizing the full benefits of the Aviation Safety Action Program

Tue, 19 May 2009 07:00:00 GMT

19 MAY 2009
The U.S. Department of Transportation's Office of Inspector General (DoT, OIG) carried out an audit to assess FAA�s implementation of the Aviation Safety Action Program (ASAP) and identify any improvements that will help FAA to maximize the program�s safety benefits. While ASAP is a potentially valuable safety tool, OIG found that FAA�s ineffective implementation and inadequate guidance have allowed inconsistent use and potential abuse of the program. Further, FAA has not devised a method to fully compile data reported through ASAP for analysis on a national level. Therefore, little is understood about nationwide trends in the types of violations reported under ASAP, and ASAP reports do not help FAA determine whether systemic, nationwide causes of those violations are identified and addressed. As a result of these issues, ASAP, as currently implemented, is a missed opportunity for FAA to enhance the national margin of safety. To realize the full benefits of ASAP, FAA must improve the program in the following areas: (1) revising ASAP guidance to clarify which incidents should be excluded from the program, (2) emphasizing to employees that ASAP is not an amnesty program, (3) clarifying the Event Review Committee (ERC)�s authority and role in ASAP and ensuring ERC members are unbiased, (4) requiring inspectors to examine repetitive reports of ASAP�related safety concerns and enhancements to ensure effective corrective actions, and (5) developing a central database of all air carriers� ASAP reports that FAA can use for trend analysis at a national level. (DoT, OIG)

CAA UK publishes Safety Plan 2009/11

Fri, 1 May 2009 07:00:00 GMT

01 MAY 2009
The U.K. Civil Aviation Authority (CAA) published a Safety Plan. It presents CAA's strategies and actions to be taken to achieve a continuous improvement in safety over the next two years. (CAA)

ATSB: preliminary report on A340-500 tail strike accident at Melbourne

Thu, 30 Apr 2009 07:00:00 GMT

30 APR 2009
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)