01 SEP 2008 _______________________________________ *Jets avoid collision by a minute, NTSB says *NTSB To Investigate Runway Incursions, Separation Incident *Boeing 737-2H6 Accident (Indonesia) *Boeing 737-291 Accident (Venezuela) *Venezuelan cargo jet, victims *Dated computers make FAA vulnerable *'Emergency' forces Qantas jet down *Japanese suspect missing washer led to 737 fuel tank fire *ATSB releases preliminary report into Boeing 747 depressurization *CASA: improvements needed after QANTAS maintenance review *************************************** Jets avoid collision by a minute, NTSB says Delta, Russian jets were headed toward each other over Caribbean Cockpit alarms sound, Russian airliner descended to avoid Delta jet Planes were 33,000 feet over water about 180 miles north of San Juan WASHINGTON (AP) -- Two airliners were one minute from colliding when at least one of the planes turned away from the other over the Atlantic Ocean this week, federal authorities said Friday. The National Transportation Safety Board said it was investigating an incident in which a Delta Air Lines flight and a Russian-registered passenger jet were heading toward each other Thursday north of Puerto Rico when cockpit alarms went off. The NTSB said the pilot of the Russian plane -- a Transaero Boeing 747 -- descended 200 feet to 300 feet to avoid Delta Flight 485. The planes were at the same altitude -- 33,000 feet over open ocean -- and were "60 seconds apart from occupying the same airspace," said NTSB spokesman Peter Knudson. Knudson said the agency doesn't have enough information yet to know if the planes would have collided had evasive maneuvers not been taken, or if they would have narrowly missed each other. The two planes were about 180 miles north of San Juan when the near-collision occurred at about 6:30 p.m. The Delta Boeing 737 -- with 152 passengers aboard -- was headed from New York's Kennedy International Airport to Port of Spain, Trinidad. The NTSB said there were no injuries. "This was every bit the classic near miss," said Doug Church, a spokesman for the National Air Traffic Controllers Association. The Delta pilot told air traffic controllers the incident was "extremely close" and that he also took evasive maneuvers, said Victor Santore, a vice president of the controllers union. NTSB's Knudson said he could not confirm the controllers' account. There was no FAA radar coverage in the area where the planes nearly collided -- as is the case over most open ocean. The NTSB says aircraft are required to remain at least 15 minutes apart when flying through areas with no radar coverage. Flight plans filed by the two airlines placed the aircraft on intersecting flight paths, which would have been fine as long as they stayed 15 minutes apart, Santore said. Delta spokeswoman Betsy Talton declined to provide any further details of the incident. "We are fully cooperating with the NTSB," said Talton. The NTSB also reported Friday that it was investigating: • A near-collision of a commuter jet and a small plane Thursday at Fresno Yosemite International Airport in California. The two aircrafts' wingtips came within 15 feet of each other during a nighttime landing. • A small plane that landed Wednesday on a closed runway at Reading Regional Airport-Carl A. Spaatz Field in Reading, Pennsylvania http://www.cnn.com/2008/US/08/29/airliners.near.collision.ap/index.html ************** NTSB To Investigate Runway Incursions, Separation Incident Close Call Over Atlantic Averted Thanks To TCAS The National Transportation Safety Board is investigating two runway incursion incidents and an aircraft separation incident, all of which occurred in the last two days. In the first runway incursion incident, a commuter jet narrowly missed a general aviation aircraft during a nighttime landing at Fresno Yosemite International Airport in California. On August 28, 2008, at approximately 9:07 pm Pacific Daylight Time, a Piper PA-46 landed on runway 29R. Before the aircraft had exited the runway, the tower controller cleared a SkyWest Canadair CRJ-200 commuter jet to land on the same runway. The CRJ pilot saw the Piper and veered to the right side of the runway, missing the aircraft by an estimated 15 feet, wingtip to wingtip. The incident occurred at night with 10 miles visibility. In the second runway incursion incident, a pilot of a general aviation aircraft landed on a closed runway at the Reading Regional Airport/Carl A. Spaatz Field, in Reading, PA. On August 27, 2008, at about 4:25 pm Eastern Daylight Time, a Cessna 172 landed on runway 18 -- which was closed -- after receiving a clearance to land on the closed runway by the tower controller. The runway had been closed for approximately four weeks due to construction activity. The incident occurred during day with 10 miles visibility. In the aircraft separation incident, two commercial jets came within 1 minute lateral separation over the Atlantic Ocean in a non-radar environment where 15 minutes of lateral separation is required. On August 28, 2008, at approximately 6:37 pm Atlantic Standard Time, Transaero flight 554, a Russian-registered Boeing 747-400, and Delta Air Lines flight 485, Boeing 737-800 en route from New York's Kennedy Airport to Port of Spain, Trinidad and Tobago, came within zero feet vertical and 1 minute lateral separation at an altitude of 33,000 feet about 179 miles north of San Juan, Puerto Rico. The Transaero 747 descended 200-300 feet after receiving an alert from its Traffic Collision Avoidance System (TCAS). NTSB investigators are responding to each of the incident locations. FMI: www.ntsb.gov aero-news.net *************** Boeing 737-2H6 Accident (Indonesia) Status: Preliminary Date: 27 AUG 2008 Time: 16:34 Type: Boeing 737-2H6 Operator: Sriwijaya Air Registration: PK-CJG C/n / msn: 23320/1120 First flight: 1985-05-23 Engines: 2 Pratt & Whitney JT8D-15 Crew: Fatalities: 0 / Occupants: 6 Passengers: Fatalities: 0 / Occupants: 123 Total: Fatalities: 0 / Occupants: 129 Airplane damage: Substantial Location: Jambi-Sultan Thaha Syarifudn Airport (DJB) (Indonesia) Phase: Landing (LDG) Nature: Domestic Scheduled Passenger Departure airport: Jakarta-Soekarno-Hatta International Airport (CGK/WIII), Indonesia Destination airport: Jambi-Sultan Thaha Syarifudn Airport (DJB/WIPA), Indonesia Flightnumber: 062 Narrative: Sriwijaya flight SJ062 overran the runway at Jambi (SJB) into a rice field. Two people working in the field were injured. The airplane sustained substantial damage. Jambi has a single asphalt runway, 13/31, 2000 x 30 meters, no ILS. (aviation-safety.net) ************** Boeing 737-291 Accident (Venezuela) Date: 30 AUG 2008 Time: ca 21:50 Type: Boeing 737-291 Operator: Conviasa Registration: YV102T C/n / msn: 21545/525 First flight: 1978-07-06 Engines: 2 Pratt & Whitney JT8D-9A (HK3) Crew: Fatalities: 3 / Occupants: 3 Passengers: Fatalities: 0 / Occupants: 0 Total: Fatalities: 3 / Occupants: 3 Airplane damage: Written off Airplane fate: Written off (damaged beyond repair) Location: near Toacaso (Ecuador) Phase: En route (ENR) Nature: Ferry/positioning Departure airport: Caracas-Simón Bolívar International Airport (CCS/SVMI), Venezuela Destination airport: Latacunga Airport (SELT), Ecuador Narrative: The Boeing 737 had been stored for a while at Caracas. It was now being ferried to Latacunga, reportedly underway to a new owner. The airplane crashed in mountainous terrain. (aviation-safety.net) *************** Venezuelan cargo jet, victims QUITO (AFP) — Search teams recovered the wreckage of a missing Venezuelan cargo jet that crashed in the mountains of southern Ecuador and the remains of the aircraft's three crew members, Red Cross spokeswoman Cristina Medina said. The plane, which went missing Saturday, was found in a mountainous area of Cotopaxi province in southern Ecuador, said Diego Valencia, a Red Cross official who led the recovery operations. "The three crew members are dead," Valencia told AFP, adding that their bodies had been taken to be examined by forensic experts. The Boeing 737-200 plane owned by Venezuela's state-owned airline Conviasa crashed after departing from Caracas's Maiquetia airport en route to Latacunga airport 80 kilometers (50 miles) south of Quito. The plane lost contact late Saturday night with Ecuadoran ground controllers after it began its descent. **************** Dated computers make FAA vulnerable Washington -- When a computer glitch at a Federal Aviation Administration center caused widespread airline delays last week, it served as a reminder that the U.S. flight system is waiting for a modernizing overhaul. But it also appears the FAA's management of its existing technologies falls short of standards in other vital sectors. By using computing practices that would be considered poor in credit card networks or power plant operators, for example, the FAA was vulnerable to a problem caused when new software was loaded at the Atlanta center that distributes flight plans. Because the FAA relies on just two computing systems, one in Atlanta and one in Salt Lake City, to handle that chore for the entire nation, the software glitch all but sank the system Tuesday. The Salt Lake center remained up and served as a backup, but it became overloaded by information coming from airlines. More than 600 flights were delayed from Atlanta all the way to Boston and Chicago. A failure at the same Atlanta center caused major delays across the East Coast in June 2007. Such breakdowns often can be prevented with sufficient redundancy, or enough different computers and communication channels to handle the same workload in an emergency. Redundancy is so critical for power and water utilities that they can be fined hundreds of thousands of dollars a day if they're found insufficiently prepared - and $1 million per day if they're found to be willfully negligent. "In the industries I work in, if you have something that critical, you generally build more redundancy," said Jason Larsen, a security researcher with consultancy IOActive Inc. who previously spent five years at Idaho National Laboratory examining electrical plants' control systems. "If this (FAA outage) happened at a power plant, I'd be telling them to open up their checkbook and expect to be fined." FAA spokeswoman Tammy Jones stressed that these types of problems "don't happen on a mass scale or a regular basis," and noted that the FAA handles 50,000 to 60,000 fights a day. And flying on U.S. airlines has never been safer. "The system is working," she said. "We are making sure people are getting from one place to another." Basil Barimo, vice president of operations and safety for the Air Transport Association of America, a trade association that represents the nation's largest carriers, says the fundamental problem is that the FAA still relies on outdated technology, including a radar-based control system designed in the 1940s and '50s. Barimo is optimistic that the FAA's NextGen modernization program - a $15 billion-plus upgrade to satellite-based technology that will take nearly 20 years to complete - will help make more efficient use of the nation's airspace and safely allow more planes in the sky. At the Atlanta center that saw this week's failure, the National Airspace Data Interchange Network computer has been owned and operated by the FAA since the 1980s, after the Dutch company that developed it went out of business. The network is being upgraded, and will have much more memory, process data much more quickly and be more robust and "fault-tolerant." http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2008/08/31/BULE12L3VQ.DTL&t ype=tech ************** 'Emergency' forces Qantas jet down A Qantas flight was diverted to Frankfurt Airport in Germany because of a 'vibration in one of the engines'. Photo: Jim Rice Qantas passengers flying from Sydney to London spent up to 12 hours grounded at Frankfurt airport after a mid-air "emergency issue", a passenger says. Qantas Flight 31 from Singapore to London diverted to Frankfurt Airport for repairs to the engine, landing about 3.15pm yesterday, a Qantas spokeswoman said. The Boeing 747-400 aircraft diverted "due to the captain being alerted to a vibration in one of the engines", a Qantas spokeswoman said. "As is standard procedure the engine was shut down," she said. "There was no safety issue at any time and the aircraft continued to Frankfurt, where it landed without incident." Jan Rees, an Australian who was returning to London after visiting family in Sydney, said she noticed a "roughness" during the flight. "In the middle of the night there was a sort of roughness, like if a car is not quite in gear," said Mrs Rees. "I did notice it but nothing was said. About 4.30am (about two-and-a-half hours before the flight landed), they said we are not going to London but to Frankfurt because of an emergency issue." Frankfurt Airport duty manager Tino Ross said the landing was "not an emergency". "It was a technical landing," he said. "There was a problem with engine four and the pilot decided to come into Frankfurt to repair the engine. "There was no incident on landing." But Mrs Rees said: "It was described as an emergency, a technical issue, but that they were in control." Mrs Rees, who was eventually confined at Frankfurt for 12 hours before being placed on an alternate flight, said stranded passengers were given little information about what was happening. "There were no Qantas staff there to help, the airport staff were pulling their hair out trying to sort out what had happened. "We were told (by Qantas staff) that we'd be taken care of; five hours later we were told absolutely nothing. A lot of people were getting very angry and distressed, and there were a lot of people with young children because of the end of school holidays over here. "It was an absolute circus. To top it all off, they've left my bag in Frankfurt (after Mrs Rees was placed on an alternate Qantas/British Airways flight from Frankfurt to London)." At Frankfurt airport, passengers from first and business class were taken one way and appeared to be placed on the first available alternate flights, Mrs Rees said. Qantas engineers were investigating the cause of the engine problem. The incident is the latest in a spate of mechanical problems affecting the Qantas fleet. On July 25, a faulty oxygen bottle blew a hole in the fuselage of a Qantas Boeing 747-400 flying from Hong Kong to Melbourne. The blast caused the aircraft, with 365 people on board, to depressurise and it rapidly descended several thousand feet before making an emergency landing in Manila. On July 29, a Adelaide-Melbourne flight returned to Adelaide when a wheel bay door failed to close, while a hydraulic fluid leak forced a Boeing 767 to return to Sydney. Hydraulics caused a flight to be delayed almost three hours in Sydney on August 4. Three days later, a noisy air-conditioning fault forced the grounding of a jet that had recently returned from routine maintenance in Malaysia with 95 defects. Then on August 12, Qantas announced it would temporarily pull six Boeing 737-400s from service after discovering an irregularity in maintenance paperwork. On August 13, a Qantas Boeing 747-300 from Melbourne was grounded in New Zealand after an engine shut down on approach to Auckland. On the same day, Qantas flight QF31 to London - the same flight affected by today's incident - was delayed because a crucial screw needed urgent maintenance, while a Boeing 767 jet had a hydraulic failure that affected the plane's steering as it landed at Sydney on a flight from Melbourne. The plane left a trail of hydraulic fluid as it touched down, forcing the runway to close for 40 minutes as the spill was mopped up. Two days later, on August 15, a technical problem delayed a Brisbane to Melbourne flight for more than 30 minutes, while a small body panel fell from a Qantas jumbo en route to Singapore from Melbourne. On August 17, a rudder problem delayed the departure of a Sydney-bound plane at London's Heathrow Airport by more than 16 hours. Three days later, two flights were cancelled between Perth and Sydney and Perth and Melbourne because of technical problems. The Civil Aviation Safety Authority has established a team to examine issues including maintenance and safety systems at Qantas. (AAP) *************** Japanese suspect missing washer led to 737 fuel tank fire A Japanese investigation, into a China Airlines (CAL) Boeing 737-800 that had a fuel tank fire last year, has said it is highly possible CAL maintenance personnel failed to attach a washer to the bolt on the right wing slat and that is why the bolt moved, puncturing the fuel tank. Japan's Aircraft and Railway Accidents Investigation Commission made the remark in its preliminary report into the CAL 737-800, local registration B-18616, that caught fire on 20 August last year soon after landing at Naha airport on the southern Japanese island of Okinawa. The commission disclosed last year that it had found a bolt on the 737-800's right wing slat that had pierced the fuel tank creating a 2-3cm hole. The fuel leaking from the tank then ignited creating a fire that completely destroyed the aircraft and led the 165 people on board to disembark quickly to safety. But until the release of the preliminary report, the reason for the bolt moving had always remained unexplained. The Aircraft and Railway Accidents Investigation Commission says since the incident Boeing has changed the design of the bolt nut to make it larger. CAL has responded to the preliminary report by issuing a statement saying it "reviewed its maintenance records and confirmed that it completed the required inspections in a timely manner on its 737-800 aircraft" and in accordance with "Boeing's service letters and service bulletins." "The aircraft involved in the incident completed its inspection from 6-13 July 2007, prior to the event in Okinawa," it adds. Source: Air Transport Intelligence news **************** ATSB releases preliminary report into Boeing 747 depressurisation The Australian Transport Safety Bureau (ATSB) released its Preliminary Factual report on the depressurisation of Boeing 747-438, VH-OJK, 475 km northwest of the Philippines. On the basis of the physical damage to the aircraft's forward cargo hold and cabin, it was evident that the number-4 passenger oxygen cylinder sustained a failure that allowed a sudden and complete release of the pressurised contents. The rupture and damage to the aircraft's fuselage was consistent with being produced by the energy associated with that release of pressure. Furthermore, it was evident that as a result of the cylinder failure, the vessel was propelled upward, through the cabin floor and into the cabin space. Damage and impact witness marks found on the structure and fittings around the R2 cabin door showed the trajectory of the cylinder after the failure. (ATSB) (aviation-safety.net) **************** CASA: improvements needed after QANTAS maintenance review CASA wants Qantas to make a range of improvements to the way it manages and delivers aircraft maintenance following a special review carried out by the Civil Aviation Safety Authority. CASA has told the airline to produce a plan to address deficiencies in meeting some of its own maintenance performance targets. At the same time Qantas will examine whether the existing lines of authority and control over maintenance within the airline are delivering the best possible outcomes. While these actions are under way CASA will be conducting two additional intensive audits of Qantas. The first will be a full maintenance audit of one aircraft of each major aircraft type in the Qantas fleet – a 747-400, 737-400 and 767-300. This will involve checking all maintenance documentation for each of these aircraft to see it has been completed, as well as physically examining the aircraft on the ground. The second audit will focus on the effectiveness of Qantas maintenance systems in managing and implementing airworthiness directives. This will identify any weaknesses in Qantas maintenance systems in relation to managing the ongoing airworthiness of its aircraft. CASA has also called on Qantas to report on how the recent failures to fully comply with airworthiness directive requirements have been addressed. (CASA) (aviation-safety.net) ***************