23 FEB 2009 _______________________________________ *Indiana Gov's Plane Makes Unscheduled Stop On Way To DC *Italian investigation into fatal Citation crash frustrated by judicial inquiry *U.K. AAIB issues safety recommendations on EMB-190 interphone system use *Indonesia: Prosecutors seek four-year jail term for Garuda pilot *F.A.A. Often Takes Years to Carry Out Lessons From Air Crashes *FAA Faces Rising Trainee Numbers in Controller Ranks *NTSB to Issue Helicopter EMS Safety Recommendations *NTSB board member on Buffalo case going to work for Airbus *************************************** Indiana Gov's Plane Makes Unscheduled Stop On Way To DC Diverts To Columbus After Windshield Cracks Develop Inflight A state-owned Beech 200 Super King Air transporting Indiana Governor Mitch Daniels made an unscheduled landing in Columbus, OH Sunday morning after the pilot opted not to continue the flight from Indianapolis to Washington, DC after cracks began to appear in the plane's windscreens. Daniels was on his way to Washington for a National Governor's Association meeting and an appearance on CBS' "Face the Nation" when cracks formed in one windshield and then the other. Daniels spokeswoman Jane Jankowski said, "They decided that the best thing to do was to divert and land in Columbus and not go any further." The flight was diverted to Port Columbus International Airport (CMH) and landed safely just before 9 am. The Associated Press said Daniels was then transported by the Ohio Highway Patrol to a TV studio in Columbus for a satellite hook-up to make his scheduled appearance on "Face the Nation." After the program, Daniels resumed his journey to Washington, DC on a commercial flight. "It's not just a job, it's an adventure," Daniels quipped. Rick Barnett, spokesman for the Indiana Department of Administration, explained such cracks are usually caused by the over-heating of the windshield heater. FMI: www.state.in.us aero-news.net ************** Italian investigation into fatal Citation crash frustrated by judicial inquiry The Italian aircraft accident investigation board ANSV (Agenzia Nazionale per la Sicurezza del Volo) reports that they are not able to conduct a thorough investigation into the fatal accident involving a Cessna 650 Citation III near Rome on February 7, 2009. The Cockpit Voice Recorder (CVR) and Flight Data Recorder (FDR) were seized for a juducial inquiry. ANSV also had to turn over documents vital to the investigation. Present regulations in Italy give primacy to the investigation of the prosecutor, whose work takes precedence over ANSV investigations. ANSV complained about the effects of these potential conflicts between criminal and technical investigation and asked the ministers of Transport and Justice to change legislation. (ANSV) (aviation-safety.net) ***************** U.K. AAIB issues safety recommendations on EMB-190 interphone system use The U.K. Air Accidents Investigation Branch (AAIB) published recommendations following an incident involving an Embraer 190 on January 15, 2008. During flight, "smoke" was seen to emanate from a galley sink and the flight deck and cabin crews took appropriate emergency action. In the course of the 'Electrical System Fire or Smoke' procedure the flight crew established the aircraft on emergency power, after which communications between the flight deck and cabin became difficult. The aircraft landed safely. Deficiencies in the interphone system were identified, and four safety recommendations are made. Safety Recommendation 2009-017: It is recommended that Embraer immediately notify all operators, of the Embraer 190 family of aircraft, to inform flight crew of the importance of advising cabin crew when an aircraft is on emergency electrical power. Safety Recommendation 2009-018: It is recommended that Embraer immediately notify all operators, of the Embraer 190 family of aircraft, to inform their flight and cabin crew of the functioning of the interphone system when the aircraft is supplied only with emergency electrical power. Safety Recommendation 2009-019: It is recommended that Embraer modify the functioning of the interphone systems of Embraer 190 family aircraft to provide crew with the facility to make both normal and emergency calls when the aircraft is supplied only with emergency electrical power. Safety Recommendation 2009-020: It is recommended that Embraer immediately notify all operators, of the Embraer 190 family of aircraft, to inform flight and cabin crew of the functioning of the flight deck access system when the aircraft is supplied only with emergency electrical power. (AAIB) (aviation-safety.net) *************** Indonesia: Prosecutors seek four-year jail term for Garuda pilot Indonesian Distict Court Prosecutors in Sleman have called for a Garuda pilot to be sentenced four years in jail for his negligence in the accident of a Boeing 737-400 at Yogyakarta in 2007. Twenty-one passengers were killed in the accident. During the court session prosecutor Modim Aristo said that the defendant had violated article 479 G, points A and B, of the Criminal Code. (aviation-safety.net) *************** F.A.A. Often Takes Years to Carry Out Lessons From Air Crashes WASHINGTON - A person born on July 17, 1996, the day that T.W.A. Flight 800 exploded off Long Island, will be old enough to earn a pilot's license - and maybe even to work for an airline - before the hardware ordered after that crash is installed on all airplanes, in about 2016. Crews cleared debris on Feb. 16 after the Continental Connection crash. It was the first commercial air disaster in 30 months. Still unresolved are some of the safety problems exposed by another accident, the crash of an American Eagle turboprop in icing conditions in October 1994. And the danger of runway collisions, with near miss piled upon near miss, has prompted improvements, but not a solution. As aviation safety officials investigate the country's first fatal airliner accident in 30 months, the crash of a Continental Connection turboprop near Buffalo on Feb. 12, experts say that although airlines are safer than ever, adopting the lessons from such disasters can be excruciatingly slow. The agency that investigates plane crashes, the National Transportation Safety Board, is an advisory body and can only make recommendations. The Federal Aviation Administration, the agency that actually regulates planes, pilots and airlines, sometimes takes years to respond to recommendations, for a variety of reasons. Some proposed solutions require inventions; others have disadvantages that make their benefits, on balance, questionable; and many are weighed down by a system based on government and industry collaboration that guarantees delay. "It's the regulatory process," said Mark Rosenker, the acting chairman of the National Transportation Safety Board. "Sometimes it's our own worst enemy." Because it is purely advisory, the safety board does not have to consider cost and operating difficulties in saying what should be done. For example, the board has recommended that when a plane leaves an airport gate that it get clearance each time it crosses a runway to reach the spot where it will initiate takeoff. The F.A.A. says the recommendation, which is being studied, might significantly slow down airport operations, a possibility that Mr. Rosenker acknowledged. The safety board and the F.A.A. have a formal communication process in which the board's chairman sends a letter to the F.A.A. administrator, who must reply within 60 days. They also correspond about technical issues, schedules and progress, or lack thereof, and they often become pen pals of long standing. The safety board says there currently are 429 outstanding recommendations, of which 146 are more than five years old. And like that of other federal agencies, the F.A.A.'s approach is cumbersome. It issues a "notice of proposed rule-making," sets a comment period, analyzes the comments and issues a final rule. The rules must be reviewed for cost-effectiveness by the White House Office of Management and Budget, where they can be held up for months and are subject to lobbying by the affected industries. That is the optimum scenario. The F.A.A. generally does not simply decide what to do and issue orders, according to Marion C. Blakey, whom President George W. Bush appointed as chairwoman of the safety board and later as leader of the F.A.A. Rather, the agency plays a role that Ms. Blakey described as "honest broker," seeking the expertise of manufacturers, airlines and academics. Before it proposes a rule, the F.A.A. often convenes "aviation rule-making advisory committees" that sometimes sit for years, trying to reach consensus. Sometimes the process is so slow that the F.A.A. persuades the airlines to solve problems outside the regulatory process. After a DC-9 operated by ValuJet crashed in the Everglades in May 1996 because of a fire in the cargo area, the F.A.A. doubted that the obvious fix - the installation of fire detection and suppression equipment - would pass muster with the White House because the cost might exceed the benefit. But following a public outcry, the airlines agreed to install the systems. When the crew of an American Airlines plane made a navigation error on a flight from Miami to Cali, Colombia, in December 1995 and hit a mountain, the airlines agreed to equip cockpits with a GPS unit to compare the plane's location with a database of mountains. That happened much faster than if it had been mandated by the government. But the 1994 crash of an American Eagle turboprop in Roselawn, Ind., shed light on a more complex problem. The F.A.A. certifies planes to fly into a variety of weather conditions, but those conditions do not include an unusual weather type apparently encountered by the American Eagle flight, in which the air holds large droplets that turn to ice on contact with the plane. NASA has conducted extensive research and produced a series of instructional videos on various aspects of icing, and crews have trained for icing conditions, but no decision has been made about expanding the "envelope" of weather conditions for which planes must qualify to include the droplets. The crew of the plane that crashed near Buffalo on Feb. 12 reported icing, according to investigators, but it was not clear if icing was a factor in the accident. The pace of progress at the F.A.A. has been hindered by not having a permanent administrator since Ms. Blakey's five-year term expired in September 2007. Ray LaHood, the transportation secretary, said on Thursday that he had submitted a recommendation to the White House for a new administrator. Resolving the problem that led to the explosion of T.W.A. Flight 800 took 12 years to negotiate, and fully implementing the solution will require an additional eight years. Investigators concluded that the plane, a Boeing 747 traveling from Kennedy International Airport to Paris, had an electrical flaw in the center fuel tank that allowed a spark to ignite fuel vapors. For years, the industry debated whether to change jet fuel so that it did not turn easily into vapor. Then experts discussed filling the air space above the fuel tank with inert nitrogen gas to preclude the possibility of a fire or explosion. Finally, the F.A.A. adapted a technology from other industries, an onboard membrane that would separate oxygen from nitrogen, with the nitrogen then being pumped into the fuel tanks. Driven by energy from the plane's engines, the system costs tens of thousands of dollars per airplane instead of perhaps $1 million per plane for other proposals. During the years it took to arrive at the solution, airlines made improvements to airplane electrical systems and newly alert maintenance crews spotted wiring flaws that could have led to catastrophe. But that is not enough for Larry Siebert, who had two daughters and two other relatives on the T.W.A. flight. "It becomes very frustrating," he said. "What are you going to feel like when you have someone go down, when it's one of your relatives, and you say, 'How come you didn't fix it?' " http://www.nytimes.com/2009/02/23/nyregion/23safety.html?ref=nyregion ************ FAA Faces Rising Trainee Numbers in Controller Ranks The FAA is hiring thousands of air traffic controllers to stay ahead of a spike in retirements, but this is raising new concerns about an increasingly inexperienced workforce. Trainees now comprise a quarter of the U.S. controller staff - up to half at some facilities - and this ratio is set to rise further. Government watchdog agencies admit the FAA has proved skeptics wrong by mounting a successful hiring campaign. However, in solving one problem the FAA has created another. Veteran controllers are being replaced by recruits who need further on-the-job training before becoming fully certified. "We do have concerns - not over the total size of the workforce, but over the skill level and training level" of the new controllers, says U.S. Transportation Dept. Inspector General Calvin Scovel. Although the FAA is confident the rising number of trainees is not causing safety problems, this issue will ensure the controller workforce remains a political football for years to come. The genesis of the staffing problem is the national controller strike of 1981, during which then-President Ronald Reagan locked out the strikers, then fired them. A new class of controllers was hired and trained, but those workers are now hitting retirement age at around the same time. After much prodding by the controllers' union and Congress, the FAA recognized the approaching crisis and began a hiring drive to replenish its ranks. The agency exceeded its hiring target for Fiscal 2008 and is on track to do the same for Fiscal 2009, according to the FAA's acting assistant administrator for policy, Nancy LoBue. The agency may have passed the peak of the retirement bubble, as the attrition rate is starting to level out, LoBue says. Former acting Administrator Robert Sturgell believes that while there are some facilities that must be watched carefully, the overall staffing situation is adequate. Scovel says the FAA has "done what I can only say is a remarkable job in hiring replacements for controllers who have decided to leave." Almost 5,000 controllers - more than a third of the total - have left since 2005, but the FAA "has managed to hire up" and now has 270 controllers more than it had in 2004, Scovel notes. The bad news, however, is the loss of experience in the workforce. Overall, controllers still in trainee status represent nearly 26% of the total, a significant increase from the 15% share in 2004, Scovel says. Numbers vary according to facility: there are no trainees at the Pittsburgh tower, but 47% of controllers at the Orlando tower are still in training. Scovel highlights the Southern California terminal radar approach control, where there will be almost 100 trainee controllers this year, about 40% of the total. Training and certifying controllers will continue to be a challenge for the agency, Scovel points out. Through 2017, the FAA will have hired about 17,000 new controllers, and it currently takes them nearly three years to become fully certified. Patrick Forrey, president of the National Air Traffic Controllers Assn. (Natca), says the crucial point is not how many controllers are being hired, but "how qualified they are and how successful they will be in training." The ATC system is being "clogged with trainees," and the ratio of new recruits will continue to grow, Forrey says. Natca and the FAA disagree over how many of the new recruits have been fully certified, but it is clear that it is a relatively small proportion of the total hired. Forrey says the problem is not the quality of the recruits. "We want them to be put in a situation where they have the best opportunity to succeed, and that's not being done," he says. Trainees are increasingly being placed in the largest and busiest facilities that aren't properly equipped for training. The union says an unpopular contract imposed on controllers in 2006 was a major cause of the retirement spike. The contract removed opportunities for veterans to increase their pay, giving them less incentive to stay on. If the FAA and controllers return to the table to renegotiate the contract, it would stem future losses, Forrey says. House lawmakers have introduced an FAA reauthorization bill that would reopen the Natca contract, but Republicans claim this would cost too much. Staffing challenges are also arising in other areas. The Government Accountability Office does not believe the FAA has enough skilled technical workers to roll out crucial NextGen modernization programs. The GAO estimates the agency will require 350 additional technical staff, systems engineers and contract management experts over the next two years to manage NextGen implementation. LoBue admits that "we're concerned about staff with technical skills . . . . We see a shortage coming, as do all technical-oriented industries." http://www.aviationweek.com/aw/generic/story.jsp?id=news/aw022309p3.xml&head line=FAA%20Faces%20Rising%20Trainee%20Numbers%20in%20Controller%20Ranks&chan nel=awst ************** NTSB to Issue Helicopter EMS Safety Recommendations Who Pays for Safety Measures? Suzanne Wedel of Boston MedFlight testified that the operation's new Sikorsky S76 C++ aircraft has $1.1 million worth of enhanced safety features, including night vision goggles, SPIFR (single pilot instrument flight rules) auto pilot, ground proximity warning, cockpit voice recorder, traffic avoidance collision system, moving map, satellite position tracking, airborne weather radar, satellite weather data, electronic nav charts, integrated GPS (global positioning system), emergency locator transmitter, Nightsun, and lightning strike protection. According to Marc Harstein, Medicare and Medicaid Services, Medicare covers helicopter EMS transport to medical facilities at a rate of $3,308 urban and $4,962 rural if the facility is not accessible by ground vehicle, transport is over great distances or is complicated by other obstacles (such as heavy traffic), or the patient's condition is not appropriate for ground transport. Air ambulance trips reimbursed by Medicare increased 24%, from 1.65 transports per 1,000 beneficiaries in 2001 to 2.04 transports 1,000 beneficiaries in 2004, Harstein said. Two nurses were among experts who testified before the National Transportation Safety Board's four-day hearing on helicopter EMS safety, which was prompted by a record year in helicopter EMS accident fatalities. "The take-home message for nurses here is we need to be engaged," said Kevin High, RN, president of the Air & Surface Transport Nurses Association and trauma program manager for Vanderbilt LifeFlight, Nashville, Tenn. "We've got skin in this game. Nurses are losing their lives in the line of duty." High was one of the nurses who answered questions from the board of inquiry Feb. 3-6. in Washington, D.C. "What I wanted them to know is this is a multi-factorial problem," High said. "All week, what I kept hearing over and over again is, 'There's no silver bullet and no one thing that's going to make [accidents] stop.'" The hearing was held to learn more about helicopter EMS operations so the NTSB can better evaluate the factors that lead to accidents and recommend safety improvements to the Federal Aviation Administration, which oversees the field. The issues discussed included operational structure and models, flight operations, aircraft safety equipment, training, and oversight. "I don't think the solution to the problem can be found inside the industry alone," High said. "I think whatever [the NTSB] comes up with, not everybody is going to like it. I think it will probably be some type of compromise. [But] I'm not worried about it. Inaction would worry me." The NTSB added helicopter EMS safety to its Most Wanted List of Transportation Safety Improvements in October, along with a list of recommendations: Conduct all flights with medical personnel on board in accordance with charter aircraft regulations. Develop and implement flight risk evaluation programs. Require formalized dispatch and flight-following procedures, including up-to-date weather information. Install terrain awareness and warning systems on aircraft. Accident Statistics Each year about 400,000 patients and transplant organs are safely transported via helicopter EMS, according to Robert L. Sumwalt, chairman of the board of inquiry. "In the last six years, we have seen 85 HEMS accidents, resulting in 77 fatalities," Sumwalt said in his opening statement at the hearing. "In calendar year 2003, we saw 19 accidents and seven fatalities; in 2004, there were 13 accidents with 18 fatalities; 2005 had 15 accidents and 11 fatalities. In 2006, 13 [helicopter EMS] accidents occurred with a total of five fatalities. In 2007, there were 11 accidents with a total of seven fatalities. However, 2008 was the deadliest year in HEMS on record, with 13 EMS helicopter accidents, and 29 fatalities. "The Safety Board is concerned that these types of accidents will continue if a concerted effort is not made to improve the safety of emergency medical flights,"Sumwalt said. Ira Blumen, MD, professor of medicine, medical director and program director, University of Chicago Aeromedical Network, testified there were 131 fatalities in 146 helicopter EMS accidents between 1998 and 2008, 77% of which were due to human error. There were 668 dedicated helicopter EMS units from 21 companies in operation in 2008, Blumen said. Kevin Hutton, MD, testifying on behalf of the Association of Air Medical Services, said growth in helicopter EMS use is spurred by: rural level of care requirements; increased time-dependent care; consolidation and critical care regionalization; increased patient destination legislation; limited or no rural ground transport capability; malpractice lawsuits; decreased local specialty capability; growth and consolidation of providers (economies of scale); and more consistent reimbursement. Hutton is CEO and chairman of Golden Hour Data Systems Inc., which provides air medical and ground transport services, integrated computer-aided dispatch, clinical charting, and other services. Focusing on Solutions Nine states require that helicopter EMS programs be credentialed by the Commission on Accreditation of Medical Transport Services, based in Anderson, S.C. Eileen Frazer, RN, executive director of the organization, testified at the hearing that CAMTS added new safety guidelines Jan. 30. "The No. 1 issue we have concerns about is fatigue and sleep deprivation," Frazer testified. She said 49% of helicopter EMS accidents happen at night, while only 34% of flights take place at night. "One of our biggest concerns is sleep inertia - that period after you wake up. What is your cognitive function? What are your psychomotor skills and what activities must you do immediately after being awakened?" CAMTS is looking to secure funding for a study on sleep deprivation and sleep inertia spefically targeting helicopter EMS crews, possibly using simulators, Frazer said. "We see more and more medical personnel working 24- and 48-hour shifts." Until that study can be done, educating personnel on the signs of fatigue is important, she said. Another hot topic is safety management systems, Frazer said. "One of the issues we run into when we go out and review programs is that there may not be anyone at a hospital helipad that you can directly communicate with you are coming in," she said. "If it's a program that's based at that hospital, usually there's sophisticated procedures and there's somebody to meet you. That may not be the case with a hospital helipad that's not within your own system." Helicopter Association International president Matt Zuccaro, who is also co-chairman of the International Helicopter Safety Team, addressed recommendations including mandatory use of night vision goggles; an all IFR (instrument flight rules) operating environment; elimination of launch/response times; study of fatigue factors in helicopter EMS; education programs; non-punitive safety reporting environments; and implementation of safety management systems. Zuccaro also asked for discussion on "the need to provide a sterile operating environment for pilots and technicians, absent of undo pressures, so that any considerations are limited to safe aeronautical decision making." "You need to be engaged on a national level - know what's going on, pay attention, read, and make your voice heard," ASTNA's High said. The NTSB invites members of the EMS community, including RNs, to make submissions related to the safety of the industry through March 9. Materials should be submitted to NTSB, Ms. Lorenda Ward, Hearing Officer, 490 L'Enfant Plaza East SW, Washington, DC 20594, or they may be submitted electronically to HEMS@ntsb.gov. http://include.nurse.com/article/20090223/NATIONAL02/302230044/-1/frontpage *************** NTSB board member on Buffalo case going to work for Airbus Steven Chealander, the National Transportation Board member who has been heading the investigation into the Feb. 12 Colgan Air crash near Buffalo, is quitting to join Airbus Americas. Airbus said Chealander will be the company's vice persidewnt of technical training, based in Miami. Chealander, a former American Airlines pilot and manager, left that carrier in 2007 when then President George W. Bush appointed him the NTSB to finished out a term on the board. His nomination for a full term has been stalled in Senate, and he is now leaving effective Feb. 28. http://aviationblog.dallasnews.com/archives/2009/02/ntsb-board-member-on-buf falo-c-1.html ************** Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC