21 JUL 2009 _______________________________________ *MEMBER KATHRYN O'LEARY HIGGINS TO LEAVE NTSB *New FAA Safety Culture Reflected In Operational Error Reporting *NTSB Board Meets To Review Oklahoma Bird Strike Accident *EASA issues emergency AD on ATR-42/72 cockpit windows *Chicago-bound jet makes emergency landing in Iceland *Pilot training is the key to recovering airline safety *AF Flight 447: French Prosecutor Opens Judicial Investigation For Manslaughter *Dragonair names James Tong as new CEO *Overlooked trim led to 737's post-V1 abort *Crew's data-entry error led to laboured 767 take-off: inquiry **************************************** MEMBER KATHRYN O'LEARY HIGGINS TO LEAVE NTSB National Transportation Safety Board Member Kathryn (Kitty) O'Leary Higgins today submitted to President Obama her resignation from the Board, effective August 3. In her letter to the President, Higgins said, "I have loved the chance to work with incredibly dedicated public servants who are passionate about the challenge of making our highways, airlines, railroads, and waterways safe for everyone." Higgins said she is leaving the Board to pursue opportunities in the private sector. *************** New FAA Safety Culture Reflected In Operational Error Reporting Reducing Emphasis On Blame In Controller Errors The FAA says it has taken another step toward a new safety culture by reducing the emphasis on blame in the reporting of operational errors by air traffic controllers. "We're moving away from a culture of blame and punishment," said FAA Administrator Randy Babbitt. "It's important to note that controllers remain accountable for their actions, but we're moving toward a new era that focuses on why these events occur and what can be done to prevent them." Effective immediately, the names of controllers will not be included in reports sent to FAA headquarters on operational errors, which occur when the proper distance between aircraft is not maintained. The controller's identity will be known at the facility where the event took place. Necessary training will be conducted and disciplinary action taken, if appropriate. Both will be recorded in the controller's record. Removing names on the official report will allow investigators to focus on what happened rather than who was at fault. "We need quality information in order to identify problems and learn from incidents before they become accidents," Babbitt said. "The best sources of that information are our front-line employees. Our success depends on their willingness to identify safety concerns." In order to avoid disrupting operations, controllers will not be automatically removed from their position following an operational error unless it is deemed necessary to remove them. Another change designed to avoid disruptions allows reports to be filed by the close of the next business day unless the operational error is significant. Reports previously had to be filed within four hours. This action is part of the transition to the FAA's new non-punitive reporting system for controllers. The Air Traffic Safety Action Program (ATSAP), which now covers one-third of the country, allows controllers and other employees to report safety problems without fear of punishment unless the incident is deliberate or criminal in nature. Today's change in the reporting requirements for operational errors provides for a more seamless transition as ATSAP is rolled out to the entire country. The reporting changes do not alter the investigation and analysis of operational errors. They also do not change the requirements for addressing the causal and contributing factors to those events. FMI: www.faa.gov aero-news.net *************** NTSB Board Meets To Review Oklahoma Bird Strike Accident Public Meeting Will Be Webcast The National Transportation Safety Board will hold a public board meeting Tuesday, July 28, at 0930 in its Board Room and Conference Center in Washington, D.C. There is one item on the agenda. The Board will consider a final report on the following accident: On March 4, 2008, about 1515 (CST), a Cessna 500, N113SH, registered to Southwest Orthopedic & Sports Medicine Clinic PC of Oklahoma City, Oklahoma, and operated by Interstate Helicopters of Bethany, Oklahoma, collided in flight with a flock of large birds and crashed about 2 minutes after takeoff from Wiley Post Airport (PWA) in Oklahoma City. Both pilots and the three passengers were killed and the airplane was destroyed by impact forces and postcrash fire. A summary of the Board's final report, which will include findings, probable cause and safety recommendations, will appear on the website several weeks after the board meeting. The board meeting is open to the public. It will also be webcast through the NTSB website. FMI: www.ntsb.gov aero-news.net **************** EASA issues emergency AD on ATR-42/72 cockpit windows EASA requires operators of certain ATR-42/72 airplanes to inspect the cockpit forward side windows for damage/absence of repair. A recent event occurred during which the LH forward side glass window of an ATR 72-212 aeroplane blew out while performing a ground pressure test. The investigation revealed some anomalies on the forward side window at the level of the z-bar on the windows external side and at the level of the inner retainer on the windows internal side. These anomalies are considered as precursors of this failure. Air or water leakages between the z-bar and the outer glass ply, or between the inner retainer and inner glass ply indicates the presence of deteriorating structural components in the window. It must also be noticed that neither ATR nor PPG Aerospace authorizes repairs on the window Z-bar / Z-bar sealant. Any attempted repairs on these forward side window Z-bars/Z-bar sealants could lead to a similar event that has originated this AD. (EASA) aviation-safety.net ***************** Chicago-bound jet makes emergency landing in Iceland (WLS) -- A United Airlines jet flying to O'Hare from London was forced to make an emergency landing in Iceland Monday morning. The crew and pilots of United Flight 949 reported smoke coming from the cockpit. The nearest airport was Iceland's main international airport in Keflavik. None of the 200 passengers on board were injured, although they were told to be prepared to brace for a crash landing. ABC7 spoke with passenger Mark Marshall on the phone: Story continues belowAdvertisement"It must have been better up front than they had hoped because they never got to the brace point. And we all were braced, but they didn't yell it across the loudspeaker," said Marshall. "And so we landed and then immediately evacuated the plane out on the runway where all the fire trucks and emergency crew were waiting." The cause of the smoke in the cockpit has not yet been released. Marshall said the passengers will resume their flight to Chicago Tuesday. http://abclocal.go.com/wls/story?section=news/local&id=6924311 ***************** Pilot training is the key to recovering airline safety Global airline safety has stopped improving for the first time in aviation's history. The accident figures for the first half of 2009 serve to confirm a trend that Flight International had previously flagged up. Meanwhile, unless there is a dramatic improvement in performance during the remainder of this year and the whole of 2010, the world will have witnessed the first decade since the Wright Brothers when safety standards remained static. Some would say safety has stopped improving because of the law of diminishing returns. Is commercial airline flying as safe as it can get? The short answer is no. When the investigators have completed their analyses of the accidents so far this year, they will find in all cases - with the possible exception of the Hudson River ditching - opportunities to prevent them were missed. Loss of control was a problem for the FedEx Boeing MD-11 pilots It is not possible to come up with a single reason why improvement has stalled, but there are several candidates. Loss of control, already a killer problem that has been rising in frequency in recent years, definitely occurred in the FedEx Boeing MD-11 accident at Tokyo and the Colgan Air Q400 at Buffalo, but it may also turn out to be true of others, like the Yemenia Airbus A310 and even the Air France A330 over the South Atlantic. In all the loss of control accidents over the last 20 years the aircraft could have been controlled. What led up to it varies from crew distraction followed by disorientation, to failure to anticipate and manage the power and control force vectors during a go-around. Several involve failure to manage a stall. All of them demonstrate flaws in pilot recurrent training. To describe it as pilot error is an oversimplification, obscuring the fact that the pilot was not trained to deal with the situation. The Turkish Airlines pilots failed to notice the uncommanded retarding of their Boeing 737-800's throttles, and the associated speed loss that caused it to stall on approach, as a result of two things: conditioned trust in the aircraft's normally reliable automation, and failure of their recurrent training to reinforce basic practices like monitoring airspeed on approach. Last year the Flight Safety Foundation said if safety is to improve beyond what we see now, airlines have to go "beyond compliance" - to do more than just meet regulatory minimum standards. The first point at which that message needs to be applied is in pilot training, because the pilots are an airline's last opportunity to contain errors or omissions made in the system upstream of them. Although it is tempting in these straitened times to cut investment in training, that would be the ultimate false economy. http://www.flightglobal.com/articles/2009/07/21/329784/comment-pilot-trainin g-is-the-key-to-recovering-airline.html **************** AF Flight 447: French Prosecutor Opens Judicial Investigation For Manslaughter French Justice have designated four experts who have the assignment of giving an independent opinion on the causes of the accident. Their profile is as follows: . One is an ex captain from Air France, now retired, . The second one is a DGAC pilot, . The third one is an engineer, . And the fourth one is retired mechanics who was previously working on single and twin piston aircraft engine. In France, there are always two investigations, one by the BEA (the equivalent of NTSB, but not as independent as the NTSB is) and one by the 'systeme juridiciare', in this case under the 'juge d'instruction - Sylvie Zimmerman'. The members of the latter group are chosen from a so-called independent pool of experts. Their official role is to protect France and the French interests. The danger is however that their judgment of the accident cause could be of more weight than that of the BEA. http://luckybogey.wordpress.com/2009/06/05/af-flight-447-french-prosecutor-o pens-judicial-investigation-for-manslaughter/ *************** Dragonair names James Tong as new CEO Hong Kong carrier Dragonair today named Cathay Pacific Airways veteran James Tong as its new CEO. He will assume the post on 17 August, succeeding Kenny Tang, says the Cathay subsidiary. Tong was previously was General Manager Sales PRD and Hong Kong at Cathay Pacific, responsible for managing the airline's passenger business in Hong Kong and the Pearl River Delta region since April 2008. Tong has held a number of managerial positions at Cathay Pacific since joining in 1987. Source: Air Transport Intelligence news **************** Overlooked trim led to 737's post-V1 abort Investigators have traced the post-V1 abort of a BMIbaby Boeing 737-300's take-off roll to an oversight which left the stabiliser trim set in the wrong position. The aircraft, departing Birmingham for Edinburgh in snowy weather on 13 February, failed to rotate at 135kt when the first officer pulled on the control column. As the aircraft continued to accelerate to 155kt the captain opted to reject the take-off, says the UK's Air Accidents Investigation Branch. Although the 737 was travelling "well above" the V1 speed of 126kt, the captain correctly judged that the aircraft would be able to stop within the remaining length of Birmingham's 2,600m (8,530ft) runway. The AAIB found that the crew had omitted to set the stabiliser trim at the usual point because of de-icing procedures under way at the time. De-icing procedures "disrupted" the crew's routine, it says, leaving the stabiliser trim incorrectly set, and the crew was "distracted" by the unusual requirement to leave the flaps up while taxiing in slush. The crew also felt pressured by de-icing holdover time constraints, and the rotation failure "reinforced" the captain's concerns that ice accretion may have affected the aircraft's control surfaces. "When the first officer said he could not rotate the aircraft, the captain quickly made the decision to reject the take-off, having judged there was sufficient runway remaining to do so and believing the aircraft was not capable of flying," says the AAIB. While the stabiliser setting was incorrect, it was still within permissible range, so there was no warning horn to alert the crew. Simulator trials subsequently indicated that the aircraft could have rotated successfully, and climbed away safely, if the crew had applied a "more forceful" pull on the control column. Source: Air Transport Intelligence news ***************** Crew's data-entry error led to laboured 767 take-off: inquiry Incorrect data entry during take-off calculations has been identified as the reason that a Thomson Airways Boeing 767-300 laboured to become airborne from Manchester last year, and suffered a tail-strike in the process. After receiving the loadsheet the crew had inadvertently entered the zero-fuel weight, about 118t, into the computer-based system for calculating take-off speeds, instead of the proper figure of 172t. This data-entry error, says the UK Air Accidents Investigation Branch, would have generated "significantly slower" take-off speeds than required. The calculated velocity for rotation was 21kt lower than the true figure. During the take-off roll for the flight to Montego Bay, however, the captain felt the aircraft might be heavier than calculated, and delayed the 'V1' call by around 10-15kt after sensing "sluggish" acceleration. Nevertheless, as the aircraft rotated, its tailskid struck the runway. The captain - while not the flying pilot - applied full power. In response to a brief stick-shaker activation, the co-pilot reduced pitch and the 767 climbed away safely, although the crew opted to dump fuel and return to Manchester. The AAIB indicates that the crew may have been distracted by taxiway works in progress at Manchester as well as time pressures from a 15min pushback delay. Since the 13 December incident, it adds, Thomson Airways has instructed pilots to extract take-off weight data from loadsheets independently, and reminded crews that checking loadsheets for "gross errors" remains "good practice". Source: Air Transport Intelligence news *************** Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC