Flight Safety Information March 19, 2010 - No. 058 In This Issue NTSB Says Northwest Pilots' Distraction Led To Overflight FAA issues second fine against American for maintenance violations Crashed An-26 had engine problem and aborted first approach Air Canada dismisses crew concerns suicidal pilot threatened to ditch plane FAA faulted on Southwest Airlines Watchdog Faults FAA for Lax Oversight of Southwest ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ NTSB Says Northwest Pilots' Distraction Led To Overflight Of Minneapolis Fri, 19 Mar '10 Notes ATC Shortcomings, Issues Recommendations On ATC Procedures The NTSB has determined that Northwest Airlines flight 188 overflew its destination airport of Minneapolis by more than 100 miles and failed to maintain radio communications because the pilots became distracted by a conversation unrelated to the operation of the aircraft. The NTSB's accident brief, released Thursday, also notes air traffic control shortcomings during the event, and the Board issued two safety recommendations to address those shortcomings. On October 21, 2009, Northwest Airlines flight 188, an Airbus A320 (N374NW) operating as a scheduled flight between San Diego and Minneapolis, did not communicate with air traffic control for approximately one hour 17 minutes. While in this NORDO (no radio communications) state, it flew past its intended destination at a cruise altitude of 37,000 feet. The crew subsequently re-established radio communications and landed without further incident. There were no injuries. The NTSB said that the pilots continued to fly through several air traffic control sectors without replying to any radio commands. The investigation found that the pilots had become engaged in a conversation dealing with the process by which pilots request flight schedules and during the conversation each was using his personal laptop computer, contrary to company policy. The pilots were not aware of the repeated attempts by air traffic controllers' and the airline to contact them until a flight attendant used the intercom to inquire about the progress of the flight. T he NTSB also found that the lack of national requirements for recording ATC instructions when using automated flight tracking systems, such as directing an aircraft to switch frequencies or to indicate that an aircraft has checked in on an assigned frequency, was a factor in the controllers delay in performing necessary actions and notifications required by lost communications procedures. In addition, because NORDO events of a short duration are not uncommon, the Safety Board found that controllers and managers may have become complacent in completing necessary NORDO actions and required notifications in a timely manner. As a result of deficiencies in ATC communications procedures revealed in this investigation and an accident involving a Pilatus PC-12/45 that crashed in Butte, Montana on March 22, 2009, the Board is making recommendations to the FAA to address the following issues: The lack of standard procedures for identifying flight crew-ATC communications in ATC facilities that use automated flight tracking systems. The lack of standard phraseology for identifying the emergency nature of emergency ATC radio transmissions. The NTSB recommends that the FAA: Establish and implement standard procedures to document and share control information, such as frequency changes, contact with pilots, and the confirmation of the receipt of weather information, at air traffic control facilities that do not currently have such a procedure. These procedures should provide visual communication of at least the control information that would be communicated by the marking and posting of paper flight-progress strips described in Federal Aviation Administration Order 7110.65, "Air Traffic Control." Require air traffic controllers to use standard phraseology, such as "on guard," to verbally identify transmissions over emergency frequencies as emergencies. The NTSB will convene a 3-day public forum on professionalism in aviation to address methods for ensuring excellence in pilot and air traffic controller performance. The forum is intended to raise awareness by promoting an open discussion between the Board and invited panelists drawn from industry, labor, academia, and government on the importance of developing and reinforcing professionalism in the aviation industry. The forum is scheduled for May 18-20, 2010. More information regarding the forum will be announced in the coming weeks. FMI: www.ntsb.gov Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ FAA issues second fine against American for maintenance violations American Airlines has received notice from the US FAA that the agency intends to issue a second fine against the carrier for maintenance violations. The proposed $300,000 penalty follows a proposed fine of $787,500 by FAA against American on 12 March for three other maintenance violations. FAA today alleges that on 2 February 2009 American mechanics deferred maintenance on a Boeing MD-80 under the aircraft's minimum equipment list (MEL), when they noted that the "pitot/stall heater light off" light on the aircraft's annunicator panel was inoperative. MELs list components and systems that the aircraft can operate safely without in certain conditions. FAA says the day after the deferred maintenance was noted, American's maintenance personnel determined the inoperative part was actually the captain's pitot probe heater. Pitot probes are placed on aircraft surfaces to measure airspeed, and since ice can build up on the probes the devices are equipped with heaters. The agency explains the aircraft's MEL allows for deferral of maintenance of the pitot probe's heater, but it restricts flights to daylight hours in visual meteorological conditions (VMC). Flights into known or forecast icing or visible moisture are prohibited. "Because the mechanics logged the discrepancy as an inoperative panel light, the flight crew was unaware that the daytime, VMC restrictions applied to further flights," says FAA. FAA explains American violated Federal Aviation Regulations by operating the aircraft on five passenger flights when the restrictions should have been applied. The fines issued against American this month follow a $7.1 million penalty levied against the carrier in August 2008 for violating regulations governing maintenance and drug and alcohol testing. Source: Air Transport Intelligence news Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Crashed An-26 had engine problem and aborted first approach Preliminary investigation into the Antonov An-26 frozen lake crash in Estonia today has found that the aircraft was experiencing problems with one of its engines, and had already aborted one approach to Tallinn Airport. The twin-engined aircraft, registered SP-FDO and operated by Polish carrier Exin, had been arriving from Helsinki. It encountered a problem with its left engine, says a spokesman for the Estonian accident investigation team, but executed a go-around during its initial approach to the airport. "They tried to land but were not successful the first time," he says. The An-26 subsequently crashed onto 30cm-thick ice covering Lake Ulemiste which lies on the extended approach centreline to Tallinn's runway 08. Investigators have yet to determine whether the decision to land on the ice was deliberate or forced upon the pilots by the circumstances. Personnel on the scene have stabilised the aircraft, preventing it from sinking into the lake, says a spokesman for the economics ministry. He adds that work is progressing to remove around 1.5t of fuel, and plans are being drawn up to transport the aircraft to shore. The lake provides drinking water to Tallinn but the city's authorities have reassured that there is no risk to health from fuel leakage. Exin is based in Lublin and operates services on behalf of freight company DHL. It was carrying DHL cargo at the time of the accident. All six occupants, which included four air crew and two handlers, survived. Source: Air Transport Intelligence news Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Air Canada dismisses crew concerns suicidal pilot threatened to ditch plane TORONTO (CP) - Air Canada is standing by a pilot at the centre of a bizarre incident two years ago in which co-workers refused to fly with him, fearing he was suicidal and accusing him of threatening to ditch his aircraft in the Atlantic Ocean. The airline insisted Thursday that the eyebrow-raising circumstances emanating from a dispute aboard a Toronto-Paris flight in July 2008 amounted to nothing more than a minor conflict between staff and a healthy, competent pilot. Public safety was never compromised, although the situation, which began as a dispute between the unnamed pilot and chief steward Hugh Bouchard, culminated in a battle in Federal Court. What prompted the original conflict remains unclear. But according to Bouchard, the pilot threatened to ditch the plane over the Atlantic, saying "he had nothing to lose as he was being fired anyway," court documents show. Airline spokesman Peter Fitzpatrick said the incident was investigated at the time, and that the ensuing report made no reference to the pilot making a threat to ditch the plane. However, the report did reflect Bouchard's claim the pilot had said: "If I lose my job, I have nothing to lose." "This was not a depressed person speaking," Fitzpatrick said. "It was said in the midst of a personnel dispute, and you can easily imagine many scenarios where someone might use this very common phrase, which has many meanings." A thorough investigation at the time turned up no safety issues with the pilot, who is still flying for Air Canada, Fitzpatrick said. Still, a month after that flight, four other flight attendants adamantly refused to set foot on a plane headed for Paris captained by the same pilot, based on Bouchard's concerns. That forced Air Canada to scramble a reassembled support crew onto the flight. An independent federal safety officer was brought in to probe the work stoppage. The safety officer talked to the flight attendants, union representatives, managers and others who knew the pilot, and found only the attendants had any concerns about him. The officer then chalked up the incident to a normal workplace dispute, and decided the attendants had no right to refuse to work. As a result, she decided there was no need to investigate whether the pilot's mental state did in fact pose any danger. Air Canada, which took the view that conflicts can arise at any time and the attendants should have used the carrier's resolution process, agreed the pilot posed no threat. However, the Canadian Union of Public Employees, which represents the attendants, challenged her findings in Federal Court. Judge John O'Keefe sided with the union. O'Keefe found the investigator was wrong to conclude the conflict between pilot and steward was a "normal condition" of employment. Instead, O'Keefe ruled this month, the investigator should have first decided whether the pilot's alleged mental state did in fact constitute a danger that justified the attendants' refusal to work. Air Canada said it was not planning an appeal and no disciplinary action was ever taken. Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ FAA faulted on Southwest Airlines (Reuters) - A government watchdog faulted the Federal Aviation Administration (FAA) for allowing Southwest Airlines Co to fly jets that had not undergone mandatory maintenance work, violating stipulated safety rules, the Wall Street Journal said. U.S. The Office of Special Counsel said on Thursday that the company failed to complete certain required maintenance involving rivets around the window frames of 55 of its Boeing 737 aircraft, the paper said, citing the counsel's documents. Southwest voluntarily disclosed the information to a senior FAA inspector who was also a supervisor in the local office charged with overseeing the airline, the Journal said. But the inspector did not determine why the company had never completed the repair work or ensure that the necessary maintenance work was eventually completed, the paper added. "These issues have been previously addressed through comprehensive audits by the FAA ... our own audits, and work by outside consultants," a Southwest spokesperson told the paper. The spokesperson told the paper that the airline officials "are confident that we have identified and remedied the issues." "A second investigation has shown that some FAA managers continue their willingness to look the other way" rather than enforce strict compliance with maintenance requirements and voluntary disclosure rules, the paper said, quoting Associate Special Counsel William Reukauf. Southwest Airlines and the FAA could not be immediately reached for comment by Reuters outside regular U.S. business hours. [http://r20.rs6.net/tn.jsp?et=1103210834732&s=6053&e=001zjDePht3B6RrN328CiS8oMz8dtgOXO5oEB0nYAHeAKjMqZ_b9KAT4joJebAYYjY92DcfuxvSNxghJCurYJ3GY0NMYfgIO2qp] Back to Top [http://r20.rs6.net/tn.jsp?et=1103210834732&s=6053&e=001zjDePht3B6RrN328CiS8oMz8dtgOXO5oEB0nYAHeAKjMqZ_b9KAT4joJebAYYjY92DcfuxvSNxghJCurYJ3GY0NMYfgIO2qp] ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Watchdog Faults FAA for Lax Oversight of Southwest By ANDY PASZTOR For the second time in less than two years, government ethics watchdogs have determined that Federal Aviation Administration managers knowingly allowed Southwest Airlines Co. to violate safety rules by flying jets that hadn't undergone mandatory maintenance work. The U.S. Office of Special Counsel-which investigates whistleblower complaints by federal employees-disclosed Thursday that Southwest failed to complete certain required maintenance involving rivets around the window frames of 55 of its Boeing 737 aircraft. The special counsel faulted FAA managers for what it said was a cozy relationship that permitted the airline to violate rules while avoiding punishment. At the time, Southwest already was under scrutiny by congressional panels and government investigators for separate violations that involved more planes. According to the documents, Southwest voluntarily disclosed the problem to a senior FAA inspector who was also a supervisor in the local office charged with overseeing the airline. The inspector subsequently neither determined why Southwest had never completed the mandatory repair work nor ensured that all the necessary work was eventually completed. The special counsel's office also said that investigators subsequently discovered that Southwest continued to fly six of the aircraft for two weeks after the airline recognized the violation, and after it told the FAA the compliance issues had been resolved. The documents don't include precise dates for when the flights took place, but they appear to have occurred sometime in 2007. The special counsel released its report on the matter Thursday, indicating it had received a report from Transportation Secretary Ray LaHood last October. In addition, investigators determined that a second, more-senior manager in the same FAA office in Texas agreed to close the matter without any kind of enforcement action or civil penalty. This manager made his decision "without reviewing the file," according to investigators. Responding to the latest findings, a Southwest spokeswoman said late Thursday that "these issues have been previously addressed through comprehensive audits by the FAA . . . our own audits, and work by outside consultants." She said the airline officials "are confident that we have identified and remedied the issues." The FAA was still gathering details and analyzing the special counsel's findings. But an agency spokesman said the FAA has "put some safeguards into place" to prevent a single manager from accepting and processing voluntary disclosures by airlines. Under such voluntary programs, airlines can avoid punishment as long as their disclosures are deemed timely, complete and violations are corrected immediately-even if that means temporarily grounding aircraft. The latest revelations of lax FAA oversight involve many of the same issues-and even the same whistleblower-that prompted a flurry of investigations of the agency in April 2008. Charalambe "Bobby" Boutris and a fellow FAA inspector made national headlines when they testified on Capitol Hill about run-ins with FAA supervisors seemingly intent on protecting Southwest. During the 2008 Congressional hearings, the inspectors described how FAA managers failed to heed years of internal warnings about maintenance problems at Southwest. They also testified that in the spring of 2007, a close relationship between some FAA managers and their Southwest counterparts allowed 46 planes to continue carrying tens of thousands of passengers without undergoing mandatory structural inspections. That controversy prompted policy and personnel changes inside the FAA, eventually sparking a national furor over spotty maintenance compliance by Southwest and other large carriers. Rep. James Oberstar, the Minnesota Democrat who led some of the hearings as chairman of the House Transportation and Infrastructure Committee, said at the time that the violations by Southwest and FAA managers were "the most egregious lapses of safety I've seen in 23 years." The more recent violations appear to have occurred just before Southwest's previous maintenance lapses were coming to the public's attention. Summarizing the latest issues, Associate Special Counsel William Reukauf wrote that the "second investigation has shown that some FAA managers continue their willingness to look the other way rather than enforce" strict compliance with maintenance requirements and voluntary disclosure rules. "If meaningful change is to occur" inside the FAA, according to Mr. Reukauf, "FAA managers must be held accountable for their complicity with airline noncompliance." The violations that were revealed in 2008 resulted in a proposed $10.2 million penalty against Southwest. A year ago, the airline and the FAA compromised on a $7.5 million penalty. The special counsel's office indicated that the penalty also took into account the series of maintenance lapses that were revealed Thursday. Most of the latest investigation was conducted by the Department of Transportation's inspector general. According to investigators, FAA managers should have been more vigilant because of prior instances of lax FAA oversight. "Once again," according to the documents released Thursday, DOT investigators "determined that FAA managers are not complying with agency policy and regulations put in place to ensure aviation safety." http://online.wsj.com/ Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC