Flight Safety Information April 13, 2010 - No. 074 In This Issue NTSB Issues Factual Report In Tahlequah Helicopter Accident 78 injured as Indonesian jet breaks in two Boeing 737-300 Runway Excursion (Indonesia)... Russia blames pilot error for Polish jet crash Both Tu-154 recorders contain complete crash record Crashed Tu-154 crew offered three alternate airports EASA orders ATR 72 checks over rudder-pedal flaw ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ NTSB Issues Factual Report In Tahlequah Helicopter Accident Pilot Was Under Investigation By The FAA The NTSB has issued its factual report in the crash of a Robinson R22 helicopter in which the pilot and his passenger were killed. The report indicates that the pilot was under investigation by the FAA for providing false and misleading information on a medical certificate. The excerpted text of the report reads as follows: "On October 14, 2009, approximately 0450 CDT, a Robinson Helicopter R22 Beta, N3234G, operated by a non-instrument rated private pilot, was destroyed when it impacted terrain near Tahlequah, Oklahoma. A post impact fire ensued. Night instrument meteorological conditions prevailed at the time of the accident. The personal flight was being conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91 without a flight plan. The private pilot and his passenger were fatally injured. The flight departed the pilot's private residence approximately 0445 and was en route to Tahlequah Municipal Airport (KTQH), Tahlequah, Oklahoma. "According to family and friends, the pilot had been up all night watching movies. The pilot intended to fly to KTQH to meet a friend, hanger his helicopter, and go hunting. The helicopter never arrived and the friend departed the airport without reporting the overdue helicopter. Family members of the passenger filed a missing persons report on the afternoon of October 15, 2009, and the wreckage was located from the air the morning of October 16, 2009. "The pilot, age 26, held a private pilot certificate with a rotorcraft helicopter rating issued on July 31, 2009. He was issued a Third Class Airman Medical and Student Pilot certificate on April 28, 2008. The certificate contained no limitations. The pilot's flight log was not located in the wreckage and the pilot's family was not aware of the location of the flight log. At the time of application for the airman medical certificate on April 28, 2008, the pilot reported a total flight time of 21 hours. According to the Federal Aviation Administration (FAA), the pilot received his private pilot certificate on July 31, 2009. At the time of application for this certificate, the pilot reported a total flight time of 85 hours, all of which were logged in the Robinson R22. The application reflected 3.5 hours of night instruction and zero hours of instrument training. "A review of FAA records revealed that a letter of investigation was sent to the pilot on September 2, 2009. The letter alleged that the pilot had provided "false or fraudulent information" on his medical certificate application dated April 28, 2008, and failed to report a motor vehicle action within 60 days as required by Federal Aviation Regulations. The letter discussed three separate alcohol-related motor vehicle actions that were recorded on the pilot's driving record. The dates of these offenses were July 14, 2003, January 26, 2004, and March 9, 2009. According to the FAA, the pilot had not responded to the letter or provided further evidence or a statement regarding the letter. "The accident helicopter, a Robinson Helicopter R22 Beta (serial number 4114), was manufactured in 2007. It was registered with the FAA on a standard airworthiness certificate for normal operations. A Lycoming O-360-J2A engine, rated at 145 horsepower, powered the helicopter. The helicopter was registered to Trevor Noble, Terry Noble, and Robert Koudelka. The original maintenance records were not in the wreckage. Trevor Noble and Robert Koudelka had both been fatally injured in separate aviation accidents on November 5, 2007, and November 2, 2008, respectively. Terry Noble could not be located. The pilot's family had no knowledge as to the location of the maintenance records. A mechanic with Sevier County hoppers came forward and provided copies of the maintenance entries from maintenance performed on the accident helicopter. According to these copies, the most recent maintenance conducted on the helicopter was a 100-hour inspection, which was conducted in accordance with the R22 maintenance manual. This 100-hour inspection was completed on July 27, 2009, at an aircraft total time of 1,542.7 hours. "The Office of the Chief Medical Examiner performed the autopsy on October 17, 2009, as authorized by the Office of the Chief Medical Examiner - Eastern Division, Tulsa, Oklahoma. The autopsy concluded that the cause of death was "internal injuries due to blunt force trauma." During the autopsy, specimens were collected for toxicological testing performed by the FAA's Civil Aerospace Medical Institute (CAMI), Oklahoma City, Oklahoma (CAMI Reference #200900245001). "Toxicology staff at CAMI noted that paperwork accompanying toxicology samples on the pilot indicated the blood source to be "RT. PLEURAL SPACE." Testing of the blood detected 20.92 ug/ml Acetaminophen, 0.125 ug/ml Amphetamine, 0.025 ug/ml Doxylamine, 1.338 ug/ml Methamphetamine, 2.077 ug/ml Norpropoxyphene, 0.49 ug/ml Propoxyphene, Dextromethorphan, and Dextrorphan. Testing of the liver tissue detected 0.281 ug/ml Amphetamine, 2.458 ug/ml Methamphetamine, 15.501 ug/ml Norpropoxyphene, 3.039 ug/ml Propoxyphene, Dextromethorphan, Doxylamine, and Dextrorphan. A review of the pilot's dental records indicated that the pilot was prescribed a combination of propoxyphene and acetaminophen for pain following a tooth extraction and a tooth repair performed the day prior to the accident. The pilot's April 28, 2008, application for 3rd Class Airman Medical and Student Pilot Certificate indicated "No" in response to "Do You Currently Use Any Medication" and to all items under "Medical History," including specifically "Substance dependence or failed a drug test ever, or substance abuse or use of illegal substance in the last 2 years," "history of any conviction(s) involving driving ... while under the influence of alcohol or a drug; or ... actions involving an offense(s) which resulted in the denial, suspension, cancellation, or revocation of driving privileges ...," and "History of nontraffic convictions (misdemeanors or felonies)." FMI: www.ntsb.gov Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 78 injured as Indonesian jet breaks in two Jakarta, Indonesia (CNN) -- A passenger plane crashed into a shallow waterway and broke in two after overshooting the runway in a remote area of Indonesia's eastern Papua province on Tuesday, injuring 78 people on board. Bambang Ervan, a spokesman for Indonesia's Transportation Ministry, said investigators to the airport in the coastal town of Manokwari where the Merpati Nusantara Airlines Boeing 737-300 had been attempting to land. There were reports that bad weather may have been a factor. The injured, many of whom suffered fractures, were taken to hospitals in the area. In all, the plane was carrying 103 passengers, including three children and three infants. Ervan said the aircraft bounced on the runway during landing, skidded and plunged into a nearby canal. Merpati, a cash-strapped state-owned airline which is in the process of upgrading its aging fleet, flies many of the more remote routes across Indonesia. Last year Merpati suffered two plane crashes in Papua. In July, a Merpati flight lost its front wheels as it took of from the town of Biak. A month later, another flight -- a Twin Otter aircraft -- crashed, killing 16 people on board. Air accidents are not infrequent in Papua, a mountainous area in the easternmost part of Indonesia. Two cargo planes and several smaller aircraft also crashed in the province last year. Indonesia has made efforts in recent years to improve its safety record. Last year the European Union's Safety Commission lifted a ban on four Indonesian carriers. In Hong Kong, Tuesday, a Cathy Pacific flight from Surabaya in Indonesia made an emergency landing injuring eight people. Flight 780 from Surabaya, Indonesia, was carrying 309 passengers and 13 crew members, Cathay Pacific CEO Tony Tyler said at a news conference. Passengers and crew deplaned through the Airbus 330's evacuation slides. The injured were taken to the territory's Princess Margaret Hospital. Tyler said a full investigation will follow but engine trouble may have played a part in the incident. The north runway at the Hong Kong International Airport was closed for almost three hours after the emergency landing. Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Boeing 737-300 Runway Excursion (Indonesia) Date: 13-APR-2010 Time: 09:36 Type: Boeing 737-300 Operator: Merpati Airlines Registration: PK-MDE C/n / msn: Fatalities: Fatalities: 0 / Occupants: 92 Other fatalities: 0 Airplane damage: Written off (damaged beyond repair) Location: Rendani Airport (MKW/WASR) - Indonesia Phase: Landing Nature: Domestic Scheduled Passenger Departure airport: Sorong-Dominique Edward Osok Airport (SOQ/WASS) Destination airport: Rendani Airport (MKW/WASR) Narrative: A Boeing 737-300 passenger plane, presumably registered PK-MDE, sustained substantial damage in a runway excursion accident at Rendani Airport (MKW/WASR), Indonesia. All 86 passengers and six crew members survived. Merpati Flight MZ836 operated on a scheduled flight from Sorong-Dominique Edward Osok Airport (SOQ/WASS). It was landing at Rendani when it overshot runway 35 by 200 meters before coming to a stop in a river bed. Rendani has a single runway, 17/35, measuring 2.000 m x 30 m. Some 20 passengers reportedly sustained minor to moderate injuries. Conflicting sources report the airplane to be either PK-MDE or PK-MDF. PK-MDE seems most likely. www.aviation-safety.net [http://r20.rs6.net/tn.jsp?et=1103299834653&s=6053&e=001J3bVinF7-IVFFLMckTU-cK3Do2_BfBNXnRYnJG8SbZZabkS1h2pzZnMU0A4fc7djJ1Duh7SzvfQ4Y5DqlZpJ-XvTmO8l6iVdsAYczfKvLuiQH73nbILbUZi0PXefidmL] Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Russia blames pilot error for Polish jet crash Russia said yesterday the air crash in Smolensk that killed the Polish president and scores of other senior officials appeared to have been caused by pilot error as the first details of the flight's data and voice recordings were disclosed. Sergei Ivanov, Russia's deputy prime minister, said initial downloadings from two of the aircraft's "black boxes" showed the crew had been clearly warned from the control tower against landing in conditions of thick fog and instructed to divert to a different airport. A Russian government official told the Financial Times that the recordings also revealed that the pilot, Capt Arkadiusz Protasiuk, 36, also "for some strange reason" did not react to an automatic voice warning that went off as the aircraft descended "dangerously close to the ground". The official, speaking on condition of anonymity, said the warning system went off while the pilot was still "negotiating" with the airport controllers. Why he did not react "is the biggest question", the official said. The crash, which killed Lech Kaczynski, the president, the central bank governor and numerous members of the government and military elite after the aircraft clipped trees, is made more sensitive by its timing and location, as Russia seeks to mend troubled ties with Poland. The delegation of Polish officials had been due to take part in commemorations of the 70th anniversary of the killing of 22,000 Polish officers by the Soviets in 1940. Russia is finally seeking to confront the past after decades of claiming the shootings were conducted by the Nazis. The best-known murder site, Katyn, where 4,000 Poles were killed, lies just outside Smolensk. But as the first details of flight recordings began to be disclosed, speculation centred on whether the Polish leadership had pressed the pilot to land in spite of the fog, in order to reach the ceremony on time. In August 2008 Mr Kaczynski had pressed a pilot to land in Tbilisi, Georgia, even though conditions were dangerous during Russia's short war with the country. After the pilot refused, Mr Kaczynski went into the cabin and later said: "If someone decides to become an officer they should not be cowardly." The pilot, who diverted to nearby Azer-baijan, was later awarded a medal for refusing to yield to the president. Poland's chief prosecutor, Andrzej Seremet told a news conference yesterday that, at this stage of the investigation, there was nothing to suggest pressure was put on the pilots. However, the Tu-154's black boxes were still being analysed to see "if suggestions were made to the pilots". The Russian government official said he could not say if such "suggestions" had been made, adding that investigations were only at an early stage. Any disclosure of pressure on the pilot to land could put Russia in a delicate position as it seeks to minimise the fallout on relations of the crash. The government official said the black box recordings were being investigated in close co-ordination with the Polish authorities. Lech Walesa, Poland's president from 1990 to 1995, told reporters he doubted the pilot would have ignored the recommendations from the control tower in Smolensk to divert to a different airport without consulting senior officials. "I can't believe that the pilot made the decision on his own. That is unlikely," he said. "Whenever I would fly, if there were ever any doubts they would always come to the leaders and ask for a decision, and only on that basis were later steps taken." Alexander Bastrykin, head of the Russian prosecutors' investigations committee, said that investigators were already ruling out a possible technical failure of the aircraft. http://www.ft.com/cms/s/0/a83e8a8a-4696-11df-9713-00144feab49a.html [http://r20.rs6.net/tn.jsp?et=1103299834653&s=6053&e=001J3bVinF7-IVTsQ9PbvObXWTQr9Pj2dTKrhCth21HiPbbLnOuLNnzdGJ8WGI-rAVMjmye6QoHBJlxLRCId0SjEek4Pyv6kdhw] Back to Top [http://r20.rs6.net/tn.jsp?et=1103299834653&s=6053&e=001J3bVinF7-IVTsQ9PbvObXWTQr9Pj2dTKrhCth21HiPbbLnOuLNnzdGJ8WGI-rAVMjmye6QoHBJlxLRCId0SjEek4Pyv6kdhw] ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Both Tu-154 recorders contain complete crash record Analysis of the two flight recorders from the crashed Polish state Tupolev Tu-154 has revealed that both contain a complete record of the accident. During a technical meeting on the investigation's progress, first deputy prime minister Sergei Ivanov stated that the technical condition of the two recorders was "quite satisfactory". He says that both the cockpit-voice and flight-data recorder were "fully functional" and registered all information "until the aircraft struck the ground". Ivanov adds that the inquiry can "reliably" confirm that "timely" warnings about the poor weather at Smolensk's northern airport, and recommendations to divert, were transmitted to the flight crew. He adds: "All further work on the analysis and interpretation of information from both recorders will be done in close co-ordination with the Polish authorities." None of the 96 occupants of the Tu-154, arriving from Warsaw, survived after it struck trees and disintegrated on approach to Smolensk on 10 April. Source: Air Transport Intelligence news Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Crashed Tu-154 crew offered three alternate airports Crew members of the Polish state Tupolev Tu-154 which crashed at Smolensk yesterday were offered three alternate airports, as a result of dense fog, but opted to continue the flight in order to assess the weather situation. Two Belarussian airports - Minsk and Vitebsk - as well as Moscow Vnukovo were suggested to the pilots, said Russia's presidential plenipotentiary representative Georgy Poltavchenko during a preliminary technical briefing with prime minister Vladimir Putin. Poltavchenko, who was among the delegates waiting to receive the aircraft, states that he was informed that the weather conditions were "difficult", with visibility below 400m - and possibly as low as 100-150m. But he says the flight crew considered they had sufficient fuel to continue flying to the Smolensk terminal area, to "look around, and then decide". "Then we were told that they were going to land," he says, adding that the Tu-154 was not heard approaching before there was the noise of an impact. He says the sounds were "strange" and "not typical" of a crash. Air transport regulator Rosaviatsia's chief, Alexander Neradko, told Putin during the briefing that visibility was below the minimum of 1,000m. Neradko says the Tu-154 struck an 8m-tall tree at a distance of 1,200m from the runway. At this distance the tri-jet should have been at a height of 60m, he says, the standard for a 3° glideslope. "The aircraft proceeded to strike more trees, broke up in mid-air, hit the ground and exploded," he adds. No indication has been given, during the briefing, on whether the crew attempted to abort the landing. Earlier information had suggested that the Tu-154 had been executing a go-around. Emergency situations minister Sergei Shoigu says that firefighting personnel were dispatched to the scene at 10:51 and that fires were extinguished 10min later. The aircraft came down about 300m from the runway, he says, with no survivors among the 96 occupants. Transport minister Igor Levitin confirmed to Putin that the pilot "made the decision to proceed independently", despite the warning from air traffic control over the foggy conditions. Polish president Lech Kaczynski and dozens of high-ranking Polish political and military figures were killed in the accident. Source: Air Transport Intelligence news Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ EASA orders ATR 72 checks over rudder-pedal flaw European safety regulators have ordered checks on seven new ATR 72-500 turboprops which may have been fitted with faulty rudder-pedal rods. The problem, caused by a manufacturing error, was detected after pre-departure flight-control checks on two ATR 72s resulted in rudder pedals sticking after their rods broke. In an emergency airworthiness directive the European Aviation Safety Agency says that most of the rods in the affected pedal assemblies have been checked. But seven in-service aircraft have been identified as potentially having had the faulty rods installed. The aircraft bear serial numbers 886, 897, 901, 902, 903, 904 and 906. Two have been delivered to Vietnam Airlines, another to its affiliate Cambodia Angkor Air, and two others to Air Algerie. MASwings and Canary Islands carrier NAYSA operate the remaining two. EASA has ordered inspections of the four rudder-pedal rods which, it says, may have been manufactured with diameters narrower than required. Source: Air Transport Intelligence news Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC