Flight Safety Information June 2, 2010 - No. 109 In This Issue Polish Tu-154 crew ignored eight 'pull up' warnings Polish Pilots Cautioned Against Landing Attempt In Smolensk Text of black box from doomed Polish jet published India to Pilots: Don't Aim for Comfortable Landings Pilot overreaction sent passengers tumbling 1 dead, 4 hurt after small plane crashes in Alaska Families honor Air France crash victims a year on Aeroflot alcohol ban results in fewer drunken incidents Dubai airports to ban noisiest older-generation aircraft TSB: Pilots exceeded A319 fin limit levels after 2008 wake encounter ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Polish Tu-154 crew ignored eight 'pull up' warnings Newly-released cockpit voice-recorder transcripts from the crashed Polish presidential Tupolev Tu-154M show that the terrain-awareness system sounded a 'pull up' warning eight times before the jet collided with trees and disintegrated. The first warning at 10:40:42, about 20s before the accident, came almost immediately after the crew had called the aircraft's height as 100m. This also happened to be the decision height for the approach, which was being attempted in dense fog. Transcripts from the accident also show that, although the aircraft was descending, the height was still being called as 100m seven seconds later at 10:40:49. This could indicate that the reading was not the aircraft's height above the runway, but rather the immediate height above terrain as given by the radio altimeter. Radio altimeter readings provide a 'snapshot' height above ground and can give a false impression of clearance margins in regions where terrain rises sharply ahead of the aircraft. The approach to Smolensk taken by the Tu-154 features a valley about 1km from the runway threshold. The transcript reveals that the Tu-154 continued to descend through the decision height, the navigator calling 10m intervals, with no apparent comment until at 80m the co-pilot said, "Odchodzimy" - or "We're leaving" - which may have been a reference to a missed approach. There is no subsequent evidence, however, that the crew opted to abort the landing. At about 60m an 'unsafe height' warning sounded. The aircraft continued to descend, despite the continuing 'pull up' instruction from the terrain-awareness system, and a caution from the air traffic controller. The transcript indicates the reduction in height from 100m to 20m took just 6.5s, equating to a descent rate of some 740m/min (2,400ft/min). This relatively high closure rate suggests that the clearance margin was rapidly being eroded by rising ground. Just after the 20m height call from the navigator, the cockpit recorder picked up sounds from the aircraft's automatic on-board control computer as well as a middle-marker beacon signal. The middle-marker's location typically coincides with the point at which an approaching aircraft would normally reach decision height. At 10:40:59 came the sound of a collision with trees, followed by the eighth and final 'pull up' instruction, and an order from air traffic control to execute a go-around. The aircraft lost its outer left wing in the collision, rolled inverted to the left, and was completely destroyed. None of the occupants, including Polish president Lech Kaczynski, survived the 10 April accident. Source: Air Transport Intelligence news Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Polish Pilots Cautioned Against Landing Attempt In Smolensk 96, Including Polish President, Were Killed In The Accident A transcript from the cockpit voice recorder carried by the TU-154 which crashed in heavy fog in Western Russia in April shows that the pilots were warned by Russian aviation authorities to not attempt the landing at Smolensk. The resulting crash killed Polish President Lech Kaczynski, his wife, and 94 others. The transcript included the final 39 minutes of the flight. It was published by Polish officials Tuesday. The Associated Press reports that the government of Prime Minister Donald Tusk was anxious to publish the report in part to quash rumors and conspiracy theories that have been reported by what he described as "tabloids." The transcript shows that Russian air traffic controllers advised the pilots of the plane not to land, and it also recorded the terrain avoidance equipment repeating "pull up, pull up." The aircraft clipped a tree, which caused it to flip over and crash. The recordings do not give a definitive answer to questions about who might have been in the cockpit, and whether the pilots were under pressure to attempt the landing. The delegation was running late to a ceremony in Smolensk, and according to the transcript, President Kaczynski's chief of diplomatic protocol Mariusz Kanzana did visit the cockpit about 15 minutes before the landing attempt. When he was told about the poor weather and the possibility of not being able to land, he reportedly says "well, then, we have a problem." The pilots also reportedly talked with the pilots of a plane carrying Polish journalists which had landed successfully earlier. They talked about the thick fog and deteriorating weather, but also said the presidential plane could try to land. The New York Times reports that the transcript shows that the pilot, Arkadiusz Protasiuk, was told by Russian controllers "There are no conditions for landing." "We'll make an attempt," Protasiuk responded, "but if the weather isn't good, we'll leave for a second round." A few minutes later, controllers told the pilot to climb from his altitude of 325 feet. "If we fail to land, we are reascending on autopilot," he responded. No official cause for the accident has been determined by Russian and Polish aviation officials investigating the crash. FMI: http://www.ulc.gov.pl/index.php?option=com_content&task=view&id=419&Itemid=421 Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Text of black box from doomed Polish jet published WARSAW (AFP)-- Poland on Tuesday published the transcript of a black box recovered from the Polish government jet that crashed on April 10 in Russia killing president Lech Kaczynski and all 95 fellow passengers. The transcript of around the last 40 minutes of the doomed flight, in both Russian and Polish, was published on the Polish interior ministry website. It appeared to confirm earlier reports that pilots had not reacted to the aircraft's automatic danger alert. The aircraft's automatic warning phrase "Pull up, Pull up," is repeated several times during the last 20 seconds before the crash, but the pilots of the Russian-made Tupolev Tu-154 appear not to have reacted to the command. The black box had been handed over officially by Russian investigators to Poland on Monday. All 96 people on board the jet including Kaczynski, his wife and scores of senior Polish officials were killed in the crash in heavy fog outside the western Russian city of Smolensk. The presidential delegation was headed to the nearby Katyn forest for ceremonies marking the 70th anniversary of a World War II massacre of thousands of Polish officers by the Soviet secret police. Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ India to Pilots: Don't Aim for Comfortable Landings We all love those smooth plane landings. You know, when the aircraft glides onto the tarmac, with no jarring thud as the wheels touch ground, and then comes to a gradual and comfortable stop. Sometimes, we even applaud the captain. Well, it turns out that type of landing may actually be a dangerous stunt in some cases. In its first concrete step since the May 22 crash of an Air India Express jet in Mangalore, India's aviation regulator has issued a directive telling pilots not to aim for such "soft" landings because their aircraft might run out of room on a short runway. Pilots have been concerned about this issue, having felt pressure from their bosses at airlines to do fewer "hard" landings so as to please finicky passengers. In India's crowded and competitive commercial aviation market, it doesn't help to be known as the airline known that thrashes people onto the runway and leaves them with whiplash while bumping-and-grinding to a halt. But the Directorate General of Civil Aviation said on Wednesday that pilots should be aiming for a middle ground known as a "correct" landing. The agency didn't specifically mention the Air India crash - an investigation is still underway to determine its cause - but did say the directive is "due to the recent events in the aviation sector." The Mangalore airport where the crash occurred has a hilltop runway that's about 8,000 feet, relatively shorter than others in the country, and one that is surrounded by deep gorges on all sides. "Landings should be judged not by how soft the landing has been, but if it has been made at the correct speed and touchdown zone on the runway," the DGCA said in the statement. The agency said it has "asked all operators to ensure that 'correct' landings are aimed by pilots" rather than soft landings that "may compromise the runway stopping distance required." The statement went on: "A good landing is not one that the passengers perceive as a soft landing, but one that is made at the correct point on the runway with the correct flight parameters." In other words: safety should trump comfort. "It's about time," said Pradeep Deshpande, a pilot who is spokesperson for the Indian Pilots Guild, a union of aviators. He said pilots have been raising the issue for some time, but "it's been brought out aggressively in the last few weeks." "In training you're never taught to worry about the comfort of passengers in a landing - you're just taught to land firmly, land the right way," Mr. Deshpande said. "If you do that, it's not going to put a passenger at risk." http://blogs.wsj.com/ [http://r20.rs6.net/tn.jsp?et=1103450850808&s=6053&e=00128v3dS-2apXYaXZ2_ptuwRU79QK4KnRP8uO4gaCRHQm0ng8nphY38fucb9ncQn_8ltRKjVBDZIznHHFm26d1YTyr7EXmorewFCvbJ82tCMo=] Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Pilot overreaction sent passengers tumbling: report EDMONTON (CP) - An Air Canada pilot fighting unexpected turbulence overreacted on the rudder, turning a tense situation into a white-knuckle hell ride for 83 passengers, slamming them into the ceiling and windows, says a report released Tuesday. Nine passengers were injured when Air Canada Flight 190, from Victoria to Toronto, began violently plunging and rotating side to side over Washington state on Jan. 10, 2008. It had to make an emergency landing in Calgary. "When the aircraft began the uncontrolled rolls, the pilot disengaged the autopilot and attempted to control the aircraft manually. In doing so, some of the control inputs -- including rudder use -- were not totally appropriate," said John Pearson, a senior investigator with the National Transportation Safety Board. The board's final report noted the passengers and five crew members were flying east around 7 a.m. on the Airbus A319 -- a medium-sized jet with a maximum capacity of 120. The aircraft was cruising in clear skies above the clouds at 10,500 metres. Soaring above it, about 15 kilometres ahead, was a United Airlines Boeing 747, one of the big machines of the sky. In the cabin, the seatbelt sign was turned off and a few of the bleary-eyed passengers got up and moved around or went to the bathroom. Flight attendants began rolling the food and drink carts down the aisle. Up front, the pilot got the OK to climb 600 metres -- to the same height as the Boeing plane -- after flight control determined the two were far enough apart to avoid the Air Canada jet getting caught in the massive wind vortices trailing off the 747. It wasn't far enough. Instead, the Airbus flew right up and into the teeth of the swirling air. Over the next 18 seconds, all hell broke loose. The spinning air slammed down on the right wing, dipping it a mild five degrees. The autopilot kicked in to correct. Whoosh! The left wing dipped more precariously, about 28 degrees. Warning lights and alarms began going off in the cockpit. The pilot, said Pearson, wasn't expecting wake turbulence and instead believed the whole onboard computer system had gone haywire. He had never faced such a crisis before, said the report. He had a split second to make a decision. He disengaged the autopilot, grabbed the controls and started working the rudder foot pedals to level the craft. "He's doing the best he can with what he has and the information available to him," said Pearson. Unfortunately, by going manual, he took things bad to a whole lot worse. Wham, wham, wham, wham. The pilot slammed the massive rudder back and forth in quick succession a total of four times, causing the plane to pitch wildly from side to side, the wings dipping to a stomach-churning 55 degrees at one point. The craft plunged over 300 metres. The G-forces hammered passengers into walls and windows. There were cuts and bruises. One woman dislocated a finger. Others were burned by hot coffee. Armrests were bent 60 degrees by white-knucklers. Two people inside the bathrooms at the back were thrown violently against the walls and ceiling. One was seriously hurt. Both carts flew up into the ceiling. A laptop computer slammed into an overhead bin so hard it left a paint streak. A flight attendant, blood dripping into her eyes from a cut across her forehead, scrambled to help people. In the cockpit, a bin containing flight manuals broke open, sending texts airborne, a heavy hardcover grazing the pilot's head. Everyone was screaming and yelling. Passenger Nisha Gill later told reporters she thought she and her two-year-old daughter were goners. The pilot managed to level the plane off but, given that he thought it might be a systems problem, he made the emergency landing in Calgary. The nine passengers and two crew members were released from hospital shortly afterward. Air Canada spokesman Angela Mah said Tuesday the company has already implemented changes following the board's recommendations. "For example, we have enhanced pilot training and made adjustments to our (traffic alert and collision) systems to reduce possible wake turbulence encounters," said Mah. Stephen Guetta, speaking for the 3,300-member Air Canada Pilots Association, added, "We've all worked together to advance the training on wake turbulence issues. That's one of the lessons learned here. There was a desire by the pilots' group for more information." The board has also advised Transport Canada that changes may be needed to reduce the risk of planes, particularly smaller ones, getting caught in the wake turbulence of other craft. Guetta said the pilots' main concern is making the distances safer. He noted the vertical distances between planes has been cut in half in recent years, to 300 metres, to accommodate more planes in the same area. The answer, he said, may lie in expanding how far apart they are horizontally. Guetta said those who would criticize the pilot should remember what he was dealing with and in what time frame. "You had the turbulence, then loss of control and then you had system failure (alarms) within the cockpit," he said. "The combination of those three in that context don't lead you to believe you're dealing with wake turbulence." Back to Top [http://r20.rs6.net/tn.jsp?et=1103450850808&s=6053&e=00128v3dS-2apW8s258tHkOxb3OCbRe2mG-6VhRTQ0z2u-45d2CGj3-Hpz0srRgFTR2TgWZdzj-wEAVecTbqHgEc6P_nqC84xyW] ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 1 dead, 4 hurt after small plane crashes in Alaska ANCHORAGE, Alaska (AP)- A small airplane crashed in a busy business district near downtown during rush hour, killing a 4-year-old boy and injuring the four other people onboard, authorities said. Bystanders rushed to help those onboard the Cessna 206 after it clipped the roof of a motel and crashed in front of an unoccupied former car lot office, sparking a fire shortly after 5 p.m. Tuesday. No other injuries were reported. "It was the citizens who did the work and pulled people out," said police Lt. Dave Parker. A witness, Hunter Brosh, said a girl was among those pulled out alive. Brosh was one of the motorists who jumped out of their cars to help get people out of the burning plane. Anchorage police said in a statement late Tuesday that 16-year-old Rachel Zientak of Texas was one of the injured passengers and was to be transferred to a Seattle hospital. Also onboard were the pilot of the aircraft, 34-year-old Preston Cavner; his wife, 32-year-old Stacie Cavner; and their son, 2-year-old Hudson, police said. The three were to be flown to a hospital in Portland, Ore. Authorities identified the 4-year-old who died as another son belonging to the couple, Miles Cavner. The single-engine plane was registered to Cavner and Julian Inc., a guide and outfitting business based in Port Alsworth, Alaska. Police said the Cavners operate a lodge at Port Alsworth, Alaska, and Zientak was one of their employees. Jennifer Rodi, a National Transportation Safety Board investigator, said it was too early to say what caused the crash. The aircraft went down after departing Merrill Field about a mile away. Rodi said the four survivors were critically injured. However, Brosh said the girl onboard was able to unbuckle herself before she was helped out of the wreckage. One witness, Adan Hernandez, said he was riding his bicycle when he heard the plane above him. The aircraft started to wobble before disappearing beyond the motel and making a thudding sound, said Hernandez, who took photos of the crash site. A small, cone-shaped piece of the aircraft landed in the motel's parking lot. Brosh was driving to a guitar lesson and had stopped at a nearby intersection when he heard a loud noise behind him. He swung his head back as the plane slammed into the ground. People started to pour out of their cars and run to the aircraft. Brosh said the plane burst into flames while those on board were still being extricated. People starting running over with fire extinguishers. At one point, Brosh heard some of those helping exclaim, "You're spraying on the baby." A man and a woman onboard appeared very hurt, he said. The woman's mouth was full of blood and it appeared her teeth were knocked out, he said. For Brosh, the experience was an "adrenaline thing," he said, as he stood outside the yellow police tape used as a barricade. "I can't say I've ever helped people out of a burning plane," he said. Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Families honor Air France crash victims a year on PARIS (AP) - Families mourned in more than a dozen languages and the Air France choir performed Verdi's Requiem in a ceremony Tuesday honoring the 228 people killed when a Rio de Janeiro-Paris flight crashed into the Atlantic Ocean a year ago. Robert Soulas was one of about 1,000 relatives attending a ceremony at the Paris Floral Park and the unveiling of a monument to honor the victims of Flight 447 at the French capital's renowned Pere Lachaise cemetery. He told The Associated Press that his biggest hope is that the flight recorders are found, and with them answers. "Our emotion is more intense than ever because we don't have many answers," said Soulas, who lost his daughter in the crash. Transport Minister Dominique Bussereau promised that the investigation into why the plane crashed will continue. He said he will set up a group to meet regularly with families to inform them of progress. Tuesday's ceremony was translated into 15 languages, and texts were read by a rabbi, a priest, a pastor, an imam, as well as relatives and Air France personnel. In the afternoon, flowers were laid at a monument inscribed with 228 birds, representing the victims. A similar memorial was inaugurated last year in Rio de Janeiro. The flight crashed June 1, 2009 after running into a strong thunderstorm. A third, euro13 million ($15.8 million) search effort ended last week and failed to find the flight recorders. Search teams have failed to find the "black box" voice and data recorders. Without those, investigators may never learn why the plane crashed in a remote part of the Atlantic Ocean, in depths of up to 4,000 meters (13,120 feet). Automatic messages sent by the plane's computers just before it crashed show it was receiving false air speed readings from airplane sensors known as Pitot tubes. Investigators have insisted that the crash was likely caused by a series of failures and not just the Pitot tubes. Air France CEO Pierre-Henri Gourgeon and President Jean-Cyril Spinetta were present along with 200 Air France staff. In Rio de Janeiro, about 80 people - family members, friends, Air France workers and France's ambassador to Brazil, Yves Saint-Geours - somberly filed into a Catholic church in the Ipanema beachside neighborhood to mark the anniversary of the accident. "I feel so bad, it was such a tragedy," said a weeping Ligia Valle, whose niece, Luciana Seba, died in the accident. "Her body was never found. I miss her physical presence so much." After the ceremony in the church, family members planned to gather at a memorial in a park overlooking the ocean. Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Aeroflot alcohol ban results in fewer drunken incidents Russian flag-carrier Aeroflot is citing a notable reduction in the number of on-board incidents fuelled by intoxication, after banning alcohol sales on specific flights. It has imposed the sales ban in the economy-class cabins. Aeroflot, which stopped distributing free alcoholic beverages in early 2006, started testing the tighter restriction on particular services in February. The carrier selected a number of long-haul flights for the trial, stating that these usually resulted in the highest proportion of passengers engaging in drunken behaviour. Over the last four months, the airline says it has recorded a "significant fall" in the number of alcohol-related behavioural violations. As a result of the trial the airline is maintaining a suspension of alcohol sales in the economy cabin on services to seven destinations from Moscow. These include Havana, Bangkok, Shanghai and the Russian cities of Khabarovsk, Vladivostok, Yuzhno-Sakhalinsk and Petropavlovsk-Kamchatsky. SkyTeam alliance member Aeroflot says the decision has been taken in order to ensure "high levels of safety and comfort" for passengers. Source: Air Transport Intelligence news Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Dubai airports to ban noisiest older-generation aircraft Dubai's airport operator is to ban older-generation aircraft from the hub later this year, bringing it into line with modern noise and emissions standards. Cargo aircraft failing to meet Chapter 3 standards will be banned at Dubai International Airport from 31 October, the beginning of the winter season, and a ban on passenger aircraft will follow on 27 March 2011. But the new Al-Maktoum International Airport will allow Chapter 1 and Chapter 2 aircraft to continue operating until 1 April 2012. The airport operator says this will ensure carriers are "not unreasonably affected". Dubai Airports chief Paul Griffiths says the limitations are an "incremental step" which will "reduce the airport's environmental footprint". Source: Air Transport Intelligence news Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ TSB: Pilots exceeded A319 fin limit levels after 2008 wake encounter The Transportation Safety Board of Canada (TSB) has determined that alternating rudder control by the captain of an Air Canada Airbus A319 that encountered wake turbulence at altitude while flying more than 18.5km (10nm) behind a United Airlines Boeing 747-400 at 36,000ft (10,973m) on 10 January 2008 stressed the aircraft's vertical fin beyond certification limit loads. In a final report released 1 June, investigators reveal that rudder input by the captain in response to what he assumed to be a control system failure caused the rear vertical stabiliser attachment fitting to see 129% of the structure's limit load, and the rear fuselage fitting to see 121% of its limit load. Airbus tests the vertical fin to 150% of its limit load during certification. TSB notes that an upper limit for what the fin can handle was not determined during A319 certification testing "due to test equipment limitations". During the 18 second event, the control inputs included a series of oscillating altitude and roll angles as high as 55 degrees, according to the report. Though the aircraft remained intact, eight passengers and crew members received minor injuries, and three passengers received serious injuries due to falls and collisions with aircraft furnishings. The pilots declared an emergency and diverted to Calgary for an uneventful landing. The incident shares much in common with the 12 November 2001 American Airlines Airbus A300 accident in New York, in which the first officer responded to a wake turbulence encounter with a Boeing 747-400 using full alternating rudder deflection. In that case, the control inputs combined with the aircraft's slideslip angle caused the vertical fin to see loads greater than its ultimate strength, snapping the fin from the fuselage and causing the aircraft to enter an uncontrolled dive to the ground. The rudder control system design was a key fixture in the US National Transportation Safety Board (NTSB) recommendations on the crash, as was the American Airlines upset recovery training programme. The two aircraft share similar designs for rudder control, with maximum rudder travel limited progressively as a function of aircraft speed. During the Air Canada event, the pilot responded to the flight upset with six cyclic reversals of full rudder input from left to right. The cause of the pitch and roll upset in the A319 was later determined to be wake turbulence from the 747, though the separation between the two aircraft was greater than required minimum standards. In addition to finding that existing separation criteria for wake turbulence avoidance "may not be effective in all cases", the TSB determined that unrestrained service trolleys pose a risk to passengers and crew, as do unrestrained flight manuals in the cockpit. TSB also notes that in the A320 family series of aircraft, "it may be possible for a pilot to apply rudder control inputs that result in aerodynamically generated structural loads in excess of certification design limits and approaching ultimate load limits". TSB explains that since the time of the incident, Airbus has now defined load limits that should trigger tail plane inspections, information previously not defined. As a result of the investigation, TSB issued two safety communications, one requesting that Transport Canada (TC) enter into discussions with ICAO, Nav Canada and the US FAA to "address ways to reduce possibilities of hazardous encounters with wake turbulence at cruising altitude or during en route climbs and descents". TSB is also requesting that TC "communicate to transport category aircraft operators in Canada the necessity to include roll scenarios in upset training and the appropriate use of rudder control during recoveries". Source: Air Transport Intelligence news Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC