Flight Safety Information September 2, 2010 - No. 180 In This Issue BA passengers tried to halt 777 take-off after taxiing error Cessna Citation 550 Accident...(New Guinea)... Comair Shedding Planes, Jobs FAA Issues Emergency AD For Some Bell Helicopter Models Nepal plane crash data recorders found American Airlines names new base maintenance chief The Difficulty in Improving Airline Safety Now ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ BA passengers tried to halt 777 take-off after taxiing error Two passengers attempted to stop a British Airways Boeing 777-200 from taking off from a Caribbean airport last September, after realising the crew had lined up at the wrong runway intersection, but were too late to prevent the departure. The pilots of the twin-jet, bound for Antigua, had intended to depart from the southwestern end of runway 07 - the 'A' intersection - at St Kitts' Bradshaw International Airport. Despite specifically requesting a departure from 'A', the aircraft mistakenly taxied instead for the 'B' intersection, near the runway's midpoint, leaving available take-off distance of just 1,220m (4,000ft). The take-off performance calculations had been based on a distance of 1,915m. The oversight escaped detection despite several references and queries in the communications between the crew and air traffic control. In details of the event released today, the UK Air Accidents Investigation Branch reveals that the carrier's station engineer and airport duty manager were on board the 777 and realised the error as the aircraft lined up on the runway. The engineer quickly moved from his seat to speak to a member of the cabin crew, telling her that he needed to contact the pilots immediately to warn them the aircraft was wrongly positioned. In the cockpit the captain had specifically commented that the runway looked short. Neither pilot had been to the airport before and the lack of a tractor meant the crew had taxied the jet from the stand themselves. But, in spite of the captain's concerns, neither cross-checked the jet's location on the runway. Instead the captain told the co-pilot to "stand on the brakes", says the AAIB, and apply a high thrust setting - some 55% of N1 level - before releasing the brakes for the take-off roll. In the cabin behind, the station engineer realised that the aircraft was powering up for take-off and abandoned his bid to reach the crew. The 777 accelerated but reached the touchdown-zone markers for the reverse-direction runway 25 by the time it passed the crucial V1 decision speed, and lifted off about 300m from the end of the paved surface. Source: AAIB Taking off from the 'B' intersection reduces the available distance by 1,110m and the AAIB says that British Airways does not authorise 777 departures from this point on runway 07. The incident, on 26 September last year, occurred in daylight although the sun was low in the west. While the AAIB attributes the event to simple lack of familiarity with the airport, combined with disorientation from poor signage, it also underlines the psychological factors which contributed to the failure to identify the error. Bradshaw is a simple airport, and the crew did not conduct a taxi briefing. The AAIB says that the crew would probably have briefed the route at a larger, more complex airport. It adds that the crew appears to have suffered from "confirmation bias", noticing only the evidence that backed their mistaken assumption of being at the correct intersection. Crew resource management training should address this tendency in two ways, says the AAIB: by emphasising the need to "seek evidence that disproves assumptions whenever they are called into doubt" and by providing communications skills needed for "confident and clear discussion" of the problem. http://www.flightglobal.com/ Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Cessna Citation 550 Accident (New Guinea) Status: Preliminary Date: 31 AUG 2010 Time: 16:30 Type: Cessna 550 Citation II Operator: Trans Air Registration: P2-TAA C/n / msn: 550-0145 First flight: 1980 Engines: 2 Pratt & Whitney Canada JT15D-4 Crew: Fatalities: 1 / Occupants: 2 Passengers: Fatalities: 3 / Occupants: 3 Total: Fatalities: 4 / Occupants: 5 Airplane damage: Written off Airplane fate: Written off (damaged beyond repair) Location: Misima Island Airport (MIS) (Papua New Guinea) Phase: Landing (LDG) Nature: Domestic Non Scheduled Passenger Departure airport: Port Moresby-Jackson Field (POM/AYPY), Papua New Guinea Destination airport: Misima Island Airport (MIS/AYMS), Papua New Guinea Narrative: The aircraft skidded off the runway into some trees while landing in heavy rain, and burst into flames. The co-pilot has survived but is in a critical condition. One of the dead passengers was reported to be the Australian co-owner of the airline. According to unfconfirmed data the airfield has a single runway, 08/26 with an LDA of 1200 m. www.aviation-safety.net [http://r20.rs6.net/tn.jsp?llr=gqvqzbdab&et=1103653703416&s=6053&e=001iRcs2dIFPEH4sUCbz3vKPSdBuCUjTmgFvScmiXm_3qpHRJE5WHpJdW1XM_rMGOQdirDd9eLvs-HaycV1hwPoSMndx5j9LbyRNm9M90L__u7sylqyYSGYvHYL4aPO8UFp] Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Comair Shedding Planes, Jobs Fleet Will Be Less Than Half Its Current Size In Two Years Comair executives told its regional airline workers in Cincinnati Wednesday that the carrier would likely be about half its current size in two years. The company says it plans to shed both planes and employees during that period. Comair currently employs about 2,600 workers, about half in the Cincinnati region. The airline reportedly has some 96 aircraft in its fleet, and the airplanes it is looking to cut are the less efficient, and profitable, 50 seat regional jets. The Cincinnati Enquirer reports that Delta bought Comair in 2000 for over $1 billion, and it is still one of the most profitable regional airlines flying according to federal statistics. But that government data does not include debt service. Comair relies far more on contracts with Delta than it does ticket sales to make it profitable. Delta, meanwhile, has been trying to sell the subsidiary for about a year. It thought it would do so when it sold Mesaba and Compass airlines in July, but that did not occur. Concourse C At KCVG, Now Closed Comair president John Bendoraitis said in a memo that "the current cost structure ... does not enable us to be competitive in the current industry environment." The airline had expected to expand to 100 aircraft by the end of this year, but instead will enter a downsizing mode. It plans to shed almost its entire fleet of 50 seat regional jets leaving it with about 44 aircraft mostly of the 70- and 76-seat configurations. Bendoraitis said in the memo that the downsizing in aircraft would occur over 2011 and 2012, determined by lease returns and maintenance schedules. Comair CRJ-700 And fewer planes means fewer people. "With such a significant change in fleet size, we must also re-align our staffing over the next two years to support the new, smaller size of the airline," the memo said. Bendoraitis said the staff would be the correct size to run a 44 aircraft airline by the end of 2012. The move is also something of a blow to Cincinnati, Northern Kentucky International Airport. It was at one time Delta's second-largest hub, but the airline has cut two-thirds of its daily flights from KCVG, which has caused a further erosion of the workforce. FMI: www.comair.com Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ . FAA Issues Emergency AD For Some Bell Helicopter Models Problems Found With The Main Rotor Piston Rod The FAA has issued an Emergency AD for several models of Bell Helicopters prompted by a main rotor hydraulic servo actuator (servo actuator) malfunction and a subsequent investigation that revealed the output piston rod assembly (piston rod) had fractured at the threaded end because of stress corrosion cracking. Also, during the investigation of that servo actuator malfunction, a nonconforming grind relief was discovered on a separate piston rod. The actions specified by this AD are intended to detect corrosion or a nonconforming piston rod that, if not detected and corrected, could result in failure of the piston rod, failure of the servo actuator, and subsequent loss of control of the helicopter. The FAA says it has reviewed Bell Alert Service Bulletin (ASB) No. 222-10-109 for the Model 222 and 222B helicopters, ASB No. 222U-10-80 for the Model 222U helicopters, ASB No. 230-10-41 for the Model 230 helicopters, and ASB No. 430-10-44 for the Model 430 helicopters. Each ASB is dated August 18, 2010, and specifies a one-time inspection of all affected servo actuators to verify the condition of the piston rod. They have also reviewed Woodward HRT ASB No. 141600-67-02, dated August 18, 2010, attached to each Bell ASB, which specifies inspecting the piston rod for corrosion and nonconforming grind relief. It also contains instructions for reworking and reassembling the unit for operation. Transport Canada, the airworthiness authority for Canada, notified the FAA that an unsafe condition may exist on these helicopter models. Transport Canada advises that it has been determined that the piston rods of the servo actuators "may be corroded and, consequently, prone for corrosion cracking." Also, in one case, an unapproved repair was found on the piston rod. This situation, if not corrected, could result in loss of control of the helicopter. Transport Canada classified the ASBs as mandatory and issued AD No. CF-2010-29, dated August 26, 2010, to ensure the continued airworthiness of these helicopters. These helicopters have been approved by the aviation authority of Canada and are approved for operation in the United States. Pursuant to our bilateral agreement with Canada, they have notified us of the unsafe condition described in the Transport Canada AD. The FAA is issuing this AD because it evaluated all information provided by Transport Canada and determined the unsafe condition exists and is likely to exist or develop on other helicopters of these same type designs. Therefore, this AD requires, before further flight: Disassembling the actuator to gain access to the piston rod. Cleaning the entire piston rod and nut using Acetone and a nylon bristle brush removing all contaminates to allow for inspections. Inspecting the grind relief configuration for the piston rod and nut. If the grind relief is unacceptable, replacing the piston rod and the nut with airworthy parts. Using a 10x or higher magnifying glass, visually inspecting the nut for corrosion or damage to the threads. If you find any corrosion or damage to the threads, replacing the nut with an airworthy nut. Using a 10x or higher magnifying glass, visually inspecting the piston rod for any corrosion, visible lack of cadmium plate (gold or grey color), or damage to the piston rod. If you find any corrosion, visible lack of cadmium plate (gold or grey color), or damage to the piston rod in the "Critical Areas," replacing the piston rod with an airworthy piston rod. If you find any corrosion or visible lack of cadmium plate on the piston rod in areas that are not considered "Critical Areas," reworking the piston rod by removing any surface corrosion that has not penetrated into the base material by lightly buffing with scotch-brite. Cleaning the part using Acetone and a nylon bristle brush to remove any residue. If you find any corrosion that is red or orange in color, magnetic particle inspecting the piston rod for a crack. If you find a crack, replacing the piston rod with an airworthy piston rod. Inspecting the portion of the piston rod for any bare base metal that is not coated with cadmium plate. If you find any bare base metal on the piston rod in this area, reworking the piston rod by applying brush cadmium plating to all bare and reworked areas. Reassembling the servo actuator. After reassembling the servo actuator, marking it with the letter "B" following the serial number on the name plate using a scribe or vibrating stylus. Performing a hydraulic system check. These actions must be accomplished by following specified portions of the ASBs described previously. This AD differs from the Transport Canada AD in that the FAA require the initial inspection before further flight rather than no later than 5 hours air time upon receiving the AD. Also, this AD requires replacing unairworthy parts with airworthy parts if certain conditions are found and this AD does not add a life limit to the servo actuator. This AD does not require a one time rectification and a complete overhaul of the servo actuator after the initial inspection. Issuing the AD is an interim action. The FAA says it may supersede this AD to require reducing the life limit and overhaul of the affected servo actuators. FMI: http://rgl.faa.gov/ Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Nepal plane crash data recorders found (BBC) The plane was reportedly called back because of bad weather Investigators have found the flight data recorders from the wreckage of a plane which crashed in Nepal last week, killing 14 people, officials said. The small passenger plane, en route to the Mount Everest area, crashed into hills outside the capital, Kathmandu, in heavy rain. The Agni Air plane went down near Shikharpur village, 80km (50 miles) south of Kathmandu. The plane had been on its way to Lukla, a popular trekking destination. But it had turned back because of bad weather. Three crew and six Nepalese passengers died along with four Americans, a Briton and a Japanese national. 'Damaged' Searchers have found both the devices and have flown them back to Kathmandu, news agency Associated Press quoted Suresh Acharya, a spokesman for the government-appointed investigation team, as saying. He said the flight data recorder was damaged in the crash but the memory plate inside it appeared to be fine. The voice recorder was in good condition. Mr Acharya said the devices would be sent abroad for analysis. Each year thousands of tourists fly to Lukla to begin the trek to Everest base camp. But the airport is considered to have one of the most difficult landing strips in the world, and unpredictable mountain weather often adds to the danger. The 550m-long (1,800ft) sloping airstrip at Lukla is perched on a hillside some 2,800m above sea level, with a steep 700m drop at one end. The area has experienced crashes before; 18 people, including 12 Germans, were killed when a small plane crashed in 2008 in Lukla. Back to Top [http://r20.rs6.net/tn.jsp?llr=gqvqzbdab&et=1103653703416&s=6053&e=001iRcs2dIFPEFEL9uFXAUJXx8_sCkUJWyfIG8D9_9Au94hTTWPur-fKAgsk7x5IpYTM18p8TKYLknzq-UZ0IAk4TVxWYEa7nkU] ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ American Airlines names new base maintenance chief FORT WORTH, Texas American Airlines named a new vice president for base maintenance on Wednesday, another new face in a department that has been in the spotlight since a 2008 maintenance snafu that led the Federal Aviation Administration to seek a $24.2 million civil penalty. William Collins has been an executive at GE Aviation, most recently leading its electric power division. American said Collins will be based in Tulsa, Okla., and oversee the airline's maintenance at its repair, overhaul, and modification bases, which employ more than 8,800 people maintaining more than 600 planes. American's last vice president for base maintenance was Fred Cleveland, who had been with American from January of 2008 until being put in charge of technical operations for American Eagle, the regional airline which, like American, is owned by Fort Worth-based AMR Corp. Collins will report to Jim Ream, American's Senior Vice President for Maintenance & Engineering. Ream himself was hired in December from ExpressJet airlines, after having worked in several finance jobs at American from 1987 to 1995. He replaced an executive who retired after 41 years at American. Last week the FAA said it would seek a record penalty of $24.2 million against American over improper fastening of wires on its McDonnell Douglas MD-80-series jets that it said could lead to fires and even fuel tank explosions. The FAA said in 2008 that American flew more than 14,000 flights on the MD-80-series jets, which made up about half its fleet at the time. American has said the FAA concerns were overblown and that passenger safety was never in danger. It's common for airlines to challenge FAA penalties or negotiate to reduce them. Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ The Difficulty in Improving Airline Safety Now This year may end up being the worst of the past five years for airline crashes worldwide, and that doesn't count some high-profile military and private-plane fatal accidents that killed major political figures. So far, there have been 13 fatal crashes of passenger-airline flights, according to Ascend Worldwide Ltd., a London-based aviation consulting company. That's through eight months. Last year there were only 10 fatal airline crashes of flights carrying passengers, and 13 total in 2008. "It's an average sort of year, but the problem is we still have four months to go," said Paul Hayes, Ascend's director of safety. The frequency of airline crashes is basically random, and they do sometimes come in bunches. In August alone, Ascend counted five airline crashes that killed passengers, including the crashes of a Boeing 737 in Colombia and an Embraer 190 in Yichun, China. In addition, the Alaska crash of a private plane claimed the lives of former Alaska Sen. Ted Stevens and four others on Aug. 9. An increase in accidents in 2010 doesn't mean safety is eroding, aviation safety experts say. And travelers need to remember that it is still a very small number among millions of flights every year. But the numbers do highlight a concern among safety officials: Rapid safety improvement that airlines have enjoyed for several decades may be bottoming out. In 1959, as the jet age was only beginning for passenger airplanes, there were 36 fatal accidents in every one million departures, according to a recent Boeing Co. report. That quickly plunged to 2.4 fatal accidents in every million takeoffs by 1969. In the past decade, the fatal accident rate for airlines hasn't been higher than 0.6 per million flights. Can it go lower? As the industry gets safer, it gets harder and harder to reduce the accident rate further. In addition, advances in cockpit technology and aircraft reliability can lull pilots into complacency, and even erode basic flying skills because computers do so much of the flying on commercial airliners. "You can look at it as a plateau in the western world," said Kevin Hiatt, executive vice president of the Flight Safety Foundation, a non-profit international safety group. To make further improvement, safety officials have focused on pilot professionalism, training and experience as key issues. One big task is getting pilots to battle complacency and better understand all the technology given to them so they can respond well to unusual events. "The technology in the cockpit works well 99% of the time. It's the 1% of the time when you look at the other guy and say, 'Why did it do that?' " said Mr. Hiatt, a former Delta Air Lines international chief pilot. Most crashes occur as planes take off and climb or as they approach and land at airports. This year has seen several landing accidents, such as the Embraer crash in China, the 737 crash in Columbia and the Polish military transport crash in western Russia in April. Regional airlines-smaller carriers that typically fly planes with fewer than 100 seats-have a worse safety record when compared with the big airlines to which they feed passengers. In the U.S., regional airlines have been involved in five of the seven fatal accidents on scheduled airline flights in the past 10 years, according to National Transportation Safety Board records. Outrage over a Continental Express accident outside Buffalo, N.Y., last year led Congress to pass requirements to raise the minimum flight experience for newly hired regional airline pilots to 1,500 hours from 250. Private planes, categorized under general aviation, have far higher accident rates than commercial aviation, which has tighter U.S. standards for maintaining and flying planes. Airline pilots even have to get required FAA medical evaluations more frequently than private pilots. NTSB shows accident rates based on flight hours instead of takeoffs. Over the 10-year period ended 2008, "corporate aviation," usually company-owned aircraft with professional pilots, had a fatal accident rate about roughly twice the rate for airlines, and general aviation had an average rate of 1.27 fatal accidents per 100,000 flight hours-65 times higher than the very low airline fatal accident rate. Multiple Causes Since 1997, roughly 80% of crashes involve some human error, either by pilots or ground workers, according to the NTSB's annual review of accident data. About 50% have some environmental contributing cause, such as bad weather, and 20% have something wrong with the aircraft. Multiple causes are typically cited in investigation reports, so the factors add up to more than 100%. Continental Divide Accident rates vary considerably by continent. African airlines have the worst safety record, with a "hull-loss" (a destroyed plane) accident rate 25-times higher than the U.S., according to a Federal Aviation Administration study of 10-year period ended with 2007. The Flight Safety Foundation notes, however, that Nigeria is making improvements. The hull-loss rate for European airlines was slightly higher than U.S., and Chinese airlines were about the same as the U.S., based on the FAA research. But airlines based in Asia (excluding China), Latin America and the Middle East had fatal-accident rates roughly five times higher than the U.S. Mr. Hayes of Ascend says many of the crashes around the world happen with smaller, perhaps even obscure airlines. Some have older planes and less training for pilots and mechanics. Some have new planes with advanced avionics flown by pilots who aren't well versed in how to us''''''''''''''''''''''''''''''''''''''''''''''''''''''''''"Airlines having the accidents are not the big majors, in general," Mr. Hayes said. In terms of planes, newer is definitely better in terms of accident rates. Boeing's annual statistical summary shows that the latest versions of the venerable 737-the 737-600, 737-700, 737-800 and 737-900-combined have a fatal accident rate of 0.11 per million departures. The A320 family of Airbus jets does almost as well, with 0.21 fatal accidents per million departures. But older planes like the DC-10 and the 727 had significantly higher accident rates-1.34 fatal crashes per million departures for the DC-10 and 0.68 for the 727. The McDonnell Douglas MD-80, still widely in use, has a fatal accident rate of 0.31 per million departures. And the safest place to sit on a plane in case of an accident? Aviation Safety Network, a unit of the Flight Safety Foundation, scoured through accident reports on air disaster survivors looking for mentions of where survivors sat, and location really didn't seem to matter. At least some survivors were seated in the front of the jet in 26 accident reports and rear-seated survivors were mentioned in 30 accident reports. Center sections only were mentioned in only 16 reports. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC