Flight Safety Information December 13, 2010 - No. 254 In This Issue Qantas jet's 'lucky escape' after water leak Report faults pilot for deadly Alaska C-17 crash Jet returns to JFK after smoky odor reported Investigators locate cockpit recorder of Dagestan Tu-154 US Airways' A320s get door straps to mitigate slide deployments Secondary oil leak affecting Trent 900 engines Report Suggests Extra Four-Month 787 Delay Coming JFK Lays Down Synthetic Ground Cover Pilot duped AMA with fake M.D. claim... Qantas jet's 'lucky escape' after water leak LEAKING water knocked out electricity to a number of systems during a Qantas 747's flight to Bangkok, forcing the crew to land using limited battery power in a race against the clock. The plane, with 346 passengers and 19 crew, was on descent in 2008 when the flight crew were alerted to a "substantial" water leak in the galley. As a result of the leak many of the aircraft's communication, navigation, monitoring and warning, and flight guidance systems were affected. Had the event occurred more than 30 minutes flying time from the nearest suitable airport, or if there had been a delay prior to landing, numerous flight-critical systems would have become unavailable, placing the flight at "considerable" risk, air safety investigators warned. The aircraft's batteries were available to provide power to critical systems for a limited period of time if the primary power sources were lost. .."The limited battery power available restricted the amount of time that the aircraft's remaining functional instrumentation and communication systems were available to the crew, which necessitated an expedited descent and landing in order to reduce the risk of those systems failing," a report by the Australian Transport Safety Bureau (ATSB) said. At the end of the taxi to the passenger terminal the plane had been using battery power for approximately 21 minutes. The crew was unable to determine the time at which the aircraft had switched to battery power, or when the 30 minutes of minimum battery life would elapse. If the plane had missed its approach or been at a different point in the flight when the use of battery power became necessary, the amount of battery power left could have been critical to the safe operation of the aircraft, the investigators said. The investigation found that the galley leak was caused by an overflowing drain after a drain line was blocked with ice that had formed due to an inoperable drain line heater. The water flowed into the aircraft's main equipment centre before leaking onto three of the plane's four generator control units, causing them to malfunction and shut down. The flight crew manuals did not contain information on means to extend the limited battery life or on managing the aircraft if the batteries were depleted. The ATSB has issued two safety recommendations and a safety advisory notice as a result of the investigation. http://www.news.com.au/travel/news/ Back to Top Report faults pilot for deadly Alaska C-17 crash ANCHORAGE, Alaska (AP) -- A pilot's overly aggressive maneuvering and overconfidence were blamed in an investigative report on a C-17 plane crash at an Anchorage military base that killed all four airmen on board. Besides pilot error, the crew on board was also faulted for failing to notice the dangerous situation that culminated with the plane stalling and crashing into some woods July 28 at Joint Base Elmendorf-Richardson. "The mishap pilot violated regulatory provisions and multiple flight manual procedures, placing the aircraft outside established flight parameters at an attitude and altitude where recovery was not possible," the report's executive summary says. Bob Hall, a base spokesman, said Friday evening he didn't know which of the three pilots was at the controls when the massive $184 million plane crashed during a training demonstration for an air show. A Pacific Air Forces spokeswoman also said the pilot's identity would not be disclosed out of sensitivity to the families. "Who sat where in the plane is not being released," said Capt. Alysia Harvey. Pacific Air Forces, based at Joint Base Pearl Harbor-Hickam in Hawaii, released the results of its investigation Friday evening. The probe "found clear and convincing evidence the cause of the mishap was pilot error," the report says. It also found evidence that other factors including overconfidence and misplaced motivation contributed to the crash. "Furthermore, the mishap co-pilot and mishap safety observer did not realize the developing dangerous situation and failed to make appropriate inputs." When the stall warning sounded, the co-pilot responded by saying "temperature, altitude lookin' good," according to the report. The investigation also found evidence that the flight deck crew ignored warnings. According to investigators - and video prior to the crash - the pilot made an aggressive right turn after the C-17's initial climb-out and left turn. The stall-warning system was activated as the plane banked, but the pilot continued the turn and there was no way to avoid a stall. "Although the pilot eventually attempted to recover the aircraft, he employed incorrect procedures, and there was not sufficient altitude to regain controlled flight," the report says. The C-17 crashed into a wooded area about a minute after taking off, sending a fireball hundreds of feet into the air and damaging a section of the Alaska Railroad's main track. Killed were Maj. Michael Freyholtz, 34, of Hines, Minn.; Maj. Aaron Malone, 36, of Anchorage; Capt. Jeffrey Hill, 31, of York, Pa., and Master Sgt. Thomas Cicardo, 47, of Anchorage. Cicardo, who was not a pilot, was posthumously promoted to senior master sergeant Friday. Freyholtz and Malone were pilots assigned to the Alaska Air National Guard's 249th Airlift Squadron. Hill was a pilot assigned to Elmendorf's 517th Airlift Squadron, and Cicardo was the 249th Airlift Squadron loadmaster and affiliated with the Alaska National Guard. No one on the ground was hurt. The long-range C-17 can carry up to 80 tons of large equipment, supplies and troops around the world. It is longer and wider than half a football field. http://www.washingtonpost.com/ Back to Top Jet returns to JFK after smoky odor reported An Israel-bound Delta flight that took off from John F. Kennedy International Airport Saturday night returned to the airport because of a smoky odor near one of the galleys, the airline said. Delta spokesman Paul Skrbec said that 20 minutes after Flight 268 took off for Tel Aviv the odor became noticeable and the captain decided to return the Boeing 747-400 to JFK in an "abundance of caution. There was no actual fire onboard the aircraft." After jettisoning fuel, the plane carrying 390 passenger and 18 crew made a "normal landing," although emergency equipment had been mobilized and was standing by, he said. The passengers were provided overnight accommodations, Skrbec said, and the flight was rescheduled for 5 p.m. Sunday. http://www.newsday.com/news/ Back to Top Investigators locate cockpit recorder of Dagestan Tu-154 Russian investigators have retrieved the cockpit-voice recorder of the crashed Dagestan Airline Tupolev Tu-154M in Moscow, nearly a week after the accident. The Interstate Aviation Committee (MAK) recovered two of the three recorders almost immediately after the 4 December crash at Domodedovo Airport. But it was unable to locate the MARS-BM audio recorder at the time. MAK says today, however, that the device has been located at the site of the crash and that it will be transferred to its analysis laboratory. "Specialists from MAK will give an assessment of its condition and open its container," says the organisation. Investigators are trying to understand why two of the aircraft's three engines failed as it climbed out of Moscow Vnukovo during a flight to Dagestan. With the third engine also performing poorly, and threatening to fail, crew members opted to attempt a landing at Domodedovo. The aircraft landed long on the runway, striking the ground hard, overran and broke up. Two of the occupants on board the Tu-154 were killed in the crash. Source: Air Transport Intelligence news Back to Top US Airways' A320s get door straps to mitigate slide deployments US Airways has added a simple strap to the forward and aft door operating handles on its fleet of Airbus A320 family aircraft to mitigate accidental emergency slide deployments. "So far this year, US Airways has experienced 20 accidental slide deployments, compared to 2009's year-end total of 23. Accidental slide deployments are not only an expense for the airline, they are also a matter of safety as they can cause serious injury when accidentally deployed," says US Airways in its latest employee newsletter. "Enter a simple solution with a big impact - the red safety strap. In an effort to reduce accidental slide deployments, a new unique feature has been added to our fleet of Airbus (A319, 320 and 321) aircraft. The red strap crosses the forward and aft door operating handles and, when properly positioned, serves as a reminder for all personnel to verify the position of the arming lever." The strap, which is attached by Velcro, also acts as a visual deterrent to anyone who may inadvertently grab the door handle instead of the arming lever, says the carrier, noting that the strap "does not serve as an indicator that the door is armed or disarmed". Company director, corporate safety Joe Nester says that while the red strap "works great" it would not be effective without the adoption of a new process by the carrier's flight attendants. The process requires flight attendants to leave the strap across the handle after a door is disarmed. When the door is opened from the outside, the red strap is automatically released. After closing the door for departure, flight attendants place the strap back over the door operating handle, says US Airways. Source: Air Transport Intelligence news Back to Top Secondary oil leak affecting Trent 900 engines The 16 Rolls-Royce Trent 900 engines Qantas Airways is modifying or replacing is due to a secondary oil leak besides the stub pipe fault identified last week as the cause behind the Qantas A380 uncontained engine failure on 4 November. These engines have oil sediment in the high pressure (HP)/intermediate pressure (IP) turbine, a Qantas spokesman says, unable to specify the exact area affected. The engines do not have a stub pipe fault, he says. "The only stub pipe [fault] we have found is on [an] aircraft awaiting delivery," the spokesman says. On 8 November, the Australian Transport Safety Bureau said three Trent 900s, including one on an A380 to be delivered to Qantas, were found with the stub pipe defect. The defect has been identified as the cause behind an oil leak and fire which resulted in the uncontained engine failure on the Qantas A380. Sources familiar with the situation say the oil sediments were only on "A mod" versions of the Trent 900 engine. The Qantas spokesman could not confirm this. The oil sediments were found after inspections required by an European Aviation Safety Agency airworthiness directive issued on 22 November, the spokesman says. This directive required inspecting the air buffer cavity and "focusing on the oil service tubes within the HP/IP structure". Rolls-Royce did not respond to requests for comment on the oil leaks found in Qantas' engines. The engine manufacturer has said it is addressing the stub pipe fault with a programme that involves "replacing the relevant module" although it has not specified what this module is. "We're either modifying or replacing engines based on advice from Rolls-Royce," the Qantas spokesman says. The modifications require the engine to be brought to the "latest standard", but he declines to specify what changes that entails and if it means bringing the engine to "C mod" standard. It is understood Singapore Airlines plans to bring all of its "A mod" and "B mod" Trent 900 engines to "C mod" standard. However, Rolls-Royce has said "there has been no design change relevant to this failure between A, B and C versions of the engine". "It is not true that we knew about a problem in the A and B versions of the engine and went on to correct it in the C version," says a Rolls-Royce spokeswoman. "The previously announced regime of inspection, maintenance and removal is ongoing." Five of Qantas' 16 affected engines have been changed so far, says the carrier's spokesman. He adds the airline does not have an indication when it will complete the changes. "It's clear Rolls needs to be able to provide replacement engines," the spokesman says. Source: Air Transport Intelligence news Back to Top Report Suggests Extra Four-Month 787 Delay Coming A report in the French newspaper Les Echos claims that first deliveries of the delayed 787 may be pushed back until June or July 2011 as a result of last month's electrical fire on ZA002. The report says the news was relayed by Boeing executives to Air France officials at a delivery ceremony for one of the airline's 777-300ERs at Everett, Wash., on Dec. 8. A broader suggestion in the report of a likely 'mid-summer' delivery target would indicate a roughly four-month program slide from the existing schedule, which still officially calls for initial delivery in mid-February 2011. Boeing has acknowledged the systems redesign and certification issues created as a result of the Nov. 9 electrical fire incident in Laredo, Texas, has effectively rendered this target unachievable, but has yet to identify a revised delivery target date. Asked about the Les Echos report, Boeing says, "..we continue to assess our schedule and will announce a new schedule when that work is complete." The report goes on to say that Boeing engineers have identified "possible solutions" to the problems with the flawed response of the electrical system and control software following a short circuit or arc caused by a suspected loose washer or some other small foreign object inside the P100 main power distribution panel. The Les Echos report says Boeing and its Hamilton Sundstrand-Zodiac partners on the electrical system aim "to complete corrections by the end of the year, to resume test flights in January, and lead to certification in June." However, it adds that Boeing must obtain clearance from the FAA before resuming flight tests. In the meantime more information is emerging about the specific areas of damage and the precise location of the fire behind the P100 panel. This takes the electrical power generated by the left engine and distributes it to power vital systems. The panel, measuring about 3.5-ft. tall, is located about 1 ft. below the passenger floor in the aft electronics bay just behind the wing. It contains electrical boxes, including control units, circuit breakers and relays. Forensic evidence from the fire damage pinpoints one of two contactors in the P100 panel, CK2435505, as the source of the ignition. The contactors are electrical control boxes that relay the power from the generators on the engine and distribute it as needed. They open circuits or close as power needs fluctuate. Contactor CK2435505, on top of the panel, was "melted" according to a leaked Boeing engineering report, while the lower contactor CK2421501 suffered "extensive fire and smoke damage to backside." Fire from the contactor burned a hole between 12 and 15 in. long in the back of the P100 panel, and badly charred the adjacent fuselage insulation blanket material which effectively did its job in preventing burn-through to the interior of the 787's primary composite fuselage skin structure. http://www.aviationweek.com Back to Top JFK Lays Down Synthetic Ground Cover New York John F. Kennedy International Airport has completed installation of 300,000 sq. ft. of Air FieldTurf, a synthetic ground cover base for runways and taxiways. The company, known for its sports arena surfaces, says the aviation-grade system improves visibility, drainage and maintenance and lessens foreign object debris and wildlife risks. The ground cover also is installed at Boston Logan, Paris Charles de Gaulle, San Francisco International and Hong Kong International airports, as well as the Miramar Marine Air Base. www.aviationweek.com Back to Top Pilot duped AMA with fake M.D. claim MILWAUKEE (AP) - He seemed like Superman, able to guide jumbo jets through perilous skies and tiny tubes through blocked arteries. As a cardiologist and United Airlines captain, William Hamman taught doctors and pilots ways to keep hearts and planes from crashing. He shared millions in grants, had university and hospital posts, and bragged of work for prestigious medical groups. An Associated Press story featured him leading a teamwork training session at an American College of Cardiology convention last spring. But it turns out Hamman isn't a cardiologist or even a doctor. The AP found he had no medical residency, fellowship, doctoral degree or the 15 years of clinical experience he claimed. He attended medical school for a few years but withdrew and didn't graduate. His pilot qualifications do not appear to be in question - he holds the highest type of license a pilot can have, a Federal Aviation Administration spokeswoman said. However, United grounded him in August after his medical and doctoral degrees evaporated like contrails of the jets he flew. He resigned in June as an educator and researcher at William Beaumont Hospital in Royal Oak, Mich., after a credentials check revealed discrepancies, a hospital spokeswoman said. Doctors who worked with the 58-year-old pilot are stunned, not just at the ruse and how long it lasted, but also because many of them valued his work and were sad to see it end. "I was shocked to hear the news," said Dr. W. Douglas Weaver, who was president of the cardiology group when it gave Hamman a training contract for up to $250,000 plus travel a few years ago. "He was totally dedicated to what he was doing, and there is a real need for team-based education in medicine," said Weaver, a pilot himself from Henry Ford Hospital in Detroit. Even after learning of Hamman's deception, the American Medical Association was going to let him lead a seminar that had been in the works, altering his biography and switching his title from "Dr." to "Captain" on course materials. It was canceled after top officials found out. Now, groups that Hamman worked for are red-faced that they hadn't checked out the tall, sandy-haired man who impressed many with his commanding manner and simple insights like not taking your eyes off a patient while talking with other team members about what to do. "This is Your Captain Speaking: What can we learn about patient safety from the airlines?" is how his training sessions typically were billed. Journals that printed articles listing Hamman with M.D. and Ph.D. degrees are being contacted in case they want to correct the work. Beaumont removed him from a U.S. Department of Defense medical simulation contract that a physician at the hospital had obtained. Doctors who attended Hamman's sessions don't have to worry - the Accreditation Council for Continuing Medical Education will not revoke any education credits they earned. "That just makes the learners more of a victim," said the council's executive director, Dr. Murray Kopelow, adding that this is a first in his 15 years on the job. "Sounds like there's lots of victims in this case - the learners, the accredited providers, the whole CME system." Hamman did not return several phone calls and e-mails seeking comment. David Nacht, an employment lawyer in Ann Arbor, Mich., acknowledged that his client did not have the medical and doctoral degrees he had claimed from the University of Wisconsin-Madison in the 1980s. "It's Mr. Hamman's desire that he clear up any misconceptions about his background that he has caused. He wants to be completely straightforward about it," Nacht said. There is no indication Hamman ever treated a patient, though his teamwork training had him videotaping in emergency rooms and other settings where patients were being treated. Hamman does have an associate's degree in general aviation flight technology and a bachelor of science degree from Purdue University. He also has "type ratings" to fly half a dozen very large commercial planes, according to the FAA. United would not discuss his job history, citing employee confidentiality. But the company confirmed that he is not currently authorized to fly. Hamman lives in Michigan and is based in Chicago. As long ago as 1992, an FAA workshop listed Hamman as an M.D. from United's flight center in Denver. In an interview last year with Cath Lab Digest, a publication for heart specialists, Hamman says that being a doctor may have "opened up some doors at United, and I ended up as manager of quality and risk assessment." In 2004, he joined Western Michigan University, a Kalamazoo school with a big aviation program in nearby Battle Creek, as co-director of its Center of Excellence for Simulation Research. In 2005, the center got a $2.8 million grant from the Michigan Economic Development Corporation to expand simulation training into medical settings. Matching funds from other groups brought the total to $4.2 million. Soon Hamman was videotaping heart attack treatment drills and deconstructing what doctors did right and wrong. He spoke at Northwestern University and for the AMA and the American College of Emergency Physicians. In 2009, he joined Beaumont Hospital. Dr. Sameer Mehta, a Miami cardiologist who runs an annual conference for heart specialists, had Hamman lead sessions in 2009 and earlier this year. He seemed to understand the jobs of the EMS, emergency room and cardiac catheterization lab staffs and how they needed to work together, Mehta said. "He was able to simulate exactly what we were doing," and to offer suggestions from aviation to help, Mehta said. It's easy for groups to assume someone else has vetted a popular speaker, said Dr. William O'Neill, a legendary cardiologist who spent 17 years at Beaumont before becoming an executive dean at the University of Miami in 2006. "Somehow you've gotten the name or seen them in the literature," said O'Neill, who has helped with many conferences. When he heard that Mehta and others had been duped by Hamman's phony degrees, "I thought, 'There but for the grace of God go I.'" Hamman's ambition may have done him in. In checking a grant proposal he wanted to submit in late spring, the Beaumont staff discovered the lack of an M.D. degree, said spokeswoman Colette Stimmell. Hamman resigned June 15. In hindsight, the careful wording in some of Hamman's comments is apparent. "I couldn't handle a full-time cardiology practice" with the demands of being a pilot, he told at least two reporters. Less clear is what, beyond basic principles of teamwork, his training really offered. "In a sense, he didn't talk about anything medical," said Dr. Stephen Mester, a Florida cardiologist who took one of Hamman's sessions at the cardiology conference in Atlanta last spring. "I did not find it worthwhile, but I believe it could be worthwhile for programs just getting started." After fessing up, Hamman asked the AMA and the cardiology group to let him continue, saying, "the work is the work." They decided that a lie is a lie. "He really didn't need to be a physician to do what he was doing. He could have been successful without titling himself," said Weaver of the cardiology college. "He made a very serious mistake." Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC