Flight Safety Information January 13, 2011 - No. 010 In This Issue Crew error led to Polish plane crash, Russians conclude NTSB ISSUES SECOND UPDATE ON JACKSON HOLE B-757 European Safety Agency Sees Boeing 787 Approval by End of 2011... AirAsia Airplane Skids Off Malaysian Runway in Rainstorm Crew error led to Polish plane crash, Russians conclude Moscow (CNN) -- The crew was at fault in a Polish plane crash that killed the country's president and nearly 100 other people last April, a Russian-led investigation found Wednesday. The crew should have decided to divert to another airport in light of "repeated and timely" warnings about bad weather in Smolensk, Russia, the Interstate Aviation Committee concluded. The presence of a Polish Air Force commander in the cockpit may also have contributed to the crash, the IAC said, noting that he had alcohol in his blood at the time of the crash. Polish President Lech Kaczynski, his wife and many top Polish officials died in the crash as they headed to a memorial service to mark a World War II massacre. Jaroslaw Kaczynski, Lech Kaczynski's twin brother, told reporters Wednesday that the Russian inquiry into the accident was biased and that there was no proof to support the main thesis of the report. "Anyone who knows Russia could have guessed that this is what the report would look like. The report gives no answers to the most important questions," he added. The crew of the Polish presidential plane was under psychological pressure to land the plane at Smolensk, fearing Kaczynski would react negatively to a decision to divert the plane, IAC chair Tatyana Anodina said. She spoke in a news conference broadcast live by Russian state television. The investigation did not find any evidence that the president ordered the pilots to land at Smolensk, she said, but the air force commander, Gen. Andrzej Blasik, may have influenced them. The presence of Blasik in the cockpit "up until the plane hit the ground had a psychological influence on the plane's commander's decision to take an unjustified risk by continuing the descent with the predominant goal of landing against the odds," Anodina said. Forensic medical examination found 0.6 ppm (parts per million) of alcohol in his blood, she said. That amount would have resulted from ingesting about 3.5 to 4 ounces of alcohol, and would be over the legal limit of intoxication for drivers. The crew also did not have sufficient training for landing in bad weather, Anodina said. The IAC will publish its report in Russian, Polish and English, "given the high profile of this case and the importance of making the investigation results available to the public," IAC technical commission chairman Alexei Morozov said at the same news conference. IAC officials said they are prepared to provide the results to an international investigation or auditors. The final report has been handed to Polish officials, Anodina said. The Russian-made Tupolev Tu-154 plane crashed on April 10, 2010, in Russia's Smolensk region west of Moscow, killing everyone aboard as they headed to the village of Katyn to commemorate the massacre in which some 22,000 Poles were executed by the Soviet secret police. The IAC is a special aviation watchdog authorized to investigate plane accidents in Russia and other countries of the former Soviet Union. Back to Top NTSB ISSUES SECOND UPDATE ON JACKSON HOLE B-757 RUNWAY OVERRUN INCIDENT In its continuing investigation of the runway overrun of a jetliner in Jackson Hole, Wyoming, the National Transportation Safety Board has developed the following factual information: At about 11:38 am MT on Wednesday, December 29, American Airlines flight 2253, a B-757-200 (N668AA) inbound from Chicago O'Hare International Airport, ran off the end of runway 19 in snowy conditions while landing at Jackson Hole Airport. No injuries were reported among the 181 passengers and crew on board. Instrument Flight Rules (IFR) weather conditions prevailed around the time of the incident with a ceiling of 400 feet, light snow and visibility of 1 mile. Winds were 10 knots from 240 degrees. Runway friction measurement data obtained before and after the event have been provided by the Jackson Hole Airport Authority for further evaluation by the NTSB. In the continuing investigation, work groups have been formed to examine the subject areas of air traffic control, airports, meteorology, flight crew operations, airworthiness, maintenance records, cockpit voice recorder (CVR), flight data recorder (FDR), and airplane performance. The NTSB systems investigator conducted testing on the incident airplane from December 31, 2010, through January 6, 2011. Operational testing and examination was accomplished on the spoiler/auto speed brake, air/ground, autobrake, and thrust reverser systems. No discrepancies were found in the air/ground, autobrake, and thrust reverser systems. Examination of the auto speed brake mechanism in the cockpit pedestal found that the linear actuator aft attachment was improperly installed and was missing a bushing. This loose connection allowed the cam to be rotated slightly relative to the switch, which could cause the switch roller and the notch in the cam to not always align. System operation with this condition present is being investigated. The maintenance group convened at the American Airlines facility in Tulsa, Oklahoma, to review airplane logbooks. The group focused primarily on the spoiler/speed brake, air/ground, and thrust reverser systems. No significant issues with any of these systems were recorded prior to the incident, and there were no open minimum equipment list (MEL) items at the time of the incident. The airplane was manufactured in June 1992 and, at the time of the incident, had accumulated 58,879 hours and 20,518 cycles. No discrepancies were noted during the last periodic service maintenance check conducted on December 26, 2010. The last heavy maintenance was accomplished in October 2005. The auto speed brake actuator was replaced in January 2008. The CVR group convened on January 4, 2011, at the NTSB recorder laboratory. The group completed a transcript of the last 30 minutes of the recording and a summary of the previous 90 minutes. The transcript will be released when the public docket is opened. The FDR group has begun the process of determining which of the documented parameters are installed and should be functional, and is checking the recorded data for validity. The group has verified the following factual information: * The FDR download contains the last 43.9 hours of data, more than the required 25 hours, and includes all of the incident flight. * The recorded speed brake handle position indicates that the speed brakes were manually extended by the flight crew during the approach after which the handle was left in the armed position until landing. The FDR records only the speed brake handle position and not the individual speed brake (spoiler) panel positions. * The FDR data indicate that the aircraft touched down at approximately 132 knots. * At touchdown, the air/ground parameter changes to "ground" for approximately one second and then switches to "air" for approximately ½ second before changing back to "ground" for the remainder of the recording. * During the time period when the air/ground parameter switched back to "air," the speed brake handle position momentarily moved toward the down position and then returned to the armed position where it stayed for the remainder of the recording. * Thrust Reverser (T/R) discrete parameters indicate that the T/Rs moved into the in-transit position during the ½ second that the air/ground logic parameter indicated "air." * The T/Rs remained in the in-transit position for approximately 10 seconds before transitioning to the stowed position for one second. The T/Rs then moved back to the in-transit position for an additional 6 seconds before becoming deployed. * The T/R discrete parameters indicate that approximately 18 seconds elapsed from the time the T/Rs began moving until they were fully deployed. Additionally, the team has examined security camera videos provided by the airport as well as a video of the landing taken by one of the passengers. The accident docket, which will contain additional factual information, is expected to be opened in 60-90 days. It will be available on the NTSB website at http://go.usa.gov/rjR RELATED INFORMATION First investigative update (12/31/10): http://go.usa.gov/rwm Media advisory announcing incident investigation (12/29/10): http://go.usa.gov/rjN Runway Safety on NTSB's Most Wanted List of Safety Improvements: http://go.usa.gov/rTn Back to Top European Safety Agency Sees Boeing 787 Approval by End of 2011 European certification of Boeing Co.'s 787 Dreamliner, already three years behind in its delivery schedule, will probably come between mid- year and year-end, the head of the region's air-safety agency said. Commercial airlines can't take delivery of 787s until the plane is certified by aviation authorities. The Federal Aviation Administration is the primary party to grant certification for planes built in the U.S., though the European Aviation Safety Agency must also grant certification for any European-based carriers to take the plane. The two authorities work closely together and usually grant certification to new models in quick succession, EASA Executive Director Patrick Goudou said today at a briefing in Paris. Goudou said he hoped the European and U.S. certifications would be close to simultaneous for the 787, adding it's difficult to guess just when that will come because of the difficulties Boeing has had with the plane. "The schedule's not clear because Boeing's had some problems, as you know," Goudou told journalists. "We're hoping for mid-year, or maybe a bit later, around year-end." Boeing's first 787 will go to Japanese company All Nippon Airways Co. The carrier was scheduled to get that plane in the first quarter of 2011, until Boeing's Japan unit told All Nippon in late December the date would be pushed back. The aircraft, originally supposed to begin deliveries in May 2008, has suffered parts shortages and other difficulties. Most recently, the schedule was hurt by an electrical fire that broke out Nov. 9 in a test plane's power panel, knocking out some controls. Boeing resumed limited flights in late December. The company hasn't yet announced what revisions may be made to the schedule. Goudou also said that the 787 may prove more expensive to certify than Airbus SAS's A380. The Airbus superjumbo took five years to certify, he said, at an average cost of about 2 million euros a year. The plane won certification in 2006. The 787 began certification proceedings around the middle of the last decade and contains more new materials than the A380, as the structure is about 50 percent made from composite materials, compared with 25 percent for the A380. Goudou didn't give a specific estimate for final 787 certification costs. http://www.bloomberg.com/ Back to Top AirAsia Airplane Skids Off Malaysian Runway in Rainstorm; Airport Closed Malaysia's biggest carrier by market value, said four passengers were treated at a hospital and released after an Airbus SAS A320 skidded off a runway in Sarawak state while landing in the rain. The passengers on flight AK5218 were taken in as a precautionary measure after the accident at Kuching International Airport late yesterday, the company said in a statement by SMS today. The airport is closed today as heavy rains have hampered efforts to remove the plane, Malaysia Airports Holdings Bhd. said on its website. The airport operator didn't say how long the shutdown may last. "The wheels of the aircraft are stuck in the grass due to soft soil caused by the rain," AirAsia said. "The captain did a good job in handling the situation." Air Asia was unchanged at 2.70 ringgit as of 1:25 p.m. in Kuala Lumpur trading. http://www.bloomberg.com/ ety Information" is a free service of: Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC