Flight Safety Information April 25, 2011 - No. 083 In This Issue Manufacturing Issues Suspected in Southwest Jet Rupture Rotary-Wing Safety, Greener Technology Top Helitech 2011 Conference Pilot Lapses Suspected After Fire Warning Air-traffic controllers union asserts safety, pushes for controlled naps Airplane hijacker overpowered on flight to Rome NTSB: Jet pulled 'alongside' small aircraft in March incident LAPD chopper makes emergency landing after being shot Air India 737 captain deeply asleep shortly before fatal approach Court directs Pakistan CAA to release report on fatal Airblue accident Report: hard landing and pitch-up after touchdown factors in A321 tailstrike accident FAA ADMINISTRATOR WANTS MROs ADOPT SAFETY MANAGEMENT SYSTEM (SMS) Manufacturing Issues Suspected in Southwest Jet Rupture By ANDY PASZTOR and PETER SANDERS (WSJ) Investigators increasingly are focused on manufacturing-related issues, rather than a possible design flaw by Boeing Co., as they strive to unravel what caused the midair fuselage rupture of a Southwest Airlines Co. jet earlier this month, according to government and industry officials. The officials said it's too early to draw definitive conclusions, and National Transportation Safety Board investigators haven't issued any statements hinting at what they suspect. But areas that federal and industry experts are examining as part of the probe, according to these officials, include riveting techniques, fixtures used to hold parts of the planes during assembly and uses of sealants on the 15-year-old Boeing 737. The plane suffered a rapid decompression and had a five-foot gash rip open in the upper part of its cabin, about four feet above the windows, while cruising at about 34,000 feet. Nobody was seriously hurt and the twin-engine jet, with 122 people aboard, made an emergency landing at a military base in Arizona on April 1. But the incident prompted Southwest to temporarily ground and inspect 79 of its other older Boeing 737s, and it also sparked a round of swift inspections of about 100 additional aging Boeing 737 models worldwide. Four other Southwest jets were found to have fuselage cracks requiring repairs, but at this point no similar problems have been discovered on other airline fleets. The primary reason for emphasizing potential manufacturing-related lapses or problems, according to these officials, stems from the fact that a number of the Southwest planes with fuselage cracks were built around the same time. And jets flown by other carriers, even some with a larger number of takeoffs and landings that the Southwest plane with the hole, haven't shown any signs of structural weakness or fatigue. So far, according to one official familiar with the investigation, investigators have spent the most effort to understand the manufacturing history of the Southwest planes that had significant cracking of their aluminum skins. The plane with the rupture had logged about 39,000 takeoffs and landings, substantially fewer than the point at which Boeing experts anticipated it could face serious metal fatigue. But according to officials familiar with the investigation, it's still too early to know whether the suspect Southwest jets illustrate a possible quality-control or manufacturing problem of relatively short duration, or some other potential causes. The stresses planes undergo each time their cabins pressurize and then depressurize during a trip are major factors in creating cracks and possibly causing metal fatigue. Possible production problems were first reported on Saturday by ABC news. Federal Aviation Administration chief Randy Babbitt previously suggested that production issues were under heightened scrutiny. He told an industry conference in Miami earlier this month that the agency, among other things, was looking into "manufacturing techniques" along with Boeing. Mr. Babbitt said agency experts were examining existing aging-aircraft inspection rules and seeking to determine "are we looking at the right things?" Eventually, more than 400 additional older 737 jets will have to be inspected around the globe, as a result of safety mandates by the FAA and foreign regulators. On Saturday a Southwest spokeswoman declined to comment on the investigation. She said the incident plane was still undergoing repairs, but the five others identified with cracks have been fixed and were returned to service. Boeing officials have said that the particular fuselage design on the affected airplanes was changed when a new version of the model was introduced in 1993. The so-called 737 "Next Generation" is the type still being built today and Boeing has delivered more than 3,500 of those, according to company data. The safety mandates issued by the FAA cover certain 737-300, 737-400 and 737-500 versions, and they kick in based on the number of takeoffs and landings planes have logged. Over the years, the FAA and industry have developed a comprehensive set of inspection standards and procedures to identify and repair fuselage cracks on older planes before they can result in major problems. The April Southwest incident shocked the airline industry, surprised regulators and spooked many travelers because until it happened, Boeing had concluded that the plane didn't need to undergo detailed structural inspections on that part of its fuselage until much later in its life. The planes under scrutiny feature a certain type of "lap joint" -- the area where Boeing and government investigators have said the structural cracks originated -- and surrounding strengtheners designed to prevent cracks from growing. The twin-engine 737, the company's most popular jet and a workhorse for carriers around the globe, first entered service in 1968. Since then, the more than 6,600 have been completed at Boeing's factory in Renton, Wash., just south of Seattle, and more than 2,000 remain on order. The planes requiring inspection were built between 1993 and 2000. Before reaching Washington state, however, 737 fuselage barrels are assembled at a factory in Wichita, Kan. That facility, now owned by Spirit AeroSystems Holdings Inc., a major aerospace supplier, was at the time a wholly-owned Boeing factory. Boeing spun off its commercial airplanes unit in Wichita in 2005. On Friday, Boeing said it continues to work closely with the safety board and the FAA to determine what caused the April 1 event. In its statement, the Chicago aerospace giant said that "to date, inspections have been completed worldwide on approximately 75 percent of the 190 airplanes affected" by mandatory inspection rules, and only the handful of Southwest planes have "shown small subsurface cracks." "Portions of the panels from those airplanes have been shipped to Boeing, and we are conducting analyses to validate the initial inspection findings." According to Boeing, "no conclusions have been reached about the root cause of the inspection findings" or how they may relate to the April 1 event, and "any attempt to draw conclusions on either would be premature and speculative." Back to Top Rotary-Wing Safety, Greener Technology Top Helitech 2011 Conference Event To Be Held In Late September In Duxford, UK The latest European safety requirements for helicopter operators is just one of the high profile topics that will be discussed in depth at Helitech's conference this year. Helitech 2011 takes place at the Imperial War Museum at Duxford, near Cambridge, from September 27-29. The Helitech Conference, which is new for 2011, will take place beginning the afternoon of the 28th and continuing on the morning of the 29th The conference will be chaired by helicopter specialist and journalist, Andrew Drwiega, who is internationally recognised for his independent insight and commentary on the rotary-wing scene. A session on the environment will look at greener helicopter development for the future and give a perspective on current research and development plans. There will be particular focus on engine development, covering areas such as the use of new fuels, creating new efficiencies and lowering costs. With energy security so prominent in news headlines, the conference will look at the development of wind farms and how the rotary-wing industry is looking to capitalise on this increasingly important utility area. This session will also consider recommended helicopter rescue techniques that have been developed for wind farm fields. Security and surveillance technology as well as parapublic air support requirements will also be covered in the highly topical agenda. The conference will be held in the Airspace facility at Duxford and is being kindly sponsored by Bell Helicopter. Helitech Exhibition Manager, Brandon Ward, said: "Our initial research into the kinds of topics to include in the conference was greeted with great enthusiasm across the industry. This is the first time we've staged our own conference during the Duxford event. Our aim is both to attract new visitors to Helitech and offer existing visitors and exhibitors the chance to hear about some of the latest developments in areas such as security technology and parapublic air support." This year marks 25 years of Helitech supporting and promoting the helicopter industry. The show enjoys the support of both the British Helicopter Association (BHA) and the European Helicopter Association (EHA). FMI: www.helitechevents.com Back to Top Pilot Lapses Suspected After Fire Warning By ANDY PASZTOR (WSJ) Pilots of a United Airlines jet apparently didn't follow proper procedures and inadvertently disabled some vital electrical systems after they received a fire warning and started an emergency return earlier this month to New Orleans, according to people familiar with the probe. A team of safety experts led by the National Transportation Safety Board has tentatively concluded that after skipping over a portion of a checklist, the pilots of the Airbus A320 also failed to restore power to some equipment, making it more difficult to carry out the emergency landing, the people familiar with the matter said. No one was hurt in the April 4 incident. Investigators haven't found any signs of fire or evidence of smoke. They suspect there may have been a faulty fire-warning sensor in the cargo hold. United has since revised a portion of the emergency checklist to help clarify how pilots should deal with electrical malfunctions, according to people familiar with the matter. Officials at the safety board declined to comment. A spokeswoman for United, a unit of United Continental Holdings Inc., declined to talk about the board's ongoing probe. "We are conducting our own internal review," she said Sunday. "Any preliminary discussion of findings would be speculative." The pilots of United Flight 497, bound for San Francisco with more than 100 aboard, declared an emergency due to "smoke issues" after reaching 4,000 feet and receiving automated warnings of auto-throttle problems and smoke in the electronics bay. The warning messages also instructed the crew to land. The crew apparently failed to turn a generator back on prior to starting the final approach to the New Orleans field, according to people familiar with the investigation's preliminary findings. The incident illustrates the challenges of dealing with an onboard fire emergency, and the complications that can result from swiftly running through a checklist that entails shutting off and then possibly restarting electrical circuits. The plane landed safely, but the pilots failed to ensure that they had necessary electrical power to steer the jet's nose gear or provide antiskid protection for its brakes, these people said. The co-pilot's primary instrument screen also went blank apparently due to loss of electricity, and the intercom between the cockpit and the cabin stopped functioning. According to a recent board update of the investigation, the captain reported using the "electronics checklist for the avionics system smoke-warning" message, "which included shutting down some of the airplane's electrical systems." The front of the plane rolled off the side of the runway and passengers evacuated using emergency slides. The flight lasted about 20 minutes, though investigators are trying to determine why the cockpit-voice recorder captured only eight minutes of conversation. The board's update said a preliminary examination showed there weren't any signs of fire or avionics malfunctions, and neither the pilots nor flight attendants recalled seeing flames or smelling any smoke. In declaring the emergency, the Airbus crew told controllers about losing "all our instruments" and asked for radar guidance back to New Orleans. Back to Top Air-traffic controllers union asserts safety, pushes for controlled naps By Alan Levin (USA TODAY) The union representing air-traffic controllers says it will continue to press for carefully controlled naps and other measures to reduce fatigue, despite the insistence by transportation officials that such measures will not be allowed. National Air Traffic Controllers Association President Paul Rinaldi also defended the safety of the air-traffic system, which has endured a withering spate of bad publicity in recent weeks. The Federal Aviation Administration is investigating six incidents of suspected sleeping by seven controllers and also suspended a controller for watching a DVD while on the job. "It is safe to fly. It has never been safer to fly," Rinaldi says in a release. Rinaldi says the union will continue to push for enactment of 12 recommendations to reduce fatigue that it came up with jointly with the FAA. They include monitored naps, better training on how to reduce fatigue and medical testing to ensure that controllers don't suffer from sleep disorders. Transportation Secretary Ray LaHood has said that he will not tolerate controllers sleeping. Back to Top Airplane hijacker overpowered on flight to Rome A MAN attempting to hijack a Paris to Rome flight and divert it to Tripoli was overpowered by cabin crew Sunday and the plane landed safely in the Italian capital, ANSA news agency reported. ANSA said the man, from Kazakhstan, threatened a female flight attendant aboard the Alitalia flight with a small knife about 7.30pm (GMT), but was overpowered by the cabin crew. The flight arrived in Rome's Fiumicino airport at 8.05pm (GMT) and he was handed over to police, ANSA said, citing police sources. The hijacker's identity and motive were not immediately known. http://www.heraldsun.com.au/news/ Back to Top NTSB: Jet pulled 'alongside' small aircraft in March incident (CNN) Acting at the request of an air traffic controller, the pilot of a Southwest Airlines B-737 pulled within one-tenth of a mile of a small, four-seat aircraft last month to check on pilot of the smaller plane, who had not responded to radio calls, the National Transportation Safety Board said Friday. The March 27 incident was publicized days after it happened, when Federal Aviation Administrator Randy Babbitt suspended the air traffic controller, for "compromising the safety" of the planes' occupants. But the details released Friday for the first time show just how close the two planes came. According to the NTSB, the planes came within 0.1 miles of each other, far closer then the required separation of three miles. They also were separated by 100 feet in altitude, less than the 1,000 feet required, the NTSB reported. The incident happened 11,000 feet over central Florida, when controllers at the Central Florida TRACON, a regional radar facility, were unsuccessful in contacting the pilot of the Cirrus SR22, which was en route to Kissimmee, Florida. The plane had been out of radio contact with the Jacksonville Center for more than an hour. A TRACON controller sought the assistance of Southwest Airlines flight 821, which was then 10 miles from the smaller aircraft, asking the Southwest pilot "to attempt to verify the condition of the occupants" of the Cirrus, the NTSB said. The Southwest pilot "obliged," and controllers guided the jetliner towards the unresponsive plane. A separate radar scope was set up and a single frequency was used by a front-line manager who provided instructions to the Southwest jet. When the Southwest jet was about five miles from the smaller plane, the pilot reported seeing the plane visually and on a collision avoidance system. The jet "maneuvered on his own alongside of" the smaller plane, the NTSB said. The crew reported seeing "two occupants in the Cirrus and no apparent movement from them" before being vectored away to its Orlando destination. The FAA said both planes landed safely. Southwest Airlines reported in March that it had suspended the pilot of the jetliner pending an investigation. Both the FAA and NTSB are investigating. Neither has issued any findings or conclusions. Aviation authorities say the protocol for intercepting unresponsive aircraft is to scramble military jets. "By placing this passenger aircraft in close proximity to another plane, the air traffic controller compromised the safety of everyone involved," FAA Administrator Randy Babbitt said in a statement in March. "This incident was totally inappropriate." "We are reviewing the air traffic procedures used here and making sure everyone understands the protocols for contacting unresponsive aircraft," Babbitt said. Southwest Airlines said the flight had 137 passengers and a crew of five. Back to Top LAPD chopper makes emergency landing after being shot Shot were fired at this Los Angeles Police Department helicopter on Sunday morning. Los Angeles (CNN) -- A Los Angeles Police Department helicopter had to make an emergency landing Sunday morning after a gunman opened fire on the chopper, authorities said. The helicopter landed safely and the pilot and observer on board were not injured, said police Detective Gus Villanueva. The incident occurred in the Van Nuys area, when police got a call at around 6 a.m. local time (9 a.m . ET) of shots being fired, police said. The helicopter was responding as backup to a patrol car dispatched to the scene. The helicopter was at the Van Nuys airport after the incident, and was to be put on a flat-bed truck to be towed downtown for investigation and repair, authorities said. The apparent shooter eventually was subdued by his family members, Villanueva said. A semi-automatic rifle was recovered, he said. Police got multiple calls that a second gunman was involved, and a search was conducted Sunday afternoon, Villanueva said. That search was called off later, Villanueva said. Back to Top Air India 737 captain deeply asleep shortly before fatal approach Indian investigators have cited a lethal combination of sleep inertia and over-dominance by the captain as having led to the fatal overrun by an Air India Express Boeing 737-800 at Mangalore. Cockpit voice recordings recorded typical breathing patterns of deep sleep from the Serbian captain, lasting for 1h 28min, until just 21min before the accident. The Indian ministry of civil aviation's final inquiry report indicates that the captain slept for at least 1h 40min. Because Mangalore radar was unavailable, the aircraft had to follow a shorter descent. But the ministry says the crew failed to prepare the descent profile properly, and the jet was "much higher" than it should have been for the instrument landing system approach to runway 24. But while the Indian co-pilot suggested three times that the aircraft should execute a go- around, the captain instead attempted to correct the badly-misaligned approach. In a bid to lower the aircraft's altitude, and capture the correct glide path for a visual landing, the captain increased the descent rate to nearly 4,000ft/min and continued the approach despite several automated 'sink rate' and 'pull up' warnings from ground- proximity systems. Mangalore has a table-top runway and Air India Express permitted only the captain to conduct the landing. The captain on the fatal flight, IX812 from Dubai, had made 16 landings at the airport. Flight-data recorder information shows that, as a result of the instability, the aircraft crossed the runway 24 threshold at a height of 200ft - four times higher than it should have been - and travelling at 160kt. It touched down about 5,200ft beyond the threshold, leaving just 2,800ft of paved surface on which to stop. Despite the long landing the captain "did not apply the brakes appropriately" and even attempted a go-around after activating reverse thrust - in contravention of standard operating procedures. The 737 failed to stop before overrunning the runway. Its right wing collided with the localiser antenna and the aircraft dropped off the edge of a steep gorge. Just eight of the 166 occupants survived the 22 May 2010 accident, none of whom was among the flight or cabin crew. In its inquiry report the ministry says the prolonged sleep by the captain, particularly during the overnight circadian low period, could have led to "sleep inertia" and possibly "impaired judgement" over the approach shortly after he woke. The ministry highlights regulations from another carrier which allow only a controlled 45min rest period, which must be completed at least 30min before top of descent. But it also emphasises that a steep authority gradient existed in the cockpit, with an assertive captain paired with a submissive first officer. The ministry points out that, even though the aircraft was not correctly positioned on the ILS glide path, the captain had "somewhat forced" the first officer to call "affirmative" when air traffic control queried whether the flight was established on the ILS approach. "With the first officer not showing any signs of assertiveness, the captain had continued with the faulty approach and landing, possibly due to incorrect assessment of his own ability to pull off a safe landing," the ministry says. The first officer did not attempt to take over the controls to discontinue the ill-fated approach. Source: Air Transport Intelligence news Back to Top Court directs Pakistan CAA to release report on fatal Airblue accident Pakistani newspaper "The Express Tribune" reported that the Peshawar High Court (PHC) had directed the Pakistan Civil Aviation Authority (CAA) to submit the inquiry report of the Airblue plane crash in Islamabad that killed all 152 people on board in July 2010. The Airblue Crash Affectees Organisation (ACAO) had filed a written petition asking for the Airblue fleet to be grounded in public interest till the findings of the inquiry report were made public. The Chief Justice observed that before the court can pass any order for interim relief, responsibility has to be fixed in the inquiry, since the grounding of the airline would have serious consequences. The bench directed the CAA to submit the inquiry report if it has been finalised by the federal government. www.aviation-safety.net Back to Top Report: hard landing and pitch-up after touchdown factors in A321 tailstrike accident The Japan Transport Safety Board (JTSB) released the final report of their investigation into a tailstrike accident involving an Airbus A321 at Osaka-Kansai International Airport (KIX/RJBB), Japan. An improper flare, hard landing and pitch-up after touchdown were factors. On October 28, 2009, an Airbus A321-200, registered HL7763, operated by Asiana Airlines, took off from Seoul-Gimpo International Airport (SEL), the Republic of Korea, as a non-scheduled flight OZ1125. The first officer was pilot flying during the approach to runway 06L of Kansai International Airport. The descent rate of 544 ft/min at the time of touchdown was high and the aircraft contacted the runway hard with a vertical acceleration of 1.91G. The nose-up stick input was continued after touchdown, while the extension of the spoilers further produced a nose-up effect. As a result the aircraft's pitch angle of 4.6 degrees at the time of touchdown increased to 10.2 degrees. This angle was in excess of the maximum allowable pitch attitude of 9.7 degrees. The first officer decided to make a go-around and moved the thrust lever in the TOGA position about four seconds after touchdown. The airplane circled and landed safely eleven minutes later. There were 147 persons on board, consisting of the Captain, 8 other crewmembers, and 138 passengers. No one was injured. The aircraft sustained substantial damage, but there was no outbreak of fire. JTSB concluded: In this accident, it is considered highly probable that, during the landing on Kansai International Airport, the Aircraft sustained damage in the aft part of the fuselage which contacted the runway, since the pitch angle became excessively large after the touchdown on the runway. It is considered highly probable that the Aircraft's pitch angle became excessive because the First Officer continued inputting pitch-up signals even after touchdown. The flare by the First Officer was inappropriate and as a result, the sink rate of the Aircraft did not fully decrease, causing the Aircraft to land with a strong impact on the ground. It is considered probable that, that the First Officer became upset by the impact contributed to his continuous input for pitch-up after touchdown. www.aviation-safety.net Back to Top FAA ADMINISTRATOR WANTS MROs ADOPT SAFETY MANAGEMENT SYSTEM (SMS) US FAA administrator Randy Babbitt is urging maintenance, repair and overhaul (MRO) firms to formally adopt safety management systems, saying SMSs will play a key role in enhancing the industry's safety culture. But some industry stakeholders have vocalized concerns about shouldering the cost of implementing SMS. A non-punitive safety reporting system, SMS allows employees to report problems or errors without fear of retribution. "We're already working with the pilots, we're working with mechanics, flight attendants, dispatchers and our air traffic controllers. All of them now have self-reporting programmes, and they're working," said Babbitt last week at the Aviation Week MRO Americas conference in Miami. "We're getting thousands and thousands of data slices that we would never get. We would never ever get. People would simply hide them for fear of being punished. For fear of retribution. We take that away. I don't care [who reported]. I just want to know the data. I want to know what happened. You want to know what happened. You can't fix things you don't know are broken and so that's why we take a fairly aggressive approach in this." With this data, the FAA is hoping to shift from a system that in the past relied on the use of forensics to understand what happened in an aircraft accident to one that uses computer analysis and trends to help the agency make decisions to stop accidents before they happen. Last fall, the FAA released a proposed rule that imposes SMS implementation on most airlines. The public comment period for the proposal closed on 7 March of this year. The agency also recently made a proposal that airports adopt SMS on ramp areas and access areas on airfields. Public comments will be accepted until 5 July. But Babbitt says he'd "like to see more companies, and airports move toward SMS, and eventually MROs". Because most airlines already have quality control and quality assurance programmes in place, SMS "simply formalizes those processes", notes Babbitt, who admits he is accustomed to hearing questions about whether adopting SMS will cost the industry more money. "I would remind all of us that SMS is considerably less expensive than an accident and so together we have to make this shift," says Babbitt. "SMS is essentially a feedback, if you think about it, it's not all that complicated. You have a way of understanding and collecting the data. You identify the problem, you analyse it, mitigate it, you design the procedure and training of the new procedure and then you implement it, and then you continue to monitor the data and see did that fix the problem. It's really a fairly simple system, and gives you continuous feedback [on how you're doing]." Many Part 145 repair stations already have SMSs in place. "However, those systems have not spread the responsibility for safety throughout all levels of the organization. Rather, they have been confined to audits or checklists in areas where a large number of accidents or incidents have occurred," notes Curt Lewis & Associates, a consultancy that specializes in assisting with SMS implementation. During the conference, Aeronautical Repair Stations Association executive director Sarah MacLeod said industry is already a step ahead of regulators: "Governments don't lead the industry. The industry leads government. And if you don't believe that, then boy this is really the wrong industry to be in because they are way behind us. Did you drink the Kool-Aid this morning with Randy [Babbitt]? The government is going to tell us how much money we're going to save with this new system that they are going to make us pay for. What the? We need to start passing out Kool-Aid at all these things. The SMS Kool-Aid. The NextGen Kool-Aid," said MacLeod. Babbitt says the "central element" to a good SMS is the employee who feels comfortable enough to willingly report safety hazards. "When you have your employees doing that, you will have achieved a safety culture," he says. But he warns that the system will never be perfect. "We'll never be safe enough. We'll never get to zero," he says, adding: "But we'll always be trying." http://www.flightglobal.com/articles/2011/04/22/355902/faa-administrator-babbitt- wants-to-see-mros-adopt-sms.html Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC