Flight Safety Information April 26, 2011 - No. 084 In This Issue NTSB Continues Investigation Of Southwest Airlines Flight 812 Passenger Jet makes emergency landing Can technology fix the FAA's air traffic troubles? Gov't hires ex-FAA exec to help improve PH aviation status (Philippines) Boeing still struggling with 787 How Alarming are Airport Ramp Accidents? NTSB Continues Investigation Of Southwest Airlines Flight 812 Finds Rivet Lines Did Not Line Up Properly Where Fuselage Opened The NTSB has updated its investigation of the April 1, 2011 incident involving Southwest Airlines flight 812, which experienced a rupture in the fuselage while in flight. The Boeing 737-300 registration N632SW, experienced a rapid depressurization caused by a rupture in the fuselage. The flight was at 34,000 feet when the depressurization occurred. The flight crew conducted an emergency descent and diverted the flight to Yuma International Airport, Yuma, AZ. At the time of the accident, the aircraft had accumulated 48,740 hours of service and 39,781 cycles (a cycle is a takeoff and landing). The accident aircraft was delivered to Southwest Airlines on June 13, 1996. On-scene inspection by NTSB investigators revealed an approximately 9-inch wide by 59-inch long rectangular-shaped hole in the fuselage crown on the left side of the airplane, aft of the over-wing exit. The 59-inch longitudinal fracture occurred in the aluminum fuselage skin along the lap joint at stringer-4 left (S-4L) between body station (BS) 666 and BS 725. At S-4L, the crown skin overlaps the lower skin forming a lap joint. The two skins are connected at the lap joint by three rows of rivets (referred to as lower, middle, and upper row of rivets.) The fracture was through the lower skin and connected 58 consecutive rivet holes in the lower row of lap joint rivets. The exterior surface of the skin in the area of S-4L is painted blue. Evidence of blue paint was also found inside the joint between the upper and lower skin and on several areas of the skin fracture surface. Following an on-scene examination of the accident aircraft, a portion of the fuselage skin that contained the hole and another portion of the skin located forward of the hole (total size 116 inches by 19 inches) were excised from the accident aircraft and transported to the NTSB Materials Laboratory in Washington, DC. The airplane was then released back to the operator. At the NTSB Materials Laboratory, microscope examination of the fracture faces of the ruptured skin revealed fatigue cracks emanating from at least 42 of the 58 rivet holes connected by the fracture. Electrical conductivity measurements, hardness tests, and X- ray energy dispersive spectroscopy elemental analysis of the skin in the area of the fracture revealed that the aluminum skin material was consistent with the specified material. The skin was the specified thickness. Non-destructive eddy current inspections conducted around intact rivets on the removed skin section forward of the rupture revealed crack indications at nine rivet holes in the lower rivet row of the lap joint. To assess the condition of the intact rivets and the skin rivet holes, X-ray inspections were performed on the skin located forward of the rupture location. This inspection revealed gaps between the shank portions of several rivets and the corresponding rivet holes for many rivets associated with S-4L. Upon removing selected rivets, the holes in the upper and lower skin were found to be slightly offset relative to each other and many of the holes on the lower skin were out of round. In this ongoing investigation, the NTSB Materials Laboratory work is actively conducting additional inspections and examinations in the following areas: Removal of rivets and examination of rivet hole dimensions, rivet dimensions, and rivet hole alignment between upper and lower skins. Detailed fractographic analysis of the skin fractures emanating from the rivet holes using optical and scanning electron microscopes. Fatigue striation analysis using a scanning electron microscope of specific skin fractures to determine the rate of crack propagation. Following the depressurization accident and on-scene examination of the accident aircraft, Boeing issued Alert Service Bulletin SB 737 53A1319-00 on April 4 instructing operators of certain Boeing 737-300, 400, and 500 aircraft to inspect the lower row of fasteners at stringer S-4R and S-4L, from BS 360 to BS 908 for cracking in the lower skin of the lap joint on airplanes. The FAA issued Emergency Airworthiness Directive AD 2011-08-51 on April 5 mandating the inspections in the Boeing Service Bulletin. To date, the NTSB has been informed that 136 airplanes have been inspected worldwide in accordance with the Service Bulletin and Airworthiness Directive including all U.S. registered airplanes covered by the Directive. As stated in a previous release, four of these airplanes were found to have crack indications at a single rivet and one airplane was found to have crack indications at two rivets. These airplanes had accumulated between 40,000 and 45,000 total cycles. The lap joints from these areas of the subject airplanes have been removed and will be fully documented as part of the NTSB investigation. FMI: www.ntsb.gov Back to Top Passenger Jet makes emergency landing North Charleston, SC (WCIV)-- An American Eagle passenger plane was forced to make an emergency landing at Charleston International Airport Monday night. Airport information staff confirmed flight 1012 was en route from Miami to Washington D.C. when maintenance problems forced the plane to divert to Charleston International. None of the 160 passengers on board were hurt - most spent the night at local hotels. The flight is scheduled to depart Tuesday at 11:30 AM. http://www.abcnews4.com/story/14513913/passenger-jet-makes-emergency-landing Back to Top Can technology fix the FAA's air traffic troubles? (CNN) -- New technology to modernize America's aging air traffic system promises to help air traffic controllers, and may have prevented a recent tarmac collision between two aircraft at a New York airport, say experts. As part of its "NextGen" plan to overhaul traffic management, the FAA plans to replace its current radar tracking system by 2020 with a more accurate GPS-based network. With the new technology, pilots and controllers can see surrounding aircraft in real time - - without the 10-second delay that comes with the half-century old radar technology. What's going on with air traffic controllers? GPS-based tracking displays certainly would have had a role to play in preventing the April 11 collision on the tarmac at New York's John F. Kennedy International Airport, said Bill Voss, former FAA air traffic development director and current president of the Flight Safety Foundation. The incident occurred when a taxiing Air France Airbus A380, widely regarded as the largest commercial airliner, collided with a much smaller Comair Bombardier CRJ-700 regional jet, which was parked. How NextGen will change air travel Another flight controller asleep on duty Asleep at the FAA? No one was hurt in the collision, but wings on both planes were damaged, according to the National Transportation Safety Board. Video of the incident showed the smaller plane appearing to turn at about a 45 degree angle after the giant Air France jet taxied by. Typically, planes taxiing at airports are tracked by air traffic controllers watching from towers. They use radar and other technology to track aircraft when bad weather makes it hard to see. But during good weather controllers usually follow planes by using their eyes -- even at night. "You'd be surprised -- almost all of this is done with pieces of paper, an eyeball and a pencil," said Voss. "It is a very visual and manual activity." If either the Air France or the Comair pilot had access to a GPS cockpit surface map, the JFK collision might have been avoided, he said. Under NextGen, animated surface maps in the cockpit will be a critical safety improvement, said Voss. Specifically, cockpit displays "might have shown the A380 crew that the regional jet was not pulled up as far as expected," Voss said. "It also may have alerted the regional jet crew that the world's biggest airliner was about to taxi behind them, in which case he might have pulled up a bit further." You'd be surprised -- almost all of this is done with pieces of paper, an eyeball and a pencil. --Bill Voss, Flight Safety Foundation The NTSB is investigating the incident. Preventing so-called ground incursions such as the JFK collision is high on the NTSB's list of priorities, say aircraft operators. Will air traffic overhaul make us safer? When the entire plan is fully implemented by 2025, NextGen is widely expected to make air travel more efficient, faster and safer in a system already widely accepted as the safest in the world. Asleep at the switch It has been a tough few weeks for the FAA as officials have acknowledged a series of reports about controllers sleeping on the job, prompting questions about worker fatigue, staffing and scheduling. Living the life of an air traffic controller The FAA wouldn't comment for this story, but FAA administrator Randy Babbitt has acknowledged the situation has left him "infuriated." The string of reports about controllers asleep at the switch began March 23, when an American Airlines flight was seeking landing clearance at Washington's Reagan National Airport. Pilots and a regional air traffic controller were unable to contact anyone at Reagan's tower, so pilots landed the airliner safely without assistance. The FAA later said the controller was asleep and was "in the process of a disciplinary proceeding which will terminate this employee." How are controllers trained? In that situation, NextGen technology wouldn't set off "any special bells or whistles to wake anyone up, unless they start mounting a cattle prod to it or something." joked Voss. A cockpit display showing the location of the incoming plane and any surrounding aircraft would go a long way toward reassuring a pilot left stranded without a controller, said Voss. Air traffic control hinges on 'human factor' It is designed to improve teamwork between pilots and air traffic controllers, say aviation officials. It's not at all meant to replace controllers. "It offers another layer of protection," he said. "However, we don't know if those other aircraft can see the pilot's plane -- that's the incremental difference. You still really do need to have a controller and a landing clearance." Shifting roles and responsibilities Does having a cockpit display lessen the importance of the air traffic controller? "The answer is no," said Melvin S. Davis, a veteran air control instructor for the National Air Traffic Controllers Association union. "But there is a lot of anxiety about the roles and responsibilities and the changes that will occur when you introduce revolutionary technology." Davis spoke to CNN last fall, before the recent spate of air traffic incidents. The union was unwilling to comment for this report. As controllers learn to use the new technology, Davis said it will take a lot of time to manage the resulting changes. "At the end of the day, the human decision-making is irreplaceable," he said. Not only controllers but also all stakeholders, including technicians and pilots, are concerned about managing the change from radar to GPS-based tracking so it doesn't decrease safety, Davis said. Aviation leaders are quick to point out the nation's impressive commercial airline safety record in 2010: zero fatal crashes. However, like many industries, air traffic controllers with more experience often look down their noses about the abilities of the younger generation. The best controllers, they say, maintain a constantly moving mental picture of all their air traffic -- what they call situation awareness. Maintaining situation awareness is critical to aviation safety, especially if there's a problem with the tracking technology. Privately, controllers have expressed concern that younger controllers may be too reliant on technology when tracking their planes -- and not as reliant on their situation awareness as they should be. NextGen technology may have helped a recent air traffic control incident involving first lady Michelle Obama, Voss said. ... there is a lot of anxiety about the roles and responsibilities and the changes that will occur. --Melvin S. Davis, National Air Traffic Controllers Association The plane the first lady was flying on, a military version of a Boeing 737, was approaching Andrews Air Force Base in Maryland when it came too close to another aircraft. Controllers directed the first lady's pilot to abort the landing. Neither plane was ever in any danger, officials said. GPS-based tracking might have given the controller more time to adjust the flight path of the first lady's plane, said Voss. This is because there would be virtually no delay on the display screen, compared to old-style radar. Airline traffic is expected to skyrocket to 1 billion annual passengers by 2021. But during the recession, the nation's aging air traffic system has enjoyed a reprieve in the form of sagging ridership. It's an opportunity to improve safety that shouldn't be missed, said Voss. "The only question is can we get enough done during this reprieve to start tightening up the airways." Back to Top Gov't hires ex-FAA exec to help improve PH aviation status (Philippines) MANILA, Philippines - The Philippines could soon regain its Category 1 aviation safety status with the help of a former US Federal Aviation Authority (FAA) executive hired by the government, the Transporation Department said Monday. "We are hopeful that we will be able to get back the FAA's Category 1 rating within the year or early next year," Glicerio Sicat, DOTC undersecretary for civil aviation and railways, said. Sicat said the agency has tapped the services of Tim Neel, a retired general and ex-FAA executive. Neel now heads his own firm which specializes in international aviation safety matters, including the assessment of aviation safety standards in government civil aviation authorities, international air carriers and airports. Neel has helped a number of countries in Latin America and the Caribbean develop their aviation oversight programs, Sicat said. "We believe he can do the same for the Philippines." The Philippines was downgraded by the FAA to Category 2 in 2008 after a safety audit conducted in November 2007 found some policies of the local aviation sector to be below international standards. Since then the aviation industry has launched efforts to address FAA's concerns. According to Sicat, only 2 of the 22 actionable items identified by the FAA as safety issues remain unresolved. These refer to the lack of qualified safety personnel and absence of an integrated information technology (IT) system to modernize the aviation industry's database. Sicat said Neel has provided the Civil Aviation Authority of the Philippines (CAAP) with a software that will allow the regulator to store and easily retrieve information such as the history of an aircraft's inspections. This computerized system, which will be operational in about 6 months, is part of the efforts to modernize the IT infrastructure of CAAP. "Soon, all aspects of CAAP's operations will be computerized and will be IT-integrated," Sicat said. To address the concern over qualified technical personnel, Sicat said CAAP already hired 22 former pilots to serve as full-time Flight Standards Inspectorate Service inspectors. http://www.abs-cbnnews.com/business/04/25/11/govt-hires-ex-faa-exec-help-improve- ph-aviation-status Back to Top Boeing still struggling with 787 While Boeing may meet its deadline to deliver the first 787 to All Nippon Airways of Japan before Sept. 30, the production pace projected for 2011 appears out of reach. As Boeing's 787 Dreamliner program creeps toward first delivery this year, managers are intensifying efforts to smooth production. But people working on the airplanes and others familiar with the state of the program say progress is painfully slow. While Boeing may meet its deadline to deliver the first 787 to All Nippon Airways of Japan before Sept. 30, the production pace projected for 2011 appears out of reach. Boeing executives told Wall Street analysts in January the company would deliver somewhere between a dozen and 20 Dreamliners this year. "It isn't going to happen," said one mechanic working on the airplanes. "There are too many jobs to be done." One job taking weeks per airplane is the painstaking removal of sealant from the interior of fuel tanks in the wings, then resealing them. And because the computerized system that provides mechanics with data on parts isn't operating well, even simpler modifications take much longer than they should. Boeing has leased extra space so it can work on multiple airplanes at the same time. Managers last week held all-hands meetings aimed at galvanizing the work force, and formed employee committees to identify and solve the major holdups. Tough questions ahead On Wednesday, when Boeing releases its quarterly earnings results, executives no doubt will be questioned about the state of the 787 program. Six Dreamliners are flying flight tests, while 29 more have rolled off the assembly line and are parked on the Everett flight line or at adjacent Paine Field. Those planes await thousands of incomplete assembly jobs and modifications necessary because of design changes since they were built. Boeing spokeswoman Lori Gunter conceded Monday that the rework is a difficult challenge, and she acknowledged the two specific problems raised by 787 insiders: the wing sealing and the computer data glitches. Still, she insisted, there is a "very specific airplane by airplane plan" for completing the rework. "Nothing we've seen ... is raising red flags for us," she said. In an effort to come to grips with the extensive rework, Boeing is modifying one Dreamliner in Texas, two more inside the main Everett assembly plant, and five airplanes inside a large hangar at the south end of Paine Field leased from maintenance and repair company Aviation Technical Services (ATS). Plenty of headaches Yet, those close to the program say production headaches continue. "The assembly process is still a mess," an engineer said. "They are building airplanes in the final-assembly process that then have to be rebuilt in the pickup process, which is many times longer." Parts that don't fit, including doors and control surfaces on the wings, still are arriving in Everett. "The wings on the 787s aren't even close to being ready," the engineer said. The employees spoke on condition of anonymity because Boeing doesn't allow them to talk about their work. The latest airplanes rolled out to the flight line from the factory with about 1,600 jobs incomplete. It has been taking on average about a month to complete 1,000 of these catch-up jobs, the 787 mechanic said. "They are just digging the hole deeper every time they send one out with that many jobs on it," he said. Gunter said she didn't have the information to comment on those numbers. Sorting it all out is made much more difficult because of the balky computerized system that manages all the data about specific parts. Mechanics are spending hours trying to call up parts information and drawings before performing any rework or modification. And individual jets have been reworked so often that engineers have a hard time just figuring out what is the particular configuration of parts and assemblies on a particular plane. "Productivity has crashed," said another employee with knowledge of how the computer system is failing. "A worker spends four hours a day on the computer just trying to pull up his work." Boeing's Gunter said the company is working to improve the digital tools, which she admitted "could work better." But she said that, even without that, productivity has been improving. "Our mechanics are doing a great job," she said. Among the major rework that must be done on every jet built so far is the laborious resealing of the wings. That's currently being done on two jets destined for Royal Air Maroc of Morocco, inside an empty bay of the main assembly plant. As the engineer put it, the planes are "essentially getting gutted." The wing seals are important not only to avoid fuel leaks but also to coat metal fasteners so as to prevent sparks inside the fuel tank during a lightning strike. Gunter said Mitsubishi Heavy Industries (MHI), which builds the wings in Japan, is not entirely at fault. "The sealing that was done did not meet our expectations," Gunter said. "We worked together with MHI to identify the need for resealing." At the root of the issue, she said, are "elements of both workmanship and design." Nothing new She added that this is "not a new discovery" and already was factored into the last schedule revision in December, which requires the first delivery by the end of September. But first delivery may not matter as much as the smoothing of the production system, said the employee who spoke about the computerized data problems. "They'll make some deliveries," that person said, "But does the assembly line work? Almost no one thinks so." Among several people who work on or with the program, the most optimistic projection was that Boeing might deliver 10 Dreamliners to customers by year end. Others predicted the number would be much smaller. Inside the ATS hangar, Dreamliners Nos. 8 and 9 are being prepared to join the fleet of flight-test planes to speed up the certification process. These jets will fly long flights to try to gain a certification known as ETOPS - Extended- range Twin-engine Operations - which an airplane needs to fly more than an hour from the nearest airport. One Dreamliner, No. 23, flew to San Antonio last month. That plane is having its wing tanks sealed there and also is being rewired. When it's done, it will fly back to Everett to have an interior installed. More employees Boeing has been hiring mechanics steadily to beef up its work force and by the summer plans to have 1,200 people working at the ATS hangar, which the work force has dubbed "Factory South." "Boeing is throwing money and bodies at the problem," the mechanic said. Back to Top How Alarming are Airport Ramp Accidents? If there's one thing you can count on in aviation it is that every aspect of it is a lot more complicated than you think. In a recent post on ramp accidents, I cited a Flight Safety Foundation report which gave some pretty alarming numbers. In the May 2007 issue of Aerosafety World, the Flight Safety magazine used numbers from the International Air Transport Association to estimate that there were twenty- seven thousand ramp accidents each year in which 240,000 people were injured. A number of readers have since told me they thought the numbers, which have appeared in other aviation magazines since the article was published were just too high. No one quibbles with the statement that ramp accidents are tremendously expensive, after all, it doesn't take too many dings in a $100 million airplane to start running up a serious repair tab. But a quarter of a million injuries? This just can't be. IATA, the source of the original numbers, is arguing with the FSS report. Anthony Concil, spokesman for IATA said, "ramp fatalities are anecdotally five to ten per year." He suggested that the quarter of a million injuries cited by FSS are on-the-job injuries, not atypical in any industry that deals with machines and moving vehicles. "To connect the number of on-the-job injury reports to ramp accidents misrepresents actual events." Curiously, while Jay Donoghue of the Flight Safety Foundation's office of publications admits there was some discussion over "the disparity in numbers", a week of exchanging emails with the Foundation yields no further explanation. The Air Transport Association tracks ground-based events, but the numbers are not shared outside of the association. So what do we know? Well, in the United States, when serious injuries or substantial damage are involved, a report must be filed with the Federal Aviation Administration. Bob Matthews - attendant of these statistics at the FAA - says that from 1996 to 2010 there were 46 fatal or serious injuries during ground operations at U.S. airports. And while the U.S. is a busy aviation market, it represents just a fraction of commercial aviation worldwide. The U.S. had a fatality-free year in 2009 and 2010, Matthews said. In other countries it is a different story. At one unidentified airport in India earlier this year, a worker's hand was trapped in an retracting jetbridge and while the employee was rushed to medical care, she did not survive. At an Asian airport, a ramp worker was crushed under the wheels of a power supply vehicle. Ramp workers have been sucked into airplane engines, crushed in scissor lifts and hit by tugs. Five of the people on board this Etihad Airways A340 were injured when the airplane crashed through a containment wall during ground tests. A factor in the loss of the airplane? Wheels not chocked during engine and brake system testing. From simple mistakes do great losses originate. Whether the emphasis on the collision between an Airbus A380 and a Bombardier CRJ 700 is due to the fact that it was video taped and uploaded to You Tube, or an appropriate reaction to the latest illustration of something larger, there should be no argument that it is imperative that the industry get a handle on the size of the problem. That the assessment of two respected aviation institutions can vary so widely tells me that the effort to quantify the issue is long overdue. Last month, IATA began the first worldwide effort to gather meaningful statistics. Overstating the problem is no better than understating it. "Ground damage is a big issue but these statistics need to be related to their source," Tony told me while explaining that the FSS numbers just don't add up. They are not, he said, "the reality." http://christinenegroni.blogspot.com/2011/04/how-alarming-are-airport-ramp- accidents.html Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC