Flight Safety Information April 27, 2011 - No. 085 In This Issue FAA fires a third controller for sleeping on duty Southwest Airlines jet slides off runway UAE F-16 overran runway at Sigonella, Italy NTSB cites crew errors and fatigue as causes of 2009 Lubbock crash Cyprus hosts international conference on aviation safety Can technology fix the FAA's air traffic troubles? FAA inspects Boeing factories after shavings found in 767 fuel tank GPS testing in Utah prompts FAA flight advisory Investigators close in on sunken AF447's flight recorders FAA fires a third controller for sleeping on duty An air traffic controller has twice fallen asleep at Seattle's Boeing Field, the FAA says. That controller fell asleep on duty in January, then again earlier this month, the FAA said Washington (CNN) -- An air traffic controller at Seattle's Boeing Field has been fired for twice falling asleep on duty, the Federal Aviation Administration said Monday. Last week, the FAA fired two air traffic controllers, one of whom worked in Knoxville, Tennessee, and the other in Miami, also for sleeping on the job. The firings follow a spate of incidents in which controllers in various cities were reported to be sleeping while on duty. NTSB calls for fatigue-fighting strategies The controllers were not identified. The FAA said in a statement that they have "a due process right to respond to these actions." The Seattle controller fell asleep on the job on January 6 and then again on April 11, the FAA said. In response to the reports of controllers falling asleep on duty, federal officials recently announced a series of new regulations aimed at preventing such incidents. The life of an air traffic controller Among other things, controllers now must have a minimum of nine hours off between shifts, instead of the current minimum of eight hours. In addition, controllers can no longer be put on an unscheduled midnight shift following a day off. Back to Top Southwest Airlines jet slides off runway, into mud at Chicago Midway A Southwest Airlines airplane slid off the runway at Chicago Midway at 1:33 p.m. Tuesday and got stuck in the mud. The National Transportation Safety Board said it was investigating. Said Southwest: "Initial reports are that no one was injured. The passengers have been safely deplaned from the aircraft using air stairs and have been bused to the terminal. Southwest officials will be working with passengers to get them to their final destinations." The airplane was carrying the usually crew of two pilots and three flight attendants, plus 134 passengers. The Boeing 737-700 has a capacity of 137 passengers. Flight 1919 was arriving from Denver in early afternoon when it landed during a rainstorm. According to the National Weather Service, Chicago Midway recorded 0.13 inches of rain between 1 and 2 p.m. The Chicago Sun-Times quoted a passenger on the flight, Charles Moelter, as saying there was water, "little ponds," on the runway: Though the landing was rough, Moelter credited the pilot with working to avoid something worse. "He swerved really hard at the end of the runway and went into the mud, and not into the embankment" at the end of the runway. "Being from Chicago I knew that runway was short," Moelter said. "If [the pilot] would have kept it straight and gone into the embankment ... it would have been much worse," Moelter believes. The newspaper said the airplane went off the runway's left side. The airplane came to rest near the corner of W. 63rd Street and S. Cicero Avenue, at the southeast corner of the airport. The only fatal accident in Southwest's history occurred at the airport's southwest corner, when a jet slid off the runway, through a fence and onto a car in December 2005. A 6-year- old boy in the car was killed. http://aviationblog.dallasnews.com/archives/2011/04/southwest-airlines-jet-slides.html Back to Top UAE F-16 overran runway at Sigonella, Italy - pilot ejected ROME, Apr 27, 2011 (AFP) - A United Arab Emirates F-16 fighter jet taking part in military operations over Libya veered off the runway after landing at an air base in Italy, Italian news agency ANSA reported on Wednesday. The pilot ejected from the plane when it was already on the ground but no-one was injured in the accident at the Sigonella air base in Sicily which has been temporarily shut down, the report said, citing anonymous sources. The plane was based at the Decimomannu base in Sardinia as part of a deployment of 12 fighter jets from the United Arab Emirates including six F-16s and six Mirages for the enforcement of a no-fly zone on Libya. Contacted by AFP, the Italian air force and the main NATO base in Naples in charge of Libya operations were not immediately able to comment on the report. Back to Top NTSB cites crew errors and fatigue as causes of 2009 Lubbock crash A FedEx plane that crashed on approach to Lubbock Preston Smith International Airport in Jan. 2009 began with the crew's improper reaction to a malfunction of the plane's flaps, the National Transportation Safety Board said today. The NTSB's report enumerates a series of crew failures that led to the crash. The flight, which began at Fort Worth Alliance Airport and was operated by Empire Airlines, experienced a "flap asymmetry" as the crew approached the Lubbock airport. As the captain tried to diagnose the problem, the first officer, who was flying the plane, failed to maintain the proper airspeed. The captain should have aborted the landing and performed a "go around" maneuver, which was suggested by the first officer. But he insisted on landing the ATR 42-320, the NTSB said. Unfortunately, the plane had already lost too much airspeed to safely land and the captain failed to respond to the stall warning. The plane crashed just short of the runway and caught fire after crashing. The pilots were injured but survived. The NTSB said the icy weather did not cause the accident, although investigators could not determine if ice caused the initial flap malfunction. The NTSB concluded: "The airplane was controllable with the flap asymmetry and airframe ice contamination and could have been maneuvered and landed safely if the appropriate airspeed had been maintained." The board also found -- after a good bit of debate -- that fatigue contributed to the accident. The flight departed Fort Worth about 3:15 a.m. and crashed about 4:37 a.m. Investigators determined that the captain had a 4.5 hour "sleep debt" that probably diminished his ability to react to the flap asymmetry. One of the board's newer members, fatigue expert Mark R. Rosekind, argued forcefully that fatigue was a contributing factor. Two board members disagreed, saying it was not clear that the captain's mistakes stemmed from fatigue as much as sloppy flying habits. But the board endorsed the finding, 3 to 2. The FAA has struggled to address fatigue in airline operations and air traffic controller schedules. Board Chairman Deborah A.P. Hersman said after the hearing that pilots who work during the night never fully adjust to working when they should be sleeping. "The myth is that you can acclimate, when in reality you cannot," Hersman said in a brief interview. "You can't reset your clock. Your body wants to do what it wants to do." http://aviationblog.dallasnews.com/archives/2011/04/ntsb-cites-crew-errors-and-fat.html Back to Top Cyprus hosts international conference on aviation safety A two-day international conference on ''Aviation Safety: Implementation, Regulation, Training'' opened in Nicosia on Wednesday, with the participation of the heads of EUROCONTROL, ECAC, Flight Safety Foundation, European Civil Aviation Conference and Federation of European Airlines. Over 150 delegates from 23 countries have said they would attend. Christos Petrou, Conference Coordinator and CEO of FSF/SE.Europe-M.East-Cyprus, has told a press conference that International Civil Aviation Organization Secretary General Raymond Benjamin will open the meeting. Benjamin will be received by President of the Republic Demetris Christofias who will also receive the heads of the international organisations participating in the conference and address the award ceremony and the presentation of an award to the ICAO Secretary General by the FSF-SEC. At the same ceremony, a Memorandum of Cooperation between the Flight Safety Foundation of Cyprus and the Russian equivalent will be signed. ''As a foundation, we are proud because with this conference we achieve our goals to contribute significantly to the improvement of safety in Cyprus and the region, while helping the state to play a leading role in the aviation sector,'' Petrou added. http://www.financialmirror.com/News/Business_and_Finance/23283 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. 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. 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." 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. Back to Top FAA inspects Boeing factories after shavings found in 767 fuel tank The Federal Aviation Administration (FAA) on Monday sent a team of safety inspectors into Boeing's Renton and Everett assembly plants to conduct a special review of its manufacturing procedures. The move follows the discovery of metal shavings inside the fuel tank of a new Japan Airlines (JAL) 767 passenger jet during ground maintenance earlier this month. The plane was delivered to JAL in early February and had flown 325 hours. The shavings are thought to be a result of the manufacturing process, likely debris from drilling rivets. The FAA review, expected to last at least several days, will focus on Boeing's procedures for preventing what the industry calls FOD, or Foreign Object Debris, meaning any material or object that isn't supposed to be on the airplane when it leaves the factory. Boeing spokesman Marc Birtel said Tuesday the review will not disrupt airplane deliveries or the ongoing certification activities on the 787 and 747-8 programs. However, coming on top of hints earlier this week that a recent 737 in-flight passenger cabin rupture may have been due to poor workmanship, the FAA action throws another embarrassing spotlight on Boeing's internal safety oversight. Birtel said a JAL ground maintenance crew troubleshooting an imbalance in the fuel tanks of the 767-300 traced the issue to "small metal particles in the fuel tank." Boeing voluntarily disclosed the safety lapse to the FAA on April 21. The company immediately reviewed its manufacturing process and reiterated to employees the FOD- prevention procedures mandating that mechanics clean, wipe and vacuum after work is completed. It also inspected fuel tanks under assembly and found no FOD or metal shavings. A person familiar with the details of the JAL airplane incident said the airline noticed abnormal fuel transfers between the fuel tanks in the wings and the central fuselage. Maintenance technicians seeking the cause found a metal shaving in the left main wing fuel tank trapped in an outlet valve, preventing it from closing all the way. Further inspections turned up more metal particles. While none were found in the filter that strains fuel going into the engines, there were some in a low spot of the wing tank used to drain fuel samples and more in the center tank inside the fuselage. "That stuff is supposed to be vacuumed out and flushed," the person said. "Even after they had flown it a while, there was still metal sloshing around at the bottom of the tank." Such particles could potentially damage an airplane. "That's a pretty unusual incident," said Jim Hall, former chairman of the National Transportation Safety Board. "It goes to the quality issue of the production. ... I'm pleased they self-reported it." He said he's worried that the quality control that has been Boeing's hallmark in the past could slip under the pressure to cut costs. "One of the reasons that aviation is so safe is the high standards," Hall said. "Boeing has stood for that high level of quality for a number of years." The agency instituted the broader safety review in Renton and Everett as an additional precaution to ensure that Boeing's FOD prevention procedures are adequate. Boeing's Birtel said the company has had "a multitiered quality system aimed at eliminating FOD from our products for a number of years." The FAA review will look at the procedures in place, inspect the paperwork and talk to people on the line about how they do their jobs. "We are going to work together with the FAA to ensure our FOD program complies with manufacturing standards," Birtel said. http://seattletimes.nwsource.com/html/businesstechnology/2014883185_boeingfaa27.html Back to Top GPS testing in Utah prompts FAA flight advisory The FAA has issued a flight advisory for potentially unreliable GPS signals in the vicinity of Wendover, Utah, between April 28 and May 13. During testing GPS signals may be unreliable or unavailable within a 395-nautical-mile radius centered at 402602N/1132936W, or the BVL VOR's 145.44 degree radial at 21.3 nm at Flight Level 400 and above. The signal's reliability also could be affected below Flight Level 400, the area impacted decreasing in radius with a decrease in altitude to a 355-nm radius at Flight Level 250, 260-nm radius at 10,000 feet msl, 265-nm radius at 4,000 feet agl, and 225-nm radius at 50 feet agl. Pilots are encouraged to report anomalies to the appropriate air route traffic control center to help determine the extent of signal degradation. Please share your reports with AOPA. Notams will be published at least 24 hours in advance of tests, but may change with little or no notice. Pilots are encouraged to check notams frequently for changes to operations in the area. Tests will be conducted during the entirety of stated times, the FAA said. The testing schedule is set for April 28 to 29 from 1700Z to 2000Z and 2200Z to 0000Z daily, April 30 through May 6 from 1700Z to 2000Z daily, and May 9 through 13 from 1700Z to 2000Z daily. http://www.aopa.org/advocacy/articles/2011/ Back to Top Investigators close in on sunken AF447's flight recorders French investigators are confident that they have identified the most likely area of wreckage in which to find the flight recorders of the Air France Airbus A330 which crashed in the South Atlantic two years ago. The fifth phase of the extensive search for the aircraft - which will focus on recovery of the recorders, flight computers and other components - has started following the arrival yesterday of the cable vessel Ile de Sein at the accident site. It has already started diving operations with a Remora 6000 underwater remote vehicle. Two working groups have been established to concentrate on analysing photographs taken during the previous search, which ended after the location of flight AF447's wreckage on 3 April, and to assess operational procedures for recovering the recorders. Bureau d'Enquetes et d'Analyses investigator in charge Alain Bouillard says: "We have a good distribution of the parts on the sea floor and we know where to send the [underwater vehicle] down to have the greatest chance of finding the recorders. "Even though we haven't localised them yet, we know where to search." BEA says that the database includes some 26,000 photographs of the crash site but "not all the parts are recognisable" and the depth of the wreckage - around 4,000m (13,000ft) remains "a major challenge". Bouillard adds: "We are sending the [vehicle] into a treacherous area with electrical cables and pieces of the wreckage. To pilot [it] 4,000m below the surface, in this environment, is extremely difficult." The Ile de Sein, which is operated by Alcatel-Lucent, is carrying 68 personnel - including its crew - and is equipped with cranes capable of lifting 5t. "Time was an important criterion," says BEA director Jean-Paul Troadec. "We chose a ship that corresponded to our technical criteria and that was available as quickly as possible." Investigators on board the vessel are accompanied by representatives from Air France and Airbus who will assist in recognising structures from the aircraft as they are raised. http://www.flightglobal.com/articles/2011/04/27/356024/investigators-close-in-on-sunken- af447s-flight-recorders.html Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC