Flight Safety Information May 11, 2011 - No. 097 In This Issue Passenger tries to open Delta airplane emergency door on flight Report: misaligned VOR track factor in Indonesian taxiway landing US Airways lands lowest satisfaction ratings in flier survey Southwest jet makes emergency landing in Oklahoma City Bail denied to man who tried to force his way into cockpit Horizon flight makes safe emergency landing in Yakima EBACE: Safety management and other safety regulation in business aviation Merpati defends MA60 after fatal crash Transportation Worker IDs Held By Scores With Criminal Records UK cabin fume study finds no danger to crew or passengers CitationAir calls back all furloughed pilots Passenger tries to open Delta airplane emergency door on flight from Orlando, Fla., to Boston BOSTON (AP) - Air travel authorities say a Delta passenger tried to open an emergency door on a flight from Orlando, Fla., to Boston but was subdued by another passenger. Boston Logan International Airport spokesman Phil Orlandella says it's unclear why the passenger tried to open the door Tuesday night on the Airbus 320 out of Orlando International Airport. Atlanta-based Delta Air Lines Inc. spokeswoman Susan Elliott says an off-duty police officer subdued the passenger and detained him while the plane continued on its journey to Boston. Delta crew members called authorities in Boston to report the disorderly passenger aboard Flight 1102. State police say after the plane landed officers arrested the passenger on charges of interfering with a flight crew. Logan is one of the nation's busiest airports, handling tens of millions of passengers each year. Back to Top Report: misaligned VOR track factor in Indonesian taxiway landing Touch down marks on the parallel taxiway at Palembang A Garuda Boeing 737-400 landed on a taxiway at Palembang in October 2008. NTSC investigators from Indonesia concluded that the captain under training and instructor captain were focussed on instrument scanning when they were following the misaligned track, leading them to the parallel taxiway. On 2 October 2008, a Boeing 737-4K5 aircraft, registered PK-GWT was being operated on an Instrument Flight Rules (IFR) scheduled passenger service from Jakarta Soekarno-Hatta Airport to Sultan Mahmud Badarudin II Airport, Palembang. There were two pilots, 4 flight attendants, and 49 passengers on board. The co-pilot who occupied the left seat was a candidate captain under training and the Pilot in Command (PIC) occupying the right seat was a training captain (instructor). The co-pilot acted as the Pilot Flying (PF) during the flight, and the PIC acted as Pilot Monitoring (PM). Prior to the departure from Jakarta, the pilots received a departure briefing consisting of weather, flight plan, and notams. The notams contained significant information for Palembang Airport that the parallel taxiway from intersection Alpha to taxiway Bravo was closed due to work in progress. The runway 29 Instrument Landing System (ILS) was not in service due to replacement of its localizer antenna. The aircraft departed from Jakarta at 23:51 UTC. When it entered Palembang's Controlled Airspace at 00:13, the crew was instructed by the Palembang Approach controller to track direct to the initial approaches point BANJAR and descends to 2,500 feet for the VOR/DME approach to runway 29. During the approach, the PIC reported that they were conducting the VOR/DME instrument approach procedure for runway 29. At 00:28 the PIC reported that the aircraft was on final approach for runway 29. At 00:30 the PIC reported that he had the runway insight after assuring the co-pilot that they both had seen the runway. The Aerodrome Controller gave the crew the clearance to land. The co-pilot was concentrating on instrument scanning during the approach by following the VOR radial. He wanted to improve his ability to fly manual (without auto pilot) during an instrument approach. The PIC then rechecked if there was any item missed prior to land. The ATC saw that the aircraft was not on the approach path properly and came close to the parallel taxiway. At 00:32 the aircraft landed on the parallel taxiway, touching down 500 meters from the eastern end. Both pilot then realized that they were on the taxiway and also saw the barrier on the taxiway indicated that some part of the taxiway was closed. The PIC immediately applied manual brake and the aircraft stopped at the intersection of taxiway Charlie. The landing roll distance was about 700 meters. The aircraft was then instructed to taxi via runway and taxiway Echo to the apron. No one was injured in this serious incident. The investigators concluded that the Pilot monitoring was not sufficiently looking outside to cross-check the flight path to the runway. Also, there was a misalignment of the VOR approach path. There had been 10 pilot reports of misalignment of the final track for the runway 29 VOR/DME approach since May 2008. The VOR/DME runway 29 approach track to the runway 29 VOR was 291 degrees while the runway direction was 293 degrees. The 2 degrees differences between VOR approach path and runway direction has an off track to the right of approximately 200 meters off the runway centreline at the threshold runway 29. The parallel taxiway used to be a temporary runway in 2003 when a new terminal was built. The runway markings on the parallel taxi way reappeared after some time. These markings were visible to the aircraft on final approach. www.aviation-safety.net Back to Top US Airways lands lowest satisfaction ratings in flier survey US Airways received the lowest marks for cabin-crew service in a Consumer Reports survey. (CNN) -- A new Consumer Reports survey reveals that air travelers want comfort without emptying their wallets -- and many airlines don't deliver. US Airways landed at the bottom of the list for overall satisfaction, also receiving the lowest marks for cabin-crew service. The airline was also ranked lowest in 2007, when the last Consumer Reports airline rankings were released. A US Airways spokesman questioned the methodology of the Consumer Reports survey and pointed out a 70 percent improvement in baggage delivery since 2007. The airline scored a 61 out of 100 in overall satisfaction on the Consumer Reports scale. Scores above 60 mean those surveyed were "fairly well satisfied," according to the ratings guide. Southwest Airlines topped the rankings for overall satisfaction, with JetBlue Airways coming in second in the survey of nearly 15,000 passengers. JetBlue and Southwest also scored highest in seat comfort. The remaining eight of the 10 airlines scored low marks for comfort. Baggage handling, check-in ease, cleanliness and in-flight entertainment were some of the other factors rated. The passengers shared their experiences from a collective 29,720 domestic flights from January 2010 to January 2011. Southwest and JetBlue battled to top each other. While JetBlue was the only airline to outscore Southwest in seat comfort, Southwest was rated the ultimate for check-in ease and cabin-crew service. JetBlue topped the in-flight entertainment ratings, with 36 channels available on each seatback screen. These survey results were compiled before cracks were discovered in some of Southwest Airlines' planes. The pileup of added fees during or after check-in is contributing to many travelers' decisions to fly less, according to the survey. Of the respondents who said they've cut back on flying, 40 percent cited fees as the major reason. While most Southwest Airlines travelers -- 93 percent -- managed to avoid extra fees, passengers flying with Continental Airlines, JetBlue, Delta Airlines, American Airlines, United Airlines, US Airways, Alaska Airlines and Frontier Airlines had to pay fees. AirTran's multiple fees were rated the worst. Back to Top Southwest jet makes emergency landing in Oklahoma City The crew of a Southwest Airlines Boeing 737 reported smoke in the cockpit. Flight 542 was carrying 49 passengers from Kansas City, Mo., to Dallas when it was diverted to Will Rogers World Airport in Oklahoma City. A Southwest Airlines jet made an emergency landing Tuesday night at Will Rogers World Airport after its crew reported smoke in the cockpit, officials said. Airport spokeswoman Karen Carney said the Boeing 737 landed safely just after 10:30 p.m. There were no signs of a fire on the plane, and it was taxied to a terminal where it will undergo a thorough inspection. Southwest Airlines spokesman Brad Hawkins said Flight 542 was carrying 49 passengers from Kansas City, Mo., to Dallas when it was diverted to Oklahoma City. "There was a problem with a heating element in one of the windows in the cockpit," Hawkins said. "When that started to have a problem, the captain elected to stop over in Oklahoma City and swap aircraft out of an abundance of caution." No one on the plane was injured. Hawkins said the airline sent another plane to Oklahoma City from Dallas to get the passengers to their destination without needing to stay in Oklahoma City overnight. newsok.com/southwest-jet-makes-emergency-landing-in-oklahoma- city/article/3566946#ixzz1M1Use3Lc Back to Top Bail denied to man who tried to force his way into cockpit of American Airlines flight A federal judge denied bail Tuesday to a Yemen native who tried to force his way into the cockpit of an American Airlines flight en route from Chicago O'Hare International Airport to San Francisco International Airport. Shortly before the end of the Sunday night flight, Rageh Ahmed Mohammed Al-Murisi left his seat near the back of the plane and made his way to the first-class cabin, according to an affidavit filed by Paul A. Howard, a federal air marshal. A flight attendant saw him trying to open the cockpit door and, thinking he had mistaken it for the restroom, tried to point Al-Murisi in the right direction. At that point, Howard said, Al-Murisi lowered his left shoulder and rammed the cockpit door. In court on Tuesday, Assistant U.S. Atty. Elise Becker said Al-Murisi was shouting "Allahu Akbar" -- "God is great" in Arabic -- as he was wrestled to the ground. It was the same phrase, she said, that the assailants who hijacked Flight 93 on Sept. 11, 2001, shouted. Al-Murisi, who has been charged with interfering with a flight crew, had no luggage, was traveling with various forms of identification, $47 and an Apple computer charger. Becker argued Tuesday that he was a threat to the community and a flight risk. A federal law enforcement source said that Al-Murisi is not tied to any terrorist groups and that there is no terrorism allegation involved. Judge James Larson denied bail. Al-Murisi is scheduled to be back in court on Friday. http://latimesblogs.latimes.com/lanow/2011/05/bail-denied-to-man-who-tried-to-force-his-way- into-cockpit-of-american-airlines-flight.html Back to Top Horizon flight makes safe emergency landing in Yakima A Horizon Airlines aircraft lands safely at McAllister Field when its right engine failed Tuesday, May 10, 2011. A Yakima Fire Department truck approaches the aircraft after it pulled to a stop on the runway. A Horizon Airlines Bombadier Q400 aircraft with 63 people aboard landed safely about 6:30 p.m. Tuesday at the Yakima Air Terminal after reporting an inflight problem. Flight 2363 from Boise to Seattle had lost oil pressure in the right engine, prompting a procedural shutdown of that engine. The flight was diverted to Yakima, according to Horizon spokesman Paul McElroy. No injuries were reported. Multiple fire engines and ambulances were at the scene. McElroy said another airplane was being brought in and was expected to continue the flight to Seattle at 8:45 p.m. with 59 passengers and four crew members. http://www.yakima-herald.com/stories/2011/05/10/horizon-flight-makes-safe-emergency- landing-in-yakima Back to Top EBACE: Safety management and other safety regulation in business aviation The Flight Safety Foundation has assessed global corporate aviation safety in 2010 as fairly good based on accident figures, but similar numbers have often been achieved in the past decade, so no serious claims for improvement can be made (see graph below). This is reinforced by the fact that, although business aviation activity has been making a comeback since the grim days of 2009, activity is still lower than in the heady days of 2007, so when the rates for serious accidents are known, they may be less flattering than the simple numbers. There were eight serious business jet accidents globally in 2010, a figure that has been recorded in four of the years since 2000 and was bettered in 2009. The new requirement for certain business aircraft operators to run a safety management system (SMS) may benefit safety performance in the long run. The relevant standard is laid out by the International Civil Aviation Organisation in Annex 6 Part 2. This states a requirement for operators of business aircraft with a take-off mass of more than 5,700kg (12,500lb) to run an approved SMS, but the measure became effective only in November last year, so the results are unlikely to show for some time yet, especially because even some global "role- model" aviation agencies, such as the US Federal Aviation Administration, remain a long way from creating regulations based on the ICAO standard. So far, it has only issued guidelines for setting up an airline SMS. Fortunately, the International Business Aviation Council (IBAC) and member organisations such as the National Business Aircraft Association have developed a code of best practices to help operators set up an SMS tailored for business aircraft operations, scalable from single- aircraft/single-pilot operations up to large multi-aircraft flight departments. The NBAA offers a toolkit to help operators develop and implement an SMS that meets ICAO standards, and an SMS e-learning course developed jointly with IBAC and FlightSafety International. Many, but by no means all, US business aviation operators have used International Standards for Business Aircraft Operation (IS-BAO) to set up an SMS, and a recent review of results carried out for the NBAA has proved it does have a measurably beneficial effect on safety (summarised later in this article). An area of concern for European operators has been the flight time limitation rules that were due to be introduced in April 2012, but have now been delayed. European Business Aviation Association president Brian Humphries says talks with the rulemakers have been positive in the sense that the regulators accept that business aviation is so different from airline operations that it would be inappropriate to apply the same rules to both sectors. Humphries points out that corporate and business aircrews rarely fly more than 400h a year, unlike the 700h or more flown by airline crews, so the potential peril faced by business aviation pilots is tiredness associated with long hours rather than accumulated fatigue from intensive flying over weeks or months. For three years, the EBAA has been engaged in a fatigue study within the sector, managed by US sleep scientist Dr Mark Rosekind and based on a survey that garnered 760 responses, and is using the results to develop a fatigue risk management system for business aircraft operators. Another piece of European regulation that has been pushed back concerns the operation of what Europe categorises as "complex motor-powered aircraft", which basically means jets of any weight, or aircraft above 5,700kg whatever their propulsion. Humphries says these rules are being drafted from scratch, which makes them less complicated. The motivation for drawing the rules up is the advent of light jets that could, theoretically, be flown by pilots unaccustomed to high-performance machines with complex systems, and the regulations are intended to set sensible training and qualification requirements. Humphries says he is encouraged by the regulators' readiness to engage with the industry on the issues. Business jets generally suffer the same types of accident as airlines, but statistically they are significantly more likely to have a runway excursion than airliners, according to the FAA. Because runway excursions or overruns are the most common type of commercial aircraft incident, simple mathematics suggest business aviation's exposure to this risk is unacceptably - and perhaps avoidably - high, and a greater awareness of this risk among pilots would, theoretically, help to reduce it. Among the eight serious accidents to business jets globally last year, six were approach and landing accidents and, of those, three were runway excursions. Despite the Flight Safety Foundation's best efforts to raise awareness of this high-risk accident category among corporate and business aircraft pilots, there has been no reduction - yet - in the excursion rate. In fact, according to FSF and IATA figures, there is a slight upward trend. About 80% of runway excursions or overruns happen in the landing phase, and only 20% during the take-off (or abandoned take-off) run. For that reason, the vast majority of them come within the ambit of the FSF's Approach and Landing Accident Reduction (ALAR) programme, for which it provides a toolkit training package. Because excursions are so common, the FSF decided to issue a specific Runway Excursion Risk Reduction (RERR) toolkit in 2009. It is difficult, statistically, to isolate all the reasons why business jets, in particular, face an even higher risk of runway excursion than airlines do, but because being high and fast on the approach is a common reason, it is impossible not to wonder whether frequent flights to unfamiliar destinations, and the higher probability of landing at small aerodromes, are factors. The RERR therefore takes the stabilised approach lessons from the ALAR and adds "stabilised landing" criteria. Put simply, the RERR exhorts pilots to ensure runway contact in the touchdown zone at the correct speed, and the immediate application of braking and/or reverse thrust, combined with checks of speed against distance to go. Avoiding tailwind landings is obviously desirable. Robert Sumwalt, a board member at the National Transportation Safety Board, presented, at the last Corporate Aviation Safety Seminar, the details from the investigation into a fatal runway excursion by a Bombardier Learjet 60 as an example of the pitfalls business jet pilots may have to cope with. The accident took place in September 2008 at Columbia Metropolitan airport, South Carolina, when a chartered Global Exec Aviation aircraft suffered a multiple tyre burst during the take-off run, but because of the causal complexity of the accident, the report was not published until relatively recently. The trigger for the tyre burst, according to the NTSB, was the failure of Global Exec to check tyre pressures, which had been allowed to fall to almost half the required value. The resultant carcass flexing during take-off run created heat, leading to tyre failure above the V1 take-off decision speed. The captain's decision to abort the take-off despite being faster than V1 preceded a nightmare sequence of system failures that resulted in a very fast overrun and the death of both pilots and two of the four passengers. Tyre fragments had caused damage to cabling and hydraulic lines in the wheel wells, which led to impaired braking and the failure of the thrust reverser buckets to deploy, leading to high forward thrust when reverse was commanded. The cause, says the NTSB, was failure by the operator to maintain tyre pressures properly, and the captain's decision to abort take-off beyond V1. Contributory factors were the vulnerability of the Learjet 60's design to critical failures following wheelwell damage, the lack of an FAA requirement that training should include tyre failure during take-off, and poor crew resource management. A good SMS backed up by a management-led company safety culture would have picked up all but the aircraft design shortcomings shown up by that accident - and maybe even those, if the results from a recent five-year survey of 58 US companies with a business aviation flight department are to be believed. Pete Agur, founder of the Georgia-based VanAllen consultancy that carried out the study, reported to the NBAA leadership conference in San Diego this February that the beneficial safety results are directly proportional to the degree of management buy-in to the organisation's SMS. "We have solid proof," he said. "It's up to you," Agur told the conference. "You must sell safety, both uphill to management above you and downhill to people in your flight department." In carrying out the study, VanAllen assigned what it calls a risk tolerance rating (RTR) to four levels of company management in each of the 58 companies. Working from the top down, Agur assigned an RTR to the company chief executive, the upper-level executive to whom the flight department was responsible, the aviation department manager and the trip commander. The scores for the latter two were weighted to take account of their very direct influence. "Behaviours, as opposed to stated beliefs, were also given double value," said Agur. "We listened to what they said they believed, and then compared that to what they actually did." Each of the management groups within a company emerged with an RTR that categorised them on a scale of five: world class, best practices, standard practices, substandard practices, and unacceptable practices. The results were categorical, said Agur. "Of those with an overall RTR that was substandard or unacceptable, 100% suffered accidents or safety events during the study." Among companies with standard practices, 22% suffered a safety event, and among those with an overall RTR indicating best practices, only 13% had a safety event. Commenting on those at the top of the scale, Agur said: "Companies with an overall RTR that qualified them as world-class in safety, exactly zero were involved in any safety events. Zero. Does conscientiously applied SMS work? The facts speak for themselves, and the data falls where it will." VanAllen reviewed nine companies that had a serious safety event that forced them to change the way they operated. They had all previously been rated in one of the bottom two categories, but after the changes were applied, their risk tolerance ratings roughly halved, raising them to best practices level. Meanwhile, the NBAA says the FAA is unlikely to mandate SMS domestically any time soon, but warns N-registered international operators that they will be expected to comply with Annex 6 Part 2 by some of the countries where they operate, particularly in Europe. http://www.flightglobal.com/articles/2011/05/10/356086/ebace-safety-management-and-other- safety-regulation-in-business-aviation.html Back to Top Merpati defends MA60 after fatal crash Merpati Nusantara Airlines has defended the safety record of the Xian Aircraft MA60 following the fatal loss of a flight in West Papua. Despite not having US FAA certification, the MA60 meets Chinese requirements, said Merpati president Sardjono Jhony Tjitrokusumo, who pointed out that an aircraft does not need FAA approval to be considered airworthy. The turboprop had been preparing to land at Kaimana airport on 7 May. While there was poor weather in the vicinity, Indonesia's transport ministry says that visibility shortly before the accident was around 2,000m and winds were calm - another aircraft, it says, had landed 20min previously despite the rain. It says that the MA60 had been holding at a height of 5,000ft, awaiting an improvement in conditions, before it lost contact. Twenty-two of those on board were killed and the ministry says another three, including two crew members, are still missing. Source: Air Transport Intelligence news Back to Top Transportation Worker IDs Held By Scores With Criminal Records WASHINGTON - A government-issued credential for transportation workers created to enhance port security can be obtained with fake identification, according to the Government Accountability Office. In testimony to the Senate Commerce, Science and Transportation Committee, a GAO official said that 27% of Transportation Worker Identification Credentials (TWIC) issued went to applicants with a criminal record. Such gaps in security leave the nation vulnerable to attacks from Al Qaeda, which targets U.S. ports for attacks. "That's why this is important," Steve Lord, director of the GAO's homeland security and justice issues, told the committee. The findings would appear to give ammunition to lawmakers who oppose holding airport security workers to the same standards as TWIC. A bill moving in the House looks to TWIC as the model for one security credential for all types of transportation workers. But Rep. John Mica (R-Fla.), the chairman of the House Transportation Committee, who helped call for the hearing, told the committee, "Roping additional transportation workers into the TWIC program is an idea destined for disaster." He added that while a biometric standard for TWIC is needed and works well, the program itself is "poorly managed." And Sen. Jay Rockefeller (D-W.Va.), the chairman of the Senate Commerce Committee, said he plans to introduce a port security authorization bill that would tighten the credentialing program. http://www.aviationweek.com Back to Top UK cabin fume study finds no danger to crew or passengers A study produced by the UK's Cranfield University into fume events in aircraft cabins has found no danger to crew or passengers after a study of 100 flights. Cranfield was contracted in 2008 by the UK Civil Aviation Authority and the UK Committee on Toxicity to carry out the study, and it cooperated with several airlines to test the air during 100 airline flights. The report says that there were fume events during the trial, but none at levels that would have triggered a mandatory occurrence report. It says that neurotoxins were present, but the levels measured were acceptable according to standards applied to the workplace or the home. The UK Minster for Transport Theresa May said: "The Department will always take the health of persons on board aircraft very seriously and I hope the publication of this thorough and independent analysis by Cranfield University will provide reassurance on this issue. "We will continue to keep in close touch on all aviation health matters with the UK's aviation regulator, the Civil Aviation Authority. The Department will now take forward the one remaining cabin air study outstanding - the swab test research being conducted by the Institute of Occupational Medicine in Edinburgh." However, Tristan Loraine, a member of the Global Cabin Air Quality Executive and a former British Airways pilot who lost his pilot licence as a result of health damage by cabin air contamination, said he disagreed with the report's conclusions. He said that several isomers of the highly neurotoxic chemical tri-cresyl phosphate were detected in the cabins during the Cranfield tests, and that the presence of these is unacceptable even at the detected levels. He said that there are no stated levels of toxic chemicals published for the travelling public's protection, so for the report to state, as it does, that the levels found were acceptable is meaningless. The trial was invalid, he added, because it was not able to measure the chemicals present during a reportable event. Source: Air Transport Intelligence news Back to Top CitationAir calls back all furloughed pilots Travel industry said to be recovering CitationAir has asked all 85 pilots laid off in 2009 to return to work. Travel is picking up, but that doesn't mean the economic downturn is over. Not all the CitationAir pilots invited to return could do so. CitationAir offers, depending on the level you choose, on-demand travel within 12 hours, or fractional and full ownership transportation at the higher levels of membership. In 2009, the company, with offices in Greenwich, Conn., said it was going to "right-size" the business by cutting it to 307 pilots. But now the right size is closer to the one it had before the recession, with 334 pilots. There would have been more, but only 53 of the laid-off 85 pilots were available to return. "CitationAir has made strides in the past couple of years not only to survive the recession, but to grow the business afterward-a feat of which we're very proud," CEO Steve O'Neill said. "In doing so, CitationAir is the only company in the private jet marketplace to have offered a recall to 100 percent of its pilots after a furlough." The company began as a fractional ownership company in 2000 called CitationShares and sold only fractional shares of Citation aircraft. It rebranded itself in 2009, and no longer requires customers to be fractional owners. A statement from the company said more announcements can be expected this year concerning expansion plans. http://www.aopa.org/aircraft/articles/2011/110510citationair_calls_back_furloughed_pilots.html Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC