Flight Safety Information May 24, 2011 - No. 106 In This Issue AF-447 Black Boxes Point to Pilot Error Schedules expose many pilots to dangerous fatigue, errors New Israeli report lists nearly 100 air safety incidents Blue Angels cancel practice, show at Naval Academy Airlines' Next Headache: Retraining Pilots ICAO team applauds FG over improved aviation safety (Nigeria) FAA proposes Boeing 757 roll fix Pilot injured after helicopter crash in northern Alta Boeing Works Toward Final 747-8 Certification Test Icelandic eruption forces British flight cancellations Black Boxes Point to Pilot Error By ANDY PASZTOR And DANIEL MICHAELS (WSJ) The pilots of an Air France jet that crashed into the Atlantic Ocean two years ago apparently became distracted with faulty airspeed indicators and failed to properly deal with other vital systems, including adjusting engine thrust, according to people familiar with preliminary findings from the plane's recorders. The final moments inside the cockpit of the twin-engine Airbus A330, these people said, indicate the pilots seemingly were confused by alarms they received from various automated flight-control systems as the plane passed through some turbulence typical on the route from Rio de Janeiro to Paris. They also faced unexpectedly heavy icing at 35,000 feet. Such icing is renowned for making airspeed-indicators and other external sensors unreliable. Ultimately, despite the fact that primary cockpit displays functioned normally, the crew failed to follow standard procedures to maintain or increase thrust and keep the aircraft's nose level, while trouble-shooting and waiting for the airspeed sensors and related functions to return to normal, according to these people. Slated to be disclosed by investigators on Friday, the sequence of events captured on the recorders is expected to highlight that the jet slowed dangerously shortly after the autopilot disconnected. The pilots almost immediately faced the beginning of what became a series of automation failures or disconnects related to problems with the plane's airspeed sensors, these people said. The crew methodically tried to respond to the warnings, according to people familiar with the probe, but apparently had difficulty sorting out the warning messages, chimes and other cues while also keeping close track of essential displays showing engine power and aircraft trajectory. Spokesmen for Air France, a unit of Air France-KLM, and Airbus, a unit of European Aeronautic Defence & Space Co., have declined to comment on any details of the investigation. Airbus last week, however, issued a bulletin reassuring airlines that the preliminary readout of the recorders hasn't prompted any "immediate recommendation" regarding the safety of the global A330 fleet. French investigators, who gave the green light for that statement, also have said their preliminary findings don't highlight any major system failures or malfunctions that could have caused the fatal dive. The Air France pilots were never trained to handle precisely such an emergency, according to safety experts and a previous report by France's Bureau d'Enquetes et d'Analyses, which is heading up the investigation. All 228 people aboard Flight 447 died in the accident. The senior captain, Marc Dubois, appears to have been on a routine rest break in the cabin when the fatal chain of events started, according to safety experts familiar with the details, but the cockpit-voice recorder suggests he may have rushed back to the cockpit to join the other two Flight 447 pilots. Though Friday's announcement won't provide final conclusions or specific causes, investigators believe Air France didn't train its pilots to cope with such automation problems in conjunction with a high-altitude aerodynamic stall, an emergency when the wings lose lift and the plane quickly becomes uncontrollable. Since the crash, Airbus and a number carriers, including Air France, have emphasized such training. According to a report issued by French investigators in November 2009, Airbus identified 32 instances involving similar model jetliners between 2003 and 2009 in which external speed probes, known as pitot tubes, suffered ice buildup at high altitude and caused "erroneous air speed indications." Over the years, the same models also suffered numerous failures of external temperature-sensors because of icing. Both issues were known to Air France. Most of the incidents with speed sensors involved probes similar to those on the A330 that crashed. Many were on Air France planes, according to the BEA report. Friday's update follows sniping between senior officials of Air France and Airbus, usually close corporate allies, who in this case have tried to shift the blame for the accident to each other. Air France began addressing problems with its pitot tubes almost a year before the crash. Amid several incidents in which air crews lost speed indication at high altitude during 2008, Air France reported the icing problems to Airbus. The two companies discussed solutions and Airbus talked to its supplier. In April 2009, roughly 45 days before the crash, Airbus proposed that Air France swap out its pitot tubes for a different model believed to be less prone to icing, according to the BEA report. Air France began the work on April 27, 2009, and it received the first batch of new pitot tubes six days before the crash. The plane that crashed hadn't yet received the new equipment. According to the 2009 report published by investigators after the crash, experts examined 13 other incidents of airspeed-sensor malfunctions on Airbus widebody jets at cruise altitudes. During most of those global incidents-none of which resulted in a crash-both the autopilots and automated engine-thrust systems disconnected on their own, and it took many of the flight crews up to a minute to manually adjust engine thrust. The earlier report found that pilots in nine of those 13 events received warnings of an impending stall. And in a finding that may have particular relevance to the upcoming update, accident investigators in 2009 also concluded that when airspeed-sensor malfunctions kick off automated thrust controls, "the absence of appropriate manual adjustments" to engines "can present a risk" of a mismatch between power settings and the jet's orientation in the air. Investigators began focusing on pitot problems from the start, because Flight 447's automated maintenance system broadcast 21 separate messages related to such malfunctions during roughly the last four minutes of the fatal flight. But the final report, which may not be released until 2012, also is expected to delve deeper into how European air-safety regulators dealt with persistent reports of pitot-tube icing prior to the crash. The previous interim report indicated that in late March 2009, less than three months before the crash, European aviation regulators decided that the string of pitot-icing problems on widebody Airbus models wasn't serious enough to require mandatory replacement of pitot tubes. Back to Top Schedules expose many pilots to dangerous fatigue, errors By Alan Levin and Barbara Hansen (USA Today) - Airlines operate thousands of flights each day that expose pilots to potentially dangerous fatigue, schedule data and the latest research on fatigue shows. A USA TODAY review of airline schedules for May found an average of 2,600 flights a day - or about 10% of all passenger airline departures from U.S. airports - operate at times that make it hard for pilots to get normal sleep. That puts them at risk for reduced alertness or, in a worst case, nodding off on the job. The flights operate at times that have been cited as contributing to accidents by the National Transportation Safety Board. The accident investigation board has cited fatigue in 15 airline accidents and incidents since 1993, with a total of 24 deaths. The airline schedules that pose a higher risk of fatigue include early morning departures, arrivals after midnight or flights during the middle of the night. Working at these times interrupts the brain's deep-seated need for sleep, experts say. "Fatigue is not something you can ever will away," says Harvard Medical School sleep researcher Charles Czeisler. "We're trying to work at a time of day when the brain wants to go asleep." Although the seven air-traffic controllers who nodded off or were unresponsive in recent months have dominated headlines, airline schedules demonstrate that the 24- hour world that pilots operate in is just as vulnerable to sleep deprivation. It also highlights the depth of the problem as the Federal Aviation Administration prepares to release new restrictions on the hours that pilots can work before Aug. 1. Tom Balkin, chief of the Department of Behavioral Biology at Walter Reed Army Institute of Research, says interfering with normal sleep patterns makes it difficult for the brain to solve problems and increases the odds of accidents or errors. The U.S. airline industry is enjoying its safest period in history. Experts say there are ways to reduce the risks of fatigue. Pilots who are rested before they begin a series of flights deal with fatigue much better than those who are already sleep-deprived, he says. Airlines can help by ensuring that pilots get adequate time for sleep between shifts. On average this month, 2,019 of a scheduled 25,624 daily flights depart from U.S. airports in early morning hours before 7 a.m., according to data from OAG-The Official Airline Guide. In addition, 612 are overnight flights or ones scheduled to land after midnight. "We operate a large number of flights when the human body has a natural drive to be asleep," says Capt. Don Wykoff, chairman of the Air Line Pilots Association's flight and duty time committee. The Air Transport Association, a trade group representing large carriers, says that the steadily declining accident rate demonstrates that its schedules are safe. Airlines would welcome "scientifically validated and data-driven countermeasures to prevent fatigue," the trade group says. Back to Top New Israeli report lists nearly 100 air safety incidents in March alone The Israel Airports Authority's safety incident report for March obtained by Haaretz lists several incidents never reported by the media. The emergency landing of an El Al airliner at Ben-Gurion Airport yesterday was the latest in a string of safety incidents revealed here for the first time. The Israel Airports Authority's safety incident report for March, a copy of which was obtained by Haaretz, listed several incidents that were never reported by the media, including one on March 15 in which a squadron of air force fighter jets failed to maintain proper altitude and got dangerously close to a foreign passenger jet taking off from Ben-Gurion. In addition, the Eilat airport closed for half an hour on March 3 after several military helicopters crossed its airspace without authorization or coordination; a foreign airliner that had swerved away from a cloud bank while approaching Ben-Gurion on March 23 began descending toward the wrong runway and was sent by flight inspectors to circle round again; and a pair of civilian helicopters passed very close to a pair of military ones in the south on the country that same day. All in all, 96 safety incidents were reported in March, 67 of which involved automated systems. Of these incidents, 35 were caused by human error, eight involved issues of procedure and administration, six were disciplinary incidents, 21 involved technical problems, seven were environmental incidents (such as bird or lightning strikes ), 11 were dangerous proximity incidents in which collision warning instruments went off, five were infrastructure incidents and the rest were listed as miscellaneous. Three of the incidents were classified as very grave, 13 as serious and 80 as mild. The number of incidents listed in the report was 1.5 times higher than the number reported in March 2010. But the summary said March 2011 did not deviate much from the yearly average and urged caution in drawing conclusions from the report. http://www.haaretz.com/print-edition/news/new-israeli-report-lists-nearly-100-air- safety-incidents-in-march-alone-1.363636 Back to Top Blue Angels cancel practice, show at Naval Academy after 4 jets flew too low at Va. air show PENSACOLA, Fla. (AP) - The Blue Angels have canceled a practice and show this week at the U.S. Naval Academy in Annapolis, Md., days after announcing a safety standown after four of the six jets flew below a specified altitude at a recent air show. The famed flight squadron said it is scrubbing Tuesday's scheduled practice and Wednesday's show. Navy Lt. Kaitie Kelly, the Blue Angels spokeswoman, says it hasn't been decided yet if the team will perform its traditional flyover at the academy's graduation Friday. Kelly said the altitude problem involved four of the six F/A-18 Hornets flying a diamond formation at Sunday's air show in Lynchburg, Va. All six aircraft landed safely about three-fourths of the way through the scheduled performance without damage to the jets or injury to the pilots. Back to Top Airlines' Next Headache: Retraining Pilots Regulators may impose higher emergency training costs Pricey jet fuel and environmental problems ranging from severe storms to last week's new eruption of volcanic ash over Europe have given airline stocks their share of fits and starts this year. After all, as major carriers like Delta (NYSE:DAL), United Continental (NYSE:UAL), AMR Corp.'s (NYSE:AMR) American Airlines, US Airways (NYSE:LLC) and Southwest (NYSE:LUV) can attest, higher costs are the bane of airlines' existence. But if the Federal Aviation Administration gets its way, airlines will face yet another headwind: the rising cost of air safety. In the biggest change to flight crew training requirements in 20 years, the FAA is proposing a new safety rule that would send pilots back to school. The plan, which will be out for comment until July 19, would require airlines to put their pilots through "real-world" emergency training scenarios in flight simulators. In addition to this enhanced individual training, flight crews also would have to train together, learn to coordinate their actions tand fly scenarios based on actual events. The new rules would require remedial training for pilots who have failed proficiency checks or tests or whose performance has been unsatisfactory. This new rule represents the FAA's second stab at beefing up flight training requirements in the wake of the February 2009 crash of Colgan Air Flight 3407. That flight, marketed as Continental Connection under a code-share with Continental, crashed on landing approach, killing all 49 aboard and one person on the ground. The crash was blamed on flight crew fatigue and inadequate training in how to recognize and respond to an aerodynamic stall. No one argues that air safety isn't a paramount consideration for all industry stakeholders: passengers, lawmakers, regulators - and airlines. So what's the problem? In an industry already under siege from high operating costs and the whims of oil prices and travel demand, significant new costs can weigh heavily on margins. The new FAA rule not only would force airlines to revamp their entire crew training programs, they would also have to dramatically expand the use of full-motion flight simulators. In its first draft of the rule in late 2009, FAA estimated the cost of more frequent training and greater use of simulators to be $230 million over 10 years. The Air Transport Association insisted FAA had seriously low-balled the cost, estimating the true cost to U.S. airlines at $3.3 billion. The FAA contends that the new rule, which covers pilots, flight attendants and dispatchers will cost U.S. airlines $391 million over the next decade. The ATA is reviewing the nearly 700-page rule and will issue its comments soon. The industry received another setback last Friday when House Republicans dropped an amendment that would have made it more difficult for the FAA to issue new safety rules such as those proposed above. The amendment was stripped from a FAA funding bill because it faced opposition in the Senate. Bottom Line: No one can argue against the importance of air safety. The rub lies in the cost of air safety - or perhaps more accurately, the balance of cost with actual value. The airline industry, whose high fixed costs and slim margins have been characterized as looking more like a charity than a business, must pick and choose between important expenditures and essential expenditures. So investors are well served to keep one eye on fuel prices and environmental problems, and the other on the high cost of new regulations. http://www.investorplace.com/42169/airlines-next-headache-retraining-pilots/ Back to Top ICAO team applauds FG over improved aviation safety (Nigeria) The International Civil Aviation Organisation (ICAO) on Friday commended the Federal Government for the improved safety in the aviation industry. Mr Sadon Marafa, leader of ICAO team on inspection of airport facilities in Nigeria, told newsmen in Lagos that the group was pleased with the progress so far made in aviation safety. The Tactical Action Group (TAG) of ICAO has been on a five-day tour of airport facilities in Nigeria, ahead of the ICAO audit of the nation''s aviation industry, scheduled for June. The two-man delegation of ICAO regional office in Dakar, which completed the inspection of Lagos and Kano airports, would depart Lagos on Friday night. Marafa said that from what the team had seen, the Nigerian government was committed to developing the nation''s aviation industry in line with the current global practices. "I was with my team in Nigeria two years ago and what we have seen in these five days is progress and improvement. 'I want to congratulate Nigeria on this feat, though there is still more to be done by way of improving certain areas,'' he said. In his response, Dr Harold Demuren, Director-General of the Nigerian Civil Aviation Authority (NCAA), assured the team that Nigeria would continue to develop its aviation infrastructure. Demuren assured the delegation that the areas highlighted by it would be improved upon before the general audit. "They have given us what should be done and what should not be done. We would continue to comply with the recommended procedure of ICAO safety,'' he said. The NCAA boss, however, stated that part of the safety recommendation, as issued by ICAO, was for the country to move from terrestrial navigational aid to satellite base navigational aids. http://www.vanguardngr.com/ Back to Top FAA proposes Boeing 757 roll fix The US FAA is proposing that operators of 686 US-registered Boeing 757 perform corrective actions on the twin-jets within five years to prevent possible unintended roll axis motions just before landing in windy conditions. "We have received numerous reports of Boeing 757 events where flight crews experienced unintended lateral oscillations during final approach, just before landing," says the FAA in a notice of proposed rulemaking to be published on 24 May. "One event resulted in a nose gear collapse after a hard landing and another event resulted in a tail strike during a landing that was aborted because of the oscillations." The FAA notes that the oscillations "are characterized by large [control] wheel inputs at high rates that are out of phase with the airplane response and typically occur under certain gusty and turbulent wind conditions during landing." Modifications for some aircraft will include the installation of new relays that will prevent the deployment of certain wing spoilers (used in conjunction with ailerons for large roll manoeuvres) when landing flaps are selected. The proposed directive is related to a 2006 airworthiness directive (AD) that called on 757 operators to install a control wheel damper and flap vortex generators to reduce unintended roll control oscillations due to spoiler-induced flow separation on the flaps near touchdown. http://www.flightglobal.com/articles/2011/05/23/357071/faa-proposes-boeing-757-roll- fix.html Back to Top Pilot injured after helicopter crash in northern Alta. STARS transported a helicopter pilot after his chopper crashed near Calling Lake, Alberta on May 23, 2011. A pilot has been injured after his helicopter crashed at an industrial work site north of Calling Lake Monday morning. Crews at the Joint Rescue Co-ordination Centre in CFB Trenton were first notified when the craft's emergency beacon was activated at 9:40 a.m., which sparked a search effort involving Alberta Forestry in Lac La Biche and the company which owns the downed helicopter. Each sent a chopper to locate the downed aircraft, and it was found in the area about 100 kilometres away from Slave Lake. The pilot was stabilized on scene, and then airlifted by STARS to a hospital in Edmonton. The aircraft was not involved in firefighting efforts in the area. The Transportation Safety Board is investigating this crash, and officials say it could take some time before it's clear what happened. "These things take a little bit of time for the info to get to us," Transportation Safety Board western regional manager Jon Lee told CTV News over the phone. "Right now the priority is of course looking after the pilot." This crash comes days after a pilot died when his helicopter crashed while fighting the wildfires near Slave Lake. He died on Friday afternoon after his chopper went down in the waters of Lesser Slave Lake, a short distance away from where crews have been battling massive wildfires that have destroyed hundreds of homes in the Town of Slave Lake. The pilot, who was the only one on board, has not been identified. Police said the man was declared dead at the scene of the crash. A witness to that crash said the helicopter was attempting to scoop water from the lake when it suddenly veered onto its side and crashed into the water. The Transportation Safety Board is currently investigating that crash. http://edmonton.ctv.ca/ Back to Top Boeing Works Toward Final 747-8 Certification Test Boeing is deliberating with the FAA and Honeywell over whether software in the Boeing 747-8F is sufficiently representative to begin the last step toward final certification. Agreement is key to enabling functionality and reliability (F&R) tests to get under way by the last week of May, keeping Boeing on track to achieve certification around midyear. Boeing declines comment on specifics of the test effort, but a spokesman says, "We're working with the FAA to get the go-ahead to begin F&R testing, and look forward to receiving it soon." The FAA says, "The purpose of F&R testing is to evaluate the production version of the aircraft to ensure that the airplane, its components and equipment are reliable and function properly. We are reviewing the aircraft configuration to make a final determination on readiness to begin F&R testing." The debate over readiness centers on the standard of software in the Honeywell- supplied Next Generation Flight Management System (NGFMS) at the heart of the 747- 8 avionics suite. The system enables Required Navigation Performance (RNP) 0.1, and enables operators to comply with both the U.S. NextGen Air Traffic Management (ATM) and the Single European Sky ATM Research (SESAR) program. The system also supports Wide Area Augmentation System Localizer Performance with Vertical guidance, Future Air Navigation System 1 (FANS-1) and FANS-2 requirements. The core of the new FMS also is flying on the Gulfstream G650 ultra-long range business jet, but incorporates an architecture that partitions the flight management code from the user interface. This has enabled 747-8-specific user interfaces, inputs and outputs to be connected to the advanced FMS via a number of "abstraction" layers. The NGFMS software also will run in the same basic FMS box as the current Boeing 747-400, which will be upgraded by inserting a single processor card. Separately, the FAA also conducted evaluations on May 20 of the 747-8's maneuver characteristics with the outboard aileron modal suppression (OAMS) system, which is designed to dampen out a structural vibration in the wing. The tests, which took place on the first aircraft, RC501, over the Pacific off the California coast, are thought to be aimed at meeting the test requirements of the FAA's Special Conditions issued on the OAMS on March 9. These call for basic validation of the system, which counters a limit cycle oscillation with the aircraft's roll-axis fly-by-wire flight controls. They also call for Boeing to show the oscillation is "stable throughout the nominal aeroelastic stability envelope" when OAMS is inoperative and "must be shown to have negligible impact on structure and system, including wear, fatigue and damage tolerance." Testing on May 20 included maneuvers at high speed with the system selected on and off. http://www.aviationweek.com Back to Top Icelandic eruption forces British flight cancellations Winds could disperse the ash toward the rest of Europe Airlines have begun cancelling flights to parts of Britain as fears over the ongoing eruption of the Grimsvotn volcano in Iceland continue. Eruptions continued at the Grimsvötn volcano in Iceland on Tuesday as a plume of smoke headed toward Britain, causing flight disruptions and stoking fears of a repeat of an eruption last year at another Icelandic volcano. "The low-level winds are ... blowing strongly towards the UK," said Peitur Arason of the Icelandic Meteorological Office, as British air traffic operator NATS said volcanic ash was expected to reach Scottish airspace by early Tuesday. Regional Scottish airline Loganair said it had already cancelled 36 flights, whilst British Airways, Dutch carrier KLM, Irish airline Aer Lingus and budget airline Easyjet also suspended flights late Monday bound for northern Britain. The eruption - the Grimsvotn volcano's most powerful in over a century - has spewed ash particles across Iceland and forced the closure of the country's airspace on Sunday. Obama was forced to leave Ireland ahead of schedule US President Barack Obama, on a four-nation tour of Europe, was forced to cut short his visit to Ireland on Monday out of concern that the ash cloud could disrupt air traffic, a White House official said, leading to his arrival in Britain a day ahead of schedule. Ash cloud spreads The Grimsvotn eruption has stoked memories of a flare-up last year at the Eyjafjallajokull volcano, which caused travel chaos around the globe. European aviation experts and volcanologists, however, have predicted little chance of similar widespread airspace closures. Volcanologists said the plume's content was heavier than that of the 2010 Eyjafjallajokull eruption, meaning it was less likely to spread. Sunday's disruptions in the Icelandic capital, Reykjavik, and of some transatlantic flight paths took place during a mobile low-pressure zone in the north Atlantic whose movement is hard to predict, experts said. During the crisis last year, however, the spread of ash from Eyjafjallajokull was aided by a stable high-pressure zone causing the ash cloud to wreak havoc across Europe. That eruption triggered a six-day air travel ban, which stranded tens of thousands of airline passengers and caused considerable economic damage around the globe. http://www.dw-world.de/dw/article/0,,15096848,00.html Back to Top Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC