Flight Safety Information June 8, 2011 - No. 117 In This Issue Air France Crash Probe Raises Pilot Training Questions... Tiger airlines probed over low flying... EASA prepares to broaden icing certification criteria... Gabonese government bans Antonov aircraft after DHL crash... "A Practical Approach to Safety Management Systems" Course Air France Crash Probe Raises Pilot Training Questions Air France Flight 447 stalled high over the Atlantic Ocean and plunged into the sea even as the pilots repeatedly tried to pull the nose up - a reaction opposite to what was needed to recover from the stall. The preliminary findings from French authorities has industry insiders questioning the pilot training needed to handle extreme confusion and the growing role of automation in the cockpit. The Airbus A330-200 was enroute to Paris from Rio de Janeiro on June 1, 2009 when it experienced a high-altitude stall after it is thought ice blocked the plane's air speed sensor and flight instruments were therefore unreliable. French investigators have not released their final report into the crash that killed all 228 people aboard, but an initial report offers telling details about the flight's final minutes. Most tellingly, a pilot stated, "so we've lost the speeds" approximately two hours and 10 minutes into the flight. According to authorities, the pilot then stated, "alternate law... ." Investigators have interpreted this to mean flight instruments were no longer displaying the correct airspeed, although that does not necessarily mean the plane was actually losing airspeed. "Alternate law" refers to the fly-by-wire system controlling the flight control surfaces. The flight data recorders stopped approximately four minutes later, presumably when the airplane hit the water. The plane fell from an altitude of approximately 38,000 feet and its last recorded data points were a descent at almost 10,912 feet per minute (a typical descent is 1,000 fpm or less), a ground speed of 107 knots and a nose-up attitude of 16.2 degrees. It is widely believed the airplane entered an aerodynamic stall, although the pilots may not have realized because of conflicting information they were seeing in the cockpit. An aerodynamic stall occurs when the smooth airflow passing over the wings separates from the wing surface, resulting in a loss of lift. It has nothing to do with the engines, which in the case of Flight 447 were operating until the plane hit the water. Seconds before the pilot said the aircraft had "lost the speeds," the autopilot and auto- thrust systems disengaged and the pilot took control of the plane. The captain, who had been taking his regularly scheduled rest break, was back in the cockpit within 90 seconds. By that time, the pilot had made a "nose-up input" - meaning he pulled back on the control stick - and "the stall warning sounded twice in a row," according to investigators. The recorded airspeed fell from about 275 knots to 60 knots, according to information released by French authorities. The airplane was in a stalled condition without the lift needed to maintain altitude. In the first minute of the fall, the pilots tried repeatedly to regain control of the plane. The fly-by-wire system was operating in "alternate law" mode, allowing the pilots to exceed certain flight parameters that govern the flight controls. This includes exceeding the angle of attack protections meant to reduce the chance of entering a stall. Once the captain was back in the cockpit, it became apparent the airspeed indicated by the instrumentation was invalid. That suggests the pitot tube, a device outside the aircraft that senses airflow and therefore airspeed, had frozen over. Pitot tubes are heated to prevent that, as a frozen tube would provide inaccurate airspeed data to the pilot and, more importantly, the fly-by-wire computer. At this point Flight 447 was still at 35,000 feet, but the angle of attack exceeded 40 degrees (well past the normal stall angle) and the airplane was beginning its rapid fall. Over the next few minutes the pilots used various amounts of engine power and control inputs to regain control. But according to the initial report from the Bureau d'Enquetes et d'Analyses[.pdf], the crew did not push forward on the control stick long enough to point the nose down, reduce the angle of attack on the wing and recover from the stall. This is typically how pilots are taught to recover from a stall. For an unknown reason, the Air France pilots did the opposite, holding the control stick back during most of the descent. There are, however, some instances where pushing the controls forward is not advised. Unless more information is known about the cause of the loss of control, it is difficult to say what else was happening in the cockpit and whether the pilots were panicked or confused by the flurry of information and alarms they were receiving. "The scene inside the cockpit certainly would have been chaotic with darkness adding to the turmoil of heavy rain and turbulence" said former airline pilot Robert Mark. He adds they would have also been facing "an array of warning lights and chimes all threatening certain death at the same moment." Such a response is not unheard of. The pilot of a Colgan Air crash that killed 50 people on February 12, 2009, near Buffalo, New York improperly reacted to a warning that the plane had slowed too much and pulled the nose upward. And a West Caribbean Airways flight crashed in Venezuela on August 16, 2005, following a high-altitude stall. Investigators blamed the pilots for failing to recognize the plane had stalled. That has some calling for better pilot training and more thorough instruction for dealing with unusual circumstances. Aviation Week's Fred George points out little training time, if any, is spent covering high altitude upset recovery. And even the basic understanding of angle of attack is not always thoroughly understood. Diagram showing the flight path of Air France flight 447: BEA Source: http://www.wired.com/autopia/2011/06/air-france-flight-447 Back to Top Tiger airlines probed over low flying A Tiger Airways flight that flew too low as it approached Melbourne Airport on Tuesday night is under investigation. The Airbus A320 flight from Brisbane reached an altitude below the prescribed safety limit as it approached the airport, the Australian Transport Safety Bureau said. The bureau has classified the incident as an "operational" occurrence and estimates the investigation will take one year. Tiger spokeswoman Vanessa Regan said the airline was co-operating fully with the investigation. She said the incident had made no impact on the airline's operations. "Safety underpins the operation at all times," she said. "As the occurrence is currently under review by Tiger Airways and the appropriate authorities, it's not appropriate for the airline to comment further at this time." In March, the Civil Aviation Safety Authority (CASA) issued Tiger with a show cause notice, believed to be centred on aircraft maintenance and pilot training standards. Source: http://news.ninemsn.com.au/national/8258910/tiger-airlines-probed-over-low- flying Back to Top EASA prepares to broaden icing certification criteria David Kaminski-Morrow Europe's safety authority is preparing to assess feedback over a proposed overhaul of icing certification criteria that would broaden the scope to include other hazardous icing phenomena such as supercooled large drops and crystallisation. The changes are part of an extensive revision on the adequacy of certification in the wake of several fatal accidents. While the European Aviation Safety Agency highlights, in its proposal, the ATR 72 crash at Roselawn, Indiana in October 1994 - the result of freezing drizzle - it also mentions pitot icing and the possibility that this contributed to the loss of Air France flight AF447 in 2009. Freezing drizzle and rain constitute an icing environment consisting of supercooled large drops. While EASA has said that these have caused at least six accidents since 1988, they are outside the icing envelope defined by the CS-25 certification standards document for large transport aircraft. "It has been evidenced that the icing environment used for certification of large [aircraft] and turbine engines needs to be expanded to improve the level of safety when operating in icing conditions," it said in its proposal. The suggested rules would provide a new section to CS-25, designated appendix O, detailing the size, water content and other characteristics of supercooled large drops and the capabilities aircraft must demonstrate when confronted by such conditions. Other icing phenomena - mixed phase and crystallisation - have not resulted in fatal accidents but have contributed to engine power loss incidents over the past two decades. "They are considered as a serious safety threat," EASA added in a detailed notice of proposed amendment to CS-25, the consultation period for which closes this month. EASA said it considered the US Federal Aviation Administration's similar proposed rulemaking of June 2010 but added that, while its objective is to "harmonise as much as possible" the two authorities' regulations, the European proposal contains some differences. It will apply to all new large aircraft, not be limited to a specific category, as well as all flight instrument external probes. EASA also proposes clarifying and extending provisions for alerting flightcrew when a probe's anti-ice system is not operating normally. EASA said it looked at using terminal radar and airborne sensors to identify icing zones with supercooled drops, but concluded these were "not mature enough". Another alternative, use of predictive weather tools, was also rejected. Both options would have still required additional rulemaking. Source: http://www.flightglobal.com/articles/2011/06/08/357682/easa-prepares-to- broaden-icing-certification-criteria.html Back to Top Gabonese government bans Antonov aircraft after DHL crash The Gabonese government has banned several Antonov type aircraft from operating in the African nation after a DHL Aviation cargo plane crashed in the sea off its capital, officials said. The accident happened on late Monday morning when an Antonov An-26 freighter crashed just off the coast of Libreville, the capital of Gabon. The aircraft was being operated by Solenta Aviation, which operates aircraft on regional routes on behalf of DHL Aviation. Solenta Aviation flight 122A was flying from Port Gentil, the second-largest city of Gabon, and was attempting to land at Libreville International Airport when it crashed. Three crew members, one Bulgarian and two Ukrainians, and a Gabonese passenger, were rescued without serious injuries by emergency services. According to Gabonese Transport Minister Julien Nkoghe Békalé, the accident happened while the aircraft was on its final approach to the airport. It had obtained landing clearance but then announced a go-around due to hydraulic problems before crashing in shallow waters just off the coast. As a result of the accident, Békalé has ordered the establishment of a commission to investigate the causes of the accident. He further announced that the government would ban all Antonov 12, 24, and 26 aircraft from flying in the country. He gave no reason for the ban. In June 2004, a Gabon Express passenger plane also crashed off the coast of Libreville, killing 19 out of the 30 people on board. The Gabonese government quickly banned Gabon Express from operating in the country, forcing the airline to cease its operations just 7 days later. Source: http://news.rickey.org/gabonese-government-bans-antonov-aircraft-after-dhl- crash-2/4597 Back to Top A Few Seats Remain, Act Now to Reserve Your Spot Curt Lewis & Associates, LLC in conjunction with Beyond Risk Management Ltd. are pleased to host "A Practical Approach to Safety Management Systems" a course designed for the aviation industry. With the ICAO recommendations and standards for the introduction of Safety Management Systems throughout the world - you can get ahead of the curve and save time and money by learning the potential pitfalls and challenges associated to its implementation. The Canadian large aircraft aviation industry has experienced many of the same challenges likely to be faced by others. To better prepare you and your organization to meet these challenges we are pleased to bring to you the Canadian experience with regulated Safety Management Systems adapted to the your needs. Dates - June 17 & 18, 2011 (Friday and Saturday), SEATS ARE LIMITED- to ensure good discussion and time to question in a workshop environment class size is intentionally intimate. Register now to avoid disappointment. Important Details - This course covers the ICAO standards, the proposed FAA Safety Management Systems requirements and the Canadian experience. The content is global in nature enabling participants from other nations and industries to find the material both useful and beneficial. For Canadian attendees this course fulfills the requirements for CASO training (non 705 operators.) Schedule Day One (Friday) 0730 - 0800 hrs. Registration & continental breakfast 0800 - 1200 hrs. Session #1 1200 - 1245 hrs. Lunch 1245 - 1700 hrs. Session#2 Day Two (Saturday) 0730 - 0800 hrs. Continental breakfast 0800 - 1200 hrs. Session #3 1200 - 1245 hrs. Lunch 1245 - 1630 hrs. Session #4 1630 - 1700 hrs. Closing remarks and Presentation of certificates Location - The hotel is the Element Dallas Fort Worth North (3550 W. IH 635 Irving, Texas 75063 United States ˇ Phone: (972) 929-9800ˇ Toll-Free: 1-877-353-6368. Shuttle service from airport is available. Book your overnight stay directly with the hotel early. (http://www.elementdfwnorth.com) Overview - Improve safety performance by applying the fundamentals of SMS within your organization. Get past the barriers of independent departments to an integrated system. This two-day course gives you the comprehensive understanding of SMS and the tools to assist you in preparing for change in your organization. Who should attend - Any individuals who will be actively involved in the organization's Safety Management System (safety program). Individuals with previous experience and those with no knowledge in safety management will find this course useful for the formation or expansion of safety programs within their organizations. What you get - Participants will receive a consolidated reference binder of class material as well as an electronic version of the material which will provide guidance for setting up a system within their organization. Upon successful completion of the course a certificate will be issued. Subjects that will be reviewed are: * Safety and security * What Safety Management Systems is (definitions) * Corporate culture - The push for change (a full review of the proposed FAA Safety Management Systems, current ICAO and Transport Canada and requirements) * Risk Assessment techniques * Data collection and processing * Front line involvement and committee process * Incident Reporting * Incident/Accident investigation techniques and process * Trend Analysis * Response to events and emergencies * Safety promotion * Implementing change (and the obstacles to change) * Documentation process. Logistics - Tea/coffee/juice/water will be provided in the classroom at all times, continental breakfast and lunch on both days is included. Cost - $1,195.00 US funds per person SPECIAL OFFER: When you register three people from one organization the fourth attendee is our guest! Facilitators - Captain Elaine Parker, Inspector (ret'd) Brendan Kapuscinski, Curt Lewis PE, CSP & Darwin Copsey - Seating Restricted for better workshop discussion - - Registration is limited - Register now - Register on line at: www.regonline.ca/SMSDFWJun2011 For further information or questions: email - elaine@beyondriskmgmt.com Or call: Brendan Kapuscinski 403-804-9745 Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC