Flight Safety Information July 13, 2011 - No. 140 In This Issue NTSB: Pilot Error Led To 2009 Pilatus Accident In MT FAA Proposes Civil Penalties Against Eight Companies NTSB Offers Recommendations To FAA On Boeing MD-11s Embry-Riddle to Offer Short Courses Man jailed for pelting flight attendant with peanuts American Airlines Pays Tribute to Elite Mechanics Bond set for unruly airplane passenger Crews Begin Prepping EAA AirVenture Grounds NTSB: Pilot Error Led To 2009 Pilatus Accident In MT A Series Of Operational Mistakes Resulted In The Fatal Injury Of 14 People The NTSB determined Tuesday that the cause of the March 2009 deadly crash of a Pilatus airplane was a series of operational errors made by the pilot. The pilot failed to ensure that a fuel system icing inhibitor (FSII), commonly referenced by the brand name "Prist", was added to the fuel prior to the accident flight. The pilot also failed to take appropriate remedial actions, including diverting to a suitable airport, after the airplane warning systems indicated a low fuel pressure state that ultimately resulted in a significant lateral fuel imbalance. And, the pilot lost control while maneuvering the left-wing-heavy airplane near the approach end of the runway. "The pilot's pattern of poor decision making set in motion a series of events that culminated in the deadly crash," said NTSB Chairman Deborah A. P. Hersman. "Humans will make mistakes, but that is why following procedures, using checklists and always ensuring that a safety margin exists are so essential - aviation is not forgiving when it comes to errors." On March 22, 2009, at about 1432 MDT, a Pilatus PC-12/45, N128CM, crashed about 2,100 feet west of runway 33 at Bert Mooney Airport (BTM) in Butte, Montana. The flight departed Oroville Municipal Airport in Oroville, California, en route to Gallatin Field in Bozeman, Montana but the pilot diverted to Butte for unknown reasons. The pilot and the 13 passengers were fatally injured and the aircraft was substantially damaged by impact forces and a post-crash fire. The airplane was owned by Eagle Cap Leasing of Enterprise, Oregon, and was operating as a personal flight under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time of the accident. During the investigation, the NTSB determined that the pilot did not add a fuel system icing inhibitor when the airplane was fueled on the day of the accident. The Pilatus flight manual states that a fuel system icing inhibitor must be used for all flight operations in ambient temperatures below 0 degrees Celsius to prevent ice formation in the fuel system. The NTSB concluded that the airplane experienced icing in the fuel system which resulted in a left-wing-heavy fuel imbalance. The increasing fuel level in the left tank and the depletion of the fuel from the right tank should have been apparent to the pilot because that information was presented on the fuel quantity indicator. This should have prompted the pilot to divert the airplane to an airport earlier in the flight as specified by the airplane manufacturer. The NTSB issued recommendations to the Federal Aviation Administration and the European Aviation Safety Agency, to require fuel filler placards and guidance on fuel system icing prevention. FMI: http://go.usa.gov/ZSj Back to Top FAA Proposes Civil Penalties Against Eight Companies Fines Sought Range From $66,000 To Just Over $133,000 The FAA is proposing civil penalties ranging from $66,000 to $133,950 against eight companies for alleged violations of FAA regulations. They include the following: Apollo Aviation of Fruitland Park, FL: $77,300 for allegedly operating a Cessna 172 on nine flights between July 21 and 24, 2010, when it was not in compliance with FAA regulations. The aircraft crashed near Waynesboro, VA, on July 24. The pilot was not injured. The FAA alleges Apollo failed to accomplish the required tests and inspections of the altimeter, static system and transponder in the aircraft within the 24 months leading up to the accident. JetSmart, Inc., of Rochester, NY: $133,950 for allegedly operating a Hawker Beechcraft 125-800 business jet aircraft on 63 flights between Oct. 3, 2009 and Dec. 15, 2009, when it was not in compliance with FAA regulations. The FAA alleges JetSmart failed to inspect handheld fire extinguishers every 30 days, as required under the company's approved inspection program. The aircraft also made two additional flights on Dec. 10 and Dec. 15, 2009, when the passenger public address system was inoperative, but the company failed to post the required placard in the airplane confirming that fact. 26 North Aviation, Inc. of Allentown, PA: $81,000 for allegedly failing to inspect overwing emergency exits after opening them as part of crew evacuation training on several of its aircraft. The company's FAA-approved general maintenance manual mandates the inspections that must be completed and documented before the aircraft can be returned to service. The alleged violations occurred at multiple points beginning on June 2, 2009 and continued through Feb. 17, 2010. Aviation Specialties Unlimited, Inc., of Boise, ID: $77,000 for allegedly installing a night vision system on a helicopter used for emergency medical services when it was not authorized to perform that modification. The FAA further alleges that Aviation Specialties failed to perform the modification correctly and used unacceptable technical data to guide the work. The alleged violation occurred Nov. 24, 2009. Liberty Jet Management Corporation of Oyster Bay, NY: $75,000 for allegedly using a pilot who had failed his most recent checkride as second-in-command on approximately 25 charter flights. FAA regulations require all crewmembers to have passed checkrides (or other appropriate evaluations) before they may fly as required crew. The flights operated between Aug. 4 and Nov. 11, 2010. American Eagle Airlines of Fort Worth, TX: $77,500 for alleged violations of the company's operations specification for its ground de-icing/anti-icing program. The FAA alleges American Eagle's line maintenance contractor at Richmond, VA, used uncalibrated tools to test the anti-freeze used for de-icing aircraft, and that the tools were not specified for use by the airline's FAA-approved general maintenance manual and its ground deicing program. Under FAA regulations, a carrier is responsible for overseeing a contractor's maintenance. FAA inspectors discovered the problem and said the violations took place between Feb. 13 and March 9, 2010. Atlantic Southeast Airlines (ASA) of Atlanta, GA $132,000 for allegedly operating a Bombardier CRJ regional jet on 22 passenger-carrying flights between May 14 and May 18, 2010, while it was not in compliance with FAA regulations. The FAA alleges that ASA performed maintenance on the aircraft on May 13, 2010, but did not execute a maintenance release or appropriate aircraft logbook entry releasing the aircraft for service. Jet Aircraft Maintenance of Miami, FL: $66,000 for allegedly failing to perform tire changes properly on various United Airlines A320 airliners. The alleged violations occurred between Nov. 24 and Dec. 2, 2010 at Washington's Reagan National Airport. Jet Aircraft Maintenance performs line maintenance for United at the airport. The FAA specifically alleges the company did not use the proper tools and specified lubricants during the tire changes. The companies have 30 days from the receipt of the FAA's enforcement letter to respond to the agency. FMI: www.faa.gov Back to Top NTSB Offers Recommendations To FAA On Boeing MD-11s Says Pilots Should Be Better Trained In High Sink Rate Awareness, Bounce Recovery The NTSB on Tuesday sent two recommendations to the FAA concerning Boeing's MD-11. In the document, the board recommended that the FAA require Boeing to revise its MD- 11 Flight Crew Operating Manual to reemphasize high sink rate awareness during landing, the importance of momentarily maintaining landing pitch attitude after touchdown and using proper pitch attitude and power to cushion excess sink rate in the flare, and to go around in the event of a bounced landing. Once Boeing has completed the revision of its MD-11 Flight Crew Operating Manual as recommended in Safety Recommendation A-11-68, require all MD-11 operators to incorporate the Boeing-recommended bounce recognition and recovery procedure in their operating manuals and in recurrent simulator training. The recommendations stem from an accident on July 27, 2010, in which a Boeing MD- 11F equipped with General Electric CF6-80C2 engines, German registration D-ALCQ, operated by Lufthansa Cargo as flight 8460, caught fire after a hard landing at King Khalid International Airport, Riyadh, Saudi Arabia (RUH). The airplane bounced twice, experiencing a strong pitch up after the second hard touchdown, followed by strong nose-down pitch forces and vertical loads at the third and final touchdown that caused the fuselage to rupture. The two pilots, who were the only airplane occupants, were transported to the hospital with injuries. The airplane was destroyed. The flight was a scheduled cargo flight from Frankfurt, Germany, (FRA) to RUH. According to the recommendation letter, although it is not uncommon for jet transport aircraft to experience a small skip or bounce during landing, since it was entered into service in 1990, the MD-11 has had at least 14 events of such severity that the aircraft sustained substantial damage, including 4 events that were complete hull losses. Seven of these events have taken place in the last 2 years. The number and severity of these events raise concerns that MD-11 flight crews are not effectively trained to recognize and arrest high sink rates during landing or to properly control pitch attitude following a hard landing. FMI: www.ntsb.gov/doclib/recletters/2011/A-11-068-069.pdf ********** U.S. Cites Dangers in MD-11 Jet Landings By ANDY PASZTOR (WSJ) Despite more than a decade of efforts to improve the safety of McDonnell Douglas MD-11 jets, U.S. accident investigators on Tuesday called for stepped-up pilot training world-wide to counter landing incidents that continue to plague the widely used cargo planes. Prompted by seven serious MD-11 landing incidents over the past two years-including a pair of botched touchdowns overseas that resulted in a loss of both aircraft-the National Transportation Safety Board said it is concerned that cockpit crews aren't effectively trained to cope with the MD-11's difficult handling characteristics. In its recommendations, the board called on U.S. air-safety regulators to mandate enhanced training to help pilots keep the three-engine jets from descending too rapidly and then bouncing during landings. "Despite the corrective actions taken" by the Federal Aviation Administration and MD-11 operators over the years, the NTSB concluded, pilots still need additional training to make appropriate adjustments to engine thrust and flight- control surfaces to prevent accidents. Since going into service in 1990, MD-11s have suffered a total of 14 serious landing incidents, including four accidents that ended with the complete loss of the aircraft, the NTSB said. In March 2009, a FedEx Corp. MD-11 crashed and burned after landing hard, bouncing twice and snagging a wingtip on the ground at Japan's Narita International Airport, killing both pilots. In July 2010, the fuselage of an MD-11 cargo plane operated by Deutsche Lufthansa AG broke apart in Riyadh, Saudi Arabia after the jet touched down hard and bounced twice, injuring both pilots. In both accidents, the planes experienced excessive vertical forces and steep, nose-up maneuvers that exceeded normal safety guidelines Since the late 1990s, regulators, pilots and accident investigators around the globe have been aware that the MD-11's computerized flight controls produce finicky handling that can make the planes tricky to land. From the start, pilots worried about controlling the long fuselage in crosswinds, and documented a tendency of the nose to pitch up at critical moments of touchdown. The MD-11's control column, or yoke, is considered to be more sensitive than those on other large jets, so pilots are prone to over-control the planes in certain situations. Introduced by McDonnell Douglas Corp. as primarily a passenger jet, the MD-11 quickly gained a reputation as an unforgiving airplane. The FAA and Boeing Co., which inherited the aircraft when it took over McDonnell Douglas, devised various steps over the years to improve MD-11 handling, including software changes to dampen flight-control commands. The planes are now used almost exclusively to carry cargo or to fly charter trips. But the latest NTSB recommendations highlight that some of the original safety issues persist, largely because of the MD-11's handling problems close to the ground. According to the safety board, "enhanced operational guidance and recurrent training will provide near-term improvements" to reduce MD-11 risks. Once MD-11 operating manuals are updated, the safety board also wants pilots to receive special training in "bounce recognition and recovery" procedures as part of their routine simulator-training sessions. The board's recommendations aren't binding on the FAA or operators. Back to Top Embry-Riddle to Offer Short Courses in Aviation Safety and Aircraft Accident Investigation Daytona Beach, Fla./Prescott, Ariz., July 12, 2011 - The Professional Programs Office of the College of Aviation at Embry-Riddle Aeronautical University will host several five-day Center for Aerospace Safety/Security Education (CASE) short courses that combine the latest in safety, security, human factors, and aircraft accident investigation topics in a professional and dynamic classroom environment. Participants may elect to take courses independently or to complete the three courses marked with an asterisk to receive a Certificate of Management in Aviation Safety. Occupational Safety & Health / Aviation Ground Safety for Managers* Course Dates: Oct.17-21, 2011 & April 16-20, 2012 Location: Daytona Beach Campus, Florida This course gives the participant working knowledge of OSHA's General Industry Safety and Health standards. In addition, participants will gain a fundamental working knowledge of an aviation ground safety program. Participants will also receive the OSHA 30-Hour General Industry Safety & Health Training Card. Aviation Safety Program Management* Course Dates: Oct. 24-28, 2011 & April 23-27, 2012 Location: Daytona Beach Campus, Florida This course gives the participant working knowledge of the development and management of an effective safety program. Course topics include Safety Culture, Disaster-Emergency Planning, Internal Reporting Systems, Human Error and Human Performance, and Introduction to Safety Management Systems. Aircraft Accident Investigation and Management* Course Dates: Oct. 31-Nov. 4, 2011 & April 30-May 4, 2012 Location: Daytona Beach Campus, Florida This course is designed to teach the participant the fundamentals required to conduct or manage an aircraft mishap/accident investigation. The participant will review the investigation sequence from the preplanning stage through the general survey and specific analysis of a mishap/accident, culminating with the determination of contributing factors and probable cause/s. Advanced Aircraft Accident Investigation and Management Course Dates: May 7-11, 2012 Location: Prescott Campus, Arizona This course introduces the participant to advanced accident investigation procedures involving design, materials, and aircraft performance. Participants will analyze various mechanical and structural factors and loads on an airplane and will be introduced to advanced fire investigation and avionics. Extensive use will be made of crash laboratory simulated accident scenario exercises, and case examples will help participants identify, collect, and analyze data in the process of determining probable cause/s. For more information, please contact Embry-Riddle Professional Programs/CASE Short Courses: Director: Sarah Ochs Website & Registration Information: http://www.erau.edu/case Email: case@erau.edu Phone: (386) 226-6928 Back to Top Man jailed for pelting flight attendant with peanuts Salt Lake City: (AP) A man has been arrested and jailed after authorities say he pelted a flight attendant with peanuts and pretzels on a Southwest Airlines plane from Los Angeles to Utah. Pogos Paul Sefilian, of Sandy, Utah, faces a federal charge of interference with a flight crew. Authorities say Sefilian was on a flight on Monday evening when he attempted to smoke an electronic cigarette. A complaint filed on Tuesday in U.S. District Court says a flight attendant repeatedly told him it was against airline policy and to put away the device. Authorities say Sefilian became enraged and threw peanuts and pretzels at the flight attendant. He remained held. His attorney declined to comment. Read more at: http://www.ndtv.com/article/world/man-jailed-for-pelting-flight- attendant-with-peanuts-118859?cp Back to Top American Airlines Pays Tribute to Elite Mechanics American, FAA Celebrate AMTs with 50 Years of Service FORT WORTH, Texas, July 12, 2011 -- /PRNewswire/ -- American Airlines is honoring a special group of Aviation Maintenance Technicians (AMTs) for their lifetime achievement of serving five or more decades in the airline industry. At American's maintenance facilities in Tulsa, Okla., Kansas City, Mo., and Tampa, Fla., the airline paid homage to eight AMTs with the FAA's prestigious Charles E. Taylor "Master Mechanic" Award, which recognizes the lifetime accomplishments of senior mechanics. The award is named in honor of Charles E. Taylor, who worked for the Wright Brothers and was the first aviation mechanic in powered flight. To be eligible for the award, a recipient must have served 50 years as an accredited aviation mechanic and have been an FAA-certified mechanic for a minimum of 30 years. "American Airlines AMTs are the best of the best, and these gentlemen exemplify our high standards. We commend them for their excellent service over the years," said Jim Ream, American's Senior Vice President - Maintenance & Engineering. "For 50 years, our Master Mechanics have worked tirelessly behind the scenes to ensure the safety of our customers, employees and fleet. They have set a very high bar for future generations of AMTs." The honorees include: ·William Hindle (AMT, retired) - Kansas City ·Larry Olsen (AMT Crew Chief, retired) - Kansas City ·Gerald Beebe (AMT Inspector, retired) - Kansas City ·John Mulholl (AMT Crew Chief) - Tampa ·Ron Wolfe (AMT) - Tampa ·Ralph Grunhof (Manager - Production, retired) - Tulsa ·Prince Street (Supervisor - Aircraft Maintenance) - Tulsa ·Jim Roddy (AMT) - Tulsa American Airlines has three overhaul maintenance bases located in Tulsa, Okla., Fort Worth, Texas, and Dallas/Fort Worth International Airport, along with line stations located throughout its domestic and international network. American employs more than 8,400 AMTs, who repair and maintain American's fleet of more than 600 aircraft. SOURCE American Airlines Read more: http://www.sacbee.com/2011/07/12/3764177/american-airlines-pays- tribute.html#ixzz1Rz5Bsiop Back to Top Bond set for unruly airplane passenger (Cleveland)- The passenger removed from United Flight 944 after the jet made an emergency landing at Cleveland Hopkins Airport made his first court appearance. Saleh Ali Alramakh appeared in federal court Tuesday afternoon wearing khaki shorts, a black polo and flip flops. Bond was set at $25,000. A pre trial hearing has been set for July 19th. Alramakh has been a University of Akron student here on scholarship, according to his lawyer. The University of Akron says Alramakh is not currently enrolled. He is originally from Saudi Arabia. He is facing one federal count of interference with flight crew members and attendants. Earlier in the day, Alramakh was in Cleveland Municipal Court on local charges related to the incident. His bond there was set at $1 million. Prosecutors say he got up several times during the flight from Chicago to Germany Friday night to go to the bathroom and used an electronic device. Attendants told him to turn it off but he refused to comply. Later on, he allegedly shoved a flight attendant which prompted at least one passenger to help the flight crew restrain him. Alramakh then tried to spit on the passengers and the attendant. The plane resumed its flight to Germany after Alramakh was taken off the plane and it was checked out by police K-9s. Read more: http://www.wtam.com/cc- common/news/sections/newsarticle.html?feed=122520&article=8822418#ixzz1Rz2qyY3x Back to Top Crews Begin Prepping EAA AirVenture Grounds OSHKOSH, Wis. -- The aviation extravaganza that draws hundreds of thousands of people to the Fox Valley each summer is still two weeks away, but the grounds at EAA AirVenture in Oshkosh is already buzzing with activity. Preparing for more than a half million guests takes some preparation. EAA organizers rely on an army of volunteers to make the aviation convention work. From hauling picnic tables to putting up signs, about 400 volunteers from across the country are getting the grounds ready for the 7-day event, which begins July 25. More than 10,000 aircraft are expected to arrive at Wittman Regional Airport in Oshkosh during the fly-in. Read more: http://www.wisn.com/entertainment/28508935/detail.html#ixzz1Rz4SQqSc Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC