Flight Safety Information July 29, 2011 - No. 155 In This Issue BEA releases third interim report on AF447 accident Air France Crash Report Points to Pilot Errors Poland Blames Crew, Controllers for Fatal Crash Overnight search fails to locate 2 missing Asiana pilots Plane catches fire with 300 passengers onboard Asiana 747-400F had fire in hold before crash FAA weighs in on LightSquared alternate plan MTSU to master aviation safety with new degree program Air Safety Means Taking a Tougher Stance on Controllers' Blunders "The Call: Aviation Disaster Preparedness and Crisis Response" BEA releases third interim report on AF447 accident The French BEA releases the third interim report in the course of their investigation into the cause of the fatal accident involving an Air France Airbus A330 in the Atlantic Ocean. The third BEA Interim Report will be published on Friday 29 July 2011. This report will present the exact circumstances of the accident with an initial analysis and some new findings based on the data recovered from the flight recorders. At the same time, a press briefing will be organised at the BEA at 14 h 30. The report will be available here: http://www.bea.aero/en/enquetes/flight.af.447/flight.af.447.php www.aviation-safety.net Back to Top Air France Crash Report Points to Pilot Errors as Skills Undergo a Review Salvage teams work to retrieve debris from the wreckage of Air France flight 447 (Bloomberg) - Airline pilots need better training on how to fly planes in an emergency with only limited aid from computers, investigators concluded after probing how cockpit confusion doomed Air France Flight 447 and killed 228 people. Global aviation authorities should revise training for pilots and make changes to aircraft certification, flight recorders and transmission of flight data, the French BEA aircraft accident bureau said today in a report into the 2009 crash off the coast of Brazil. The document chronicles the final two hours of the Airbus A330 aircraft, revealing an airplane and engines that responded accurately to commands, and confusion on the part of the two co- pilots making the inputs while the captain was off duty. Neither pilot appeared to realize the plane had stalled, even as an alarm sounded for 54 seconds before the jet hit the ocean in the middle of the night. "There was no explicit task-sharing between the two copilots," the report said. "Neither of the pilots made any reference to the stall warning." Flight 447 crashed on June 1, 2009, after the Airbus lost speed and stalled before beginning a 3 1/2 minute plunge into the Atlantic. No announcements were made to the passengers during the decent, the report said. Data presented by BEA show the youngest of the three pilots, who was 32 and at the controls for most of the last minutes, angled the jet nose higher, a position the aircraft maintained until its impact. Air France Response Air France said there was "no reason to question the crew's technical skills." "Misleading stopping and starting of the stall warning alarm" confused the crew and contributed to the crash, it said in a statement published on its Web site in response to the report. "Air France pays tribute to the courage and determination they showed in such extreme conditions," it said. Stalls occur when a plane slows to a degree that its wings lose lift. Recovering from a stall involves dropping the nose to regain airspeed, a procedure that novice pilots begin practicing early in their training. The aircraft's captain, who returned to the cockpit after the plane had stalled, had almost 11,000 hours of flying experience. That compares with 3,000 hours for the youngest of the three-man crew, who remained in control. Recommendations Among the agency's recommendations, it called for one crew member to be designated as a "relief captain" whenever copilots are left alone in the cockpit. The pilot left for his break "without clear operational instructions," the BEA said. The recommendations are likely to rekindle debate about adequate pilot training in an era of aviation dominated by computers. Modern jets are highly automated, and computers ensure the aircraft remains in its so-called flight envelope. Regulators should require pilot training to include "regular specific exercises aimed at manual airplane handling, including approach to and recovery from stall at high altitude," the BEA said. The French investigator was able to piece together the last minutes of the doomed flight after retrieving the flight- and data recorders from the bottom of the ocean earlier this year following multiple search missions. Investigators recovered complete readings of the flight recorders, the BEA said. Icy Sensors Even before the recorders were found, the investigation honed in on the plane's airspeed sensors that malfunctioned after they were blocked by ice at cruising altitude, causing the auto-pilot to shut down while the captain was on a routine break. The junior co-pilot responded by forcing the plane into a sharp climb, the report said. He continued to pull back on the stick even after the aircraft slowed, lost lift and dropped almost vertically with the stall alarm blaring. Speed indications returned after a 54- second lapse, though they had no impact on pilot behavior, the report concluded. The audio recording of the cockpit exchanges reveals poor communication between the co-pilots and a lack of clear command in the flight captain's absence, according to the BEA. They failed to exchange information or observations on the plane's orientation and descent through the air. "No standard callouts regarding the differences in pitch attitude and vertical speed were made," the report said. At one point, both men made simultaneous inputs on the side stick, a maneuver that prompts a vibrating warning on the steering device. While the captain had returned to the cockpit, he never took back the controls and remained in the background. Captain Too Late By the time the captain had rejoined his co-pilots, the situation had already deteriorated considerably, the investigators concluded in a report in May. The pilot was among the victims recovered from the ocean surface in the weeks after the crash. Salvage crews managed to pull up the bodies of other victims from the sea bed after the jet was discovered earlier this year. Among recommendations presented by investigators is the addition of cameras into the cockpit to enable a better reconstruction of the occurrences, a move that pilot unions have so far opposed as invasive. Manufacturers should also consider making available a reading of the so-called angle of attack, which defines the angle between air flow and the longitudinal axis of the aircraft. In the case of the crashed Airbus, the angle, which wasn't available to the pilots, always remained above 35 degrees during the descent. Data transmission during emergencies should also be improved, and the BEA recommended a mandatory activation of an emergency location transmitter to help find an aircraft, after the search for the boxes turned into the most elaborate salvage mission in aviation history. The Air France plane beamed its whereabouts by satellite only every 10 minutes, and crashed almost in the middle of that interval. Back to Top Poland Blames Crew, Controllers for Fatal Crash (NYT) - Polish authorities on Friday blamed both the Polish flight crew and Russian air traffic controllers for the 2010 crash in Russia that killed President Lech Kaczynski and 95 other people. The final report on the disaster said that the Russian air traffic controllers erroneously confirmed to the pilots that the jet, a Tupolev 154, was well positioned for the landing approach at Smolensk North Airport, "which might have affirmed the crew's belief that the approach was proceeding correctly although the airplane was actually outside the permissible deviation margin." But the report, produced by the Polish government's Committee for Investigation of National Aviation Accidents, found that to be only one of the causes. It also pointed to serious training defects among the crew, noting: "Despite obtaining formal certificates confirmed in the orders by the unit commanding officer, the crew did not meet the criteria for fully trained pilots who are competent in performing the duties required on their jobs." The pilots, it noted, "had little experience" flying in difficult weather conditions using the sort of non-precision landing systems necessary at Smolensk North, an airport where conditions were relatively primitive. The most immediate cause of the crash, the report found, was the crew's "failure to monitor altitude by means of a pressure altimeter during a non-precision approach" - they descended too far below the fog without realizing it - and then failed to heed an automated warning that they pull up. The Tupolev 154, which was also carrying Poland's top military commanders, its first lady and other officials, crashed April 10, 2010 at Smolensk North Airfield, about 230 miles west of Moscow. As the plane descended in foggy conditions, its left wing clipped a birch tree, turning the aircraft over and causing it to smash into the ground. Russian investigators have cited pilot error as the main cause of the disaster. In a January report, they also found that the crew was under psychological pressure from senior officials to land under dangerous conditions. But the Polish report Friday found that though Mr. Kaczynski's protocol director appeared in the cockpit to learn about the prospects for landing at Smolensk, there was no order from the president to land. The disaster - which occurred as the Polish officials were on their way to a ceremony commemorating the 70th anniversary of the Katyn massacre, in which Soviet troops killed thousands of Polish officers in World War II - led to a chill in Russian-Poland relations. Back to Top Overnight search fails to locate 2 missing Asiana pilots JEJU, South Korea, July 29 (Yonhap) -- Local maritime police said Friday they have yet to locate two pilots who went missing when their cargo plane crashed into the sea off the southern resort island of Jeju a day earlier. The Boeing-747 aircraft, operated by South Korea's second-largest air carrier Asiana Airlines, crashed into waters about 107 kilometers west of the island early Thursday while trying to make an emergency landing due to mechanical problems. Departing from Incheon International Airport bound for Pudong, China, the plane veered toward Jeju's airport before it crashed into the sea at around 4:28 a.m. The plane's two pilots have been missing ever since. Rescue workers launched their overnight search near areas where the debris of the crashed plane was found, but failed to locate the two crew members, the Jeju Coast Guard said. About 10 police and Navy vessels were dispatched for the search but they found no traces of the missing pilots, the maritime police said. The police and Navy will send out three helicopters and two patrol planes on Friday in addition to the 10 search vessels as rescue efforts continue, they said. "Although there are some swells in the offing, the overall weather is not unfavorable for the search operations," a Coast Guard official said. The crash was presumably caused when some inflammable materials in the 58-ton cargo hold caught fire, the airline and maritime police said. But the exact cause will remain unknown until the aircraft's voice recorder and black box are secured and analyzed, the Coast Guard said on Thursday. http://english.yonhapnews.co.kr/ Back to Top Plane catches fire with 300 passengers onboard Electrical short in the cockpit caused the fire as the plane was ready for takeoff Egypt Air plane caught fire before takeoff from Cairo Airport officials say some 300 passengers were rushed off an Egypt Air plane that caught fire before takeoff from Cairo. The officials say an electrical short in the cockpit caused the fire early Friday as the plane was scheduled to fly to Jeddah, Saudi Arabia. The passengers were rushed off the plane to a transit hall as firefighters put out the flames. The officials said two firefighters were later taken to the hospital to be treated for smoke inhalation. The fire didn't affect general air traffic and another plane was being prepared for the passengers traveling to Jeddah. The officials spoke on condition of anonymity because they were not authorised to speak to the media. http://www.emirates247.com/news/world/plane-catches-fire-with-300-passengers- onboard-2011-07-29-1.410319 Back to Top Asiana 747-400F had fire in hold before crash The Asiana Airlines Boeing 747-400F that crashed into the sea off Jeju Island on 28 July had fire in its hold, but the fire's role in the crash itself is unclear. However, South Korea's Ministry of Land, Transport and Maritime affairs said the fire probably caused the crash. "The exact cause (of the crash), however, still has to be determined by MLTMA after the aircraft's black box is retrieved," MLTMA said. The aircraft was carrying 400kg of lithium batteries, paint and other potentially dangerous materials. While there is no immediate evidence that the cargo contributed to the accident, lithium batteries are considered a potentially hazardous because they pose the risk of an in- flight fire. A UPS 747-400F, which crashed in Dubai in September 2010, was transporting lithium batteries when the aircraft suffered a fire in cruise and attempted to divert. The Asiana flight took off on a regular cargo service from Seoul's Incheon airport to Shanghai Pudong airport in China at 02:47 local time. At 04:11 local time, the crew reported "control problems at an altitude of 7,600ft and was diverted to Jeju International Airport when contact was lost with the aircraft". The aircraft's "last communication with the control center in Shanghai was that there was a fire in the cargo hold", MLTMA said. MLTMA confirmed it had found aircraft debris floating in the sea and an orange life-vest from the aircraft. There were two crew, a pilot and co-pilot, in the missing aircraft, MLTMA added. The airframe was built in 2006 and has clocked 26,300h, as shown in Flightglobal's ACAS data. The aircraft is powered by four GE CF6-80C2 engines. Asiana operates five 747-400Fs, four 747-400BDSFs, and two 747-400 combis. Source: Air Transport Intelligence news Back to Top FAA weighs in on LightSquared alternate plan The US FAA says an alternate operational proposal by wholesale broadband provider LightSquared would likely cause timing issues with its terminal, enroute and oceanic air traffic control systems, among other impacts to safety of flight systems. The internal analysis, dated 12 July, included dire predictions on the impact of LightSquared deploying the baseline dual-frequency operating mode that the US Federal Communications Commission in January had approved, pending a GPS impact analysis. Along with loss of nearly 800 lives as a result of GPS-based safety systems being unusable until a replacement system could be deployed in the 2023 timeframe, the FAA estimates a financial hit of nearly $70 billion in reduced safety and efficiency benefits. The FCC-dictated GPS impact analysis, prepared by a government and industry technical working group (TWG) over a five month period from February using analysis and actual testing, found that GPS as a navigation and timing source for aviation and other applications would not be possible with a LightSquared network of 40,000 ground stations retransmitting the L band satellite signals adjacent to the GPS band at high power. In parallel with the final report, LightSquared submitted to the FCC an alternative plan to use less transmitter power and only a lower 10MHz portion of its assigned spectrum, holding off on using the upper 10MHz portion that it planned to operate in tandem until it received "a clean bill of health" from the FCC. Though limiting the frequency band from the baseline system will cut LightSquared's broadband capacity, the company says it had planned to use a single block of frequencies in the first few years of operation anyway. Initial operations, pending go-ahead by the FCC, are planned for 2012. LightSquared says only 1% of the estimated 300-500 million GPS devices - mostly those used for high accuracy applications -- would be impacted under the alternative proposal. Included in the high accuracy receivers are units that the FAA uses for timing in its air traffic control function. Critics doubt that number however. "The [technical working group's] aviation sub-group reported that operation in this lower 10MHz channel 'could not be determined definitively to be compatible' with aviation GPS uses," says the Coalition to Save Our GPS. The GPS advocacy group says the TWG's results show that "well over 50% of all GPS receivers tested would still suffer harmful interference from the lower 10MHz channel." The FAA and others says more analysis and testing is needed to understand the impact on aviation receivers under the alternative plan. Sentiments from both advocates and critcs are being submitted to the FCC as part of an ongoing public comment period on the technical report. As of 28 July, more than 2,000 comments had been posted. The FCC plans to end the comment period on 30 July and make a further determination on the LightSquared proposal after evaluating the input. http://www.flightglobal.com/articles/2011/07/29/360154/faa-weighs-in-on-lightsquared- alternate-plan.html Back to Top MTSU to master aviation safety with new degree program Partners with nonprofit to create master's track MURFREESBORO - Aviation security and safety - how to make airports and passengers safe - is one of the hottest topics in the area. To address the need for qualified personnel in this area, MTSU is beginning a new master's degree program this fall. And to do so, the university is collaborating with National Safe Skies Alliance. A representative of the Alcoa-based nonprofit organization signed an agreement Thursday morning with MTSU to work together to make the university the first in the state to offer a master of science degree in aviation safety and security. "National Safe Skies Alliance, through its independent and impartial testing of aviation- security systems and processes at airports, provides an important role in helping to strengthen and refine security measures in place throughout the nation," said Sidney McPhee, president of MTSU, before the signing. "MTSU's decision to leverage its considerable aerospace educational resources into a master's program in this discipline, and the willingness of Safe Skies Alliance to partner with us and strengthen the offerings to our students, are both mutually beneficial and in the public interest." Scott Broyles, president and CEO of the National Safe Skies Alliance, told The DNJ that Thursday's signed memorandum of understanding will provide the support his organization has in the aviation-security industry to the development of the aviation- security concentration at MTSU. National Safe Skies is a nonprofit organization formed in 1997 to support testing of aviation-security technologies and processes. With funding through the FAA and coordination support from the Transportation Security Administration, Safe Skies conducts third-party, independent tests and evaluations of technologies that have the potential for security applications at airports. Tests are conducted both operationally at airports around the country and pre- operationally at its facilities in Alcoa in East Tennessee. "What (this agreement) does for our (new master's degree) program is that instead of them sitting in a classroom for the entire two years and getting lectures on issues of safety and security at United States airports, they can now do internships at National Safe Skies to actually get first-hand, on-the-job experience of what it is like to be testing some of the new security technology," said Wayne Dorman, chairman of the Aerospace Department. The master's of science in aviation safety and security management will be the second master of science program offered by the department, he added. Currently, the university offers a master's in aerospace administration program. The aviation and security management master's degree program was applied for through the Tennessee Board of Regents last year and was approved in the spring. Courses in the major are expected to begin in the fall. "We anticipate we may have a handful of students that may start the program in the fall," Dorman said. "We anticipate it's going to become a very popular master's degree program." The university's relationship with National Safe Skies Alliance will also benefit the nonprofit. "I think working with our students in aviation-security management will create a pipeline for them," he said. "They are a growing company and are going to need our students." The new master's program is a complement to the undergraduate major at MTSU in Aerospace Administration, Dorman added. http://www.dnj.com/article/20110729/BUSINESS/107290322/MTSU-master-aviation- safety-new-degree-program Back to Top Air Safety Means Taking a Tougher Stance on Controllers' Blunders By the Editors (Bloomberg) Jul 28, 2011 - Editorial Visit the Federal Aviation Administration's website, and you will be greeted by a short video in which the U.S. agency urges pilots, mechanics, suppliers and aircraft builders to be mindful of passengers' lives. "We all have to make a commitment to put safety first," declares FAA Administrator Randy Babbitt. In important ways, though, that commitment is fraying. The FAA employs 15,600 air-traffic controllers, who ensure safe, orderly movement of aircraft through U.S. airspace. These are coveted positions, paying an average of $136,000 a year. Applicants must pass an eight-hour exam and undergo as much as four years of on-the-job development before being fully certified. Periodic drug and alcohol testing comes with the job. The FAA's financing is currently tied up in Congress over a political dispute about how to tally union votes. That momentary controversy masks deeper concerns about controllers' on-the-job accountability. In theory, when controllers make mistakes, they can be fired. Reality turns out to be much more troubling. A Bloomberg News investigation found that within the past two years, the FAA has attempted to fire 140 controllers and other air-traffic workers, only to end up rescinding, reducing or deferring penalties in 40 percent of the cases. Drug and alcohol violations are especially unlikely to lead to firings. In two-thirds of those cases, employees have kept their jobs or been allowed to retire with their benefits intact. Remember the uproar in April, when it emerged that FAA controllers in Miami, Seattle and Knoxville, Tennessee, had been napping on the job? Transportation Secretary Ray LaHood made headlines by vowing to fire sleeping controllers. So far, that has been an empty threat. The Seattle case is pending. The Knoxville worker retired. And the Miami controller still works for the FAA after the proposed termination was reduced to a lesser penalty. Deadly Crash Even more astonishing is the aftermath of an August 2009 crash between a single- engine plane and a helicopter over the Hudson River, near New York City. In the minutes before that crash, the controller who should have been advising the plane's pilot was on the phone, joking with an airport worker about how to grill a dead cat. That accident killed nine people. Safety investigators said the controller was distracted and partly to blame. The FAA tried to fire that controller, who instead has been suspended, transferred and demoted. He still works for the FAA. Controllers enjoy two forms of job protection. They can challenge disciplinary penalties through a government panel called the Merit Systems Protection Board. They can also invoke 15 pages of provisions in their union contract, letting them appeal sanctions to an arbitrator. Some disciplinary proceedings can stretch out for years. Rare Opportunity Next year, the U.S. government will have a rare opportunity to fix this mess. The union contract covering air-traffic controllers expires Sept. 30, 2012. If the FAA or its parent body, the Transportation Department, wanted, they could take aim at contract language that makes it unusually difficult to fire controllers whose conduct is a menace to public safety. LaHood was asked this spring whether he wanted to seek changes in the controllers' contract. He said he hadn't considered it. But he should. In an age of straitened government, the FAA is in a great position to demand more from its controllers. Thousands of qualified candidates -- including military veterans who have handled air traffic in Iraq and Afghanistan -- are vying for just 829 controller openings this year. The next contract should be written so that public safety and controllers' accountability are paramount. If that means picking a fight over the contract's drawn-out grievance and arbitration process, then LaHood should do so. Back to Top ABA TIPS Aviation and Space Law Committee Presents "The Call: Aviation Disaster Preparedness and Crisis Response" When: September 6, 2011 @ 2:00 - 3:30 p.m. EDT Format: Teleconference As the 10-year anniversary of the September 11, 2001 terrorist attacks approaches and we reflect on the impact that the attacks have had on the aviation industry, it is reminder to everyone involved in the aviation community to ensure that they are prepared to respond to an aviation disaster, whatever the cause. Despite the industry's best efforts, aviation disasters do occur, and in today's world of 24-hour news coverage, the internet, and social media, companies cannot afford to be caught unprepared when disaster strikes. Mistakes, miscues and miscommunication can be devastating for companies in the aftermath of an aviation accident, large or small, and proper crisis response and management is critical. On September 6, 2011, from 2:00 p.m. to 3:30 p.m. EDT, the ABA TIPS Aviation and Space Law Committee will present a teleconference as part of a TIPS Initiative on Disaster Preparedness & Response that will provide an industry insider's view on how the various industry sectors prepare for, and respond to, an aviation disaster. What are best practices for air carriers and corporate flight departments in performing emergency drills? What role does the insurer play in preparation and emergency response? What are the major concerns regarding assistance to families and victims of an accident? How can small businesses utilizing general aviation aircraft best prepare for an accident and what will be expected of them post-accident? What media issues do the various involved entities face? To discuss these issues, and many others, a panel of experienced industry leaders will moderated by the September 11th litigation defense liaison counsel, Desmond T. Barry, Partner, Condon & Forsyth LLP. He will be joined by Marc Moller, Partner, Kreindler & Kreindler LLP, Steve Predmore, Vice President & Chief Safety Officer, JetBlue Airways, Erik Grosof, Assistant to the Director-Operations NTSB-Transportation Disaster Assistance, Ellyn Slow, Senior Vice President, Risk Management, NetJets, David Nelson, AVP, Claims Manager, Global Aerospace, Inc., and Matt Barkett, Managing Director, Dix & Eaton. To register for this teleconference, click here. Visit the Pages section of this blog to view information about all the teleconferences or go to the TIPS Disaster Initiative page for information about all the upcoming programs. Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC