Flight Safety Information November 2, 2011 - No. 225 In This Issue Investigators blame pilot error in Russian jet crash Poland: Jet Lands on Its Belly 737 Cracks Prompt More Frequent Checks Nigeria Accuses Europe Of Double Standards FAA mandates Rolls-Royce AE3007 compressor checks Amsterdam Airlines ceases operations Lewis University professor earns national recognition for aviation safety work $25 million lawsuit filed in Reno air race crash Exploding battery injures airport worker AI Defers Pilot's Training Programme to Fly Boeing 787 Investigators blame pilot error in Russian jet crash that killed entire ice hockey team MOSCOW (AP) - A Russian jet crash that killed 44 people, including an entire professional ice hockey team, was caused by pilots inadvertently putting on the brakes during takeoff, investigators said Wednesday, blaming poor crew training and lax oversight. The Interstate Aviation Committee said the Sept. 7 crash of the Yak-42 plane near the city of Yaroslavl in central Russia occurred because one of the pilots accidentally activated the brakes during takeoff and then pulled the plane up too sharply in a desperate attempt to take off. It was one of the worst aviation disasters ever in sports, shocking Russia and the world of hockey, as the dead included 36 players, coaches and staff of the Lokomotiv Yaroslavl hockey team. The only player who survived the crash later died of burns. A flight engineer was the sole survivor. Alexei Morozov, who led the investigation, said the crew still had enough time to abort the takeoff safely at the moment when they realized that it had gone wrong. He blamed the plane's owner, Yak-Service, for failing to observe safety standards and adequately train the crew. The company was closed in September by Russia's federal aviation authority following a check that found severe violations. "The company practically lacked a proper system of flight oversight and controls over air safety," Morozov said. Morozov said that both pilots had flown another type of plane with a slightly different cockpit layout and apparently had never learned the correct position for their feet on takeoff. He said in the Yak-42, like virtually all other existing Russian and Western planes, a pilot steers the aircraft by pressing the lower part of pedals and activates the brakes by pressing their upper part. But instead of putting their heels on the cockpit floor as regulations require, the crew left their feet resting on the pedals, inadvertently activating the brakes and slowing the plane down on takeoff. They at first didn't notice they were putting on the brakes, and then made the fatal mistake of failing to abort the takeoff, he said. Morozov added that a medical condition of the second pilot, and the prohibited medicine he had taken contributed to the disaster. He said the pilot's illness had passed unnoticed during an official medical certification, but had been diagnosed by private doctors whom the pilot had consulted on his own initiative. The plane was already past half of the long, 3,000-meter (9,900 feet) runway, when the crew tried and failed to lift it. They then weighed on the steering wheel trying to lift the plane and at the same time applied even more pressure on the brakes. The jet sped past the runway and ran 400 meters (1,320 feet) onto the grass before finally taking off. It went up so sharply that it banked on its wing and crashed on the side of the Volga River, 150 miles (240 kilometers) northeast of Moscow. The team had been heading to Minsk, Belarus, to play its opening game of the Kontinental Hockey League season. Among the dead were Lokomotiv coach and National Hockey League veteran Brad McCrimmon, a Canadian; assistant coach Alexander Karpovtsev, one of the first Russians to have his name etched on the Stanley Cup as a member of the New York Rangers; and Pavol Demitra, who played for the St. Louis Blues and the Vancouver Canucks and was the Slovakian national team captain. Other standouts killed were Czech players Josef Vasicek, Karel Rachunek and Jan Marek, Swedish goalie Stefan Liv, Latvian defenseman Karlis Skrastins and defenseman Ruslan Salei of Belarus. The crash raised new concerns about Russia's aviation safety and prompted the president to suggest replacing all aging Soviet-era aircraft with Western-made planes. But industry experts say that recent air disasters have been rooted not simply in planes' age, but in a combination of other factors, including insufficient crew training, crumbling airports, lax government control and widespread neglect of safety in the pursuit of profits. ********* Pilot's inadvertent braking led to Yak-42 crash Russian investigators have determined that a pilot of the Yakovlev Yak-42 which crashed on departure from Yaroslavl had inadvertently been braking during the take-off roll. The inquiry found that the crew had accumulated extensive flight time on the smaller Yak-40 in which, said the Interstate Aviation Committee (MAK), techniques include using feet to cover the brake in case of rejected take-off. But the pedal design on the Yak-42 is different. MAK said there had been "negative transference" of pilot skills, regarding foot position, by the crew. The aircraft, bound for Minsk on 7 September, failed to rotate and overran, hitting an antenna before crashing in a river. MAK has criticised "serious shortcomings" in the training of the crew, as well as the management of safety at the carrier, Yak Service. MAK said the organisation of the airline "did not allow" it to perform safe flight operations. The airline nevertheless passed regulatory compliance tests earlier this year. Only one of the 45 occupants - including an entire high-profile ice-hockey squad - survived the accident, and investigations concentrated on a braking force which had emerged during the take-off roll. The inquiry found that in the history of Yak-42 operations, amounting to 1.2 million flights, there had been only five cases of brake failure, and that none of these was similar to the Yaroslavl accident. MAK said the parking brake was off, and added that the chances that a technical failure could lock the main wheels spontaneously was "virtually impossible" given their design. The aircraft had been carrying sufficient fuel for the flight, its weight and balance were within limits, and there was no evidence of failure in the engines or aircraft systems - including jamming of the elevator. Control and stability was in line with the type's characteristics, said MAK, and the crew checked that the rudder and ailerons were responding correctly to control inputs. MAK found that the crew had not performed a correct take-off calculation, citing the V1 speed as 102kt rather than 113kt. The inquiry also said that the crew did not decide to abort the take-off despite the failure to rotate. Source: Air Transport Intelligence news Back to Top Poland: Jet Lands on Its Belly (AP) An airliner carrying 231 people from the United States landed on its belly on Tuesday in Warsaw after its landing gear failed to open, triggering sparks and small fires. No one was hurt on the flight on the national commercial airline, LOT, but some passengers sobbed as they prayed for a safe landing. The Boeing 767 had flown from Newark. Polish LOT Airlines Boeing 767 Plane Crash Landing - Gear Up Belly Runway Landing 11-01-11 Back to Top 737 Cracks Prompt More Frequent Checks The FAA has issued an airworthiness directive (AD) requiring earlier and more frequent fuselage inspections of a specific area on some Boeing 737-300, -400 and -500 series aircraft after a report of two similarly situated cracks that went through the frame and fail-safe chord. "We are issuing this AD to detect and correct cracking in the fuselage frames and frame reinforcements, which could reduce the structural capability of the frames to sustain limit loads and result in cracking in the fuselage skin and subsequent rapid depressurization of the airplane," the FAA says in AD 2011-23-05, issued on Nov. 1. The directive affects 605 U.S.-registered aircraft and is effective as of Nov. 16, the FAA says. The new AD supersedes AD 2009-02-06 RI, which requires repetitive inspections for cracking of the 1.05-inch nominal diameter wire penetration hole in the frame and in the frame reinforcement, between stringers S-20 and S-21, on both the left and right sides of the airplanes. The 2009 directive resulted from reports of cracking in the frame, or the frame and frame reinforcement, common to the penetration hole intended for wire routing, and followed a December 2007 Boeing Alert Service Bulletin on the same issue. Since that 2009 directive, the FAA says, it has received a report of four adjacent cracked frames in the forward cargo compartment between S-20L and S-21L on a 737-300. Two of the cracks went completely through the frame and fail-safe chord. The cracks were discovered when the aircraft had accumulated 44,535 flight cycles and 44,876 flight hours-before the compliance time required by the earlier directive. That discovery led Boeing in September to revise its service bulletin to shorten the compliance time for the initial inspection to 30,000 cycles and to reduce the repetitive interval from 14,000 cycles to 4,500. The directive adopts the initial inspection revision. It also requires reinspections within 4,500 flight cycles, with a grace period of 90 days. Airlines have up to 90 days to inspect aircraft that already have accumulated more than 40,000 cycles. http://www.aviationweek.com/aw/generic/story_channel.jsp?channel=mro&id=news/avd/2011/11/02/02.xml&headline=737%20Cracks%20Prompt%20More%20Frequent%20Checks Back to Top Nigeria Accuses Europe Of Double Standards Nigeria's head of civil aviation is accusing Europe of using safety blacklists as a mechanism for unfair competition and he also says many of the air accidents that occur in Africa are due to foreign registered aircraft or aircraft operating there illegally. The U.S. FAA has a system where if it deems that a country is unsafe, it bans all airlines from that country and it also prevents U.S. carriers from operating there, noted Nigerian Civil Aviation Authority Director General H.O. Demuren, but the Europeans only ban the airlines from the blacklisted country while allowing European airlines to continue flying there. When Europe blacklists an African nation, European carriers immediately boost flights there to fill the void left by the African carriers, Demuren told delegates yesterday at the Flight Safety Foundation's Air Safety Seminar in Singapore. If the Europeans really believed a country was unsafe, then they should prevent all airlines from flying there, he said, adding that "there are people using safety for commercial advantage....If a place is unsafe, let's shut it down and work together to improve it." Africa has a far higher air accident rate than many other regions of the world. But Demuren said many of Africa's air accidents actually involve foreign registered aircraft. Some countries recognize foreign air operator certificate (AOC) holders. Demuren says problems arise because the African regulator may then fail to properly regulate those foreign AOC holders, many of which come from former Soviet states. He also says an issue that Africa faces is that some people are able to get away with operating aircraft in Africa illegally, because they base themselves in war-torn African countries. Demuren says the Nigerian CAA is pushing for greater regional cooperation to help ensure no African nation is left behind when it comes to safety. He says the Nigerian CAA has been helping poorer neighboring nations by, for example, sending Nigerian aircraft safety inspectors there to assist. It is in Nigeria's interest to do this, because airlines from those nations may end up flying to Nigeria, he adds. Another challenge African civil aviation authorities face is political interference. "Many director generals of civil aviation have been removed [in Africa] for standing up for safety," said Demuren, adding that it is important that there be "safety regulation with no political interference." http://www.aviationweek.com/aw/generic/story_channel.jsp?channel=comm&id=news/avd/2011/11/02/01.xml&headline=Nigeria%20Accuses%20Europe%20Of%20Double%20Standards Back to Top FAA mandates Rolls-Royce AE3007 compressor checks Operators of an estimated 616 US-registered aircraft powered by Rolls-Royce AE3007 engines will be required to perform initial and recurring compressor checks on the turbofans to prevent possible uncontained engine failures under an airworthiness directive (AD) to be issued by the US FAA on 2 November. Along with a variety of business jets and military aircraft, the AE3007 powers the Embraer ERJ-135/140/145 twinjet family. The AD, set to become effective on 17 November, will require an eddy current inspection of the outer circumference on the hub wheels of the sixth through 13th stages of the 14-stage compressor in search of cracks. The FAA said it received "reports of low-cycle fatigue cracks" on the parts during shop visits. The problem, flagged up by Rolls-Royce in June through an alert service bulletin, has been found on wheels having both chrome-carbide coated knife edge seals as well as those without the coating. "These cracks can deteriorate the integrity of the compressor wheel by lengthening into the outer circumference of the wheel," said the FAA in an advance copy of the final rule. "This condition, if not corrected, could result in uncontained failure of the 6th-13th stage compressor wheel, leading to damage to the airplane." Along with an initial inspection, the timing of which is function of the number of engine cycles since new and the knife edge seal coating, engines must receive a follow-up inspection every 5,000 cycles. Wheels found to be damaged must be replaced. Highest time engines, those with more than 18,185 cycles and using chrome-carbide coated knife edge seals must be inspected with 15 cycles. The FAA estimates that the inspections and potential wheel change outs will cost US operators more than $36 million. The FAA in 2009 issued an emergency AD requiring inspections on the two-stage high pressure turbines for the AE3007 based on reports of cracks being found. Source: Air Transport Intelligence news Back to Top Amsterdam Airlines ceases operations Dutch charter carrier Amsterdam Airlines has ceased operations after finding itself under increased authority supervision due to previous regulatory violations. The Amsterdam-based airline notified the Dutch transport ministry, Inspectie Verkeer en Waterstaat (IVW), yesterday that it had stopped all operations because it was unable to provide "normal flight services", said a spokeswoman for the administration. The carrier had already been under extra supervision by the authority "for several months", because its quality management system and log files were not in line with regulations, she added. What finally led the company to stop its operations, however, was not clear, she said. The authority has started the process of suspending its air operator's certificate permanently. Technically, the carrier is entitled to rectify the problems within three months and have the license reinstated. However, the authority is not aware what the company's plans are, the spokeswoman said. Amsterdam Airlines operated three Airbus A320s, according to Flightglobal's ACAS database. Two of these are leased from International Lease Finance Corporation and powered by International Aero Engines V2500 powerplants, while the third one is equipped with CFM International CFM56 engines and owned by AerCap subsidiary AerCo. The airline could not be immediately reached for comment. Source: Air Transport Intelligence news Back to Top Lewis University professor earns national recognition for aviation safety work Dr. Randal J. DeMik, director of graduate studies in Aviation and Transportation at Lewis University, was awarded the John K. Lauber Award for Aviation Safety. DeMik recently received the award at the University Aviation Association Fall Education Conference in Indianapolis. The award is given in honor of John K. Lauber, a pioneer in the field of aviation safety and human factors. Each year, it is given to an individual or organization, who demonstrates clear advancement in aviation safety. The UAA is a non-profit organization and the voice of collegiate aviation that represents the aviation industry, government and general public. DeMik was invited to be a member of the Aviation Rulemaking Committee, which convened in Washington D.C. to report on policies critical to airline safety and collegiate aviation training from the ARC. He also addressed the 2010 UAA conference in St. Paul, Minn. DeMik's aviation safety work includes over 28 years and 18,000 hours of accident- and incident-free aviation experience including 20 years as a pilot with United Airlines. He served as Line Check Airman for United Airlines from 2005-2009 where he trained United Captains and First Officers and evaluated their ability to operate the Boeing 737 in order to provide safer airline service. Among the many articles he has published, he co-authored an article in the International Journal of Applied Aviation Studies regarding human factors and safety issues for regional airline pilots. In 2008, DeMik completed his doctorate work in the field of Technology Management at Indiana State University. As director of graduate studies in Aviation and Transportation at Lewis University, DeMik has developed and taught graduate courses focusing on the theory and practice of Safety Management System in the aviation industry. Lewis University is a Catholic university offering distinctive undergraduate and graduate programs to nearly 6,500 traditional and adult students. Lewis offers multiple campus locations, online degree programs, and a variety of formats that provide accessibility and convenience to a growing student population. Sponsored by the De La Salle Christian Brothers, Lewis prepares ethically grounded, globally aware, and socially responsible graduates. The ninth largest private not-for-profit university in Illinois, Lewis has been nationally recognized by The Princeton Review and U.S. News & World Report. Visit http://lewisu.edu for more information. http://triblocal.com/romeoville/community/stories/2011/11/lewis-university-professor-earns-national-recognition-for-aviation-safety-work/ Back to Top $25 million lawsuit filed in Reno air race crash A Texas physician who lost her husband when a vintage plane crashed into the tarmac at the Reno National Championship Air Races, killing 11 and injuring about 70, filed a $25 million wrongful death lawsuit Tuesday in Texas state court. The suit, the first to be filed after the Sept. 16 crash, claims the Reno Air Racing Association's conduct was "motivated out of a drive for profit and a disregard for safety" making it guilty of negligence. The suit was filed in the Collin County, Texas, District Court by Houston-based lawyer Anthony Buzbee on behalf of Dr. Sezen Altug, wife of Craig Salerno, who was killed instantly in the Sept. 16 crash. "It's pretty obvious that the promoters of this event realized it was dangerous and even though they were involved in inspecting the aircraft, they did not take adequate precautions to protect spectators, or let the spectators know what the real risks were," Buzbee said. Reno Air Racing Association chief executive Michael Houghton said he had not seen the suit and could not respond in depth. "We're still dealing with the emotional tragedy that took place in September, and lawsuits were not unexpected," said Houghton. "Until we can read it, I can't say much more." He said his condolences go out to Salerno's family. "I can't understand what the contentions in the suit might be," he said, "It will be up to the courts to determine the validity of the claims." Besides the air racing association, the suit also names pilot Jimmy Leeward, who was killed in the crash, his Ocala, Fla.-based racing team called Leeward Air Ranch, Texas-based mechanic Richard Shanholtzer of Frontier Aviation, Aeroacoustics Inc. and Aero-Trans Corp., the owner of the Galloping Ghost. The Leeward Air Ranch, Shanholtzer, Aeroacoustics and Aero-Trans Corp. could not immediately be reached for comment. Salerno, 50, of Friendswood, Texas, was a private pilot, volunteer firefighter and worked as a dispatcher for Continental Airlines, according to Buzbee. He had been invited by friends to sit in the box-seat section to watch the races, and was there when the modified P-51 Mustang lost control and slammed into the tarmac at about 400 mph, the suit said. Salerno is survived by his wife, Altug, and an 8-year-old daughter and 6-year-old son, Buzbee said. The National Transportation Safety Board began its investigation into the cause of the crash immediately, but its final report may not be complete until next year. NTSB investigators in Reno noted that photographs showed that a piece of the airplane's tail piece had fallen off before the crash. The elevator trim-tab keeps the plane flying level. The P-51 Mustang had just rounded the final pylon when it pitched up, before rolling to the right and then went nose-first into the tarmac. Buzbee said they filed the suit now because the NTSB has named the race promoter and the Federal Aviation Administration as parties in the case, and is allowing them to participate in the investigation. Buzbee said they want to be sure that the victims have a voice in that probe. He said he voiced his concerns in a letter to the NTSB, and said the next step was to file a lawsuit to be sure they are included in any decisions made. "It is flat out wrong to allow a private company whose entire viability may hinge on an investigation to participate as a party in that investigation," Buzbee said. "We hope (the NTSB) realizes that people are watching." The P-51 Mustang has a history of fatal crashes, the suit said, and there is "a long history of senseless mishaps, injuries and death at air shows in the United States and all over the world," the suit said. "The Reno air crash was the third-deadliest in U.S. history." The suit said that the air race association knew that there had been deaths at previous air races but "did not inform those wishing to purchase tickets, ticket holders or spectators of those deaths," the suit said. The association also knew about previous P-51 crashes, and problems the P-51 had at prior air race events, but didn't warn spectators, the suit said. "Defendant RARA was aware that the racing planes would be flying at speeds in excess of 500 mph, wing to wing, little more than 100 feet from the ground and that this would create a great risk of danger to spectators," the suit said. But the association did not tell spectators of those risks, the suit said. The association did not "take adequate precautions to ensure spectator safety," the suit said. and the people involved in modifying the Galloping Ghost did not adequately test the airplane to ensure its safety, the suit said. http://www.rgj.com/article/20111101/NEWS/111101026/First-lawsuit-filed-Reno-Air-Races-crash?odyssey=nav%7Chead Back to Top Exploding battery injures airport worker Baggage handler at Chicago's O'Hare International Airport hospitalized CHICAGO - A baggage handler at O'Hare International Airport was hospitalized on Tuesday after a small explosion believed to be caused by an exploding battery, officials said Tuesday. Fire officials believe that a battery being shipped in a container exploded while being handled by a United Airlines baggage handler, according to Chicago Fire Department spokesman Will Knight. A Chicago Police Department spokesman said the package fell and hit the baggage handler. "It was very minor," said Karen Pride, a spokeswoman for the Department of Aviation. "There was no criminal activity." Chicago Fire Department spokesman Richard Rosado said the handler's injuries were serious but not life-threatening. Rosado said the battery was in a small carrying case. "It overheated and it exploded," Rosado said. http://today.msnbc.msn.com/id/45121888/ns/today-travel/t/exploding-battery-injures-airport-worker/ Back to Top AI Defers Pilot's Training Programme to Fly Boeing 787 Air India has deferred a training programme for its pilots to fly the latest Boeing 787 Dreamliner aircraft by about a month following protests by a section of its cockpit crew, airline officials said today. While two pilots are already undergoing training in Singapore, the programme to train the rest of the first batch of 16 pilots was scheduled from tomorrow at Gatwick in the UK and the southeast Asian city state, they said. The entire batch of pilots, barring the two who are already undergoing training, have been called back, they said. While an AI spokesperson said the postponement of the training schedule by a month was due to the winter schedule and requirement of pilots for possible foggy weather, the airline informed the Bombay High Court that it had been deferred as negotiations on the issue were going on with the Indian Pilots Guild (IPG). A Boeing 787 simulator would be installed in Mumbai by January end next year after which the airline would be able to launch in-house training for the Dreamliner pilots, the officials said. Duration of training would be about a week-and-a-half for pilots trained to fly a wide-body Boeing 747 or 777, while those who have been operating the Airbus type would require about three weeks, they said. The protesting pilots, owing allegiance to the IPG which represents the cockpit crew of the erstwhile AI, have charged the management with adopting discriminatory attitude in the training schedule against them vis-a-vis their erstwhile Indian Airlines counterparts. They have been contending that the experience of Indian Airlines pilots was less than their's on Boeing wide-bodied planes and the management should not adopt a policy to have equal number of pilots from both the erstwhile carriers for the 787 training. Only AI pilots should be assigned duty on these new advanced aircraft, according to IPG. While the first Dreamliner is slated to be inducted in the AI fleet in December, airline officials said the postponing of the training schedule would not delay the aircraft's induction as an average of 16 days was required for training of pilots for the new plane which is made of composite materials. Government is yet to take a decision on whether to allow AI go ahead with its original plan to acquire 27 Dreamliners or slash the order to 14. It would also have to decide whether to allow the airline to purchase these planes or have a sale-and-lease back arrangement, given its precarious financial position. A Group of Ministers, headed by Finance Minister Pranab Mukherjee, is to decide on these crucial issues before the Union Cabinet takes them up. In Mumbai, Air India informed the high court that the 787 training schedule had been deferred till the month end as negotiations were on with the IPG over the issue. The court was hearing a petition of IPG which challenged the management's decision to draw equal number of pilots from the erstwhile AI and Indian Airlines to train them for the 787 planes. IPG claims such a schedule goes against a December 2006 agreement it had reached with the management. Over the past few days, Air India has been grappling with fresh turbulence with talks between protesting pilots and the management failing to make much headway. Operations of budget carrier Air India Express has been affected with the cancellation of 13 flights over the past week with 23 of its cockpit crew, on deputation from the erstwhile Air India, reporting sick. Last week, 101 AI pilots, owing allegiance to IPG, sent a signed letter to the management threatening to quit, saying they were "compelled to seek a no-objection certificate so that we may consider seeking employment elsewhere". The IPG represents around 200 pilots of the pre-merger Air India, while the Indian Commercial Pilots Association that had gone on strike in April-May this year represents around 1,400 pilots of the erstwhile Indian Airlines. http://news.outlookindia.com/items.aspx?artid=740195 Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC