Flight Safety Information May 30, 2012 - No. 108 In This Issue Planes in Fatal Crash Owned by Aviation Agencies' Employees French investigator to release final report into deadly 2009 Air France crash on July 5 Safe Air fined over employee death Aircraft safety: Experts call for independent inquiry into Bhoja Air crash Racing the Storm: The 1999 Crash of American 1420 PRISM CERTIFICATION CONSULTANTS Cyber-attack concerns raised over Boeing 787 chip's 'back door' GULF FLIGHT SAFETY COMMITTEE AGM - DUBAI 6 JUNE 2012-05-21 ISASI regional meeting in the Middle East (Abu Dhabi) 2012 US/Europe International Aviation Safety Conference...June 12-14, 2012 ISASI - 2012, August 27-30 Planes in Fatal Crash Owned by Aviation Agencies' Employees By Alan Levin (Bloomberg) U.S. aviation accident investigators have obtained help from Canada to investigate a collision yesterday between two small planes that were owned by employees of separate federal aviation agencies. A plane owned by a National Transportation Safety Board employee collided over Sumerduck, Virginia, with another small aircraft owned by a Federal Aviation Administration employee, according to an e-mail release from the NTSB. Two people in the NTSB employee's plane died, the release said. The sole occupant of the FAA-owned plane, Thomas Proven, survived the collision, Corinne Geller, a spokeswoman for the Virginia State Police, said in an interview. Proven, 70, works as an accident investigator with the FAA, the agency said in an e-mail statement. He was off duty at the time of the accident, according to the statement. The Virginia Office of the Chief Medical Examiner didn't respond to a call seeking the identity of the NTSB employee and the second occupant of the plane. Because the accident involved U.S. government employees, NTSB Chairman Debbie Hersman, after consulting FAA acting Administrator Michael Huerta, asked the Transportation Safety Board of Canada to handle the investigation, the agency said in the release. The NTSB, an independent agency that reports directly to the White House, determines the cause of aviation accidents and makes non-binding safety recommendations. The FAA regulates the aviation industry. Back to Top French investigator to release final report into deadly 2009 Air France crash on July 5 PARIS (AP) - French investigators say the final report into the causes of the crash of Air France flight 447 will soon be published, three years after the jet went down in the mid- Atlantic killing all 228 people aboard. France's accident investigation agency, or BEA, said in a statement Wednesday that the final report will be released at a news conference on July 5. A preliminary report released last July highlighted a chaotic cockpit scenario before the crash, with a confused crew getting incoherent speed readings from faulty sensors, but it didn't draw a conclusion on whether pilot error, equipment failure or other unknown factors caused the crash. The Airbus 330 passenger jet flying from Rio de Janeiro to Paris crashed on June 1, 2009 Back to Top Safe Air fined over employee death A Safe Air employee was sucked into the engine of a plane he was servicing A subsidiary company of Air New Zealand has been fined $56,000 after an employee died when he was sucked into an engine. Safe Air - which specialises in aviation maintenance and repair - has also been ordered to pay more than $20,000 reparation following the accident in Blenheim last August. Two employees were servicing the engine at Woodbourne Airfield when one walked in front of it, past the air intake, without holding onto the handrail, Blenheim District Court was told. The Department of Labour says a proper safety guard should have been put in place and may have prevented the accident. Read more: http://www.3news.co.nz/Safe-Air-fined-over-employee- death/tabid/423/articleID/256116/Default.aspx#ixzz1wM3ygP71 Back to Top Aircraft safety: Experts call for independent inquiry into Bhoja Air crash "Independent experts should be made part of the investigations," SASI president said. KARACHI: The Society of Air Safety Investigators (SASI) Pakistan has expressed serious concern over the ongoing investigation into the Bhoja Air crash in which 127 people lost their lives. The investigation being carried out by the Civil Aviation Authority (CAA) cannot be impartial as it is responsible for safety of aircraft using the country's airspace, said Syed Naseem Ahmed, the president of SASI Pakistan on Tuesday. "Independent experts should be made part of the investigations," he said. "They don't necessarily have to be from SASI Pakistan but qualified people with experience in dealing with aircraft crashes." SASI Pakistan has recently been established as an NGO to lobby for better safety of the aircraft flying in the country. It has five members who are affiliated with the International Society of Air Safety Investigators. Ahmed said recent air crashes have worsened Pakistan's air safety record. "We need to make sure that recommendations made by the investigators are implemented." Without naming anyone, he said that no one was qualified in the CAA team investigating the causes of Bhoja Air's Boeing 737-200 crash. Ahmed was flanked by about half a dozen families of the passengers who lost their lives. FIR Criminal charges against Arshad Jalil, the managing director of Bhoja Air, will further complicate matters for the families and won't assist the investigation, Ahmed said. Jalil, who also owns a majority stake in the airline, is refusing to come back to Pakistan, fearing arrest as a first information report (FIR) has been registered against him. Boeing SASI Pakistan's general secretary Air Commodore (retd) Rasheed Ahmed Bhatti said that Boeing officials should not be allowed to examine the evidence. "Boeing will always try to keep its name away from the crash," he said. "It is very easy to manipulate the evidence. They should not be made part of the investigation." Legal Adviser for SASI Pakistan Dr Abdul Razzaq said families were entitled to a minimum compensation of Rs5 million. "This amount is the no-fault liability, which an airline has to pay in any case," he said, citing the Carriage by Air Act 2012. The compensation does not come with any strings attach, he said. "Bhoja Air cannot force any family to sign pledges that they won't sue the airline, aircraft manufacturer or the suppliers for more compensation." Unfortunately, he said, Pakistan has yet to set a precedent where a court has awarded anyone compensation according to the worth of the individual as deemed fit by the family. http://tribune.com.pk/story/385878/aircraft-safety-experts-call-for-independent-inquiry- into-bhoja-air-crash/ Back to Top Racing the Storm: The 1999 Crash of American 1420 By Dan DePodwin, Meteorologist National Transportation Safety Board investigator Michael Kelly looks at the crash site of American Airlines Flight 1420 at Little Rock National Airport in this June 4, 1999 photo in Little Rock, Ark. A flight attendant on the plane told jurors Tuesday, May 17, 2005 at a federal trial in Little Rock that she never felt her life was in danger while Capt. Richard Buschmann flew American Airlines Flight 1420 from Dallas to Little Rock on June 1, 1999. The data for the following story was gathered from the official accident report issued by the National Transportation Safety Board. As the sun set on the first day of June in 1999, passengers of American Airlines Flight 1420 boarded an MD-82 aircraft in Dallas, Texas, destined for Little Rock, Ark. It was warm, the air humid and the stage set for disaster. A "Bowling Alley" Approach In springtime, cool, dry Canadian air races southward while sticky, sultry, warm air resides across the Deep South. When these two air masses clash, the stage is set for violent thunderstorms. These ingredients came together on June 1, 1999 across Arkansas as Flight 1420 flew towards Little Rock. Already delayed by poor weather in the Dallas area, Captain Richard Buschmann and First Officer Michael Origel were behind schedule and in danger of going beyond their allowed duty times. Prior to leaving Dallas, the crew was briefed on the developing thunderstorms in Arkansas, but believed they would be able to make it to Little Rock. While in the air, an American Airlines flight dispatcher informed the flight crew that storms were closing in on Little Rock, but a "bowling alley" of clear air still existed and recommended expediting their approach to avoid the weather. Just before 11:30 p.m. as Flight 1420 was about 30 minutes away from Little Rock, the airport weather observing station began reporting a thunderstorm. At this point, winds were still light, just 10 mph. In the cockpit, Buschmann and Origel began to feel the effects of the increasingly bad weather with turbulence and frequent lightning. The increased workload of landing in poor weather would take its toll. The "Bowling Alley" Closes-In As Flight 1420 was on final approach, the weather rapidly deteriorated and the "bowling alley" closed in. Visibility on the runway dropped below the minimum required for landing and winds increased above the acceptable limit. Yet the pilots, tired from a long day of work, did not decide to abandon the approach and go to their alternate airport. With lightning engulfing the plane, turbulence rocking it from side to side, and rain pelting the windows, the MD-82 touched down on the runway. Immediately, the plane began sliding, not losing speed. Despite applying the brakes, the plane continued through the end of the runway and careened into a steel walkway, coming to rest on the bank of the Arkansas River. Captain Buschmann was killed instantly while 10 other passengers perished in the crash; 134 people survived. The focus of the National Transportation Safety Board (NTSB) investigators quickly turned to the lack of braking and the weather. What they found would reveal a startling pattern in the aviation community. "Get There-Itis" and a Culture of Flying Through Storms After months of investigation, witness interviews and studies of pilot behavior in thunderstorms, the NTSB found that two out of three pilots would land in a thunderstorm. They were more likely to do so if it was nighttime, they were behind schedule, or if other planes had landed in front of them. This unsafe practice shocked many in the aviation community. It was also found that American Airlines had a vague policy about flight through thunderstorms. In response, more specific guidelines were adopted. The storm that hit Little Rock late in the evening on June 1 was a severe thunderstorm. Just after the fatal crash, a wind gust to 88 mph was reported at the airport-clearly unsafe weather to attempt a landing. However, the flight crew decided to land anyway. Lead NTSB investigator Greg Feith described the insistence of landing despite weather "get there-itis." But despite the poor weather, Flight 1420 had successfully landed. Why had the plane skidded off the runway without stopping? The key to unlocking this mystery was found on what was NOT heard on the cockpit voice recorder. There was no mechanical click signifying that the spoilers were armed. The spoilers aid in braking by disrupting flow of air over the wing. In addition, they reduce lift which allows the plane to put its full weight on the wheels. In the case of Flight 1420, the flight crew forgot to arm the spoilers to deploy upon landing. As a result, the pilots had extremely limited braking ability and could not slow the plane in time. In the aftermath of this tragic accident, the NTSB recommended numerous improvements in cockpit procedures, communication of weather forecasts and flight crew training. Despite the changes and lessons learned from June 1, 1999, weather continues to be a leading cause of aviation disasters. Incidentally, exactly 10 years later, Air France Flight 447 would vanish over the Atlantic Ocean, killing all 228 people on board--more on that fatal night coming soon. http://www.accuweather.com/en/weather-news/racing-the-storm-the-1999-cras/65789 Back to Top Back to Top Cyber-attack concerns raised over Boeing 787 chip's 'back door' Researchers claim chip used in military systems and civilian aircraft has built-in function that could let in hackers The Boeing 787 Dreamliner uses the Actel ProASIC chip that is troubling researchers. Photograph: Graeme Robertson for the Guardian Two Cambridge experts have discovered a "back door" in a computer chip used in military systems and aircraft such as the Boeing 787 that could allow the chip to be taken over via the internet. The discovery will heighten concerns about the risks of cyber-attacks on sensitive installations, coming on the heels of the discovery this week of the 'Flamer' virus which has been attacking computer systems in Iran, Syria and Saudi Arabia. In a paper that has been published in draft form online and seen by the Guardian, researchers Sergei Skorobogatov of Cambridge University and Chris Woods of Quo Vadis Labs say that they have discovered a method that a hacker can use to connect to the internals of a chip made by Actel, a US manufacturer. "An attacker can disable all the security on the chip, reprogram cryptographic and access keys ... or permanently damage the device," they noted. Woods told the Guardian that they have offered all the necessary information about how the hack can be done to government agencies - but that their response is classified. "The real issue is the level of security that can be compromised through any back door, and how easy they are to find and exploit," Woods said. The back door may have been inserted by Actel itself, whose ProASIC3 chip is used in medical, automotive, communications and consumer products, as well as military use. Woods said that "a back door is an additional undocumented featured deliberately inserted into a device for extra functionality" - in effect, a secret way to get into the chip and control it. Crucially, in this case it exists as part of the design of the silicon chip - meaning that it cannot be removed because it is inherent in how the chip reacts to certain inputs. He suggested that it may have been put there by design by Actel, because there are some traces of the existence of such a back door in the system files of Actel development software. But, he said, that creates serious risks: "The great danger comes from the fact that such a back door undermines the high level of security in the chip making it exposed to various attacks. Although Actel makes a big claim that their devices are extremely secure because there is no physical path for the configuration data to be read to the outside world, a back door was added with a special key to circumnavigate all the security set by themselves or one of their users." Connecting to the chips would be comparatively easy over the internet if the chip is wired to an internet-enabled controller, he said. Normally a special cryptographic key would be needed, but the back door does not need an encrypted channel. Among applications where the ProASIC3 are used are remote surveillance systems, drones, and for flight-critical applications on the new Boeing 787 Dreamliner. Actel did not respond to requests for comment by the time of publication. Rik Ferguson, director of security research at the online security company Trend Micro, said: "This kind of flaw that gives somebody access right into the device has inherent flaws. The fact that it's in the hardware will certainly make it harder - if not impossible - to eradicate. We're already seeing a steady flow of devices such as digital picture frames coming out of factories with malware already on them - but that's software which can be fixed. If you have this sort of flaw, then you need to replace the hardware, which means the chips." But suggestions that it is part of a cyber-attack by China, where the chip is made, have been discounted. "It was very likely done at the design stage," said Woods. "However, the traces left in the Actel development software suggest that this feature was well thought through from the very beginning." He doubts it is part of a Chinese state-sponsored sabotage attempt. Skorobogatov and Woods will present a paper on their findings at a conference in Belgium in September. http://www.guardian.co.uk/technology/2012/may/29/cyber-attack-concerns-boeing-chip Back to Top GULF FLIGHT SAFETY COMMITTEE AGM - DUBAI 6 JUNE 2012-05-21 The Gulf Flight Safety Committee, the regional aviation safety forum for the Gulf, will hold its annual general meeting at the Emirates Training Centre in Dubai from 0830 to 1630 on 6 June 2012. In addition to the annual appointment of the executive committee and other GFSC business, there will be the usual mix of incident reviews and industry debate, followed by some informative safety presentations. All existing members are urged to attend and take part in shaping the next steps for the GFSC, and others with an interest in regional safety matters and perhaps thinking of joining are welcome to attend on this occasion. Further information is available on the website www.gfsc.aero and queries should be directed to chair@gfsc.aero or to the current chairman Jo Gillespie jgillespie@gatesaviation.com . Sponsored by NEXUS Flight Operations Services in Jeddah, Kingdom of Saudi Arabia. Back to Top Back to Top 2012 US/Europe International Aviation Safety Conference June 12-14, 2012 Cleveland, Ohio USA Time is short but it is not too late to register for the 2012 US/Europe International Aviation Safety Conference scheduled June 12-14, 2012 at the Renaissance Cleveland Hotel. The FAA and the European Aviation Safety Agency (EASA) are joining forces for the advancement of aviation safety through global leadership. In keeping with the conference theme, "Maintaining the Course for International Collaborative Success", FAA and EASA are teaming with colleagues from civil aviation authorities around the world as well as international companies whose products and services contribute to the safety of air travel. Continuing the tradition of previous years, this conference will provide a forum for aviation safety leaders to share ideas and initiatives on international cooperation, harmonization, and emerging safety challenges. The conference will be of interest to government aviation standards, certification, operations, and maintenance personnel as well as representatives from both domestic and international aviation industries and associations. Deadline for registration is June 1, 2012. For more information on site and agenda, call or email Diane Migliori (202 385-8948; diane.migliori@faa.gov) or visit the conference website at: http://www.faa.gov/news/conferences_events/2012_us_eu. ********** 2012 US/Europe International Aviation Safety Conference June 12-14, 2012 Cleveland, Ohio USA Maintaining the Course for International Collaborative Success The FAA and the European Aviation Safety Agency (EASA) are again joining forces to advance aviation safety through global leadership at this year's International Aviation Safety Conference in Cleveland, Ohio, June 12-14, 2012. FAA and EASA look forward to teaming with colleagues from civil aviation authorities around the world and international companies whose products and services contribute to the safety of air travel. Continuing the tradition of previous years, this conference will provide a forum for aviation safety leaders to share ideas and initiatives on international cooperation, harmonization, and emerging safety challenges. Bill Ayer, Chairman and Chief Executive Officer, Alaska Airlines, has accepted our invitation to deliver the Keynote Address on the second day of the conference. Who Should Attend: * Government aviation standards, certification, operations, and maintenance personnel * Representatives from both domestic and international aviation industries and associations Conference Sessions Contact For more information, contact: Diane Migliori (202) 385-8948 diane.migliori@faa.gov Registration Hotel Cleveland Agenda Back to Top International Society of Air Safety Investigators presents ISASI 2012 "Evolution of Aviation Safety - From Reactive to Predictive" 43rd Annual Seminar Baltimore, Maryland Baltimore Marriott Waterfront Hotel August 27-30, 2012 Welcome to the World's Leading Aviation Safety Investigation and Accident Prevention Seminar Please join us in Baltimore where you will learn about the latest trends and practices in accident investigation and prevention. You will also have an opportunity to network with safety professionals from all walks of the international aviation community. For access to the seminar website and all up to date information please go to www.isasi.org. For Sponsorship and Exhibitor opportunities please contact Ron Schleede at ronschleede@cox.net or Barbara Dunn at avsafe@shaw.ca Curt Lewis, P.E., CSP, FRAeS, FISASI CURT LEWIS & ASSOCIATES, LLC