Flight Safety Information September 25, 2012 - No. 194 In This Issue 'Black Box' Expert Uncovers Airplane Crash Mysteries Pilots Say Controllers' Warnings Were Late NTSB names Clint Johnson, senior air safety investigator, to head Alaska regional office PRISM Certification Support Brazilian plane maker sees growing executive jet market in Africa Air France, the first major European airline to equip its pilots with iPad Accident Investigation for Aviation Management Cranfield University, UK...29 October - 9 November 20 'Black Box' Expert Uncovers Airplane Crash Mysteries At the National Transportation Safety Board (NTSB) James Cash has applied engineering expertise to solve some of the biggest aviation mysteries as the nation's expert on black box devices that record the voices of cockpit crews and other sounds that can help explain the cause of airplane crashes. As the chief technical advisor for the NTSB's Office of Research and Engineering, Cash has continually found ways to improve the quality of retrieved data, helped uncover key information and contributed to reforms leading to greater safety for the traveling public. "Jim has helped grow the science of cockpit recording devices. He's been here through the history of recording devices and has led the next generation of recorders," said NTSB Chairman Deborah Hersman. One of Cash's innovations involved designing specifications for cutting-edge voice analysis and transcription software that performs readouts and analysis of cockpit voice recorders and other audio devices. Cash's work also led to the development of software giving the NTSB the ability to extract and analyze recorder data from multiple accidents, which has helped the agency spot trends on safety issues. After a 1997 jetliner crash that killed 104 people, Cash pieced tiny fragments of damaged recording tape from black box devices. "We were able to develop a means of reading individual pieces, digitizing each piece of audio track and reassembling it. It was like gluing together a shredded document," he said. During another investigation, Cash analyzed a quarter second of noise to help determine why a 747 exploded 12 minutes after takeoff. He also has assisted in investigations into two space shuttle accidents and a nuclear submarine collision, and helped the Drug Enforcement Administration analyze GPS data from a vehicle in which agents had been killed in Mexico Cash said that the ultimate goal of his work is to contribute important information that will save lives and prevent future accidents. "You've got to figure out what happened this time before you have any chance of preventing it from happening again," he said. This is the second in a series of profiles featuring the recipients of the 2012 Samuel J. Heyman Service to America Medals. Presented to outstanding public servants by the nonprofit Partnership for Public Service, and sponsored in part by Bloomberg, Booz Allen Hamilton, The Boston Consulting Group, Chevron and United Technologies Corporation, the prestigious Sammies awards are offered in nine categories. To nominate a federal employee for a 2013 medal go to servicetoamericamedals.org. http://www.govexec.com/excellence/promising-practices/2012/09/black-box-expert- uncovers-airplane-crash-mysteries/58289/ Back to Top Pilots Say Controllers' Warnings Were Late By ANDY PASZTOR (WSJ) After air-traffic controllers mistakenly put passenger jets on collision courses at Chicago O'Hare International Airport twice last year, only swift action by cockpit crews prevented deadly midair accidents, according to pilot testimony released Monday by federal accident investigators. In detailing the sequence of events Monday, the National Transportation Safety Board revealed how worried the pilots were about the close calls, and why they subsequently told investigators that controllers had failed to issue corrective instructions quickly enough. Nobody was hurt in either incident, which occurred less than three months apart. In both incidents, regional jets sped toward each other with one aircraft coming in to land and the other accelerating to take off, and the planes were separated by less than 300 vertical feet. Each time, pilots realized the danger and took evasive action on their own before controllers transmitted any warnings, they told the safety board. The Federal Aviation Administration didn't discipline any controllers involved in the close calls, in keeping with its policy of retraining rather than punishing employees who commit good-faith errors. Such a non-punitive approach also is designed to encourage controllers to voluntarily report mistakes. On the morning of May 16, 2011 in good weather, one O'Hare controller cleared a a SkyWest Airlines Bombardier jetliner coming from Michigan to land to the east on one runway, while another controller instructed an Embraer 145 flown by ExpressJet Airlines, bound for Buffalo, to take off to the northwest from a nearby runway that would put it on an intersecting course At the point the departing jet normally would have become airborne, which pilots also refer to as upward "rotation" of the plane's nose, the ExpressJet captain testified that he saw the SkyWest jet barreling down final approach from his left at an altitude of around 300 feet. It was "on a collision course with us if we performed a normal rotation," the safety board quotes the ExpressJet captain as saying. So the pilot ordered the co-pilot, who was at the controls of the twin-engine jet to "stay low, stay low." He then took control of the plane and continued the takeoff roll well past the convergence of the two flight paths. In spite of the controllers' ordering the landing jet to break off its approach and climb, the board said the two planes were separated by 275 feet vertically and about 400 feet horizontally. The pilot told investigators that after he "was able to gain a little composure back after nearly being killed," he cursed at the control tower. Despite briefings to some O'Hare tower employees after the incident, a different group of controllers there was involved in a similar slipup on Aug. 8. The safety board's data indicate the risks from the second incident may have been greater. A Chautauqua Airlines Embraer jet en route from La Crosse, Wis., and cleared to land on the same easterly runway, came within 125 feet vertically of another Embraer jet, operated by Trans States Airlines, that was taking off from the intersecting northwesterly strip. The lateral separation was about 350 feet. The landing aircraft was ordered to break off its approach. Once again, the departing pilots delayed liftoff until their plane was clear of the danger. But in recounting the event, the Trans States captain said that without acting on his own, the first warning from controllers about the jets' intersecting paths "may have been too late" to prevent an accident. The FAA said that after the close calls, it stepped up training and improved procedures, including radar warnings. Among other things, the FAA also placed controllers handling the two runways directly next to each other to reduce the chances for confusion. O'Hare controllers failed to file a report immediately after the May incident acknowledging an operational error, according to the safety board. Even after FAA headquarters concluded such a report was required, local controllers and managers unsuccessfully sought to have the incident reclassified as a "non-event," investigators disclosed. Another portion of the material released Monday by investigators suggests that some O'Hare controllers may have been distracted at the time of the May event by the earlier arrival of Vice President Joe Biden's plane at the airport and then by communications between the tower and a White House helicopter near the airport. When investigators asked the controller who mistakenly issued the takeoff clearance for the ExpressJet plane what would have kept him more focused, he replied, "It won't happen again." A veteran manager in the O'Hare tower, according to the safety board, told investigators that controller slip-ups involving planes on intersecting flight paths to the same two runways "had been a problem for some time" and contributed to "losses of separation" between planes. Back to Top NTSB names Clint Johnson, senior air safety investigator, to head Alaska regional office ANCHORAGE, Alaska (AP) - A senior air safety investigator has been named head of the Alaska regional office of the National Transportation Safety Board. NTSB Chairman Deborah A. P. Hersman on Monday announced Clint Johnson as chief of the Office of Aviation Safety's Anchorage regional office. Hersman says in the announcement that Johnson has deep roots in Alaska. He has been investigator-in-charge of more than 700 Alaska aviation accidents in Alaska and around the world. Johnson as a senior air safety investigator has worked in the Alaska regional office for 15 years. He led the investigation of the crash that killed former U.S. Sen. Ted Stevens and four others. Johnson also serves as the agency lead on helicopter safety and as NTSB liaison to the Helicopter Association International's safety committee. Back to Top Back to Top Brazilian plane maker sees growing executive jet market in Africa Brazilian aerospace group Embraer is forecasting rapid expansion in business aviation in Africa. "The African business aviation market is growing fast and is offering a lot of opportunities," Embraer Executive Jets media relations executive Ricardo Santos told Engineering News Online. There are currently some 420 business jets in service in Africa and the Brazilian group predicts that the continent will require about another 250 over the next ten years. In financial terms, this amounts to a $6.3-billion market. "It's a great opportunity for us," he affirmed. Embraer has just had its largest participation to date at the Africa Aerospace and Defence (AAD) exhibition, the 2012 edition of which was held at Air Force Base Waterkloof, just south of Pretoria, last week. Its display included four business jets - a Phenom 100, a Phenom 300, a Legacy 650 and a Lineage 1000. The Phenom 100 seats, in standard format, four passengers while the Phenom 300 takes six. The Legacy 650 is the latest model in the Legacy family - there are also Legacy 450, Legacy 500 and Legacy 600 versions. The 650 can accommodate up to 14 passengers over long ranges - for example, Dubai to London. The Lineage 1000 can carry at least ten passengers over intercontinental distances. The Legacy series is derived from the company's ERJ-145 regional jet airliner family while the Lineage 1000 is a derivation of the E-190 94- to 100-seat airliner. "There are a lot of potential customers in Africa, even for the Lineage 1000," he reported. "Embraer has a large presence in the African market with commercial aircraft and military planes, and we are now increasing our presence on the business aviation side." Embraer is organised into three main divisions - Commercial, Executive and Defence and Security. Embraer Defence and Security also participated at AAD 2012, but had no aircraft on show. http://www.engineeringnews.co.za/article/brazilian-plane-maker-sees-growing- executive-jet-market-in-africa-2012-09-25 Back to Top Air France, the first major European airline to equip its pilots with iPad Air France has started to equip its 4,100 pilots with iPads that they are using instead of their laptops, outside the cockpit. Boeing 777 pilots started receiving these iPads back in June 2012, and the roll-out shall be completed during summer 2013. With the iPad, pilots have access to an electronic version of all their personal aircraft documentation, of which they previously had a paper version at their home. They will be able to download the manuals of their choice anywhere in the world and be automatically informed of their updates. Pilots will also be able to access airport maps. These dedicated applications will be available for download at the "Pilot Store" specially developed by Air France. The use of iPad will facilitate communication processes by giving pilots the ability to electronically draft and dispatch regular reports, such as the Air Safety Report, Captain's Report and Security Report, at the end of the flight. "We are always looking for new ways to enhance the safety and performance of our flights" declared Eric Schramm, Air France Executive Vice President of Flight Operations and Boeing 777 captain. "Equipping our pilots with iPads will simplify access to critical information and also strengthen vital communication channels within the company", he added. Pilots will also be able to access the Air France intranet website for specific services and to send and receive emails. Beginning 2013, Air France pilots will also be able to use the iPad to complete training courses, review aircraft systems and complete self-service briefings. Air France is also working towards the implementation of Electronic Flight Bags in the cockpit for its pilots which will lead to greater convenience and efficiency while reducing fuel consumption and CO2 emissions. http://www.traveldailynews.com/news/article/51373/air-france-the-first-major Back to Top Accident Investigation for Aviation Management Cranfield University, UK 29 October - 9 November 2012 The Cranfield Safety and Accident Investigation Centre is proud to offer its world renowned two-week investigation course for aviation managers. The course brings together the considerable expertise of investigators, operators and researchers to deliver a learning experience that is tailored to those working at a management level. Cranfield University has run aircraft accident investigation courses each year since 1977 and was recognised earlier this year for its world-leading work in aviation safety through teaching and research in air accident investigation through a Queen's Anniversary Prize for Higher and Further Education - the highest honour that can be given to a UK academic institution. Course description The aim of the two-week course is to provide safety professionals and operational staff with the fundamentals behind both incident and accident investigation and the roles that will be played by operators, regulators, manufacturers, legal and government investigation agencies. Upon completion of the course, delegates will be able to conduct incident investigations within their organisation's safety management system and also co-operate with major accident investigations. Who should attend? The course is designed for professionally qualified flight crew, airline or military flight safety officers, managers, union representatives, regulatory authority or air traffic services management and others concerned with the operational aspects of flight safety. In particular, the course is aimed at those who may be required to carry out investigations into occurrences, or to act as advisors or technical representatives to official aircraft accident investigation teams. The course is primarily intended to provide an introduction to fundamental investigative techniques and procedures in accordance with international requirements. Those who are aiming to become full-time investigators may find that their needs are more comprehensively covered in our six-week Aircraft Accident Investigation Course. Course content * Notification and reporting of incidents and accidents * Investigation within the context of safety management systems * ICAO Annex 13 recommended practices * European regulation 2010/996 * Emergency response and crisis management * Health and safety on site * Sources and preservation of evidence * Interviewing techniques * Human factors * Passenger behaviour and cabin safety * Engineering investigations * Medical factors * Analytical techniques * Management of investigations * Relations with the government investigation agency, police, media and others * Developing and managing recommendations * Investigation report writing * Safety promotion * Accident prevention * Visit to the AAIB at Farnborough * Case studies - including the investigation process and outcomes * Practical investigation field exercise * Use of accident investigation laboratory. Further Details http://www.cranfield.ac.uk/soe/shortcourses/training/accident-investigation-aviation- management.html Curt Lewis