Flight Safety Information July 26, 2013 - No. 154 In This Issue Southwest jet hit runway nose first, investigators say Official: Body falls from Air France jet as it approaches for landing in Niger Oven on Boeing 787 Overheats During Air India Flight Firefighter who hit Asiana crash victim was driving alone Think ARGUS PROS Embry-Riddle Worldwide hosts online human factors course Asiana crash families hire prominent New York law firm NTSB Chief Hersman Unsure She'll Keep Job as Term Ends GRADUATE RESEARCH REQUEST Military Aviation Safety Workshop Southwest jet hit runway nose first, investigators say STORY HIGHLIGHTS Boeing 737's nose gear collapsed on landing in New York Plane skidded down runway before coming to a stop; passengers evacuated down slides Several people hurt in incident involving largest domestic airline National Transportation Safety Board investigating; Southwest Washington (CNN) -- The Southwest Airlines jet that skidded down a LaGuardia airport runway on its nose on Monday touched down on its front wheels first, which then collapsed, according to federal accident investigators. The unusual landing, in which investigators said the plane's nose pitched down seconds before touchdown, is the surest clue yet to explain the accident involving the Boeing 737 that injured several people. The National Transportation Safety Board said on Thursday that video and other sources provide evidence that the nose gear contacted the tarmac before the main wheels. Under a normal landing in a big jet, the main landing gear under each wing would touch the runway first and simultaneously -- absorbing the main stress of landing -- and the nose gear then lowered gradually as the plane decelerates down the runway. That model jet is expected to cross the runway threshold at about 140 knots or 161 mph, according to Boeing figures. Investigators said the pilot evidently adjusted the wing flaps less than a minute before landing, suggesting to veteran pilots who spoke with CNN that the plane may not have been on a stabilized approach as it neared the runway. Landing the way it did "would potentially have overstressed the nose gear to the point where it would have failed," said Capt. Mark Weiss, a former 737 pilot and civil aviation leader at The Spectrum Group in Washington. The NTSB said the flaps were set from 30 to 40 degrees about 56 seconds prior to touchdown. "What this brings into question is whether they were on a stabilized approach to make a normal landing," Weiss said. The safety board, coincidentally, is looking at whether Asiana Flight 124, which crashed- landed in San Francisco earlier this month, was also on a stabilized approach. Details released late Thursday about the New York accident show the plane changing its pitch suddenly in the final seconds of flight -- and in a direction opposite than desired. When the plane was just 32 feet in altitude, four seconds before landing, the plane was pitched 2 degrees nose up. At touchdown, the plane was pitched approximately 3 degrees nose down, the safety board said. Video shows the plane careening down the runway, the nose to the pavement, sending up showers of sparks. After touchdown, the aircraft came to a stop within approximately 19 seconds, the NTSB reported. Southwest said in a statement that the landing scenario the NTSB describes from video and other sources "is not in accordance with our operating procedures." Word that the landing was unusual could remove suspicion of a mechanical failure. Such a conclusion could have major implications for commercial aviation worldwide, given the 737's status as the most widely used commercial jet. The company operates only 737s and has more than 600 in its fleet. Back to Top Official: Body falls from Air France jet as it approaches for landing in Niger NIAMEY, Niger (AP) - Niger's interior minister says a body fell from an Air France plane as it approached the West African country's capital, Niamey, and was discovered lifeless in western suburb. Abdou Labo said a resident was standing just a few meters from where the body landed at around 5 a.m. Thursday. He said police arrived and found "the lifeless body of a black person, lying in blood." He also said blood had been spotted on the left wing of the plane. Labo said the plane was coming from Burkina Faso's capital, Ouagadougou, and was scheduled to continue to Paris. Officials were holding the plane in Niamey so crew members and passengers could be interviewed. Investigators in Ouagadougou are also looking into "the conditions in which the passengers boarded." http://www.foxnews.com/world/2013/07/25/official-body-falls-from-air-france-jet-as-it- approaches-for-landing-in-niger/#ixzz2a9r1pP2X Back to Top Oven on Boeing 787 Overheats During Air India Flight Air India Ltd., the nation's only operator of Boeing Co. (BA)'s 787, said an oven for warming food on a Dreamliner overheated during a domestic flight, prompting the crew to take measures to contain smoke. The oven's overheating on the flight from New Delhi to the eastern city of Kolkata on July 24 didn't cause a fire, Air India spokesman G. Prasada Rao said by telephone today. The flight was not diverted because of the incident and the aircraft continues to be in service, he said. The latest incident involving a 787 comes amid U.S. aviation regulators ordering inspections of emergency beacons that were linked to a July 12 fire on a Dreamliner parked at London's Heathrow Airport. Air India, which has taken delivery of seven of the jets, has begun removing the emergency locator transmitters as a precautionary measure, according to an India civil aviation ministry official. India's Directorate General of Civil Aviation is looking into what may have caused the oven's overheating, Arun Mishra, who heads the regulator, said in a mobile phone text message. He didn't elaborate. The Federal Aviation Administration yesterday issued an order that United Continental Holdings Inc., the only U.S. airline flying the Dreamliner, must complete the inspections of emergency locator transmitters by Aug. 5. The blaze that broke out on an Ethiopian Airlines Enterprise 787 parked at Heathrow was traced to a Honeywell International Inc. (HON) transmitter powered by a lithium battery. More Protection Bhawna Singh, Boeing's external spokeswoman in India, didn't immediately respond to a call and an e-mail seeking comments on the Air India incident. The Mumbai-based carrier, which has 20 more 787s on order, is adding new destinations including Sydney and Melbourne using the Dreamliners. In January, the global fleet of 787s was grounded because of overheating of lithium-ion batteries on two of the aircraft. The FAA cleared the jet to fly again after Boeing redesigned the battery to include more protection around individual cells to contain any overheating, a steel case to prevent fire and a tube to vent any vapors outside the fuselage. http://www.bloomberg.com/news/2013-07-26/boeing-787-oven-overheats-during-air- india-domestic-flight.html Back to Top Firefighter who hit Asiana crash victim was driving alone SAN FRANCISCO (KGO) -- The ABC7 News I-Team has learned exclusive new details about what that lead to the death of the 16-year-old Chinese student run over by a fire truck after the Asiana Airlines crash. It is a case of a veteran firefighter trying to do the right thing, and having something horrible happen. The story is so sensitive, long-time police and fire sources don't want to appear on camera -- even when they praise the firefighter, who drove the truck that hit the girl. Forty-nine-year-old Elyse Duckett is known as a sharp, competent veteran of the fire department. Sources say several problems occurred, including those by other firefighters and top brass, which contributed to the tragic accident. Duckett has been in the spotlight before -- in an award-winning documentary that mentions her career as a San Francisco firefighter. Working out of the "crash house" -- station No. 2, right at the intersection of the runways, Duckett prepared 24 years for that day. But, as her colleagues rushed to the crash site, sources tell say Duckett was out buying food for the firehouse . She came back to Station No. 2 to find everyone gone. She jumped in a reserve Aircraft Rescue and Firefighting (ARFF) truck, Mobile 37. Issue No 1: Sources say she drove by herself with no rider or spotter to help navigate. Department policy is to have two firefighters in the truck when fully staffed, but solo driving is allowed in an emergency. "As it turns out, there was a small person stuck between the seats," San Francisco Fire Lt. Chrissy Emmons said in a July 8 press conference. Duckett's fellow firefighters beat back the flames and boarded the aircraft, rescuing passengers. "There were two non-ambulatory patients that we put on backboards, and one other person was basically just taken out of the plane," Emmons said. Sources say a firefighter carried 16-year-old Ye Meng Yuan from the back of the plane and left her near the left wing, a hazardous place as the huge ARFF rigs jockeyed to fight the fire. Issue No. 2: Whether the firefighter thought the girl was alive or dead, multiple sources say he should have gotten her to a safer spot. "There was in the area where the victim was found a blanket of foam that was applied to suppress the fire on the aircraft," San Francisco Fire Chief Joanne Hayes-White said in a July 19 press conference. The fire chief says a blanket of foam may have covered the girl, and Mobile 37, the truck Duckett was driving, did not have Forward Looking Infrared (FLIR) that can pick up a person's heat signature through fog, darkness, or even foam. "And it reflects that on a screen in various shades of white or gray," San Francisco Fire Assistant Deputy Chief Dale Carnes said. Issue No. 3: Carnes says his three frontline ARFF rigs have FLIR, but not reserve unit Mobile 37, even though the Federal Aviation Administration has funding available to retrofit rigs like it. "As far as our reserve pieces, because we use them so rarely, it just hasn't been done," Carnes said. Sources confirm the department told Duckett this week that it was the truck she was driving that rolled over Ye Meng Yuan and they offered her counseling. The San Mateo County Coroner reported the girl died of blunt force injuries consistent with being run over. "Those injuries she received, she was alive at the time," Robert Foucrault said in a July 19 press conference. The ABC7 News I-Team has learned there are several videos taken by firefighters that have been passed on to the National Transportation Safety Board. Issue No. 4: Sources say the videos show Ye Meng Yuan in a fetal position on the ground before Mobile 37 rolled over her -- several firefighters walk by, perhaps not realizing she needed help. It is a tragedy on top of a tragedy. The airport fire chief says their investigation is wrapping into the NTSB's, so we may not hear the full story of what happened for a year. http://abclocal.go.com/kgo/story?section=news/local/peninsula&id=9185603 Back to Top Back to Top Embry-Riddle Worldwide hosts online human factors course Embry-Riddle Aeronautical University-Worldwide has opened registration on an online aviation human factors course that is free and open to the public. The Massive Open Online Course (MOOC) is the first of a series of free courses that the university plans to offer. "Our first MOOC covers a particularly timely subject, The Human Factor in Aviation," Embry-Riddle Worldwide Chancellor John R. Watret said. The crash of Asiana Airlines Flight 214 in San Francisco has definitely made the industry and public more aware of the intricacies of aviation safety, he added. The five-week course will focus on the psychological or physiological elements related to aviation disasters. Its instructor is Dennis Vincenzi, department chair of undergraduate studies in the College of Aeronautics at Embry-Riddle Worldwide. Registration opened July 19, and the class begins Aug. 19. Class size is limited to 500 students. For more information, see the website Back to Top Asiana crash families hire prominent New York law firm (Reuters) - Families of the three passengers who died when an Asiana Airlines Boeing 777 crashed in San Francisco this month have retained the prominent New York law firm Kreindler & Kreindler to represent them as legal maneuvering over liability and damages heats up. Kreindler & Kreindler, which specializes in aviation law, made a name for itself representing victims in catastrophic air disasters, including the September 11, 2001, attacks. Partner Jim Kreindler confirmed in an interview late Wednesday that he would handle the cases of the three Chinese teenagers who died, as well as 12 injury cases involving U.S., Chinese and Korean residents. He said he intends to file lawsuits in the coming weeks. Dozens were seriously injured in the crash of Asiana Flight 214, which had 307 people aboard when it hit a seawall in front of the runway, lost its tail and caught fire after skidding to a halt. Kreindler's clients include the family of Ye Meng Yuan, who survived the crash but died after being run over by a fire truck. Kreindler sent a letter to the San Francisco Fire Department on Wednesday requesting documents, videotapes, photographs and other evidence related to the department's response to the crash. A spokesman for the San Francisco city attorney declined to comment on the law firm's request. Meanwhile, South Korea-based Asiana is marshaling its own legal resources, hiring Frank Silane, a complex litigation specialist at the Los Angeles firm Condon & Forsyth. Advising a team of about 70 airline employees, Silane helped Asiana coordinate payments for medical expenses, hotel rooms and car rental for the dazed survivors. In an interview last week, he called it a "humanitarian response." Some plaintiff attorneys are warning passengers not to let Asiana's post-crash assistance go to their heads. "My concern is that it's used as a PR opportunity to send the message that we're nice people, you can deal with us, and to start to lay the foundation that they don't need a lawyer," said Frank Pitre, a California attorney who represents two passengers. He said he has been contacted by about two dozen. Silane declined to disclose how much Asiana has paid passengers in the aftermath of the crash. Plaintiff lawyers and one passenger contacted by Reuters say the airline has not yet proposed any formal legal settlements. At least one lawsuit has already been filed in the wake of the crash. Asiana passenger Eugene Rah said Asiana paid for one week of car rental but not a second. "I don't think they are doing anything aggressive," Rah said. "I think they are being cautious and careful." CALM BEFORE THE STORM Attorneys cannot contact victims until 45 days after a plane crash. A law requiring the waiting period was enacted in 1996, to prohibit lawyers from immediately descending on crash victims. Following the Asiana crash, the National Transportation Safety Board circulated an email to plaintiff attorneys threatening a State Bar referral for any lawyers who acted too quickly. The law doesn't prevent passengers from acting on their own to seek out attorneys, and many already have. As of last week, Asiana's Silane said he had been contacted by roughly seven attorneys who said they would sue in the near future. "There is going to be a lot more," Silane said, "and we know that they have multiple passengers." Once litigation gets underway, plaintiff attorneys expect the airline to move as many claims as possible out of U.S. courts, where judgments tend to be much higher. To do that, lawyers said Asiana will likely argue that an international aviation treaty called the Montreal Convention disqualifies certain passengers from bringing a lawsuit in the United States. According to the treaty, only passengers who are permanent U.S. residents, purchased tickets in the United States, or were flying to the United States as a final destination may sue Asiana in the country. It was not immediately clear how many passengers fell into those categories. The people onboard the flight included 141 Chinese passengers, 77 South Koreans and 64 Americans, according to an Asiana spokeswoman. The other passengers came from a variety of other countries, he said. Under the treaty, Asiana is automatically liable for about $150,000 in damages per injured passenger, lawyers said. But passengers could recover more if they show the airline was at fault, they said. If non-U.S. citizens can't sue Asiana in the United States, they could try to file lawsuits against third-party U.S.-based companies, such as Boeing, that may have contributed to the crash. Kreindler said that his cases will largely target Boeing as the primary defendant. A Boeing spokesman declined to comment on potential litigation. At the time of the crash, an airport instrument landing system called glide path was out of service. That could make the airport a target for litigation, said lawyer Michael Danko, who is representing a separate group of crash victims. Potential plaintiffs, such as Ye's family, must jump through hoops to successfully sue a government entity like the San Francisco Fire Department. To recover damages, they must show that the department didn't follow specific protocols. Silane declined to comment on Asiana's legal strategy. The airline also declined to comment. Asiana said it is covered by LIG Insurance, a Korean firm. Korean authorities have said the airline carries over $2 billion in coverage. The NTSB, charged with investigating the crash, expects to issue its report in about a year. Back to Top NTSB Chief Hersman Unsure She'll Keep Job as Term Ends Deborah Hersman's term as chairman of the U.S. National Transportation Safety Board ends Aug. 3, with no word on whether she'll be retained, during the accident investigation agency's busiest stretch since the 1990s. Hersman, 43, will conclude her second term as chairman as Congress leaves Washington for a five-week recess. Asked when or whether she'll be renominated, Hersman said it's out of her control. U.S. National Transportation Safety Board Chairman Deborah Hersman has been the public face of the board's two highest-profile investigations this year. Photographer: Andrew Harrer/Bloomberg "I don't know the answer to that question," she said in a telephone interview. "That is a decision that the White House will make. Right now I'm focused on the work that's in front of us from this past week." Matt Lehrich, a White House spokesman, said the administration won't "speculate on possible future personnel announcements." Hersman's term as a board member extends through Dec. 31. The safety board chairman, who must be confirmed by the Senate, is the top U.S. transportation accident investigator. The position provides a platform to lead probes, hold hearings and recommend safety improvements without authority to implement them. Hersman has been the public face of the board's two highest-profile investigations this year -- its probe into what caused battery fires on the Boeing Co. (BA) 787 Dreamliner that prompted the plane's grounding, and the July 6 crash in San Francisco of Asiana Airlines Inc. Flight 214, the first fatal commercial plane accident in the U.S. in four years. Rockefeller Endorsement She was passed over to succeed Ray LaHood as U.S. transportation secretary despite an endorsement in a Twitter messsage by her former boss, West Virginia Senator Jay Rockefeller, one of Congress's most senior Democrats. President Barack Obama instead chose Charlotte, North Carolina, Mayor Anthony Foxx. Rockefeller leads the Senate Commerce Committee, where Hersman was the senior Democratic staff member before being appointed to the safety board in 2004 by Republican President George W. Bush. Obama named her chairman in 2009 and reappointed her two years later. Nominations for the board and, separately, its chairman require Senate confirmation. There is a scenario that could effectively keep Hersman in charge if Obama doesn't act before her chairman's appointment expires. Board rules dictate that if there's no designated chairman, the vice chairman serves as acting chairman. The vice chairman position, held now by Christopher Hart, doesn't require Senate confirmation. Vice Chairman Hart's term ends Aug. 24. Because that is so soon after Hersman's term ends, Obama could name her vice chairman, said Ted Lopatkiewicz, who retired in 2011 as the board's top spokesman. Vice chairmen have served as acting chairman on other occasions after a term expired, he said. While Hersman has inspired fan blogs for her expertise and calm demeanor before television cameras, pilot unions in the U.S. and South Korea have criticized her handling of the Asiana investigation, saying she's disclosed too much information and put excessive focus on pilot errors. Hersman has said she's been careful to stick to facts. "We are the advocate for the traveling public," Hersman said at a briefing earlier this month. "We think it's important to show our work." Mobile Phones Hersman's call to ban the use of mobile phone in cars, even with hands-free devices, went beyond the position of LaHood, who made distracted driving his signature cause as transportation secretary. She failed to gain Transportation Department support to lower the blood-alcohol content limit for drunken driving to 0.05. The board is working on at least 16 major-accident investigations opened this year including the Asiana probe. It's also looking into the failure of landing-gear on a Southwest Airlines Co. (LUV) plane in New York, a train crash involving hundreds of commuters in Connecticut, two highway-bridge collapses, and an auto accident that sent a car over the side of Maryland's Chesapeake Bay Bridge. Yesterday the board announced a two-day forum in September on whether transportation operators have a "safety culture." http://www.bloomberg.com/news/2013-07-25/ntsb-chief-hersman-unsure-she-ll-keep- job-as-term-ends.html Back to Top GRADUATE RESEARCH REQUEST A fellow aviator of 40 years is continuing to conduct doctoral research study on pilot decision-making. The study - which examines why otherwise competent and certified pilots make mistakes that result in the need to repeat a simulator check-ride - will be the first qualitative research study to generate emergent new theory based on the erring pilot's perspective. Although many quantitative studies have looked at what pilots do wrong, researchers have not previously sought pilot input on why the erring pilots made substandard mistakes. Pilot volunteers interested in participating must have had to repeat a recurrent training simulator proficiency check ride. Pilot volunteers must also hold a current Federal Aviation Administration medical certificate and must be currently qualified and in an active flying bid status. All pilot interviews are confidential, and pilot participants will have an opportunity to review a draft of the study before results are submitted to the dissertation committee. The study has the support of both organized labor and the commercial aviation flight departments. The research is being conducted across the United States. Professional pilots are loath to discuss performance shortcoming, however the importance of pilot perspective must not be left in the closet. Help us help the profession - please participate. Click here for more information or email the researcher directly at PHDpilotstudy@conflictcounts.com With deepest appreciation! Captain Gary Boettcher PhD Candidate Doctoral Researcher Sullivan University PHDpilotstudy@conflictcounts.com 540-287-7817 (M) Back to Top Military Aviation Safety Workshop August 19, 2013 Vancouver, Canada In association with the 44th Annual Seminar of the International Society of Air Safety Investigators (ISASI) Representatives of military forces, associated contractors, educators, and researchers from all nationalities are invited to participate in the international Military Aviation Safety Workshop which is offered as a tutorial in association with the 2013 ISASI annual seminar. The workshop planning committee is very pleased with the finalized list of speakers and topics. It was our desire to tap the vast wealth of global expertise in military aviation to address a range of hot topics for military air safety investigators. Presentations were selected from proposals covering human factors, proactive detection of hazards, and safety culture, in addition to more traditional accident investigation topics. A diverse group of international speakers will perform 10 presentations during the workshop, which is open to all interested participants and will be particularly valuable for manufacturers of military aircraft and equipment, support contractors engaged in military operations, military air safety investigators and safety program managers. Dress code for participants is business casual, no neckties. The workshop planning committee consists of Dave Harper and Tony Cortés of the U.S. Air Force Safety Center, Bret Tesson and Jim Buse of Boeing, and Davy Thorn of Lockheed Martin. ISASI 2013 website: http://www.isasi.org/isasi2013.html WORKSHOP SCHEDULE TIME EVENT PRESENTER 0700 Continental Breakfast 0800 Opening Remarks Mr. Dave Harper U.S. Air Force Safety Center 0815 When the Exercise Became Reality - The Last Flight of HAZE01 Mr. Agne Widholm and Mr. Jens Olsson Swedish Accident Investigation Authority 0910 Inherent Hazards of a Government-Funded, Contractor-Lead, Flight Test Program, i.e. 'The Humans Factor' Mr. Michael Buran Lockheed Martin 0940 Refreshment Break 1010 The Organizing of a Common Helicopter Command from a Flight Safety Perspective Lt Col Robert Persson Swedish Armed Forces 1040 Military Air Safety Investigation Down Under WGCDR Alf Jonas Royal Australian Air Force 1115 It's Unmanned, How Much Risk Can There Be? Col Mike Smith UK MAAIB 1200 Lunch 1300 Implementation of Flight Data Monitoring for Flight Safety in the Dutch Air Force Mr. Rombout Wever NLR Air Transport Safety Institute 1345 Target In Sight: Leading Indicators & Risk Analysis Dr. Mark Friend, Embry-Riddle Aeronautical University 1420 The Day Bobby Died - Preventing Mishaps through Personal Intervention Mr. Pat Daily, Convergent Performance 1500 Refreshment Break 1530 Immediate Risk Management - Is it Worth the Time? LCDR Natalee Johnston, Royal Australian Navy 1605 A Just Culture in the Swedish Air Force Mr. Hans Sjöblom, Saab Aeronautics 1640 Workshop Wrap-Up Mr. Dave Harper, U.S. Air Force Safety Center; Mr. Bret Tesson, Boeing For further information please contact the U.S. Air Force Safety Center (GMT - 0600): +1.505.846.5277 antonio.cortes@us.af.mil +1.505.846.0996 david.harper@kirtland.af.mil Curt Lewis