Flight Safety Information June 25, 2014 - No. 128 In This Issue Pilots blamed for Asiana crash Gunmen fire on Pakistan passenger jet, killing one Airplane Lands Safely After Pilots Blinded by Laser Beam Flight MH370 Pilot Flew to Indian Ocean in Simulator PRISM TO HELP PREPARE FOR E-IOSA THE ALPA 60TH AIR SAFETY FORUM Upcoming Events Pilots blamed for Asiana crash Pilots lacked automation understanding in Asiana crash STORY HIGHLIGHTS The National Transportation Safety Board released its final report on the 2013 accident Investigators said actions by the cockpit crew caused the crash in San Francisco The Boeing 777 crashed short of the runway; three people were killed, 187 hurt (CNN) -- Pilots botched the approach and landing of Asiana Airlines Flight 214 in San Francisco nearly a year ago, causing a crash that killed three people and injured 187 others, U.S. safety investigators concluded on Tuesday. But the National Transportation Safety Board also found that crew training and the complexities of a key flight system on the Boeing 777 and how it was described in operating manuals contributed to the July 6 disaster. Investigators, however, primarily faulted the crew of the Korean-based carrier for not fully executing intricate systems of the jetliner packed with more than 300 people before it struck a seawall and careened down Runway 28L trailing sparks and debris. In a final report on its probe, the board found that the flight crew mismanaged the plane's descent being carried out without the help of navigational instruments and one of the pilots unintentionally deactivated a system that automatically regulates airspeed. The crew also delayed its decision to abort the landing with the plane flying too slowly to avoid catastrophe, investigators found. The final conclusion was largely in line with early assumptions of investigators facing the most serious commercial airline crash in the United States since a Colgan Air commuter plane fell out of the sky over Buffalo, killing 49 people in February 2009. Crew actions were also singled out in that accident. Aviation experts agree that aircraft automation has made flying safer, and the 777 is one of the most sophisticated jetliners in service. "But the more complex automation becomes, the more challenging it is to ensure that the pilots adequately understand it," Christopher Hart, the acting safety board chairman said in a statement. "In this instance, the flight crew over-relied on automated systems that they did not fully understand. As a result, they flew the aircraft too low and too slow and collided with the seawall at the end of the runway." http://www.cnn.com/2014/06/24/us/asiana-ntsb/ Back to Top Gunmen fire on Pakistan passenger jet, killing one UNIDENTIFIED gunmen opened fire on a passenger plane as it landed at the main airport in Peshawar in Pakistan's troubled north-west, killing one passenger and wounding two crew members, police and airline officials said. The incident took place late on Tuesday as the Pakistan International Airlines (PIA) flight arrived in Peshawar from Riyadh in Saudi Arabia with more than 170 passengers on board, airline spokesman Mashud Tajwar said. "The shots were fired from outside the airport, one lady passenger and two stewards were wounded, the woman later died in the hospital," Mr Tajwar told AFP, adding that the aeroplane landed safely. Flights at the Bacha Khan International Airport in Peshawar have been temporarily halted following the gunfire, police said. Muhammad Faisal, a senior police official, said that four to five bullets hit the aeroplane. "Flight operations have been temporarily suspended," Mr Faisal told AFP. The attack comes after the Pakistan military launched a major offensive on June 16 in the most dangerous tribal district of North Waziristan along the Afghan border, where Taliban and al-Qa'ida-linked militants had taken refuge. Police cordoned off an area outside the airport after the attack and have launched a search for those responsible, Faisal said, adding that one air steward was in a critical condition. Another senior police official said the incident could have been catastrophic, as the PIA plane was flying only 1,500 metres above ground level when it was attacked. "Credit goes to the aeroplane pilot that he managed to land safely," Najeeb Ur Rehman said. Separately, Ansar-ul-Mujaheddin militant group, a faction of the Pakistani Taliban, threatened Tuesday to carry out more attacks after claiming responsibility for a car suicide bombing in North Waziristan which killed two soldiers and a civilian. "It is beginning of our offensive and we will launch attacks against government and local tribesmen if they form an anti-Taliban force," militant group spokesman Abu Baseer told AFP via telephone from an unknown location. Though officials have not blamed any group for the incident at Peshawar airport, Taliban militants last week warned international firms and airlines to wind up their business in Pakistan or face attacks in the wake of the military offensive. There have been several past incidences of firings at the airport, which is a commercial hub and also serves as a Pakistan Air Force (PAF) base in Peshawar, located on the edge of the tribal belt. Aside from multiple rocket and mortar firings, in December 2012 Taliban militants launched a deadly attack on the airport targeting fighter jets and gunship helicopters, killing five civilians and wounding 50 others. http://www.theaustralian.com.au/news/world/gunmen-fire-on-pakistan-passenger-jet- killing-one/story-e6frg6so-1226965990995?nk=f8f1a17c22ab5aac2ec717dd47dec0d4 Back to Top Airplane Lands Safely After Pilots Blinded by Laser Beam Unidentified assailants shot a powerful laser-pen beam at a commercial airplane. Police have opened an investigation after unidentified assailants shot a powerful laser- pen beam at a commercial airplane that was descending in the Siberian city of Omsk, temporarily blinding the pilots, a news report said. The Boeing 757 with 226 passengers and eight crew members aboard managed to land safely after being hit by the green-colored beam, which appeared to have been directed from a central street in Omsk, the regional Interior Ministry branch said in a statement, Interfax reported. The aircraft was about five kilometers away from the landing strip when the incident happened early Wednesday, according to the report. Nobody was injured during landing, and operations at the airport were not disrupted, the report added. http://www.themoscowtimes.com/news/article/airplane-lands-safely-after-pilots- blinded-by-laser-beam/502485.html Back to Top Flight MH370 Pilot Flew to Indian Ocean in Simulator The pilot of the missing Malaysia Airlines jet used his personal flight simulator to practice journeys to remote parts of the Indian Ocean, U.S. sources told NBC News. Deleted files recovered by investigators show Zaharie Shah, 53, also embarked on virtual trips on many other routes and there did not appear to be any patterns, NBC News correspondent Tom Costello reported on Tuesday's TODAY. The news comes as a Malaysia Airlines boss reportedly said it might take "decades" to find the remains of Flight MH370 which disappeared March 8, an hour after leaving Kuala Lumpur en route to Beijing. The new search area is estimated to cover 20,000 square miles of the southern Indian Ocean. http://www.nbcnews.com/storyline/missing-jet/flight-mh370-pilot-flew-indian-ocean- simulator-sources-n139321 Back to Top Back to Top THE ALPA 60TH AIR SAFETY FORUM A Celebration of Pilots Helping Get the Job Done Safely & Securely August 4-7, 2014 | Washington Hilton | Washington, DC SPONSORSHIP & EXHIBITING OPPORTUNITIES AVAILABLE Contact Tina Long at tina.long@alpa.org for more information or click here to download the sponsorship brochure. AGENDA AT A GLANCE Visit http://safetyforum.alpa.org for full agendas MONDAY - AUGUST 4, 2014 8:30-9:00 General Session-ALPA Air Safety Organization Update (Open to all ALPA Members Only) 9:30-6:00 ALPA ASO Group Workshops & Council Meetings - (invitation only) 9:30-4:30 Jumpseat Forum (invitation only) 12:00-5:00 Aviation Security Forum (invitation only) TUESDAY - AUGUST 5, 2014 8:00-6:00 ALPA ASO Group Workshops & Council Meetings - (invitation only) 9:00-5:00 Joint Aviation/Security Forum - (invitation only) WEDNESDAY - AUGUST 6, 2014 - 60TH AIR SAFETY FORUM 8:30-9:00 Opening Ceremony 9:00-10:30 Panel: Surviving a Main Deck Lithium Battery Fire: New Technological Solutions 10:30-11:00 Break with the Exhibitors 11:00-12:30 Panel: Smoke In the Cockpit-Where Seconds Matter 12:30-1:45 Keynote Luncheon-100 Years of Commercial Aviation Mr. Paul Rinaldi - President, National Air Traffic Controllers Association 1:45-3:15 Panel: Finding the Runway with a Smoke-Filled Cockpit-Using All the Tools 3:15-3:45 Break With the Exhibitors 3:45-5:15 Panel: Landing A Distressed Airliner-What's Waiting at the Airport? 5:15-5:25 Presentation of the ALPA Airport Safety Liaison and ALPA Airport Awards 5:25-5:30 Closing Remarks 5:30-6:30 Hospitality Reception (Sponsored by Boeing) THURSDAY - AUGUST 7, 2014 - 60TH AIR SAFETY FORUM 8:30- 10:00 Panel - Current Security Threats and Countermeasures 10:00-10:30 Break with the Exhibitors 10:30-11:30 Panel: A Discussion With Key Regulators 11:30-11:40 Presentation of the ALPA Presidential Citation Awards 11:40-1:00 Lunch (on your own) 1:00-2:30 Panel: Pilot Health & Occupational Safety 2:30-3:00 Break with the Exhibitors 3:00-4:30 Panel: Modernizing Our National Airspace System: The Flight Path, The Potholes and the Promise 4:30-5:00 Closing Ceremony 6:00-7:00 Awards Reception (Sponsored by Airbus) 7:00-10:00 Awards Dinner 10:00-11:00 Post Awards Reception Back to Top Upcoming Events: 6th Annual Aviation Human Factors & SMS Seminar June 24th & 25th 2014 Dallas, TX www.regonline.com/builder/site/Default.aspx?EventID=1384474 21st Century Pilot Reliability Certification Workshop June 30th and July 1st, 2014 Hasbrouck Heights, NJ 07605 Please contact Kacy Schwartz kacy@convergentperformance.com 719-481-0530 International System Safety Society Annual Symposium 04-08AUG2014 - St. Louis, MO http://issc2014.system-safety.org Curt Lewis