Flight Safety Information December 18, 2018 - No. 255 In This Issue Incident: KLM Cityhopper E190 at Amsterdam on Dec 16th 2018, could not retract a flap Incident: Trans States E145 near Toledo on Dec 17th 2018, loss of cabin pressure. Accident: Spirit A320 near Denver on Dec 16th 2018, fumes injure 3 passengers and 2 cabin crew. EVAS - Cockpit Smoke Protection Incident: Virgin Australia AT72 at Canberra on Dec 13th 2018, both engines rolled back New Low Airspeed Alerting System could save Lives and Money Lion Air charters ship to search for JT610 recorder ATSB INVESTIGATING VIRGIN AUSTRALIA ATR 72 ENGINE FLAME-OUT INCIDENT. Robinson Safety Course Logs 21,000 Graduates High Altitude Flying Course Helicopter Accident Investigation from SCSI Najeeb E. Halaby Graduate Student Fellowship Incident: KLM Cityhopper E190 at Amsterdam on Dec 16th 2018, could not retract a flap A KLM Cityhopper Embraer ERJ-190, registration PH-EZZ performing flight KL-1767 from Amsterdam (Netherlands) to Frankfurt/Main (Germany), was climbing out of Amsterdam when the crew stopped the climb at FL070 reporting one of the flaps did not retract. The crew considered Amsterdam and Eindhoven (Netherlands) to divert to, but ruled both airports out due to weather advising they needed to perform a manual landing, an automatic approach wasn't possible, too. The crew considered to divert to Brussels (Belgium) but then decided to divert to Maastricht (Netherlands) also declaring "low fuel". The aircraft landed safely in Maastricht about 50 minutes after departure. The aircraft remained on the ground for about 2 hours, then departed again and reached Frankfurt with a delay of 4 hours. http://avherald.com/h?article=4c1b18b3&opt=0 Back to Top Incident: Trans States E145 near Toledo on Dec 17th 2018, loss of cabin pressure A Trans States Airlines Embraer ERJ-145 on behalf of American Airlines, registration N612AE performing flight AA-3789 from Chicago O'Hare,IL to Baltimore,MD (USA), was enroute at FL370 about 20nm west of Toledo,OH (USA) when the crew initiated an emergency descent due to the loss of cabin pressure. The aircraft landed safely in Toledo about 16 minutes later. The remainder of the flight was cancelled. https://flightaware.com/live/flight/AAL3789/history/20181217/1507Z/KORD/KBWI http://avherald.com/h?article=4c1b162a&opt=0 Back to Top Accident: Spirit A320 near Denver on Dec 16th 2018, fumes injure 3 passengers and 2 cabin crew A Spirit Airlines Airbus A320-200, registration N653NK performing flight NK-395 from Philadelphia,PA to Las Vegas,NV (USA) with 71 people on board, was enroute at FL380 about 150nm east of Denver,CO (USA) when the flight crew donned their oxygen masks reporting fumes on board and diverted to Denver and requested medical services to await the aircraft on landing. The aircraft landed on runway 16L about 30 minutes later and taxied to the gate with the flight crew still on their oxygen masks. Three passengers and two cabin crew reported feeling ill. Emergency services attending to the aircraft detected carbon monoxide on board of the aircraft and treated all five injured at the gate. The passengers refused transport to a hospital, the two cabin crew were taken to the hospital. A replacement A321-200 registration N678NK reached Las Vegas with a delay of about 3 hours. https://flightaware.com/live/flight/NKS395/history/20181217/0055Z/KPHL/KLAS http://avherald.com/h?article=4c1b1b50&opt=0 Back to Top Back to Top Incident: Virgin Australia AT72 at Canberra on Dec 13th 2018, both engines rolled back temporarily one after the other A Virgin Australia Avions de Transport Regional ATR-72-212A, registration VH-FVN performing flight DJ-660 from Sydney,NS to Canberra,AC (Australia), was descending through 11,000 feet towards Canberra when the right hand engine (PW127) rolled back and flamed out. The engine automatically restarted about 5 seconds later. The crew continued the descent, descending through 10,000 feet now the left hand engine rolled back and flamed out, also automatically re-lighting. The crew selected manual ignition for the remainder of the flight and landed safely in Canberra. Australia's TSB (ATSB) rated the occurrence a serious incident and opened an investigation. The flight data recorders have been downloaded. The occurrence aircraft returned to service about 84 hours after landing Canberra. http://avherald.com/h?article=4c1ae760&opt=0 Back to Top Back to Top New Low Airspeed Alerting System could save Lives and Money As a result of analyses that showed that a large percentage of fatal accidents in Commercial Aviation were caused by poor energy management, the National Transportation Safety Board (NTSB) issued a strongly worded safety recommendation to the FAA in 2010 that calls for the development and installation of multi-sensory low airspeed alerting systems. "For all airplanes engaged in commercial operation...require the installation of low-airspeed alert systems that provide pilots with redundant aural and visual warnings of an impending hazardous low-speed condition. The Board recognizes that there are unresolved technical, operational and human-factors issues that will need to be carefully evaluated and addressed in connection with the design and implementation of a low-airspeed alert system. Despite these unresolved issues, the Board concludes that a requirement for the installation of low-airspeed alert systems could substantially reduce the number of accidents and incidents involving flight-crew failure to maintain airspeed." As a result of their own analyses, the Commercial Aviation Safety Team - CAST (a joint FAA-Industry organization) published 19 Safety Enhancements (SEs) to stimulate research that could reduce fatal accidents caused by a lack of 'Airplane State Awareness'. One of these SEs was specifically focused on the development of low airspeed alerting systems that could be installed in current production aircraft and easily retrofitted into aircraft in the field. "To improve flight crew awareness of low airspeed, manufacturers should develop and regulators should ensure implementation of systems that alert flight crews when the airplane reaches its minimum maneuvering speed. In addition, in order to improve early flight crew awareness of a decreasing energy state, manufacturers should develop and implement multi-sensory low airspeed alerting at the caution level in existing and in-development airplanes, as practical and feasible. The focus of this Safety Enhancement is on low cost, low technology solutions with ease of retrofit and production incorporation." In direct response to these safety recommendations from the NTSB and CAST, a small aeronautical engineering company in California named Tiger Century Aircraft (TCA) launched a project to develop such a system. TCA's CEO, Andrew Skow (former Chief Engineer on the F-20 Tiger Shark), joined forces with close friend Peter Reynolds (former VP Flight Test at Bombardier) to define the technical and human factors requirements for their system. The result of their work is called the "Q-Alpha Flight Energy Awareness Display". The Q-Alpha display is unique in 2 important ways: 1. Whereas current low airspeed alerting systems are based on angle-of-attack (AoA), the alerting thresholds in Q-Alpha are set by using both AoA (Alpha) and dynamic pressure (Q - which includes airspeed and pressure altitude terms). This approach allows the alerting thresholds to be set at higher airspeeds without creating nuisance alerts or false alarms. 2. Whereas the visual sensory approach taken in current low airspeed alerting systems places the information on the already highly cluttered Primary Flight Display (PFD), the Q-Alpha display is placed near the outboard extent of the glare-shield and uses a simple circle of green-yellow-red lights. This approach means that the Q-Alpha alerts can be easily seen by a pilot that is looking outside of the cockpit, either over the nose (as in a straight-in approach) or out the side window (as in a circling approach). In addition, the Q-Alpha display formats were selected so that the alerts can be instantly recognized and understood by a pilot without the need to look directly at the display. Skow believes that Q-Alpha is also unique because it is a safety system that, in addition to saving lives, could actually save airlines money. A very achievable 25% reduction in fatal Approach/Landing and LoC-I accidents over 10 years can save 600+ lives and $8+ Billion A very achievable 25% reduction in non-fatal Approach/Landing accidents over 10 years can save $3+ Billion After the untimely passing of Pete Reynolds, Skow continued the development of Q-Alpha and the system has now been tested in Commercial, Business/Corporate and General Aviation aircraft with rave reviews from all evaluation pilots. A very positive article by Ross Detwiler was published in Business and Commercial Aircraft magazine earlier in 2018 (see below). TCA is currently conducting piloted demonstrations of the Q-Alpha Display to potential customers. Skow is hoping that the FAA will conduct an independent evaluation of the effectiveness of the Q-Alpha display to determine its potential to mitigate against accidents like Asiana 214, Turkish 1951, Air France 447 and others where poor energy management by pilots was a causal factor. More information can be seen on the Q-Alpha website; www.skovaero.com ************* Back to Top Lion Air charters ship to search for JT610 recorder Lion Air has chartered a ship from a Dutch company to assist in the search for the cockpit voice recorder (CVR) of JT610, a Boeing 737 Max 8 that crashed on 29 October. The low-cost operator said in a statement that the ship, MPV Everest, will arrive in the Indonesian town of Karawang on 19 December, after departing the Malaysian city of Johor Bahru on 17 December. Lion Air did not specify the length of the ship's charter, but estimates costs related to the search for the CVR at Rp38 billion ($2.62 million). "The continued search effort is a form of Lion Air's commitment, and is based on requests from family members," says the airline. The carrier's direct involvement in the search for the CVR comes after an 11 December Reuters report indicated that Indonesia's National Transportation Safety Committee (NTSC) has faced budgetary constraints and bureaucratic hurdles in its attempts to raise the main aircraft wreckage and locate the CVR. The flight data recorder was recovered on 2 November, three days after the crash. Data drawn from the device featured in the 28 November preliminary report. An anonymous source told Reuters that the NTSC has "no further funds to rent the ship," making a reference to the need to obtain specialised equipment for the search. The source goes on to say that the NTSC does not have any emergency funds allocated, as "there is no legal basis". "We have already asked the coordinating minister for the economy, but there is no regulation and it would need to be discussed by the parliament," the source added in the Reuters report. Lion Air's insurers were also reportedly reluctant to pay for the search, which also led to the airline's direct involvement. NTSC officials will also oversee "all operations on board" the ship, despite obtaining funding from Lion Air. The Lion Air jet, registered PK-LQP, was operating flight JT610 from Jakarta's Soekarno-Hatta International airport to Pangkal Pinang when it crashed into the sea near the town of Karawang. There were 189 on board. https://www.flightglobal.com/news/articles/lion-air-charters-ship-to-search-for-jt610-recorder-454497/ Back to Top ATSB INVESTIGATING VIRGIN AUSTRALIA ATR 72 ENGINE FLAME-OUT INCIDENT The Australian Transport Safety Bureau (ATSB) says it is investigating an incident involving a Virgin Australia ATR 72 where both engines on the regional turboprop airliner flamed out, one after the other, while flying in heavy rain. The incident near Canberra airport involved ATR 72-600 VH-FVN while on a flight from Sydney, the ATSB said on Monday afternoon. "While the aircraft was descending through 11,000ft in heavy rain, the right engine's power rolled back (decreased) and the engine flamed out. The engine automatically re-started within five seconds," the ATSB said. "The descent continued and, while passing through 10,000ft, the left engine's power also rolled back and that engine flamed out before automatically relighting. The crew selected manual engine ignition for the remainder of the flight and the landing." The aircraft landed safely without further incident, but the flight tracking website flightaware.com shows VH-FVN remained on the ground in Canberra for the following three days, before returning to service operating a flight to Sydney on Monday morning. The track flown by VH-FVN on its December 13 flight from Sydney to Canberra. (flightaware.com) The ATSB says it has begun the evidence collection phase of its investigation into the incident, and that it has downloaded the aircraft's flight data recorder. Investigations typically take 12 months to be completed, but the safety investigator says that: "Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate action can be taken." VH-FVN was delivered new to Skywest Airlines, for operations on behalf of Virgin Australia, in September 2012 (a month before Virgin Australia announced its intention to acquire Skywest, which was subsequently renamed Virgin Australia Regional Airlines). The aircraft is powered by Pratt & Whitney Canada PW127M turboprops. http://australianaviation.com.au/2018/12/atsb-investigating-virgin-australia-atr-72-engine-flame-out-incident/ Back to Top Robinson Safety Course Logs 21,000 Graduates Robinson Helicopter has had more than 21,000 pilots attend the three-and-a-half-day safety course at its California factory since the mid-1980s and thousands more at foreign-based courses sponsored by its dealers in 30 different countries to date. Robinson exports roughly 70 percent of the helicopters it builds. In any given year the factory teaches 14 to 16 courses with attendance averaging 55 to 60 for each one. Attendance for the foreign-taught courses can run from 15 to 110 students each, depending on location, with larger markets such as Australia, Brazil, and South Africa. This year the company also held four separate safety courses in China with the assistance of Chin Tu, owner of Civic Helicopters in Carlsbad, California. Tu speaks fluent Mandarin. Flight portions in foreign-taught courses vary based on helicopter and instructor availability. The course typically includes 1.5 hours of dual instruction flying time in Robinson R22, R44, or R66 models and extensive classroom instruction in safety, operations, and maintenance. Any licensed helicopter pilot with at least three hours in a Robinson is free to attend, although 65 percent of attendees are instructors or potential instructors. The course is an FAA-approved flight instructor refresher course (FIRC) and can be used toward CFI renewal. Fees vary from $500 for the R22 course to $1,100 for the R66; even so, the company offers the course at a loss. And that is just fine with CEO Kurt Robinson. "We've had the distinction of making helicopter flying less expensive and whenever that happens it gets into more hands. You have to convince people that it has to be approached differently than driving a car on the ground," he told AIN. Robinson is the world's largest manufacturer of low-cost civil helicopters by volume. It has made numerous safety improvements to its helicopters, including the availability of crash-resistant fuel bladders. Also, more than half of all R66 turbine singles are ordered with autopilots, and the new R44 Cadet provides more safety margins, is easier to hover, and is becoming a popular IFR trainer. Despite all this, Robinson said any helicopter's main safety feature remains between the pilot's ears. "People need to set limits before they fly; corporations do it with their safety management systems (SMS). Safe flying is not just skill, it's judgment and we spend a lot of time in the course focusing on getting people to make better decisions. I can't be more proud of our safety course." Kurt Robinson points out that Robinson was the first factory program to teach the Vuichard vortex ring state (aka settling with power) recovery technique back in 2011, which has now become the international standard for escaping this potentially deadly flight condition. The recovery consists of increasing the collective to climb power, keeping the nose straight with left pedal, and simultaneously applying right cyclic to a 10-20 degree bank angle. Tim Tucker has logged 10,000 hours in Robinsons and is the company's chief instructor pilot. "Not everyone who buys a helicopter goes through the course," he said, "but some insurance companies require it. We certainly do a lot of things to encourage buyers to take the course," chief among them keeping the cost low. Tucker said that crashes in Robinsons have four main causes: wire strikes and weather (29 percent each), low rotor rpm stalls (21 percent), and low G mast bumping. When Robinson started the course, the highest cause (36 percent) was low rpm rotor stall, but that has decreased significantly with the advent of the course and improvements to the helicopter, including adding an engine governor and a low rpm warning indicator, Tucker said. All of the leading causal factors are discussed at length during the course. "The whole thing is safety. On the first day, we show some pretty vivid (crash) videos and that turns some people off," Tucker admits. Only accidents in Robinsons are discussed. The first day of ground instruction covers topics common to all Robinson models, while the second and third days focus on the pilot's operating handbook (POH) for the student's specific model. There also is a more extensive discussion of model systems and maintenance on day three. The flying portion focuses on the Vuichard recovery, recovery from low rpm, advanced techniques for maneuvering in autorotations, recovery from hydraulics malfunction in applicable models (R44 Raven II and R66), and, time allowing, anything else of student interest. Tucker, like Kurt Robinson, is a major proponent of SMS for all helicopter pilots-including private license holders. "The commercial pilot may have an SMS in place, but trying to get an individual owner to think about SMS is tougher," Tucker said. "That's why some of our course videos are pretty graphic and gruesome; you have to be up front about the accident consequences. The people who attend our safety courses probably already have their heads in the right spot. It's the people who say, 'Oh, I don't need that,' those are the people who should come." https://www.ainonline.com/aviation-news/general-aviation/2018-12-17/robinson-safety-course-logs-21000-graduates Back to Top Click here to sign up for the next session with Captain Shem Malmquist beginning in late January. Or call us at 231 720-0930 (EST). High Altitude Flying Overview Back to Top Back to Top Najeeb E. Halaby Graduate Student Fellowship The Najeeb E. Halaby Graduate Student Fellowship was established by the National Center for Atmospheric Research (NCAR) to shape the next generation of aviation researchers, honoring the late Najeeb Elias Halaby, an eminent aviator and administrator, for his vision and more than five decades of extraordinary contributions to aviation (https://ral.ucar.edu/opportunity/halaby-fellowship). The Fellowship The recipient of a Najeeb E. Halaby Graduate Student Fellowship will spend three months (in 2019 or early 2020) in residence with NCAR's Aviation Weather Research Program, which Mr. Halaby was instrumental in establishing in the 1980s. As the nation's leader in addressing aviation weather research, NCAR plays a unique role in meeting user needs by transferring research results to operations through its Research Application Laboratory (http://www.ral.ucar.edu/). The Fellow will conduct research broadly aimed at mitigation of weather sensitivities (e.g., weather impact avoidance) on aviation. We particularly encourage applicants interested in weather impacts on emerging modes of transportation, like unmanned aerial system operations and urban air mobility. The Fellowship will provide: • a monthly stipend for three months, including temporary living expenses • round-trip travel expenses to and from Boulder, CO • travel to a conference to present results • page charges (if necessary) for one publication of key results Eligibility and Application The Halaby Fellowship targets graduate students (late Masters or early PhD level) enrolled in an aviation-relevant department or program of a domestic or international university. Interested candidates should have advanced research skills, far-reaching vision, and dedication to get things accomplished. Consideration for this Fellowship will be given to candidates based on the following submitted material: • Curriculum vitae • Proposal (maximum five pages) presenting the research to be conducted at NCAR, the anticipated outcome of that, and how the proposed effort ties into the candidate's ongoing graduate research project(s) • Contact information for three references (one of which should be the student's primary advisor) NCAR will accept applications for the Halaby Fellowship each year. Email Applications by February 28, 2019 to halabyfellowship@ucar.edu Brochure: https://ral.ucar.edu/sites/default/files/public/opportunity/halaby-fellowship/docs/halabyfellowship_0.pdf Curt Lewis