Flight Safety Information March 14, 2019 - No. 055 In This Issue FAA orders the temporary grounding of Boeing 737 MAX aircraft Boeing and the FAA Already Lost Control of the Narrative Pilots complained at least 5 times about Boeing 737 MAX problems, records show Incident: Delta B763 at Beiing on Mar 13th 2019, engine problem Incident: United B763 at Munich on Mar 12th 2019, flaps problem Incident: China Airlines B744 near Taipei on Mar 9th 2019, fuel emergency Chinese air safety regulators gain global influence as FAA refuses to ground Boeing 737 Max A second 737 Max crash raises questions about airplane automation Conference aims to ensure aviation safety on continent Flight Safety Foundation, Aireon Forge Partnership to Advance Global Aviation Safety NTSB To Read FDR, CVR from Crashed Ethiopian Max 8 in U.S. NTSB Renews Call for Mandatory FDM, SMS for Part 135 GRADUATE RESEARCH SURVEY RTCA Global Aviation Symposium Call for Papers - ISASI 2019...*** Deadline March 18th *** ISASI-Mid-Atlantic Regional Chapter (MARC) Dinner/Meeting--2 May 2019 FAA orders the temporary grounding of Boeing 737 MAX aircraft 13 March 2019 The FAA is ordering the temporary grounding of Boeing 737 MAX aircraft operated by U.S. airlines or in U.S. territory. Worldwide concerns over the observed similarities between two recent fatal Boeing 737 MAX accidents (Lion Air 601 and Ethiopian 302) led several countries and airlines to ground the aircraft on March 11 and March 12, 2019. The FAA states that it received newly refined ADS-B satellite data on the morning of March 13. On the same day, the FAA was notified of "new information from the wreckage concerning the aircraft's configuration just after takeoff that." These pieces of evidence led the FAA to decide to issue an Emergency Order for the temporary grounding of the Boeing 737 MAX. The grounding will remain in effect pending further investigation, including examination of information from the aircraft's flight data recorders and cockpit voice recorders. https://news.aviation-safety.net/2019/03/13/faa-orders-the-temporary-grounding-of- boeing-737-max-aircraft/ Back to Top Boeing and the FAA Already Lost Control of the Narrative They had a responsibility to err on the side of safety by grounding the 737 Max sooner. Too little, too late. Boeing Co.'s "proactive" grounding of its top-selling, and troubled, 737 Max plane is too little, too late. It already lost control of the narrative. On Wednesday afternoon, the planemaker said it recommended to the U.S. Federal Aviation Administration that all 371 of the aircraft currently in operation globally be temporarily grounded as a "proactive step out of an abundance of caution" following the second fatal crash in just five months. Indeed, President Donald Trump had announced moments before that the FAA would prohibit U.S. airlines from continuing to fly the planes, abandoning a defense of their airworthiness that was becoming an increasingly isolated proposition after Canada joined regulators across the world in deciding precautionary measures were justified. A more conservative approach by Boeing and the FAA was long overdue, but their new-found appreciation for putting safety first doesn't excuse their previous reluctance. We still don't know for sure what caused the most recent crash of an Ethiopian Airlines flight Sunday that killed 157 people, although the CEO of that airline told CNN there were "substantial" similarities to the deadly incident involving a Lion Air flight in Indonesia in October. Canada's Transport Minister Marc Garneau backed up that stance Wednesday, noting that new satellite data suggested a link and while inconclusive, it was enough to justify safeguards. The FAA, a key regulator of the aviation industry in America, will have to explain why it was so late to do its job. But Boeing also had a responsibility to err on the side of safety and an opportunity to control the story by advocating conservatism earlier. It chose not to, and it will have to wrestle with the reputational damage wrought by that decision. Clipped Wings Boeing shares have declined following the second crash involving its 737 Max, but they remain up for the year My colleague David Fickling made the comparison to Johnson & Johnson's handling of the crisis spurred by the death of seven people after a criminal lacing of its Tylenol painkiller. The incident is a PR case study for a reason: J&J got out in front of the issue, recalled all its Tylenol products, and replaced them free of charge; today, households everywhere buy the drug regularly, without concern. Boeing should have mimicked this strategy and recommended that airlines ground its planes until it had more information and could get more answers on the causes of the crash. Or it could have recommended that the FAA put limits on the operation of the plane or require the temporary disabling of the flight-control system that's being highlighted as a possible cause of the crashes. Instead, CEO Dennis Muilenburg reportedly called Trump personally to express his confidence in the plane, which risks only further deepening the perception that the FAA and Boeing are too closely entwined for either's own good. Trump said the U.S. worked with Canada on the plane grounding. Maybe; I am personally skeptical that the U.S. would have allowed Canada to go first if that was the case. Again, we still don't know what caused the Ethiopian Airlines crash, and Boeing maintains that it has full confidence in the safety of the plane - but we do know that a combined 346 people have died on board brand new 737 Max aircraft at a time when fatal commercial-jet incidents are rare. I think it could have been anticipated that passengers and governments alike would be concerned, and that repeated assurances of confidence might not be enough on their own. 1 The 737 Max program is likely to be perfectly safe over the long term, and Boeing is finalizing a software fix for the flight- control system that's being tied to the Lion Air crash. It would have been in Boeing's best interest to vow from the start to remove even the slightest shadow of a doubt before putting these planes back in the sky. Top Seller The 737 Max accounts for a substantial portion of Boeing's backlog There's undeniably a cost to this: a global grounding will likely lead to a pause in deliveries until a fix is installed and certified, which Vertical Research Partners analyst Rob Stallard estimates would require Boeing to house an additional $1.8 billion a month in inventory. Norwegian Air has already said it expects to be remunerated by Boeing for the cost of sidelining 1 percent of its overall seat capacity. But Boeing now has to take on those expenses and cash flow hits without any PR benefit. Whether it's true or not, by deflecting, the company now comes across as trying to hold on to every last dollar of profit that it can. Boeing's miscalculation may have stemmed from faith in the FAA as the global arbiter of flight safety. That perception has been upended by foreign governments' decision to decide for themselves whether or not they feel comfortable boarding their citizens on Boeing's planes. In another snub, Ethiopia plans to send data and voice recorders collected from the crash site to European authorities, rather than to the U.S., which the carrier's public relations director called "a strategic decision." 2 Playing follow the leader - in this case, China - on grounding the plane has damaged both Boeing and the FAA's credibility and put them on the defensive in dealing with this crisis. * The Financial Times reports that large U.S. companies are asking travel agencies to avoid booking their staff on 737 Max 8 planes. * Ethiopia reportedly wanted to send the black boxes to Germany, but regulators there declined to receive them because they lack the necessary software. https://www.bloomberg.com/opinion/articles/2019-03-13/boeing-and-the-faa-737- max-grounding-damage-is-already Back to Top Pilots complained at least 5 times about Boeing 737 MAX problems, records show In a report from October, a pilot complained that a MAX 8's autothrottles - which command the plane to accelerate to a set speed within certain parameters - were not working properly even though the crew had engaged them. | Stephen Brashear/Getty Images Pilots in the U.S. complained at least 5 times in recent months about problems controlling their Boeing 737 MAX 8 jets during critical moments of flight, federal records show, adding to questions raised by deadly crashes involving that model of jetliner in Ethiopia and Indonesia. Some of the incidents appear to involve the same anti-stall system that has come up as a potential cause of October's Indonesia crash, according to a review of a Federal Aviation Administration incident database that lets pilots self-report trouble. Investigators have not said whether the same technology had emerged as a possible cause of Sunday's crash in Ethiopia, although both involved airliners that mysteriously plunged to the ground minutes after takeoff. For one U.S. incident in November 2018, a commercial airline pilot reported that during takeoff, the autopilot was engaged and "within two to three seconds the aircraft pitched nose down," in a manner steep enough to trigger the plane's warning system, which sounded "Don't sink, don't sink!" After the autopilot was disengaged, the plane climbed as normal, according to the report. The reports are submitted anonymously to help improve reporting of safety problems and so do not include any information about which airline was involved. In addition, though the reports have a spot to note what airport was involved, often pilots do not fill out that field. By signing up you agree to receive email newsletters or alerts from POLITICO. You can unsubscribe at any time. The November incident occurred days or weeks after the October crash in Indonesia, which killed 189 people aboard a Boeing 737 MAX 8 operated by Lion Air. The report noted that before the plane involved in the November incident took off, the crew had "discussed the recent MAX 8 [anti-stall] guidance" issued by the FAA and Boeing. In both the Ethiopian Airlines and Lion Air crashes, the plane descended sharply more than once as pilots wrestled with the controls before crashing. In the case of Lion Air, preliminary facts suggest that the cause may have been the anti-stall system, which was designed to force the plane's nose down if it seemed to be rising steeply enough to risk a stall. Pilots groups have complained that Boeing did too little to ensure that pilots or airlines were aware of the new anti-stall feature - or knew how to turn it off if it were malfunctioning or acting on faulty data. In a separate U.S. incident in November, a pilot reported that trouble started when he or she engaged the autopilot after leveling off from takeoff: The co-pilot "called out 'DESCENDING,' followed by an almost immediate: 'DONT SINK DONT SINK!'" warning, the pilot wrote. But the plane resumed climbing after the crew disengaged the autopilot. In another report, a commercial airline pilot complained about how the FAA and Boeing were handling the problem. While the FAA had issued an emergency directive on Nov. 7, 2018, to help pilots understand how to handle problems with the anti-stall technology, "it does nothing to address the systems issues," the pilot wrote. The pilot further noted that the flight manuals had yet to be updated with that information at that time. "I think it is unconscionable that a manufacturer, the FAA, and the airlines would have pilots flying an airplane without adequately training, or even providing available resources and sufficient documentation to understand the highly complex systems that differentiate this aircraft from prior models," the pilot wrote. "The fact that this airplane requires such jury rigging to fly is a red flag. Now we know the systems employed are error prone - even if the pilots aren't sure what those systems are, what redundancies are in place, and failure modes." The pilot added: "I am left to wonder: what else don't I know? The Flight Manual is inadequate and almost criminally insufficient. All airlines that operate the MAX must insist that Boeing incorporate ALL systems in their manuals." In a separate report from October, a pilot complained that a MAX 8's autothrottles - which command the plane to accelerate to a set speed within certain parameters - were not working properly even though the crew had engaged them. The pilot noticed quickly and adjusted the thrust manually to continue to climb. "Shortly afterwards I heard about the (other carrier) accident and am wondering if any other crews have experienced similar incidents with the autothrottle system on the MAX?" the pilot wrote in the report. The pilot wrote that both he or she and the captain were new with this model plane and thus "not able to identify whether it was the aircraft or me that was in error." https://www.politico.com/story/2019/03/12/pilots-boeing-737-1266090 Back to Top Incident: Delta B763 at Beiing on Mar 13th 2019, engine problem A Delta Airlines Boeing 767-300, registration N1610D performing flight DL-128 from Beijing (China) to Seattle,WA (USA), was climbing out of Beijing when the crew stopped the climb at 7500 meters (FL246) due to indications of a possible problem with one of the engine (CF6). The crew decided to return to Beijing and landed safely about 100 minutes after departure. The airline reported the crew returned to Beijing due to an engine warning. The occurrence aircraft is still on the ground in Beijing about 17 hours after landing back. http://avherald.com/h?article=4c555853&opt=0 Back to Top Incident: United B763 at Munich on Mar 12th 2019, flaps problem A United Boeing 767-300, registration N652UA performing flight UA-30 (dep Mar 11th) from Newark,NJ (USA) to Munich (Germany), was on approach to Munich's runway 26R when the crew went around from about 3000 feet MSL reporting a problem with the flaps. The aircraft entered a hold, while the crew worked the related checklists solving the problem. The aircraft landed safely and at normal speed on runway 26R about 15 minutes after the go around. http://avherald.com/h?article=4c555573&opt=0 Back to Top Incident: China Airlines B744 near Taipei on Mar 9th 2019, fuel emergency A China Airlines Boeing 747-400, registration B-18211 performing flight CI-122 from Taipei (Taiwan) to Okinawa (Japan), was on approach to Okinawa's runway 18 about 64 minutes after departure from Taipei when the crew initiated a go around due to weather. The aircraft entered a hold for about 22 minutes to wait for weather improvement, then the crew decided to return to Taipei. The crew declared emergency reporting they were low on fuel and received priority. The aircraft landed safely back in Taipei about 100 minutes after the go around. Taiwan's ASC reported, the event was rated an aviaton occurrence (editorial note: signifying the aircraft landed with less than required minimum fuel) and opened an investigation. http://avherald.com/h?article=4c553fa3&opt=0 Back to Top Chinese air safety regulators gain global influence as FAA refuses to ground Boeing 737 Max Family members mourn at the crash site of the Ethiopian Airlines-operated Boeing 737 MAX aircraft, at Hama Quntushele village in the Oromia region, on March 13. (Tony Karumba / AFP/Getty Images) The second fatal crash of a Boeing Co. 737 Max aircraft in less than five months is creating a new hierarchy in aviation safety - thrusting to the top none other than U.S. rival China. Three days after an Ethiopian Airlines jet crashed, killing all 157 people on board, country after country ignored assessments by the U.S. Federal Aviation Administration that the plane is safe to fly. Even close U.S. ally Canada agreed Wednesday to ground the plane and restrict it from its airspace. In doing so, Canada and other long-time American allies, including the U.K. and Australia, broke convention by snubbing an authority that has defined what's airworthy - and what's not - for decades. New Zealand, the United Arab Emirates and Vietnam also joined Wednesday in blocking the 737 Max, helping legitimize China's early verdict on Monday that the plane could be unsafe. "The FAA's credibility is being tested," said Chad Ohlandt, a Rand Corp. senior engineer in Washington. "The Chinese want their regulatory agency to be considered a similar gold standard." One day after the Ethiopian Airlines flight plunged to the ground, the Civil Aviation Administration of China (CAAC) drew a possible connection between the crash and Lion Air's in October. A preliminary report into the earlier disaster, which killed 189 passengers and crew, indicated pilots struggled to maintain control following an equipment malfunction. Both flights, on almost brand-new planes, ended minutes after takeoff. Ethiopian Airlines Chief Executive Tewolde GebreMariam told CNN that the latest crash and the Lion Air tragedy had substantial similarities. Separately, the Wall Street Journal reported that Ethiopia plans to send the flight-data and cockpit-voice recorders to the U.K., causing U.S. investigators to hold intense behind-the-scenes talks to bring the parts to America. Meanwhile, the CAAC asked domestic airlines to ground their 737 Max 8 fleets. "There needs to be reason for us to change that decision," said CAAC's deputy head Li Jian. Domestic carriers including China Southern Airlines Co. and Air China Ltd. account for about 20% of 737 Max deliveries worldwide through January, according to Boeing's website. Chinese aviation regulators do tend to be conservative. They banned the use of cellphones on aircraft until 2018, years after regulators in developed countries gave them the green light. But China is gaining influence. As an air travel market, it's on track to surpass the U.S. as the world's biggest around 2022. It's also seeking some degree of self-sufficiency through its national champion: Commercial Aircraft Corp. of China Ltd., which is known as Comac. As a regulator, recent events indicate China is on its way to attaining the level of authority enjoyed by the FAA and the European Union Aviation Safety Agency, giving the country global recognition for its ability to determine when an aircraft is safe to fly. In a deal signed between CAAC and FAA in 2017, aviation regulators from China and U.S. agreed to recognize each other's airworthiness standards, paving the way for Chinese-made aircraft to win FAA certifications to sell in the global market. A similar deal is also being finalized with their European counterpart. China's first homemade commercial aircraft C919, which state-owned Comac has developed to break the duopoly held by Airbus SE's A320 and Boeing's 737 in the narrow-body market, is trying to get airworthiness certification from both CAAC and EASA. https://www.latimes.com/business/la-fi-chinese-regulators-faa-boeing-737-max- 20190313-story.html Back to Top A second 737 Max crash raises questions about airplane automation Regulators, airlines, and Boeing need to grapple with how much information pilots are given as systems become more complex. As you read this, over a million people are in flight. Close to a third of the commercial airplanes in the sky at any given moment are Boeing 737s: it is the best-selling jetliner in history. The 737 has safely carried over 20 billion passengers on long trips and on short ones. That legacy of safety is now under scrutiny as the 737 Max, the newest variant of the jetliner, has crashed twice in rapid succession. Ethiopian Airlines Flight 302 crashed on Sunday, a few minutes after taking off from Addis Ababa, killing all 157 people on board. It was the second such tragedy in five months, following an October crash in Indonesia that killed all 189 passengers and crew on Lion Air Flight 610. Airlines and regulators around the world have now grounded the model-though Boeing and the US government insist that it is safe. The brief history of the 737 Max raises the question of whether Boeing made mistakes in its pursuit of efficiency. America's Federal Aviation Administration (FAA) and other regulators will also have questions to answer about their oversight of the way changes to the plane were communicated to pilots. As of the time of writing, it is impossible to definitively say if the two airplanes crashed for the same reasons. According to a preliminary report released by the Indonesian air safety investigative agency, Lion Air 610 crashed because a faulty sensor erroneously reported that the airplane was stalling. The false report of a stall triggered an automated system that tried to point the aircraft's nose down so that it could gain enough speed to fly safely. The pilots fought the automated system, trying to pull the nose back up. They lost. The 737 Max has bigger engines than the original 737, which make it 14% more fuel efficient than the previous generation. As the trade publication Air Current explains, the position and shape of the new engines changed how the aircraft handles, giving the nose a tendency to tip upward in some situations, which could cause the plane to stall. The new "maneuvering characteristics augmentation system" was designed to counteract that tendency. Did these more efficient engines-and the changes they necessitated to the airplane's automation systems-compromise the aircraft's safety? As sociologist Charles Perrow wrote in his classic 1984 book Normal Accidents, new air-safety technologies don't always make airplanes safer, even if they work just as well as they are supposed to. Instead of improving safety, innovations can allow airlines "to run greater risks in search of increased performance." A high-ranking Boeing official told the Wall Street Journal that "the company had decided against disclosing more details to cockpit crews due to concerns about inundating average pilots with too much information-and significantly more technical data-than they needed or could digest." But what good is a safety system that's too intricate for highly trained professional airline pilots to understand? Each new automatic device, Perrow wrote, might solve some problems only to introduce new, more subtle ones. Make the system too complicated, he said, and it's inevitable that regulators will lose track of which pilots had been told what, and that some pilots will get confused about which procedures to follow. It didn't, he said, make much sense to blame pilots in cases like this. Pilot error, he said, "is a convenient catch-all." But it's the complexity of the system that's really to blame. The Lion Air crash-and the news that some pilots may not have been given all the information they needed about the new systems on board-caused an uproar among those who fly the 737 Max. As the Seattle Times reported, one American Airlines pilot wondered: "I've been flying the MAX-8 a couple times per month for almost a year now, and I'm sitting here thinking, what the hell else don't I know about this thing?" Investigators recovered Ethiopian 302's voice and data recorders-the so-called black boxes-on Monday afternoon. This will help them determine the cause of the crash. Following the earlier crash in Indonesia, the FAA issued an airworthiness directive that set in place new procedures for disengaging the plane's automated systems if pilots have reason to believe that erroneous sensor readings are causing the autopilot to force the plane's nose down. On Monday, after the crash in Ethiopia, Boeing released a statement vouching for the safety of the 737 Max. But that same statement also announced a software update that would make the flight control software better able to cope with erroneous sensor inputs. The remarkable safety record of commercial airliners is an achievement of bureaucracy rather than technology. Airplanes are not safe because they are made of strong materials, nor because the computers that help fly them are so sophisticated. They are safe because of an elaborate international system of regulation that, with scores of checklists and reams of systematized procedures, makes "Safety first" not a slogan but a reality. That system is now showing signs of strain. Politics should have nothing to do with an airplane's ability to fly. The 69 airlines around the world that have taken delivery of 737 Max planes should find them all to be equally safe: those in China should be no more safe or less safe than those in the US. However, within a day of the crash, 23 airlines had grounded their 737 Max fleets. None of these are American-flagged. China was the first country to ground them all. By contrast, the FAA issued a "Continued Airworthiness Notification to the International Community": a proactive announcement vouching for the safety of the American-made 737, even though, as Boeing itself has said, the cause of the crash remains uncertain. This demonstrates a fracturing of technocratic consensus. The last time something similar happened, in 2013, the international aviation community grounded all Boeing 787s until problems with the airplane's batteries could be resolved. Times are different now. Taking things at face value, maybe China is showing an abundance of caution, and the FAA is not jumping to conclusions. But it sure looks as if China is taking the chance to undermine confidence in its global rival, while the US government is doing what it can to protect America's largest exporter, which is an important source of manufacturing jobs. Each year, airspace grows more crowded as more and more people fly, and as drones of various sizes grow in popularity. Commercial air travel has remained so safe, in part, because a thorough infrastructure of investigation makes it possible to learn from mistakes, and thus avoid repeating them. At the time of writing, investigators have not definitively ruled on the causes of either 737 Max crash. It sadly appears, however, that the lessons from Lion Air 610 were not learned in time to prevent the crash of Ethiopian 302. Hopefully the particular problem of this automated anti-stall device causing a plane to nosedive will be solved by the changes Boeing and aviation regulators are currently in the process of implementing. Nevertheless, even in the best case, the cycle will surely continue. As Perrow wrote, "The hard core of system accidents, while small, will probably not get smaller. This is because with each new advance in equipment or training, the pressures are to push the system to its limits." https://www.technologyreview.com/s/613106/a-second-737-max-crash-raises- questions-about-airplane-automation/ Back to Top Conference aims to ensure aviation safety on continent Cape Town - Improving aviation safety security and growth came under the spotlight at the three-day National Aviation Conference hosted by the SA Civil Aviation Authority (Sacaa) this week. The gathering came at a time when Africa was reeling after one of its worst aviation disasters to date, where 157 passengers including eight crew members were killed when Ethiopian Airlines Flight ET 302 crashed on Sunday. According to reports, this was the second crash involving the Boeing 737 Max 8 after an Indonesian crash in October where 189 people were killed. The crash data is still being investigated and no evidence has yet linked the incidents. Sacaa director Poppy Khoza said: "Information sharing forums such as this one are very important. "An incident-free airspace over the African continent can only become a permanent reality when we get into the habit of engaging each other as regulators, manufacturers, and operators in an honest and robust manner about what could sometimes be uncomfortable topics." Khoza said Sacaa aimed for their regulations to be developed in sync with innovation. "That is where we are dependent on the industry, such as manufacturers and designers, to keep us in the loop, and indicate what we need to be prepared for. "We ideally want any new inventions in the aviation field to become part of our aviation safety culture from the beginning by us working on safety parameters together. "Furthermore, regulations will eventually need to be adopted to talk to specific operations and to be adaptable as innovations progress." They also want to have regulations that were not "unnecessarily burdensome and time- consuming". "Enforcements of any kind are purely aimed at fulfilling our mandate of ensuring safety and security for all passengers, aircrew and those on the ground. "We therefore have to execute our mandate without any form of fear, favour, or prejudice, and I am sure that all the delegates here would agree with me in this respect." Meanwhile, Sacaa has started the process of getting South Africa ready for the ICAO's Universal Security Audit Programme Continuous Monitoring Approach (USAP-CMA). "The objective of the USAP-CMA is to promote global aviation security through continuous auditing and monitoring of member states' aviation security performance in order to enhance their aviation security compliance and oversight capabilities," Khoza said. Gender equality in the industry was also in the spotlight as Sacaa said only 3% of commercial pilots globally were women. https://www.iol.co.za/capetimes/news/conference-aims-to-ensure-aviation-safety-on- continent-19868520 Back to Top Flight Safety Foundation, Aireon Forge Partnership to Advance Global Aviation Safety The Foundation will oversee the development of safety performance indicators (SPIs) and other important safety metrics and analytics using space-based ADS-B data. MADRID - Flight Safety Foundation has announced an agreement with Aireon to collaborate on applying spaced-based automatic dependent surveillance-broadcast (ADS-B) data to develop, share and identify safety risks in global airspace and use this information to inform emerging issues. Under a new phase of the Foundation's Global Safety Information Program (GSIP), the Foundation will oversee the development of safety performance indicators (SPIs) and other important safety metrics and analytics using space-based ADS-B data. The announcement was made at the World ATM Congress in Madrid. "The goal of GSIP is to accelerate the knowledge gained from collecting and analyzing operational data in order to impact future safety performance," said Dr. Hassan Shahidi, president and CEO of the Foundation. "We believe that Aireon's ADS-B data, derived from their real-time air traffic surveillance system, is a key component of the operational information needed to produce safety performance knowledge, which can provide new insights into safety of operations in all regions around the world." The Foundation will be building on the global risk areas identified as part of GSIP and will focus the initial space-based ADS-B-derived SPIs on risks in approach and landing, loss of separation, and surface safety. "Aireon is honored to be partnering with the Foundation to utilize our data for improving global aviation safety," said Don Thoma, CEO of Aireon. "The Foundation has an incredible history and is a leader in promoting and influencing aviation safety. With a 70-year legacy in advancing aviation safety globally, we are pleased that they have chosen to use space-based ADS-B and apply it in an impartial and independent manner to further enhance aviation safety globally." In the near term, the Foundation will be instituting an oversight and governance process for handling the data and establishing partnerships to develop SPIs and safety insights. The derived safety performance indicators will be made available to industry stakeholders as part of the Foundation's activities. About Flight Safety Foundation Flight Safety Foundation is an independent, nonprofit, international organization engaged in research, education, advocacy and communications to improve aviation safety. The Foundation's mission is to connect, influence and lead global aviation safety. https://www.aviationpros.com/engines-components/aircraft-airframe- accessories/avionics/press-release/21071646/flight-safety-foundation-flight-safety- foundation-aireon-forge-partnership-to-advance-global-aviation-safety Back to Top NTSB To Read FDR, CVR from Crashed Ethiopian Max 8 in U.S. The U.S. National Transportation Safety Board (NTSB) will take the flight data and cockpit voice recorders from the Ethiopian Airlines Boeing 737 Max 8 that crashed outside Addis Ababa on Sunday to Washington, D.C., for analysis by the end of the week, according to officials from the Ethiopian Civil Aviation Authority (ECAA). Although the ECAA has taken the lead in the investigation, it does not have the instrumentation and expertise needed to conduct the analyses. The Ethiopian Ministry of Transport and ECAA established a national accident investigation committee that commenced work on Monday. Experts from Boeing, the NTSB, and the UK Air Accidents Investigation Branch arrived at the Ethiopian capital Addis Ababa on Tuesday morning to assist Ethiopian authorities on the accident investigation process. A team of experts from the NTSB held discussions with the minister of transport, Dagmawit Moges, and the director general of the ECAA, Wossenyeleh Hunegnaw, on how best to collaborate on the investigation process. Sources close to the investigation process told AIN that both NTSB and AAIB requested to take the recorders to work on the data interpretation process. However, due to the longstanding cooperation between Ethiopia and the U.S. in the aviation sector, Ethiopian aviation authorities will opt to send the black box to Washington. The ECAA's chief accident investigator and a senior captain from Ethiopian Airlines will accompany experts from the NTSB to the U.S. The U.S. lost eight nationals in the crash of Flight ET302, in which a total of 157 passengers and crew perished. Seven Britons died in the crash. A senior ECAA official told AIN on Monday that the FDR incurred partial damage. However, he said that the memory chip could still be intact. "It is the outer part which is affected," he said. "Experts of the NTSB will put the memory chip in another instrument and read the data." https://www.ainonline.com/aviation-news/air-transport/2019-03-13/ntsb-read-fdr-cvr- crashed-ethiopian-max-8-us Back to Top NTSB Renews Call for Mandatory FDM, SMS for Part 135 The National Transportation Safety Board (NTSB) yesterday renewed its call for the FAA to mandate flight data monitoring and to implement measures to improve training and safety management on all Part 135 operations. In all, the NTSB made three new and reissued six previous recommendations as a result of its findings on the May 15, 2017 crash of a Learjet 35A (N452DA) near Teterboro Airport in New Jersey (TEB). Both the pilot-in-command (PIC) and second-in-command (SIC) were killed on the Part 91 positioning flight after they lost control of the aircraft during a circling approach to TEB's Runway 1 and crashed into a nearby commercial building and parking lot. During its March 12 board meeting in Washington, the NTSB agreed that the probable cause of the accident was "the PIC's attempt to salvage an unstabilized visual approach, which resulted in an aerodynamic stall at low altitude." The Safety Board cited as a contributing factor the decision of the PIC to allow an unapproved SIC to act as the pilot flying, the PIC's inadequate and incomplete preflight planning, and the flight crew's lack of an approach briefing. The NTSB additionally pointed to operator Trans-Pacific's lack of safety programs, which the agency said, "would have enabled the company to identify and correct patterns of poor performance and procedural noncompliance." Further faulted were ineffective FAA safety assurance system procedures, which failed to identify company deficiencies, the Safety Board added. The fatal crash occurred on the crew's third and final scheduled flight of that day. Earlier, the crew had flown from TEB to Laurence G. Hanscom Field (BED) in Bedford, Massachusetts, and then from BED to Philadelphia International Airport (PHL), before the return to TEB. While the PIC checked the weather at the beginning of the day, he did not check the weather again before that last leg from PHL to TEB, where the winds were reported as strong and gusty at the time of the accident. Company policy stipulates that pilots check weather within three hours of departure. In addition, the crew's flight plan for the 28- minute PHL to TEB leg called for a cruising altitude of 27,000 ft. NTSB noted that the flight plan's time and altitude entries "were incompatible with each other, [suggesting] that the crew devoted little attention to preflight planning." Further, since the crew had limited time during the flight to brief the approach, no such approach briefing was conducted, despite company policy. Cockpit voice recorder data indicated that the SIC was the pilot flying (PF) on that last leg, even though the SIC did not meet the company's minimum level of experience for such flight. The PIC regularly coached the SIC, coaching that the NTSB believes "likely distracted the PIC from his duties as PIC and pilot monitoring, such as executing checklists and entering approach waypoints into the flight management system." The NTSB found that "collectively, procedural deviations and errors resulted in the flight crew's lack of situational awareness throughout the flight and approach to TEB." The airplane's navigation equipment had not been properly set for the instrument approach clearance that the flight crew received, but neither pilot realized this and, as a result, improperly executed the vertical profile of the approach. The flight crossed an intermediate fix and the final approach fix hundreds of feet above the altitudes specified by the approach procedure. The controller vectored the flight for the ILS Runway 6 circle-to-land to Runway 1 approach. But when the crew initiated the circle-to-land maneuver, the aircraft was 2.8 nm beyond the final approach fix and the crew was unable to line up with the landing runway. This should have prompted a go-around, NTSB said, but neither pilot called for one and the PIC-who by this time had taken control of the airplane-continued the approach. The aircraft, below approach speed, stalled and crashed one-half mile south of Runway 1. Previously, the NTSB revealed that during the 30-minute cockpit voice recorder reading, the captain had uttered 131 expletives, 115 of which involved the "F-bomb." "This captain would say things like: 'What the bleep; we're a bleeping Learjet; get us bleeping higher; we won't bleeping make it if we got 4,000; she's a bleeping idiot; get us someone else if she can't do it,'" said John DeLisi, director of the NTSB's Office of Aviation Safety, substituting the expletive with bleeping. The NTSB said the accident highlighted four primary safety issues: the need for flight- data monitoring (FDM) programs in Part 135 operations; the need for the FAA to implement procedures to identify Part 135 operators whose pilots do not comply with standard operating procedures; the need for Part 135 operators to monitor pilots with performance deficiencies; and, the need for better guidance for Part 135 crew resource management (CRM). The crash "raises important questions about what can be done to improve the safety of Part 135 operations," NTSB chairman Robert Sumwalt said during the hearing on the investigation. "This accident illustrates the potential safety benefits of applying knowledge gained in Part 121 investigations, and adapting solutions already introduced in Part 121 flight, to Part 135 operations. The chairman pointed to FDM, CRM and safety management systems (SMS) and added, "If Part 135 aviation had the same tools as Part 121...we might not be here today." As a result of its findings, the NTSB issued three new recommendations, including a requirement for Part 135 operators to implement programs to provide additional training and oversight of crewmembers with demonstrated performance deficiencies. The NTSB also called for guidance for effective CRM training programs and for the FAA to review Learjet 35A operations manuals to determine whether they contain manufacturer-recommended approach speed wind additives. The NTSB additionally reiterated six previous recommendations seeking mandatory flight-data monitoring, pilot leadership training programs, and SMS programs. Further, the recommendations call on the FAA to improve its oversight systems. https://www.ainonline.com/aviation-news/business-aviation/2019-03-13/ntsb-renews- call-mandatory-fdm-sms-part-135 Back to Top GRADUATE RESEARCH SURVEY Participants for a 5-minute survey regarding hypoxia and high altitude chamber training are being sought for a study assessing hypoxia perceptions and experiences related to hypoxia awareness training. To be eligible for participation, you must have previously completed high altitude chamber training. All responses are anonymous and no identifying information will be collected. The study is being conducted by Kasey Stevenson, a graduate student studying Aviation Management and Human Factors at Arizona State University. Kasey's research is being conducted at the Del E. Webb High Altitude Chamber; previously the Williams Air Force Base High Altitude Chamber. The research is being completed with the goal of improving hypoxia awareness and training methods, in an effort to reduce hypoxia- related incidents and accidents. The survey can be accessed at: https://asu.co1.qualtrics.com/jfe/form/SV_ealbH4xwJRL8P2J Back to Top Back to Top Call for Papers - ISASI 2019 *** Deadline March 18th *** Future Safety: has the past become irrelevant? The Hague Marriott Hotel & World Forum The Hague September 3 - 5, 2019 Suggested topics for presentations to support the theme may include: * Recent accidents/incidents investigations of particular interest. * Novel investigation techniques for aircraft, helicopter and drone accidents. * Human factors investigation methods, techniques and future developments. * Data investigation methods, techniques and future developments. * Airport investigation methods, techniques and future developments. * Investigator selection, training and future needs. * Lessons learned and potential future developments in recommendations. Presentations must be in English and should be 25 minutes long. There will be an additional 5 minutes for questions at the end of each presentation. If you who would like to submit an abstract, please download and use the ISASI 2019 abstract template, which can be found at: www.ISASI2019.org. Important dates: March 18, 2019 - Last date for receipt of abstracts May 8, 2019 - Presenters informed of acceptance May 22, 2019 - The 2018 Seminar Technical Program will be published July 9, 2019 - Last date for receipt of completed paper and PowerPoint presentations. For questions related to the program: program@isasi2019.org Curt Lewis