Flight Safety Information May 7, 2019 - No. 092 In This Issue Boeing Knew About 737 Max Sensor Problem Before Plane Crash In Indonesia Incident: KLM B738 at Amsterdam on May 5th 2019, engine problem Incident: Spirit A320 near Dallas on May 5th 2019, unuusal odour on board Accident: British Airways B772 over Atlantic on May 5th 2019, turbulence causes 14 injuries Incident: Nordstar B738 at Norilsk on May 6th 2019, overran runway on landing Private jet leaving Las Vegas crashes in Mexico, killing all 13 people aboard, authorities say Couple aboard deadly Southwest Airlines Flight 1380 sues airline, claiming negligence Cracked Windshield Forces United Flight to Return to Dulles Airport ISASI - DFW Regional Chapter Meeting GRADUATE RESEARCH SURVEY Last Chance to Take HOT-STOP Survey - Win $100 Gift Card Call for Nominations For 2019 Laura Taber Barbour Air Safety Award Boeing Knew About 737 Max Sensor Problem Before Plane Crash In Indonesia Boeing said on Sunday that it was aware of problems with a key safety indicator in 2017, but it didn't inform airlines or the FAA until after the Lion Air crash a year later. Here, 737 Max jets built for American Airlines (left) and Air Canada are parked at the airport adjacent to a Boeing production facility in Renton, Wash., in April. Boeing knew that there was a problem with one of the safety features on its 737 Max planes back in 2017 - well before the Lion Air crash in October 2018 and the Ethiopian Airlines crash in March. But it did not disclose the issue to airlines or safety regulators until after the Lion Air plane crashed off the Indonesian coast, killing all 189 aboard. In a statement Sunday, Boeing said its engineers discovered a problem with a key safety indicator within months of Boeing delivering the first 737 Max planes to airlines. The indicator, called an angle of attack disagree alert, is designed to warn pilots if the plane's sensors are transmitting contradictory data about the direction of the plane's nose. Boeing intended for the indicator to be standard on the 737 Max, in keeping with the features available on previous generations of 737s. But its engineers discovered that the sensor worked only with a separate, optional safety feature. Boeing said the faulty software was delivered by a vendor, which it didn't name. When it learned of the issue in 2017, Boeing says it conducted a safety review and concluded that the nonworking alert did not affect airplane safety or operation. The review also concluded that the indicator could be decoupled from the optional indicator at the time of a future software update. Boeing says its senior leadership wasn't aware of the problem until after the Lion Air crash. Boeing says it discussed the indicator problem at that point with the Federal Aviation Administration - a year after the company knew about the problem. The company then convened another safety review, which concluded once again that the absence of the alert was not a safety issue. It shared the analysis with the FAA. The FAA said in a statement that its review board "determined the issue to be 'low risk' and would be required to be a part of Boeing's overall enhancement announced after the Lion Air [crash]. However, Boeing's timely or earlier communication with the operators would have helped to reduce or eliminate possible confusion." A spokesperson for Southwest Airlines, the largest operator of the 737 Max, told The Associated Press that Boeing had informed it of the indicator issue in November, following the Lion Air crash. Southwest then added the optional feature so the angle-of-attack disagree indicator would work. But only 20% of customers had purchased the optional feature, and neither Lion Air nor Ethiopian Airlines had functioning angle of attack disagree indicators on their 737 Max fleets, The New York Times reports. If angle of attack sensors indicate the nose of the plane is too high, an automated flight control system on the 737 Max automatically forces the nose of the plane down, as NPR's David Schaper reported in March: "Investigators of the Lion Air plane crash ... say a faulty sensor fed the system erroneous data, and the system forced the nose of the plane down repeatedly. The pilots may not have known the system even existed and engaged in a futile struggle to regain control of the aircraft." Boeing maintains that the 737 Max was safe to fly even without the alert, which it says provides only "supplemental information." But the new disclosure raises questions about how forthright the company has been about issues with the planes. "We thought [the disagree light] worked," Jon Weaks, the president of the Southwest Airlines Pilots Association, told the Times. "If they knew it in 2017, why did we get to nearly the end of 2018 until the manual was changed?" The 737 Max, the fastest-selling plane in Boeing's history, has been grounded around the world for almost eight weeks. The company is working on a software fix it hopes will get the planes flying again this summer, as it faces congressional scrutiny and lawsuits by family members of those who died in the crashes. https://www.npr.org/2019/05/06/720553748/boeing-knew-about-737-max-sensor-problem-before-plane-crash-in-indonesia Back to Top Incident: KLM B738 at Amsterdam on May 5th 2019, engine problem A KLM Boeing 737-800, registration PH-BGC performing flight KL-1692 from Lisbon (Portugal) to Amsterdam (Netherlands), was on short final to Amsterdam's runway 36R when the left hand engine (CFM56) emitted a loud bang and streaks of flames. The crew continued for a safe landing on runway 36R maintaining routine communication and taxied to the apron. The airline confirmed an engine issue, it may have been a bird strike. The occurrence aircraft remained on the ground for about 36 hours before returning to service. http://avherald.com/h?article=4c79c0ce&opt=0 Back to Top Incident: Spirit A320 near Dallas on May 5th 2019, unuusal odour on board A Spirit Airlines Airbus A320-200, registration N635NK performing flight NK-1128 (dep May 4th) from Las Vegas,NV to Tampa,FL (USA), was enroute at FL350 about 400nm west of Dallas Ft. Worth,TX (USA) when passengers complained about an unusul odour on board, a number of passengers felt sick because of the odour. The crew descended the aircraft to 10,000 feet, initially considered to divert to Albuquerque,NM (USA) but then decided to divert to Dallas Ft. Worth where the aircraft landed without further incident about 90 minutes after leaving FL350. A number of passengers were examined by paramedics awaiting the aircraft, none was taken to a hospital though. The airline reported they are investigating the source of the odour. A replacement aircraft was to take the aircraft to Tampa. A replacement A320-200 registration N603NK reached Tampa with a delay of 3.5 hours. https://flightaware.com/live/flight/NKS1128/history/20190505/0520Z/KLAS/KTPA http://avherald.com/h?article=4c79bbf1&opt=0 Back to Top Back to Top Accident: British Airways B772 over Atlantic on May 5th 2019, turbulence causes 14 injuries A British Airways Boeing 777-200, registration G-VIIO performing flight A-2167 from London Gatwick,EN (UK) to Tampa,FL (USA), was enroute at FL390 about 500nm northeast of Bermuda (Bermuda) when the aircraft encountered turbulence causing injuries to 12 passengers and 2 crew. The aircraft continued to Tampa for a safe landing about 3.5 hours later. The FAA reported 12 passengers and 2 crew received "unknown" injuries, the aircraft sustained "unknown" damage. The occurrence was rated an accident (indicating serious injuries and/or substantial damage) and is being investigated. The occurrence aircraft remained on the ground in Tampa for about 5.5 hours, then departed for the return flight. https://flightaware.com/live/flight/BAW2167/history/20190505/1030Z/EGKK/KTPA http://avherald.com/h?article=4c79b9e7&opt=0 Back to Top Incident: Nordstar B738 at Norilsk on May 6th 2019, overran runway on landing A Nordstar Boeing 737-800, registration VQ-BPM performing flight Y7-217 from Krasnojarsk to Norilsk (Russia) with about 100 people on board, landed on Norilsk's runway 19 (length 11,250 feet/3430 meters) at 13:16L (06:16Z) but overran the end of the runway and came to a stop on the paved surface of the runway end safety area. There were no injuries, the aircraft did not sustain damage. The occurrence aircraft is currently enroute for flight Y7-208 back to Krasnojarsk departing Norilsk about 7:45 hours after landing. http://avherald.com/h?article=4c797dd7&opt=0 Back to Top Private jet leaving Las Vegas crashes in Mexico, killing all 13 people aboard, authorities say A handout photo made available by La Voz de Monclova newspaper shows wreckage of a private jet that disappeared in the northern Mexican state of Coahuila en route from Las Vegas. All 13 people aboard were killed in the crash. (Photo: LA VOZ DE MONCLOVA / HANDOUT, EPA-EFE) Search crews on Monday found no survivors following the crash of a private jet in northern Mexico over the weekend. The jet carried three crew members and 10 passengers who were returning from a trip that included seeing a boxing match between Saul "Canelo" Alvarez and Daniel Jacobs on the Las Vegas Strip, local media reported. An air search located the plane wreckage in a remote mountainous area in the municipality of Ocampo on Monday, the Coahuila state government said. Officials did not release the names or nationalities of the victims. The cause of the crash is under investigation. The jet was expected to land Sunday evening in the northern Mexican city of Monterrey after leaving Las Vegas in the afternoon. Flight controllers lost contact with the plane over Coahuila. "I deeply lament the terrible accident of the plane coming from Vegas," he wrote on Twitter. "I'm deeply grateful for the support of all the people who travel to see my fights. My prayers are with their families." Mexico's civil aviation authority said it and other agencies had begun recovering bodies and what remained of the plane Monday. The plane was registered to Utah-based TVPX, listed as an insurance, customs and trust company. Canada's Bombardier Inc. identified the jet as a Challenger 601 in a statement to Reuters. https://www.usatoday.com/story/news/nation/2019/05/06/mexico-jet-crash-13-killed-las-vegas/1124935001/ Back to Top Couple aboard deadly Southwest Airlines Flight 1380 sues airline, claiming negligence An Albuquerque couple aboard Southwest Airlines' deadly Flight 1380 is suing the Dallas-based carrier, alleging negligence and seeking compensation for injuries suffered in the 2018 accident, according to the Santa Fe New Mexican. The Dallas-bound flight from New York LaGuardia Airport suffered midflight engine failure, sending debris shooting into the fuselage, breaking a window and depressurizing the cabin at an altitude of over 32,000 feet in what was the most serious U.S. aviation accident in recent history. Andrea and Kevin Nelson are accusing the airline, as well as the makers of the airplane and its parts, of knowing about possible deficiencies with the plane's fan blades after a similar incident had occurred in 2016. The Nelsons' lawsuit alleges the companies involved failed to conduct due diligence inspection and testing. The engine's manufacturer, CFM International, was also named in the lawsuit. The Dallas Morning News contacted Southwest Airlines and CFM International, but both companies declined to comment on pending litigation. The Nelsons are seeking an unspecified amount in damages for mental, emotional and physical trauma as well as lost earnings. The lawsuit alleges the couple incurred "severe physical injuries." "The Nelsons witnessed in horror as the force of the depressurization pulled an innocent passenger partially through the shattered window and they watched as passengers risked their lives to pull the passenger back into the aircraft and attempted to save her life," their lawsuit said. Jennifer Riordan, the 43-year-old New Mexico woman pulled through the plane's window, died on the flight. The plane was landed without crashing. The Nelsons' suit was filed April 15, one day before the accident's first anniversary. At least eight other passengers from the flight are also suing Southwest over physical and emotional injuries. https://www.dallasnews.com/business/southwest-airlines/2019/05/06/couple-deadly-southwest-flight-1380-files-lawsuit-airline-alleging-negligence Back to Top Cracked Windshield Forces United Flight to Return to Dulles Airport A cracked windshield forced a United Airlines flight headed to Las Vegas to return to Dulles International Airport on Sunday evening. About 45 minutes into United Flight 1910, the pilot noticed an issue with the windshield, according to a statement from United. The flight turned back to Dulles about 8:25 p.m. A map from the flight-tracking site FlightAware.com shows the plane looping back toward the airport. The plane landed without incident on was met by Metropolitan Washington Airports Authority Fire and Rescue, who cleared the plane to taxi to the gate. The passengers were transferred to another flight to Las Vegas. https://www.nbcwashington.com/news/local/Cracked-Windshield-Forces-United-Flight-to-Return-to-Dulles-Airport-509522801.html Back to Top Back to Top GRADUATE RESEARCH SURVEY Dear Aviation Professionals, My name is Marta Delbecchi. I am an MSc student in Organisational Psychiatry and Psychology from King's College London, andas part of my degree requirements I am conducting a research study entitled: The wellbeing of air, marine and rail accident investigators. I am carrying out this research study with the support of Cranfield University's Safety and Accident Investigation Centre. I am looking for current or retired civil air accident investigator to complete an online survey. The purpose of the survey is to learn more about the health and wellbeing of personnel who investigate the causes of accidents and serious incidents in the air, marine, and rail transportation modes. Your participation would be a very important contribution to the current paucity of scientific literature and understanding concerning the psychological and emotional wellbeing of accident investigators. Completing the survey should take no more than 35 minutes of your time and participation in this research study is entirely voluntary and anonymous. All your responses will be treated in the strictest confidence, and you will be able to withdraw from the survey at any time. If you are able to assist by completing the online survey then please email me directly at marta.delbecchi@kcl.ac.uk and I will forward you an information sheet and a link to the survey. Thank you for your kind consideration, Marta Delbecchi Department of Psychosis Studies, PO63 Institute of Psychiatry, Psychology and Neuroscience King's College London De Crespigny Park London SE5 8AF Back to Top Back to Top Call for Nominations For 2019 Laura Taber Barbour Air Safety Award ALEXANDRIA, Va. -- The Laura Taber Barbour Air Safety Foundation is now accepting nominations for the 2019 Laura Taber Barbour Air Safety Award, honoring a leader in global aviation safety. The Award will be presented during the 72nd Annual International Air Safety Summit, taking place Nov 4-6 in Taipei, Taiwan. Presented since 1956, the Laura Taber Barbour Air Safety Award recognizes notable achievement in the field of civil or military aviation safety in method, design, invention, study or other improvement. The Award's recipient is selected for a "significant individual or group effort contributing to improving aviation safety, with emphasis on original contributions," and a "significant individual or group effort performed above and beyond normal responsibilities." Mechanics, engineers and others outside of top administrative or research positions should be especially considered. The contribution need not be recent, especially if the nominee has not received adequate recognition. Nominations that were not selected as past winners of the Award can be submitted one additional time for consideration. Please note that self-nominations will not be considered. The Laura Taber Barbour Air Safety Award's story dates back 74 years. On April 14, 1945, after visiting family in Pittsburgh, Laura Taber Barbour was aboard a Pennsylvania Central Airlines DC-3 when it crashed into the rugged terrain of Cheat Mountain near Morgantown, West Virginia. All passengers and crew were killed. In the years following, her husband, Dr. Clifford E. Barbour and son, Clifford E. Barbour, Jr., established the Laura Taber Barbour Air Safety Award in her honor. The Award Board, composed of leaders in the field of aviation, meets each year to conduct a final review of nominees and selection of the current year's recipient. Please help us honor this year's most deserving recipient. Nominations, including a 1-2-page narrative, can be submitted via the Laura Taber Barbour Foundation website at http://ltbaward.org/the-award/nomination-form/. Nominations will be accepted until May 10, 2019. For more information, including a complete history of Award recipients, see www.ltbaward.org. ABOUT THE LAURA TABER BARBOUR AIR SAFETY AWARD: The Award was established in 1956 through early association with the Flight Safety Foundation and from its founding has enjoyed a rich history of Award Board members, nominees and Award recipients. In 2013, the non-profit Laura Taber Barbour Air Safety Foundation was formed from members of the Award Board, the aviation community and the Barbour family. As the foundation plans to broaden the scope of its intent, with great purpose, the Laura Taber Barbour Air Safety Award will continue to spotlight those champions who pioneer breakthroughs in flight safety. CONTACT: Philip Barbour, 205-939-1700, 205-617-9007 Curt Lewis