Flight Safety Information - August 18, 2023 No. 160   In This Issue : Incident: CAA A333 at Lubumbashi on Aug 16th 2023, engine shut down in flight : Incident: American A319 at Memphis on Aug 16th 2023, engine shut down in flight : Incident: Southwest B737 at Houston on Aug 15th 2023, engine shut down in flight : Raytheon 390 Premier I - Fatal Accident (Malaysia) : Pilots made errors before crash near Lake Tahoe that killed all 6 on board, investigators say : Fire helicopter lacked collision-avoidance system before midair crash : Passengers mistakenly drive rental vehicle across Palm Beach International Airport runways Incident: CAA A333 at Lubumbashi on Aug 16th 2023, engine shut down in flight A CAA Compagnie Africaine Aviation Airbus A330-300, registration 9S-ABS performing flight BU-1612 from Lubumbashi to Kinshasa (DR Congo), was climbing out of Lubumbashi's runway 07 when the crew stopped the climb at about FL250 due to the failure of one of the engines (CF6). The crew secured the engine and returned to Lubumbashi for a safe landing on Lubumbashi's runway 07. The aircraft is still on the ground in Lubumbashi about 22 hours after landing. DR Congo's Civil Aviation Authority have dispatched investigators on site. https://www.avherald.com/h?article=50d28312&opt=0 Incident: American A319 at Memphis on Aug 16th 2023, engine shut down in flight An American Airlines Airbus A319-100, registration N821AW performing flight AA-1182 from Memphis,TN to Phoenix,AZ (USA), was climbing through FL330 out of Memphis when the crew received a right hand engine (V2524) stall indication and shut the engine down. The aircraft returned to Memphis for a safe landing on runway 36C about 50 minutes after departure. Attending emergency services inspected the aircraft and followed the aircraft to the gate. The flight was cancelled. The aircraft is still on the ground in Memphis about 15 hours after landing back. https://www.avherald.com/h?article=50d2467a&opt=0 Incident: Southwest B737 at Houston on Aug 15th 2023, engine shut down in flight A Southwest Airlines Boeing 737-700, registration N7737E performing flight WN-307 from Houston Hobby,TX (USA) to Cancun (Mexico), was in the initial climb out of Hobby's runway 31L when the right hand engine (CFM56) emitted bangs and streaks of flames, an engine fire warning occurred, prompting the crew to stop the climb at 3000 feet, shut the engine down and return to Houston Hobby for a safe landing on runway 04 about 15 minutes after departure. The aircraft vacated the runway and stopped clear of the runway for inspection by emergency services. A replacement Boeing 737-700 registration N555LV reached Cancun with a delay of about 2.5 hours. The occurrence aircraft is still on the ground in Houston about 33 hours after landing back. The airline reported a potential mechanical problem. https://www.avherald.com/h?article=50d24395&opt=0 Raytheon 390 Premier I - Fatal Accident (Malaysia) Date: 17-AUG-2023 Time: c. 14:49 LT Type: Raytheon 390 Premier I Owner/operator: Jetvalet Sdn Bhd Registration: N28JV MSN: RB-97 Fatalities: Fatalities: 8 / Occupants: 8 Other fatalities: 2 Aircraft damage: Written off (damaged beyond repair) Category: Accident Location: Elmina, Shah Alam, near Sultan Abdul Aziz Shah Airport (SZB/WMSA) - Malaysia Phase: Approach Nature: Private Departure airport: Langkawi Airport (LGK/WMKL) Destination airport: Kuala Lumpur-Sultan Abdul Aziz Shah Airport (SZB/WMSA) Confidence Rating: Information is only available from news, social media or unofficial sources Narrative: A Raytheon 390 Premier I impacted a highway in Elmina, Shah Alam, after a loss of control while on approach to Sultan Abdul Aziz Shah Airport (SZB/WMSA), Kuala Lumpur. The two pilots, six passengers, a car driver and a motor cyclist on the ground perished. Preliminary information indicates that the aircraft first contacted the SZB ATC at 14:47 local time, a landing clearance was given at 14:48, and three minutes later, the ATC noticed smoke coming from the crash site. Online photos and a car dashcam indicates that the airplane impacted the ground at a high rate of descent, bursting into flames. The wreckage was highly fragmentated and spread over the highway and a wooded area. https://aviation-safety.net/wikibase/343582 Pilots made errors before crash near Lake Tahoe that killed all 6 on board, investigators say Investigators are blaming pilot error for the 2021 crash of a private jet in California that killed all six people on board Errors by the two pilots caused a business jet to go into an aerodynamic stall and crash near Lake Tahoe in 2021, killing all six people on board, federal investigators said. The co-pilot made a mistake in making a steeply banked left turn in an effort to fix a poor approach and line up with one of the runways at Truckee-Tahoe Airport in California, the National Transportation Safety Board said Thursday. The captain failed to correct the co-pilot’s error, and both ignored stall warnings from the plane, said the NTSB. The pilots were cleared to land on one of the airport's two runways, which are perpendicular to each other, but calculated that they needed to use the longer runway because of the weight of their twin-engine Bombardier Challenger 605 jet. Instead of making a straight-on approach to the longer runway, they continued nearing the shorter one, then circled around and made an unnecessarily sharp turn to line up with the longer runway, the NTSB said. They were also flying too fast and too high, and the co-pilot improperly deployed the flight spoilers — hinged surfaces on the wings that are used to slow down or descend — according to the investigators. The flight from Coeur d’Alene, Idaho, carried four passengers. The crash in a wooded area a few blocks from the airport and near houses ignited a wildfire that was contained before it could threaten Truckee. The plane was destroyed in the fire, but investigators were able to retrieve information from the so-called black boxes that record flight data. The 43-year-old captain had 5,680 hours of flying experience although only 235 in the Bombardier model. The 56-year-old co-pilot had 14,308 hours. https://abcnews.go.com/US/wireStory/pilots-made-errors-crash-lake-tahoe-killed-6-102349696 Fire helicopter lacked collision-avoidance system before midair crash One of two firefighting helicopters that collided in midair over a Southern California brush fire lacked an electronic warning device that alerts pilots to approaching aircraft — a critical deficiency, according to at least one former wildland fire pilot. As the National Traffic Safety Board continues to investigate the fatal, Aug. 6 crash of two contract California Department of Forestry and Fire Protection helicopters, a career pilot and advocate for collision avoidance systems is calling attention to the fact that one of the choppers lacked a traffic collision-avoidance system, or TCAS, which audibly alerts pilots when another aircraft is nearby. “I’m frankly shocked that this is not required on contract helicopters to this day,” said Juan Browne, a former U.S. Forest Service lead plane pilot who now flies Boeing 777s out of Los Angeles for a major airline. “That’s the one last piece of safety equipment that could have prevented this accident,” he said. The surveillance systems and accompanying transponders are standard technology on all state-owned Cal Fire aircraft. Also, a Forest Service smokejumpers guide describes TCAS as “an invaluable safety tool” that is “only effective if all aircraft have their transponders operating.” However, not all aviation experts interviewed by The Times agreed that the system would have averted disaster. At least one said the system was designed for fixed-wing aircraft, and would be less useful for firefighting helicopters. What experts did agree on though was that the collision points to a loss of situational awareness. The big question, they said, is how that awareness broke down and crew members aboard each helicopter lost track of where the other was located. For ground crews and commanders working the small brush fire in the Riverside County community of Cabazon, word that something had gone horribly wrong crackled over their radios at 6:48 p.m. — roughly an hour before sunset. “Midair collision with two of the copters involving 37 Sierra and 5 Alpha Sierra,” a voice said, referring to the aircrafts’ call signs. Both helicopters had lifted off just minutes apart from Hemet-Ryan Airport — a Cal Fire air attack base some 18 miles from the fire — and swooped through mountain passes before heading into the valley below. They collided less than 15 minutes after takeoff, and were just a couple hundred feet off the ground when the impact occurred, according to data available on flight tracking websites. One of the choppers — a water-dropping Sikorsky S-64E Skycrane — was able to make a hard landing in a nearby field. Its two occupants walked away. But the other aircraft — a Bell 407 that had been serving as the mission’s helicopter coordinator — plummeted to the ground, killing Cal Fire Assistant Chief Joshua Bischof, 46; Capt. Tim Rodriguez, 44; and contract pilot Tony Sousa, 55. An NTSB spokesperson said only that the investigation would evaluate all factors in the crash — human, environmental and mechanical. However, experts contacted by The Times said one of the main questions investigators would need to address was why the aircraft failed to recognize each other’s proximity before the crash. Southern California is notorious for its congested airspace, and the Cabazon fire was no exception. A total of six aircraft were dispatched to the scene — three airplanes and three helicopters — and the fire was burning close to Banning Municipal Airport, which may have posed a distraction because it’s possible the pilots had to change frequencies to deal with the air traffic, Browne said. And although the weather was clear, the helicopters converged as the sun was setting behind them, which may have resulted in shadows being cast by the San Jacinto Mountains. “They merged together at a very acute angle and it’s probably going to turn out to be right in the blind spots of these two helicopters, because of the design, where the pillars are located, the way the cockpit is laid out — all that,” Browne said. In addition, the Bell was silver, which may have made it more difficult to see. Cal Fire aircraft are painted bright colors, usually red and white. After using flight tracking data to reconstruct the collision in a video posted to his popular YouTube channel, Browne speculated that the Bell may have contacted the Skycrane’s landing gear, which caused the Bell’s rotor and blades to separate from the rest of the aircraft. Images of the crash site show that the helicopter’s rotor landed some distance away from its fuselage, he added. Hunt Norris, general manager of Yuba City-based Siller Helicopters, owner-operator of the Skycrane, described the collision as “extremely rare” and said the Skycrane sustained minor damage that was confined to its landing gear. It remains unclear why the helicopters were flying at the same altitude. Cal Fire has procedures to ensure that aircraft are in communication with each other and that they maintain proper altitude separation, officials said. Typically, when aircraft are dispatched to a fire, pilots check in with the air tactical group supervisor to learn their responsibilities and altitude assignments before they arrive. “For whatever reason, there was not an altitude deconfliction in this case, and that’s very unusual,” said Jack Cress, an instructor in helicopter accident investigation at USC. “Cal Fire spends a lot of time choreographing the way that the aircraft are going to be brought into the scene.” To figure out what went wrong, investigators will look into both the optical visibility of the two helicopters, as well as their electronic visibility — what instrumentation was available on board that could have prevented the collision, he said. In that regard, there are two key pieces of equipment. One is the Automatic Dependent Surveillance-Broadcast, or ADS-B, in which an aircraft transmits information about its altitude, positioning and speed to air traffic control ground stations and other aircraft that have the equipment installed. All civilian helicopters have this technology, he said. The other is the traffic collision avoidance system, which audibly alerts pilots when another aircraft is nearby and tells them what evasive action — a turn, climb, or descent — they need to take to avoid it, he said. All commercial jetliners are required to have TCAS installed, but the Federal Aviation Administration does not mandate it for helicopters, said Hassan Shahidi, president and chief executive of the Flight Safety Foundation, an international nonprofit. And while aircraft owned by Cal Fire are equipped with TCAS, the agency does not require it to be installed on all of its contract aircraft, said Nick Schuler, the agency’s deputy director of communications and emergency incident awareness. Aircraft and pilots that contract with Cal Fire are required to obtain an interagency qualification card issued by the Forest Service, U.S. Department of the Interior or Cal Fire. Those rules state that TCAS systems are required only on helicopters that are authorized to carry passengers other than the essential flight crew, Schuler said. The Bell 407, which met this standard, was equipped with TCAS, he said. The Skycrane, which was not authorized to carry nonessential passengers, did not have TCAS, he said. In order for TCAS to alert one aircraft that another is nearby, both aircraft must have the technology installed and their transponders turned on, Shahidi said. “I’ve been fighting this lack of TCAS my whole career, and we’ve slowly been getting TCAS implemented into the firefighting command,” Browne said. When Browne was flying C-141s for the U.S. Air Force many years ago, he lost a co-pilot in a midair collision off the coast of Africa, he said in a YouTube video. Surviving family and colleagues successfully lobbied for TCAS equipment to be installed in Air Force transport aircraft, he said. Then, when Browne served in the Forest Service lead plane program, he took over the job of a pilot who died in a 1995 midair collision with an air tanker while responding to a fire in Ramona, he said. After more lobbying, TCAS was installed in the agency’s fixed-wing air tankers, he said. Although Browne insists that TCAS could have prevented the collision, Shahidi was skeptical. He said TCAS are geared toward fixed-wing transport airplanes that have set flight paths. The technology would not necessarily be useful in firefighting helicopters that are highly maneuverable and operating at high speeds, low altitudes and in close proximity to one another during an emergency, he said. “If they were equipped with these alerts, because of the logic of the software, they would be going off all the time in terms of alerts to the pilots to descend or increase their altitudes,” Shahidi said. “And it would actually be counterproductive for the pilot to have that.” In that type of environment, he said, a centralized command and control entity that is able to manage the tight airspace and ensure that aircraft are in position and aware of each other’s location is key. ADS-B, which provides a visual display but no alerts, would also help make pilots and ground controllers aware of the aircrafts’ location, he added. “Those are the tools that are going to be important to make sure a tragedy like this does not occur, where there’s a collision because pilots are losing situational awareness of who is in the area and what their proximity is,” he said. https://www.latimes.com/california/story/2023-08-17/helicopter-lacked-electronic-warning-device-before-collision Passengers mistakenly drive rental vehicle across Palm Beach International Airport runways Two people were detained by sheriff’s deputies and agents with the Transportation Security Administration after they drove their rental car across multiple active runways at Palm Beach International Airport Tuesday. Investigators said a father and son landed in a private plane at Atlantic Aviation and a rental car from Go Rentals met them on the tarmac. But instead of leaving the airport, the father and son turned the wrong direction and drove all the way to the commercial gates. “I could see how this could happen very easily,” said aviation expert John Nance. Nance has been a pilot for more than 50 years. He said it’s common for rental car agencies to bring cars directly to private planes. But he said part of that service is supposed to be making sure the client leaves in the right direction. “It’s not the situation in regards to the car,” Nance said. “It’s the instructions that were given to the individual.” Your neighborhood: Local coverage from WPBF 25 News Airport officials are saying the same thing, issuing a statement that blamed the incident on Go Rentals for not escorting the rental car off of airport property. A spokesperson for the airport said Go Rentals’ permit to operate at the airport has been revoked. Atlantic Aviation is also facing discipline as the airport suspended the security clearances of all employees who were involved in the incident. The airport is also requiring all Atlantic Aviation employees to undergo safety training. Nance said an incident like this is extremely rare but is also something pilots prepare for and are trained to avoid. “In the commercial aviation world, that’s one of the things that we pull on each other in the simulators quite a bit, truck on the runway,” he said. The sheriff’s office said the two people in the rental car will not face charges since it appears to have been an honest mistake. Wednesday night, Atlantic Aviation released a statement to WPBF 25 News. "Safety and security are of utmost importance for our customers, vendors, airport partners and employees," the statement read. "We are cooperating fully with the airport administration and relevant authorities on their investigations, and we will work closely with the airport to review all vendor and third-party protocols to ensure an incident of this type could not occur in future." https://www.wpbf.com/article/florida-passengers-drive-across-palm-beach-international-airport-runway/44833009# ERAU Prof Develops Procedures To Boost Go-around Safety Report on procedures to be handed to FAA Embry-Riddle Aeronautical University associate professor Barbara Holder and second-year aviation PhD student, Hui (Angel) Wang collaborated on research that could improve flight deck procedures during go arounds. Embry-Riddle Aeronautical University (ERAU) researchers plan to present a report to the FAA later this year with recommendations on procedures that can be used to help improve the safety of go-arounds. Associate professor Barbara Holder has spearheaded the research on go-arounds over the past three years under an FAA grant—initially as a technical fellow with Honeywell and now with the university—and recently held a workshop with industry and government leaders to gather feedback on the findings. The workshop brought together training and flight standards leaders from airlines, manufacturers, the FAA, and NASA. Participants provided thoughts on go-around standardization and training, as well as priorities for future research. Plans call to summarize the findings and recommendations on the procedures in the report, which the FAA will review and publish next year. Holder’s research led to the development of proposed procedures that incorporate joint responsibility for crew call-outs to reduce single-point disruptions, direct attention to the flight path, balance workload among the flight crew, and facilitate recall of the procedure. These were then evaluated by crews at three major U.S. airlines—10 of which flew the Boeing 737 and seven flew the Airbus A320. The crews conducted 18 go-arounds per session and then reported on their experiences. “The procedure forces you to look at power and pitch and say it, do it, not just recite it,” one pilot reported about the new go-around procedures. Another had said the procedures provided a “consolidated, clear picture,” while others maintained “call-outs are wordy, they seem right,” the university said. Before conducting the procedures, crews were briefed but were not required to do formal training. They were able to acclimate to the protocols after three to four repetitions. ERAU said the results “showed a decreased risk of error during go-arounds by more appropriately allocating pilots’ cognitive resources.” “The first phase of the research set out to understand the hazards associated with go-around maneuvers,” Holder said. “We identified 10 mitigations and applied human factors science to develop new go-around procedures for the 737 and A320 aircraft to mitigate the highest risk, which is loss of control in flight. We evaluated those procedures with three airline partners and the results are very promising. Now we are drafting our final report with recommendations to the FAA for their implementation and training.” ERAU noted the importance of research, expressing concerns that go-arounds come with a potential reduction of situational awareness. The university pointed to an Advancing Safety Through Science report that found that “one out of every 10 reports about go-arounds cite a potentially hazardous outcome, including exceeding aircraft performance limits or fuel endurance.” Further, one out of every six is mishandled, according to the report that was presented to the FAA earlier this year. “We continue to see risk factors for LOC-I [loss of control inflight] during the go-around in the operational data,” said Holder. “Precursors to loss of control in-flight, such as aerodynamic stall, low airspeed, low altitude, and so on continue to be present in go-around execution across operators and aircraft fleets.” Holder found go-arounds in training are generally less complicated and more predictable than real-world go-arounds, which can involve any number of complicating factors such as numerous heading and altitude changes directed by air traffic control, noise distractions, a fatigued crew, and operational pressures related to fuel, scheduling, and traffic and more. She maintained that to improve safety, the gap between training and the real world must be closed. Assisting Holder in this research is a second-year aviation Ph.D. student, Hui (Angel) Wang, who also earned her master’s degree in aeronautics from Embry-Riddle, as well as her bachelor’s in air traffic management. https://www.ainonline.com/aviation-news/air-transport/2023-08-17/erau-prof-develops-procedures-boost-go-around-safety Curt Lewis