Flight Safety Information - September 26, 2023 No. 186 In This Issue : Incident: Austrian A320 near Vienna on Sep 24th 2023, captain temporarily incapacitated : Accident: Jetblue A320 enroute on Sep 25th 2023, turbulence causes 8 injuries : Incident: Delta A339 near Kansas City on Sep 25th 2023, engine shut down in flight : Incident: Anadolujet B738 at Perm on Sep 22nd 2023, overran runway on landing : Part One: Exploring Aviation's Human Factors 'Dirty Dozen' : N.J. aviation company fired pilot who reported safety concerns to FAA, lawsuit says : Air Canada Orders Up To 30 Boeing 787-10 Widebody Aircraft : Vietnam's Bamboo Airways struggling to pay pilot wages; some depart - sources : Air France-KLM says it plans to buy 50 Airbus A350 jets : Turkish Airlines to Ground Several Aircraft Due to Pratt & Whitney Jet Engines Recall Incident: Austrian A320 near Vienna on Sep 24th 2023, captain temporarily incapacitated An Austrian Airlines Airbus A320-200, registration OE-LZA performing flight OS-188 from Stuttgart (Germany) to Vienna (Austria), was enroute at 310 nearing the top of descent towards Vienna when the captain started to feel unwell. While descending towards Vienna the captain became incapacitated, the first officer took control of the aircraft, continued the descent towards Vienna and intercepted the localizer for runway 34. Upon intercepting the glidepath the captain recovered and was able to resume his duties. The aircraft continued for a safe landing on runway 34. https://www.avherald.com/h?article=50edc051&opt=0 Accident: Jetblue A320 enroute on Sep 25th 2023, turbulence causes 8 injuries A Jetblue Airbus A320-200, registration N569JB performing flight B6-1256 (dep Sep 24th) from Guayaquil (Ecuador) to Fort Lauderdale,FL (USA), was enroute at FL360 near Jamaica when the aircraft encountered turbulence causing altitude deviations of about -50 feet and injuring a number of occupants of the aircraft. The aircraft continued to Fort Lauderdale for a safe landing without further incident about 55 minutes later. The NTSB reported: "NTSB has opened an investigation into today's turbulence incident that occurred on JetBlue #1256, an Airbus A320, during cruise flight near Jamaica while en route from Guayaquil, Ecuador to Fort Lauderdale, Florida. Numerous injuries reported." The airline reported the aircraft experienced sudden severe turbulence while nearing Florida. Seven passengers and one crew member were taken to a local hospital. https://www.avherald.com/h?article=50ed6f08&opt=0 Incident: Delta A339 near Kansas City on Sep 25th 2023, engine shut down in flight A Delta Airlines Airbus A330-900, registration N406DX performing charter flight DL-8867 (dep Sep 24th) from Las Vegas,NV to Pittsburgh,PA (USA) with the NFL team of the Pittsburgh Steelers and total 182 people on board, had been enroute at FL410, later descended to FL370 and was enroute about 150nm west of Kansas City,MO (USA) when the crew reported they had to shut the right hand engine (Trent 7000) down due to loss of oil pressure and decided to divert to Kansas City. The aircraft landed safely on Kansas City's runway 01L about 35 minutes after leaving FL370. The crew reported no assistance was needed and taxied to the apron. The NFL team reported the crew announced there was an "oil pressure failure" in one of the engines. https://www.avherald.com/h?article=50ed56c2&opt=0 Incident: Anadolujet B738 at Perm on Sep 22nd 2023, overran runway on landing An Anadolujet Boeing 737-800 on behalf of Turkish Airlines, registration TC-JGV performing flight TK-3964 from Antalya (Turkey) to Perm (Russia) with 174 people on board, landed on Perm's runway 21 at about 13:21L (08:21Z) but overran the runway end by about 70 meters and came to a stop past the paved surface of the runway end safety area. There were no injuries. The aircraft received minor if any damage. The aircraft is still on the ground in Perm about 11 hours after landing. https://www.avherald.com/h?article=50eb795a&opt=0 Part One: Exploring Aviation's Human Factors 'Dirty Dozen' Covering the first six precursors of errors. Conditions that limit one’s work performance or decision-making and, therefore, affect the safety of aviation processes and methods are considered “human factors.” Safety is the top priority in aviation, and the involvement of human factors in aviation-related incidents and accidents is particularly noted. Aviation regulatory authorities such as the Federal Aviation Administration (FAA) in the United States and the European Union Aviation Safety Agency (EASA) across the pond have strict measures for compliance with human factors in aviation. The FAA emphasizes the importance of human factors in all aspects of aviation by stating, "Human factors entail a multidisciplinary effort to generate and compile information about human capabilities and limitations and apply that information to equipment, systems, facilities, procedures, jobs, environments, training, staffing, and personnel management for safe, comfortable, and effective human performance." Whether it’s the pilots flying an aircraft or maintenance personnel performing repairs on critical airplane parts, training and information related to human factors must be provided. Aviation personnel learn about common errors, aviation accidents, contributing factors, root causes, and best practices. Human factor training is one of the many regulatory aspects of training that aviation personnel in most areas of work must take. Not only that, such training must be refreshed periodically (generally every 1-2 years). The “Dirty Dozen in Human Factors” refers to twelve of the most common conditions of human error in aviation. A concept developed by Gordon Dupont in 1933 during his time in aviation maintenance with Transport Canada. While the list was conceptualized for aviation maintenance, it was later accepted for all areas of aviation safety. Notably, the twelve elements are not the only precursors of aviation errors, but they cover most aspects of human error. This two-part article series will explore the Dirty Dozen by briefly explaining each one of the elements. Aviation-related examples are provided where appropriate. Let's begin with the first six factors. 1 Lack of Communication Poor communication between the workers appears at the top of the list of most aviation accident investigation reports. For effective communication, the sender, receiver, and the communication medium must be effective. Lack of communication leads to errors, whether because of the communicative parties or a poor medium. Airbus states that an increased workload usually leads to a lack of communication between workers. There have been numerous aircraft incidents due to human error where pilots failed to communicate with each other or the Air Traffic Controllers (ATC). Poor communication gives rise to more assumptions and lacks realistic scenarios. Pilots, workers, and even the top management group must communicate efficiently and effectively to ensure there is no room for error. Recommendations: Aviation personnel must precisely write out the completed work and ensure the other parties understand it. Verbal communication must be repeated and verified. 2 Complacency The feeling of self-satisfaction and affirmation due to performing specific tasks regularly is referred to as complacency. Complacent behavior can result in ignoring or overlooking the potential dangers of regular habitual work. People only see what they expect to see rather than focusing on and preparing for hidden hazards. Both over-stress and under-stress situations can lead to an individual being complacent. Several maintenance workers inspecting a jet engine. Photo: Juice Flair | Shutterstock Under normal circumstances, humans don’t tend to find faults in the system. Instead, they expect the system to work perfectly fine, as it happens most of the time. As such, continuous exposure to typical situations may increase the chances of complacency. Recommendations: Aviation personnel must always check their work and routine procedures to look for anomalies. Verification of the work is better than having a potential risk. 3 Lack of Knowledge This is another human performance factor that has resulted in numerous aviation incidents. Not having complete knowledge of the work can result in human errors. Airbus states that an increased workload also contributes to a lack of knowledge. People tend to perform the job without receiving proper education and training. Workers may misjudge situations and make poor decisions due to a lack of information. In today’s environment, where technology is continuously advancing, and processes are evolving, aviation personnel must stay at the top of their game when it comes to knowledge and training. Most aviation sectors face postponed training due to production having priority over anything else. As such, many incidents related to a lack of knowledge or training can occur. Recommendations: Aviation personnel must say no to any work that is outside the scope of their knowledge. Agreeing to duties without completing information jeopardizes the aviation industry’s safety. Personnel must always ask for assistance should they feel unprepared. 4 Distraction In a world where technology is very literally in the palm of our hands, distraction accounts for some of the worst aviation disasters in history. Distractions can also occur in the workplace due to mismanagement of work and responsibilities. While some distractions are unavoidable, such as loud noises or regular interruptions, major distractions must not lead to excessive errors. An employee inspecting composite materials. Photo: US Navy via Wikimedia Commons. Aviation personnel are sometimes also distracted by the amount of work or the variety of things they are involved in. While they may respond to a query affirmingly, the job is not done due to other distractions. Pilots may get distracted by faulty sensors in the cockpit or continuous warnings and alerts. This may limit their ability to make the most sound decisions. Recommendations: Aviation personnel must go through all the steps that were completed after the distraction is over. It is always preferred to complete a request before responding to an unrelated query. In this way, work will rarely be forgotten or left incomplete after it has been received or agreed to. 5 Lack of Teamwork Aviation is a vast and complex industry where most tasks are performed as a team. While individual work has its merits, a lack of teamwork may be a precursor to human error. Manufacturers rely on suppliers, and suppliers rely on raw materials experts; the aviation industry is closely linked. As such, teamwork is a necessity to complete tedious tasks. Two employees wearing yellow safety vests look over a clipboard next to a United Airlines aircraft. Photo: United Airlines An effective organization will establish a team that communicates well and ensures safe and efficient solutions to problems. Competence, willingness, and recognition are essential elements of a good team. Lack of teamwork may result in poor decisions by one or more individuals without consulting the group. Recommendations: Aviation personnel must discuss all tasks and solutions within the team before making decisions. Tasks must be equally divided among the team members to ensure the effectiveness of results. 6 Fatigue Prolonged physical or mental work or stress can lead to human fatigue. This physiological phenomenon is very much evident in the aviation industry. Countless air crashes over the decades have resulted from physical and mental fatigue. Aviation regulatory agencies mandate the number of hours individuals in critical positions can work. Commercial pilots, cabin crew, and air traffic controllers are some examples of roles with strict work hours regulations. Fatigue can cause people to make mistakes and poor decisions. Such exhaustion can also overtake an individual’s temper and lead to anger, mismanagement, and errors. Aviation experts encourage effective sleep, diet, and physical fitness routines for aviation personnel. Increased workload can lead to fatigue and subsequent errors. Recommendations: Aviation personnel must be on the lookout for signs of fatigue. Whether related to one’s sleep routine or stressful work, early warnings, and remedies, can prevent major aviation incidents. Individuals must also be aware of their limits and avoid engaging in complicated tasks when fatigued. https://simpleflying.com/aviation-human-factors-dirty-dozen-part-one/#lack-of-communication N.J. aviation company fired pilot who reported safety concerns to FAA, lawsuit says An airline pilot with decades of experience says she was fired from a New Jersey aviation company after she reported safety concerns to the Federal Aviation Administration, according to a lawsuit. Pamela Mincey, of Gainesville, Florida, worked for Short Hills Aviation LLC, based in Morristown, for about a year before she was unlawfully terminated on Sept. 1, 2022, according to allegations contained in court documents. “The termination of her employment was in retaliation for her multiple reports to company management and federal authorities of unsafe practices while carrying members of the public in its jet charter service,” states the suit, filed Aug. 31 in Superior Court of Morris County. Representatives with Short Hills Aviation, a luxury airline company, did not respond to requests for comment on the lawsuit. Mincey, 67, has more than 25 years of flying experience, and worked for two decades as a commercial pilot who flew Boeing 747 aircrafts on international routes with no accidents or regulatory violations, according to the lawsuit She “was trained to, and practiced, the highest standards of aviation safety and understood the requirements of federal aviation regulations as they pertained to flight safety,” the lawsuit says. Throughout her employment with Short Hills Aviation, Mincey was the only woman pilot, the lawsuit notes. Mincey’s troubles with the company began on Nov. 5, 2021, when she was assigned to fly second-in-command with a captain who told her not to touch the aircraft controls. “I don’t allow co-pilots to fly my airplanes,” the captain allegedly told Mincey. “You will never fly my plane.” The refusal to allow Mincey to participate in flying the aircraft was a violation of federal regulations, as pilots in a two-member crew “must be independently qualified to fly the aircraft,” the suit states. Mincey later complained to a chief pilot about the incident, pointing out that it was unsafe to prohibit qualified pilots from manipulating the controls and making landings, the suit says. However, no changes were made and Mincey was never allowed to fly while acting as second-in-command while flying with that pilot, the suit states. On Jan. 7, 2022, Mincey wrote an email to the chief pilot and a supervising captain in which she “discussed specific concerns with (Short Hills Aviation’s) safety culture and made suggestions for improvement,” the suit states. Her complaints included a captain she flew with to Mexico who missed an approach to the airport, flying off a prescribed route and allegedly “jeopardized the safety of the flight, the paying passengers, and the crew, although it did conclude in a safe landing,” the suit says. From Jan. 8 through March 8, 2022, Mincey was paired with a captain who refused to use a company-issued iPad Mini designated as the primary onboard navigation system, the suit says. Failure to use the device was a violation of “FAA operations specifications” and again jeopardized the safety of the flight, the suit alleges. The lawsuit claims that on one occasion, the captain’s failure to use the device caused the crew to “lose situational awareness,” and that the captain falsely blamed Mincey in reports he made to company managers, the FAA, and in a report to NASA, the suit alleges. Mincey says she then tried to set the record straight by reporting the captain’s “dishonest and erroneous” statements to both the chief pilot and in an interview with the FAA. Short Hills Aviation’s president Dudzinski made the decision to terminate Mincey shortly after her FAA interview, the lawsuit says. The lawsuit alleges violations of New Jersey’s Conscientious Employee Protection Act. Mincey’s lawers are demanding she be reinstated to her job, and compensated for lost pay, health benefits and insurance. https://www.nj.com/morris/2023/09/nj-aviation-company-fired-pilot-who-reported-safety-concerns-to-faa-lawsuit-says.html Air Canada Orders Up To 30 Boeing 787-10 Widebody Aircraft The airline will be one of a handful to fly all three Boeing 787 variants. SUMMARY • Air Canada has placed a firm order for 18 Boeing 787-10 aircraft and has the option for 12 more, making it one of a few carriers to operate all three variants of the 787 family. • The Canadian flag carrier aims to invest in passenger experience and is excited to offer a larger version of the popular Dreamliner with a new, state-of-the-art interior design. • The 787's fuel efficiency will help Air Canada achieve operational savings and align with its sustainability goals of reducing emissions. Air Canada has today revealed that it has placed firm orders for 18 Boeing 787-10 aircraft, with 12 more options for further deliveries. The Canadian flag carrier expects to take delivery of these aircraft from the American planemaker as soon as 2025. The deal means that Air Canada will become one of just a handful of carriers to operate all three variants of the Dreamliner. Commenting on the order, Michael Rousseau, President and Chief Executive Officer of Air Canada, remarked, "Air Canada has made investing in the passenger experience a core priority. Our experience shows customers greatly enjoy flying on the Dreamliner, so we are pleased to offer them a larger version of this popular aircraft, which will premiere a new, state-of-the-art interior cabin design. As importantly, the 787 is highly fuel efficient and will generate operational savings as well as support our sustainability goals of reducing emissions." Air Canada says that the aim of today's Boeing 787-10 order is to cut carbon emissions from its widebody fleet. The first aircraft will be delivered from October to December 2025, and the airline has hinted that they will have a brand-new cabin design that is state of the art but is yet to elaborate further. Air Canada will be using the new aircraft to replace older aircraft in its fleet, leading to a 25% lower fuel burn. At a guess, given the numbers involved, it would seem as though the 787-10 is due to replace the Airbus A330-300 to create an all-Boeing widebody fleet, though it hasn't been confirmed which aircraft are being replaced. Air Canada also has four inactive passenger Boeing 767-300ERs, though these are already earmarked to be converted into freighters. It also had two orders for new Boeing 777-200 freighters. When announcing today's order, Air Canada clarified that it will replace the existing Boeing 777F order, meaning that these are no longer expected to join the fleet. "The Boeing 787-10 aircraft order announced with Boeing today substitutes for a previously announced agreement to purchase two Boeing 777 freighter aircraft and, as a result, Air Canada will no longer take delivery of the two freighters." Joining a small club When the 1st Boeing 787-10 is delivered to Air Canada, the airline will join a small club of just five airlines that operate the Boeing 787-8, -9, and -10. ANA, British Airways, and United Airlines are the only other airlines that currently fly all three variants. Korean Air could also be considered in this exclusive group once its 1st 787-10s are delivered, though this is with a caveat. While Korean Air is listed as operating a single Boeing 787-8 alongside its 10 787-9, the 787 is a Boeing Business Jet (BBJ) that doesn't wear the Korean Air livery. https://simpleflying.com/air-canada-boeing-787-10-order/ Vietnam's Bamboo Airways struggling to pay pilot wages; some depart - sources Summary • Some 30 foreign pilots have left in last two months -source • Internal chat forum shows some salary payments have been late • Bamboo says pilot departures due to restructuring efforts • Bamboo says planning to raise capital from Samcombank, others HANOI, Sept 26 (Reuters) - Some pilots have left Vietnam's restructuring Bamboo Airways in the last two months after late payments in salaries, according to two people familiar with the matter. About 30 foreign pilots departed during that time, more than 10% of the airline's total pilot staff in June, according to one of the people, who declined to be identified as the information was not public. A second person said some pilots had recently quit and others were dismissed. Embattled Bamboo, Vietnam's No. 3 airline, said in a statement to Reuters that it has undertaken drastic restructuring and those efforts encompass its route network, fleet and human resources. "Bamboo Airways has reduced a number of pilot personnel recently to serve this goal," the statement said, denying that late payments of salaries were the reason behind the departures. It did not respond to questions about how many pilots have left. Many staff at Bamboo have sometimes had to face delays in salary payments but this had not, until recently, affected foreign pilots who make up a large majority of the airline's pilot staff, the sources said. Messages seen by Reuters from an internal company chat forum that management uses to communicate with foreign pilots show some salary payments have been late. An Aug. 21 message from a company representative in the forum told foreign pilots they would have received on that day 35% of their monthly salary that had been due a week earlier, and they would be informed about the remainder when there was more information. A similar message was sent a month earlier. The amounts were later paid in full but foreign pilots had not received their pay for August that had been due on Sept. 15, according to information from one of the people that was current as of Sept. 25. Bamboo also said in statements to Reuters that it is operating stably and is planning to raise capital from strategic shareholders. It said one of its major financial backers, Vietnam's Sacombank (STB.HM), had expressed confidence in its long-term prospects and the desire to increase its investment in the airline. Sacombank has not provided comment. Bamboo's new chief executive, Nguyen Ngoc Trong, said in a letter to staff last month, which was seen by Reuters, that the airline was facing "tough times" but added the government was committed to supporting the company. Vietnam's Government Office did not reply to a request for comment. Trong was appointed CEO in July when his predecessor resigned after less than two months on the job. Bamboo had flagged in 2021 plans to list in the United States but has been struggling with rapid management changes and aggressive restructuring since a former chairman was arrested in March 2022 over allegations of stock market manipulation. It was not immediately clear which companies have the biggest stakes in Bamboo. A spokesperson for Bamboo said details about its ownership would be disclosed at a later date. Bamboo, which flies both internationally and domestically, has around 17% of Vietnam's market share, its then CEO told local media in March. It booked losses of 17.6 trillion dong ($722 million) last year, the government has said. Bamboo's flights continue to regularly depart, schedules at the country's two main airports show. Seven of its 30 planes, including some of those recently acquired, are currently parked for maintenance, according to tracking website Planespotters.net. https://www.reuters.com/business/aerospace-defense/vietnams-bamboo-airways-struggling-pay-pilot-wages-some-depart-sources-2023-09-26/ Air France-KLM says it plans to buy 50 Airbus A350 jets PARIS, Sept 25 (Reuters) - Air France-KLM (AIRF.PA) said on Monday it plans to order 50 Airbus (AIR.PA) A350 long-haul jets, together with purchase rights for an additional 40, in its largest-ever wide-body purchase as the Franco-Dutch group revamps its long-haul fleet. The provisional deal includes both the A350-900 and the larger A350-1000 models, and the aircraft will be delivered between 2026 and 2030, the group said after its board backed the deal, estimated to be worth several billion dollars. It follows a tight contest between Airbus and Boeing (BA.N) supported by engine makers, as the airline's fleet planners juggled range, size and cost to find replacements for Airbus A330 jets and most of the group's older Boeing 777s. The Air Current, an industry publication, reported earlier this month that the airline was closing in on an order for 50 wide-body jets and that one factor was the range involved in skirting Russian airspace amid ongoing Ukraine war sanctions. "We are taking the assumption that the ban on Russian overflights is with us for at least the mid-term," CEO Ben Smith told reporters after announcing the order. Smith said the A350 had won on either range or size compared with their 787 equivalents given the specific shape of the post-Ukraine network, while the larger Boeing 777X had yet to be certified and would not be available in the time required. However, he said Air France-KLM would look at the 400-seat twin-engined jumbo to replace its Boeing 777-300ER long-haul jets which would continue to fly through this decade. Asked about widespread production delays, Smith said Air France-KLM had considered splitting the order between Airbus and Boeing but had benefited from competitive prices by sticking to one supplier and would still have a diversified fleet. Shares in the group earlier closed down 3.7% amid weaker travel stocks. FLEET FLEXIBILITY Air France-KLM, the product of a 2004 merger between French and Dutch national carriers, said the deal would give it flexibility to allocate aircraft among its brands based on market or regulatory conditions. That includes the possibility to shift jets to any carriers it may buy, Smith said. Air France-KLM is among potential suitors for the upcoming privatisation of Portugal's TAP. It also leaves open the possibility that capacity could be withheld from Amsterdam's Schiphol where the airline is locked in a dispute with the Dutch government over flight curbs. "If certain jurisdictions where we have operations become non-viable, or the return expected in the business case is no longer possible, (that) may force us to put them elsewhere," Smith said when asked about such operational restrictions. The purchase is the latest stage of a sweeping renewal and simplification of the 500-strong fleet carried out under Smith since he joined the group from Air Canada in 2018. It comes weeks after Airbus was stung by British Airways owner IAG's decision to place a top-up order for Boeing 787s, following what industry sources described as a rift over support prices with A350 engine supplier Rolls-Royce. Airbus and Rolls-Royce have both declined comment. At Air France-KLM, in-house maintenance arms have repair partnerships with General Electric, the leading engine supplier for the 787. To win the deal and open the door for Airbus, Rolls had to overcome that apparent advantage for Boeing, Smith said. "Not easy as you can imagine. However, we've already ordered 41 (A350s) so Rolls is quite familiar with us," he added. https://www.reuters.com/business/aerospace-defense/air-france-klm-says-plans-order-50-airbus-a350-jets-2023-09-25/ Turkish Airlines to Ground Several Aircraft Due to Pratt & Whitney Jet Engines Recall Turkish Airlines expects to ground more than 10 planes by the end of the year after Pratt & Whitney parent RTX said it would recall hundreds of jet engines for inspection due to suspected contaminated metal in some parts that could lead to cracking. Turk Hava Yollari, as the Turkish flag carrier is formally known, has 58 Airbus A320 and A321neo aircraft equipped with Pratt's geared-turbofan engines. The airline grounded nine such planes last month due to issues with the engines, according to a media relations representative. "Our expectation is to ground 11-12 aircraft by the end of the year, but due to the uncertainties in the process, there is a possibility that this number will be revised upwards," the media relations representative said late Monday. RTX, previously known as Raytheon Technologies, said in July that suspected contaminated metal in some engine parts would require accelerated inspections. An average of 350 Airbus jets will be grounded per year for the inspections of engines over the next three years. Turkish Airlines counted 428 aircraft in its fleet at the end of August and, while the expected number of aircraft to be grounded appears small in proportion, the carrier has already seen a loss in passenger capacity due to the grounding of planes in August, the media relations representative said, though the group still expects capacity will grow 15% to 20% on year in 2023. The airline flies to more than 340 destinations, and is among a rare few that still operate direct flights to Russia after the invasion of Ukraine. "Our negotiations with the manufacturer on this issue continue. Since there are still unclear issues regarding the affected engines and maintenance plans, it seems possible that there will be changes in the quantities mentioned above in the coming period," the media relations representative said. https://www.marketwatch.com/story/turkish-airlines-to-ground-several-aircraft-due-to-pratt-whitney-jet-engines-recall-d709e879 Curt Lewis