An accident involving a Cessna 208B Grand Caravan in Guadeloupe led the French accident investigating agency to recommend EASA to extend the obligation to carry a flight data recorder on board any aircraft in commercial air transport.

On September 5, 2010, the Cessna 208B suffered a failure of one or more blades of the turbine compressor when over sea, some eleven minutes after takeoff. Engine power was lost and the pilot shut down the engine and feathered the prop. The pilot attempted to return to the airport of Pointe-à-Pitre, Guadeloupe and tried to restart the engine. The engine could not be restarted and the pilot decided to carry out a  forced landing in a sugar cane field. The airplane sustained substantial damage but the pilot and six passengers were not injured.

The BEA investigators concluded that the accident resulted from a creep rupture of one or more blades of the turbine compressor leading to failure of the engine in flight. The causes of creep could not be determined. It could have resulted from operating the engine over the temperature-threshold or non-detection during maintenance.

The presence of a flight data recorder would have provided information on the parameters of the engine during the accident flight and previous flights.

More information:

• ASN Accident Description
• BEA report (in French)

Filed under: Investigation Reports, Safety Recommendations by admin
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Boeing 737-800 PK-LKS during the evacuation process (photo: NTSC)

The Indonesian National Transportation Safety Committee (NTSC), published a preliminary report of their investigation into the cause of the accident involving a Lion Air Boeing 737-800 near Bali, Indonesia.

On April 13, 2013 Lion Air Flight JT-904 crashed into the sea just 300 meters short of the runway threshold while on final approach to the Denpasar-Ngurah Rai Bali International Airport, Indonesia. There were 101 passengers and seven crew members on board. All aboard survived.

The flight departed Bandung with the copilot as Pilot Flying. About 15:00 the flight was descending towards Bali and the crew received vectors for a VOR DME approach for runway 09. At 15:08, with the aircraft at approximately 1,600 ft AGL, the Tower controller saw the aircraft on finals and gave a landing clearance with additional information that the wind condition was 120° at 5 kts.

While descending through 900 feet the copilot stated that the runway was not in sight. At 15:09:33, after the EGPWS called out “Minimum” at an altitude of approximately 550 ft AGL, the pilot disengaged the autopilot and the auto throttle and continued the descent. Twenty seconds later, at 150 ft AGL the captain took over control. The copilot handed the control to the captain and stated that he could not see the runway.

At 15:10:01, the EGPWS called out “Twenty”, and the captain commanded a go around. One second later the aircraft impacted the water.

As a result of the factual information and initial findings, the NTSC issued three immediate safety recommendations to Lion Air:

1. To emphasise to pilots the importance of complying with the descent minima of the published instrument approach procedure when the visual reference cannot be obtained at the minimum altitude.
2. To review the policy and procedures regarding the risk associated with changeover of control at critical altitudes or critical time.
3. To ensure the pilots are properly trained during the initial and recurrent training program with regard to changeover of control at critical altitudes and or critical time.

More information:

• ASN Accident Description
• Preliminary report (PDF)

Filed under: Investigation Reports, Safety Recommendations by admin
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30-second GPS data points were insufficient to determine the aircraft attitudes and movements leading up to the apparent loss of control, the pilot’s actions, and the functioning of the aircraft systems (source: TSB)

The Transportation Safety Board of Canada (TSB) is calling on Canada’s small aircraft operators to equip their fleets with lightweight recorders to monitor flight data, and is pressing Transport Canada to work with industry to make it happen. This TSB recommendation is part of an investigation report in which investigators could not conclusively determine why a de Havilland Canada DHC-3T Turbo Otter lost control and broke up in flight in the Yukon, Canada in March 2011.

The turbine-powered DHC-3 Otter, operated by Black Sheep Aviation and Cattle Co. Ltd, was flying from Mayo to the Rackla Airstrip in the Yukon, a 94-mile flight. Approximately 19 minutes after departure, the aircraft experienced a catastrophic in-flight breakup.  The aircraft broke up in flight and the pilot, who was the sole occupant died.

Investigators could not conclusively determine the cause of the break-up. While recorded flight data on larger transport aircraft has helped investigators determine the causes of accidents, smaller commercial aircraft usually don’t have recording devices.

In Canada, 91% of commercial aircraft accidents in the last 10 years involved these operators, and together, these accidents accounted for 93% of commercial aviation fatalities, TSB reported. Flight data monitoring could be an important tool to help smaller airlines to manage safety in their operations as well as help investigators in case of an accident.

More information:

• TSB press release

Filed under: Investigation Reports, Safety Recommendations by admin
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A Boeing 727 that overran the runway at St. Johns International Airport (photo: TSB)

The Transportation Safety Board of Canada (TSB) released its annual reassessment of responses to Board recommendations. When the TSB identifies serious safety deficiencies during an investigation, it issues recommendations to the regulator or industry, putting a direct spotlight on what needs to be addressed. Troubled by slow progress, the TSB is now calling on Transport Canada to intensify efforts on a number of outstanding safety recommendations, especially in aviation.

A major challenge remains in aviation which has seen very limited movement on recommendations. Only 60 percent of recommendations have received the TSB’s highest rating of “fully satisfactory”. Canada has seen a number of aircraft accidents over the past few years that have involved factors relating to these outstanding recommendations. For instance, the TSB has revived three dormant recommendations relating to post-impact fires as a result of ongoing accident investigations. In addition, not enough is being done to address a recommendation which calls on Transport Canada to require airports with Code 4 runways (1800m) to have a 300m runway end safety area or a means of stopping aircraft that provides an equivalent level of safety – landing accidents and runway overruns are on the TSB Watchlist.

More information:

• TSB News Release

Filed under: Safety Recommendations by admin
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Surface movement radar picture showing illuminated stop bar and NEF025 (image: SAIF)

 The Finnish Safety Investigation Authority published their investigation report on a serious  runway incursion incident that occurred at Helsinki-Vantaa Airport on December 29, 2011 blaming the crew’s misinterpretation of traffic information and inadequate CRM. 

A Saab 340 aircraft operated by RAF-AVIA Airlines, call sign NEF025, was preparing to take off for a cargo flight and entered the runway. Simultaneously, a Golden Air ATR-72 aircraft, call sign BLF218, which had already been cleared to land, was approaching the same runway. NEF025 had two crew members. BLF218 had 67 passengers and 4 aircrew members.

In accordance with the instructions of the air traffic controller, NEF025 was taxiing to the holding point for runway 22R. Since NEF025 had not contacted Aerodrome Control Tower West (TWR-W), responsible for traffic on runway 22R, the controller switched on the red stop bar so that NEF025 would not taxi onto the runway in front of the landing aircraft. Shortly afterwards NEF025 called TWR-W. At this time the controller informed NEF025 of the landing aircraft: “NEF025 one landing”. The pilot-in-command of NEF025 interpreted the traffic information to be a clearance  to taxi onto the runway. Although the co-pilot was unsure of the clearance, the pilots did not confirm this from the air traffic control. NEF025 continued to taxi onto the runway past the illuminated stop bar.

The ATR-72 was approaching runway 22R and received a landing clearance from the TWR controller. During the final stage of the approach the pilots of the ATR-72 noticed that the runway was occupied and aborted the approach. Simultaneously, the TWR controller also noticed that NEF025 had entered the runway and cleared BLF218 for a go-around.

The serious incident occurred because the flight crew of NEF025 misinterpreted the traffic information, crossed the illuminated stop bar and entered the active runway 22R without an air traffic control clearance. Inadequate multi-crew cooperation between the pilots of NEF025 was a contributing factor.

In the spring of 2012 the Latvian Civil Aviation Agency (LV CAA) organised two flight safety meetings with RAF-AVIA and audited the company’s operations. As a result of the meetings and the audit LV CAA issued several recommendations for the purpose of correcting the observed anomalies. RAF-AVIA agreed to the recommendations of LV CAA.

Safety Investigation Authority, Finland (SIAF) issued five safety recommendations: two of them were directed at the Latvian Civil Aviation Agency and three at Finavia Corporation. Finavia maintains Finland’s network of 25 airports and the air navigation system.

SIAF recommend that LV CAA ensure that the pilots of RAF-AVIA are familiar with the procedures related to stop bars. Furthermore, SIAF also recommended that LV CAA make certain that RAF-AVIA pilots possess sufficient multi-crew cooperation skills.

SIAF recommend that Finavia emphasise the importance of disciplined radiotelephony communications in air traffic control operations and that Finavia focus particular attention on correct read-backs. Secondly, SIAF recommended that Finavia make certain that air traffic controllers include the pertinent air traffic control clearance, as applicable, when they complement the standard radiotelephony phraseology with traffic information. SIAF also recommended that Finavia study the possibilities of introducing a runway incursion alerting system.

More information:

• SIAF Incident Investigation Report

Filed under: Investigation Reports, Safety Recommendations by admin
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The (red) route followed by fire services before reaching the aircraft (photo: ANSV)

According to a report by the Italian aircraft accident investigation agency ANSV it took emergency services ten minutes to reach an ATR-72 passenger plane that had suffered a runway excursion at Roma-Fiumicino Airport, Italy. Two interim safety recommendations were made.

On February 2, 2013, an ATR-72 passenger plane, registered YR-ATS, sustained substantial damage in a landing accident at Roma-Fiumicino Airport (FCO), Italy. Of the fifty occupants, four were injured.
Alitalia flight AZ1670 had departed Pisa-Galileo Galilei Airport (PSA) on a domestic flight to Roma-Fiumicino Airport (FCO). This flight was operated by Carpatair on behalf of Alitalia.

The airplane flew the approach in strong cross wind conditions with wind shear reported at runway 16L some fifteen minutes before the landing. Shortly before touchdown the airplane suddenly lost altitude and impacted the runway with the nose landing gear. It bounced three times, causing the nose and main gear to collapse. The airplane slid off the left side of the runway and came to rest in the grass near taxiway DE, at a distance of about 1780 meters from the runway threshold.

It came to rest at 20:32:33 h, at 400 m from fire station nr.1. The crash alarm was raised at 20:33:22 when the tower failed to establish radio contact with flight 1670. The tower then established radio contact with the fire services. The fire services arrived at taxiway DD at 20:35:59 and contacted the Tower controller, requesting information about the position of the aircraft.  It was dark and they were not able observe the airplane. The Tower controller responded “Shortly after Delta Echo”, which was confirmed by the fire services. Procedures called for the use of a grid map reference to point out the location of an accident. The Tower did not communicate this grid reference, nor did the fire services request such a reference. Meanwhile the emergency services had trouble locating taxiway DE. They drove all the way to the end of the runway and returned, initially passing taxiway DE. At 20:43:02 one of the fire services radioed that they had found the airplane, about ten minutes after the accident.

Two safety recommendations were made:

1. In line with what has already been recommended by ANSV with safety recommendation no. ANSV-13/1836-10/5/A/12, it is recommended to ENAC and the National Fire Department to adopt urgent initiatives deemed most appropriate under the educational profile and representative training to enable staff of firefighters working on Italian airports to have an actual full knowledge of both aviation terminology and of the airport grounds on which it operates, so as to avoid misunderstandings in communications related to disaster relief, to the benefit of timely detection aircraft requiring rescue.
2. ANSV recommends ENAC and ENAV, in general, that the Tower, in directions to be supplied in the activation of the rescue operation, gives references correlated to the GRID-MAP of their airport.

More information:

• ASN accident description Flight AZ1670
• ANSV Recommendations (in Italian)

Filed under: Safety Recommendations by admin
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The nose landing gear actuator of N218YV. (Photo: NTSB)

Several recent incidents involving nose landing gear (NLG) cracks and leaks on Beechcraft 1900D airplanes prompted the NTSB to issue three safety recommendations.

On May 17, 2011, a Beechcraft 1900D, N218YV, sustained minor damage when the left main landing gear (MLG) collapsed during the landing roll on runway 35L at Denver International Airport (DEN), Denver, Colorado. There were no injuries. The NTSB determined that the probable cause of the incident was the fatigue failure of the NLG end cap, which resulted in insufficient hydraulic pressure to secure the left MLG into the down-and-locked position. During the investigation the NTSB learned of five previous NLG end cap failures.
Altough the maintenance manual was changed, two additional instances of fatigue cracks of NLG end caps on Beechcraft 1900D airplanes had occurred.

The NTSB concludes that the repetitive inspections using the current Hawker Beechcraft-developed and -approved method are not capable of detecting subcritical fatigue cracks in the NLG end caps. Without an effective inspection method, the 1,200-cycle inspection interval is not adequate to ensure that cracks are detected before failure occurs in service. Therefore, the NTSB recommends that Hawker Beechcraft Corporation revise the Beechcraft 1900D NLG end cap repetitive inspection procedure and time interval to ensure that fatigue cracks are detected prior to failure and issue updated guidance to operators regarding the inspections.

Therefore the National Transportation Safety Board makes the following recommendations to Hawker Beechcraft Corporation:

• Determine the fatigue life (life limit) of the Beechcraft 1900D nose landing gear (NLG) end cap with the longitudinal grain direction both aligned and not aligned with the longitudinal axis of the NLG. (A-13-04)
• Develop and implement a replacement program for all Beechcraft 1900D nose landing gear end caps based on the fatigue life determined in Safety Recommendation A-13-04. (A-13-05)
• Revise the Beechcraft 1900D nose landing gear end cap repetitive inspection procedure and time interval to ensure that fatigue cracks are detected prior to failure and issue updated guidance to operators regarding the inspections. (A-13-06)

More information:

• NTSB Safety Recommendation Letter

Filed under: Safety Recommendations by admin
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An Antonov 24 aircraft that came to rest in the snow at Saransk, Russia

Russia’s Federal Air Transport Agency, Rosaviatsiya, issued a safety bulletin to prevent runway or taxiway excursions following several incidents in Russia during January 2013.

Rosaviatsiya voiced its concerns over five recent incidents in which passenger aircraft suffered runway or taxiway excursions in snowy weather conditions. Human factors as well as low friction coefficients are cited as the main factors in these incidents.

The safety bulletin urges major airport operators to take all necessary measures to make sure that runways or taxiways have a proper friction coefficient. It further requests airlines to share information about these incidents with flight crews together with a memo that gives specific guidance on operations on contaminated runways or taxiways.

The incidents reported in the bulletin are:

• 9 January: An-24 of Mordovia Airlines at Saransk
• 12 January: Airbus A319 of S7 Airlines at Rostov-on-Don
• 17 January: Boeing 737-400 of Globus at Moscow-Domodedovo Airport
• 20 January: Airbus A320 of Aeroflot at Chelyabinsk
• 22 January: Airbus A321 of Ural Airlines at Chelyabinsk

More information:

• Safety bulletin (in Russian)

Filed under: Safety Recommendations by admin
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UPS DC-8 following cargo fire at Philadelphia (photo: NTSB)

The U.S. National Transportation Safety Board issued three recommendations to reduce the impact of in-flight fires aboard cargo airplanes, saying current fire protection regulations are inadequate.

The recommendations urge the Federal Aviation Administration to require active fire suppression systems in all cargo containers or compartments of cargo aircraft. They also recommend improving early detection of fires within cargo containers and pallets and urge that cargo containers provide better fire resistance.

The NTSB has led or participated in the investigation of three fire-related accidents involving cargo aircraft in the past six years. One involved a UPS aircraft in Philadelphia that was substantially damaged in 2006; another was a UPS flight that crashed in Dubai, United Arab Emirates, in 2010; and the third was an Asiana Cargo flight that crashed into the East China Sea off the coast of South Korea in 2011. The Dubai and South Korea investigations are ongoing under the direction of the repsective authorities.

NTSB investigators found that the early stages of a fire burning inside a cargo container are concealed from detection. In later stages, when the fire grows and does become detectable, it rapidly intensifies and burns through the container to become a substantial threat to the aircraft and crew. In the UAE crash, the crew had just two and a half minutes between the fire detection and the onset of aircraft system failures.

The air cargo industry is already actively researching and implementing new fire prevention and suppression technologies. FedEx for example is in the process of installing a fire-suppression system on its long-haul fleet.

More information:

• NTSB Safety Recommendations A-12-68 through -70 (PDF)
• ASN Accident Description UPS DC-8 fire at Philadelphia (2006)
• ASN Accident Description UPS Boeing 747 fire at Dubai (2010)
• ASN Accident Description Asiana Cargo Boeing 747 fire off the coast of South Korea (2011)

Filed under: Safety Recommendations by admin
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Live camera views on an A380 as shown on the primary flight displays
(PFD) or on the system display (SD). This camera system does not display wingtips or wingtip paths yet (photo: NTSB).

The U.S. NTSB recommended that the Federal Aviation Administration (FAA) require that large airplanes be equipped with an anti-ground collision aid, such as an on-board external-mounted camera system, to provide pilots a clear view of the plane’s wingtips while taxiing to ensure clearance from other aircraft, vehicles and obstacles.

On large airplanes (such as the Boeing 747, 757, 767, and 777; the Airbus A380; and the McDonnell Douglas MD-10 and MD-11), the pilot cannot see the airplane’s wingtips from the cockpit unless the pilot opens the cockpit window and extends his or her head out of the window, which is often impractical.

The NTSB said that the anti-collision aids should be installed on newly manufactured and certificated airplanes and that existing large airplanes should be retrofitted with the equipment.

The recommendations follow three recent ground collision accidents (all currently under investigation) in which large airplanes collided with another aircraft while taxiing:

May 30, 2012: The right wingtip of an EVA Air Boeing 747-400 struck the rudder and vertical stabilizer of an American Eagle Embraer 135 while taxiing at Chicago’s O’Hare International Airport (Preliminary Report).

July 14, 2011: A Delta Air Lines Boeing 767 was taxiing for departure when its left winglet struck the horizontal stabilizer of an Atlantic Southeast Airlines Bombardier CRJ900 (Preliminary Report).

April 11, 2011: During a taxi for departure, the left wingtip of an Air France A380 struck the horizontal stabilizer and rudder of a Comair Bombardier CRJ701 (Preliminary Report).

The NTSB made the same recommendation to the European Aviation Safety Agency, which sets standards for aircraft manufacturers in Europe.

More information:

• NTSB Safety Recommendation letter

Filed under: Safety Recommendations by admin
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