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)

File photo of Challenger 300 OH-FLM (photo: Eric Bannwarth / AviaScribe CC-by-nc-sa)

An inexperienced pilot caused an in-flight upset of a corporate jet when he overcontrolled the pitch immediately after the autopilot was disengaged, according to an investigation by the Finnish Safety Investigation Authority.

On 23 December 2010 a Bombardier BD–100–1A10 Challenger 300 business jet, registration OH-FLM, departed Moscow, Russia for St. Petersburg. The flight was a familiarisation flight for the co-pilot, who acted as Pilot Flying. There were three passengers and three crewmembers of the on board.

During the initial climb when the Engine Indication and Crew Alerting System (EICAS) annunciated an Autopilot Stabilizer Trim Failure (AP STAB TRIM FAIL) warning. In accordance with the fault checklists the captain disengaged the autopilot. This resulted in a porpoising oscillation which was quickly brought back under control. As a result of the occurrence two passengers were injured and some of the cabin interior was damaged. The aircraft returned to Moscow’s Sheremetyevo Airport.

Whereas the aircraft’s checklists advise the pilots to firmly grip the control column prior to autopilot disengagement, they do not instruct the flight crew to consider adjusting the airspeed to correspond to the horizontal stabilizer angle. Neither did the checklists include any mention of turning on the Fasten Seat Belt sign.
The cause of the occurrence was the overcontrolling of the aircraft’s pitch attitude immediately after the autopilot was disengaged. Contributing factors included the pilots’ unfamiliarity with the characteristics and operating principle of the aircraft’s artificial pitch feel system as well as shortcomings in system training. Further shortcomings were also observed in the flight crew’s checks and in crew cooperation. High airspeed was yet another contributing factor to the considerable acceleration (g) forces experienced during the upset.

More information:

• Finnish SIA report

A GE90-110B1 engine, mounted on a Boeing 777-200LR

Two in-flight engine shutdowns due to technical problems caused the U.S. FAA to issue an emergency Airworthiness Directive (AD) on certain GE90 turbofan engines.

The emergency AD was prompted by reports of two failures of transfer gearbox assemblies (TGBs) which resulted in in-flight shutdowns. Investigation has revealed that the failures were caused by TGB radial gear cracking and separation. Further inspections found two additional radial gears with cracks. This condition, if not corrected, could result in additional shutdowns of one or more engines, loss of thrust control, and damage to the airplane.

The AD only pertains to General Electric GE90-110B1 and GE90-115B turbofan engines with specific  TGB part- en serial numbers as listed in the AD. No later than five days after receipt of this emergency AD, U.S. airlines are not allowed to operate the airplane if more than one installed engine has a TGB serial number listed in the AD.

These engine models can be found on Boeing 777

More information:

FAA emergency AD 2013-10-52

Peak acceleration during landing was +2.32g (graphic: AAIU)

Excessive approach speed and inadequate control of aircraft pitch during a crosswind landing in very blustery conditions caused a hard landing of an ATR-72 passenger plane at Shannon, Ireland, according to an AAIU investigation.

On July 17, 2011, an Aer Arann ATR-72 aircraft carried out a round trip from Shannon (SNN), Ireland to Manchester Airport (MAN), U.K. on behalf of Aer Lingus Regional. On the return leg, the crew commenced an approach in strong and gusty crosswind conditions. Following a turbulent approach difficulty was experienced in landing the aircraft, which contacted the runway in a nose-down attitude and bounced.
A go-around was performed and the aircraft was vectored for a second approach. During this second approach landing turbulence was again experienced. Following bounces the aircraft pitched nose down and contacted the runway heavily in a nose down attitude. The nose gear collapsed and the aircraft nose descended onto the runway. The aircraft sustained damage with directional control being lost. The aircraft came to rest at the junction of the runway and a taxiway.

The Irish Air Accident Investigation Unit (AAIU) concluded that confusing wording in the FCOM led the crew to compute an excessive wind factor in the determination of their approach speed. The inexperienced pilot-in-command, with 212 flying hours as captain on ATR-72 aircraft, used an incorrect power handling technique while landing. It was also established that inadequate information was provided to the flight crew regarding crosswind landing techniques.

More information:

• ASN Accident Description
• AAIU report

The number of reported serious runway incursions increased substantially from fiscal year 2010 to fiscal year 2012, from 6 to 18. Additionally, the total number of all runway incursions increased 21 percent between fiscal years 2011 and 2012, from 954 to 1,150.
Since the OIG’s last review of this program in July 2010, FAA has reorganized its Runway Safety Office and changed the way that the Agency reports and evaluates runway incursions.
The OIG’s objectives are to evaluate FAA’s (1) progress in implementing initiatives to prevent runway incursions, and (2) effectiveness in reporting and evaluating runway incursions.

More information:

• OIG press release
• Review of FAA’s Call to Action Plan for Runway Safety (July, 2o10)
• FAA runway incursion statistics

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)

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

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

Currently, FAA is responsible for overseeing nearly 4,800 repair stations used worldwide by U.S air carriers. The OIG found that while FAA developed a risk assessment process to aid repair station inspectors in identifying areas of greatest concern, its oversight continues to emphasize completing mandatory inspections instead of targeting resources where they are needed based on risk. Less than half of its inspection elements are evaluated based on risk, and foreign repair stations are not inspected using a risk-based system. In addition, FAA’s oversight of foreign and domestic repair stations lacks effective, standardized processes for identifying deficiencies and verifying that they have been addressed. As a result, the OIG reports it found numerous systemic discrepancies at the repair stations visited during the review.
FAA concurred with all nine of the OIG’s recommendations to enhance the Agency’s oversight of repair stations, citing its plans to implement a new oversight system—the Safety Assurance System (SAS)—in fiscal year 2015, and proposing actions to address our concerns in the interim. However, we are requesting additional information or alternative actions for three recommendations to ensure adequate oversight until SAS is complete.

More information:

• OIG audit AV-2013-073

The FAA alleges that UPS failed to follow FAA-approved procedures for making structural repairs to two DC-8 aircraft and two MD-11 aircraft. UPS operated the four planes on more than 400 flights between October 2008 and June 2009.

These violations stem from UPS’s failure to fully comply with the terms of a consent agreement in which the carrier agreed to inspect all aircraft in its fleet and compare actual repairs with maintenance records. This would have ensured the four aircraft were in compliance with the regulations.

UPS has 30 days from the receipt of the FAA’s civil penalty letter to respond to the agency.