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Loss of situational awareness after intrument failure cited in fatal Swedish CRJ-200 accident
12 December 2016

Loss of situational awareness after intrument failure cited in fatal Swedish CRJ-200 accident

Italian safety agency issues safety recommendations for drones

The Italian National Agency for Flight Safety (ANSV)  issued five safety recommendations to reduced the safety risks of the operation of drones in Italian airspace.

Over the year 2015 the ANSV received 18 reports of unmanned vehicles interfering with flight operations in civil airspace, a sharp increase compared to previous years.

As a result of further investigation of these cases and meetings with aviation industry stakeholders, ANSV published five safety recommendations:

  1. The Italian Civil Aviation Authority (ENAC) should create a register for all small unmanned aircraft, comparable to the register recently initiated by the U.S. Federal Aviation Administration,
  2. ENAC should start an information campaign, aimed at encouraging the development of an aeronautical culture among drone users,
  3. The Interior Ministry and Italian Municipalities should raise awareness among local police forces to sanction in an effective, fair and prompt way those drone operators who violate existing legislation.
  4. ENAC should, in coordination with the Ministry of Economic Development, consider the installation of geofencing software on drones, which automatically limits in areas where the use of drones is not allowed.
  5. ENAC should, in coordination with the Ministry of Economic Development, and the Aero Club of Italy, evaluate the possibility of identifying specific frequency bands to be allocated for professional drone use.

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EASA recommends MD-11 operators to install system to prevent bounced landings

The European Aviation Safety Agency (EASA) recommends MD-11 operators to install a landing gear Struts Extended Annunciation System (SEAS) to prevent bounced landing accidents.

In the light of several bounced landing accidents involving MD-11 aircraft, Boeing developed a system which gives additional information about the aeroplane’s air/ground status to pilots during landing. The so called landing gear Struts Extended Annunciation System (SEAS) illuminates dedicated lights on the glare shield in front of both pilots when the main landing gear struts are close to, or are at full extension. In this way, pilots are more aware if a bounce has occurred, and control inputs can be made which will avoid the bounce developing into a more serious event.

EASA recommends operators to install the Landing Gear SEAS per Boeing SB MD11-32-093 (or its equivalent which matches the specific aeroplane cockpit) as mitigation for the risk of inappropriate control inputs after bounced landings. This should be combined with enhanced training using amended FCOM procedures and special maintenance tasks provided by the Boeing Company.

A system to show the landing/strut gear touchdown status was first recommended by the Japanese TSB in April 2013. This recommendation followed the investigation into a fatal MD-11F accident at Tokyo-Narita Airport, Japan, in March 2009. Both pilots died when the left wing fractured following a bounced landing. The airplane rolled over and a fire erupted.

More information:

MD-11F accident sequence at Tokyo-Narita, 2009 (JTSB)

MD-11F accident sequence at Tokyo-Narita, 2009 (JTSB)

FAA urges airlines to assess lithium battery risks

A DC-8 cargo fire in 2006 was likely caused by lithium batteries

A DC-8 cargo fire in 2006 was likely caused by lithium batteries

The U.S. Federal Aviation Administration (FAA) issued a safety alert to U.S. and foreign commercial passenger and cargo airlines, urging them to conduct a safety risk assessment to manage the risks associated with transporting lithium batteries as cargo.

The FAA also is issuing guidance to its own inspectors to help them determine whether the airlines have adequately assessed the risk of handling and carrying lithium batteries as cargo.

FAA battery fire testing has highlighted the potential risk of a catastrophic aircraft loss due to damage resulting from a lithium battery fire or explosion. Current cargo fire suppression systems cannot effectively control a lithium battery fire. As a result of those tests, the International Civil Aviation Organization (ICAO) and aircraft manufacturers Boeing and Airbus have advised airlines about the dangers associated with carrying lithium batteries as cargo and also have encouraged them to conduct safety risk assessments.

Hazardous materials rules currently ban passenger airlines from carrying lithium-metal batteries as cargo. In addition, a number of large commercial passenger airlines have decided voluntarily not to carry rechargeable, lithium-ion batteries. The safety risk assessment process is designed to identify and mitigate risks for the airlines that still carry lithium batteries and to help those that don’t carry them from inadvertently accepting them for transport.

The SAFO  encourages airlines that previously conducted safety assessments to reevaluate them in light of new evidence from the agency’s recent lithium battery fire tests.

More information:

EASA recommends airports to make sure runway-holding points do not interfere with ILS signals

Hamburg Airport map with critical zone (BEA)

Hamburg Airport map with critical zone (BEA)

Following a serious incident in 2012, the European Aviation Safety Agency (EASA) recommends airports to make sure runway-holding points do not interfere with ILS signals.

The serious incident happened at Hamburg, Germany on March 28, 2012. An Airbus A320 was on final approach when the Primary Flight Display (PFD) began displaying erroneous glidepath information. The aircraft descended below the glideslope while the PFD showed the airplane to be on the glideslope. The A320 descended even further below the glideslope, yet the PFD showed it to be almost one dot above the glideslope. A go around was initiated after which the aircraft landed safely. An investigation published early 2015 by the French BEA revealed that a Boeing 737 that was holding short on the taxiway was positioned in an area that was considered a critical zone near the glideslope antenna. The aircraft caused a disturbance in the glideslope signal, leading to erroneous information being displayed on the PFD of the approaching aircraft.

EASA recommends that:
(a) Aerodrome operators review the locations of established runway-holding positions, particularly at locations where runway-holding positions are established within critical areas of ILS signals, and ensure that they comply with the applicable provisions, and that relevant procedures for the protection of the ILS signals are contained in the aerodrome manual;
(b) ANS providers review their procedures for ILS approaches in order to ensure that they contain the unconditional requirement that ILS critical areas are kept clear during ILS approaches to avoid permanent infringements of these areas;
(c) NAAs take into account, during their safety oversight activities, the recommendations in (a) and (b) above.

More information:

EASA recommends airlines to conduct a safety risk assessment for lithium batteries

Lithium battery fire on a laptop (CAA)

Lithium battery fire on a laptop (CAA)

The European Aviation Safety Agency (EASA) recommends airlines to conduct a safety risk assessment when transporting lithium batteries.

Lithium batteries may have been the cause of, or contributed to, uncontrolled fires in cargo that lead to the loss of 3 freighter aircraft between 2006 and 2011:

  1. 8 February 2006, UPS, DC-8-71F at Philadelphia International Airport, U.S.A.
  2. 3 October 2010, UPS, Boeing 747-400F, near Dubai, U.A.E.
  3. 28 July 2011, Asiana Airlines, Boeing 747-400F, off Jeju, South Korea

Subsequently, the FAA performed tests that led to the decision of the ICAO Dangerous Goods Panel to prohibit the carriage of lithium metal batteries as cargo on passenger aircraft. This prohibition does not include lithium metal batteries contained in, or packed with equipment. Lithium metal batteries can continue to be transported in freighter aircraft, and lithium ion batteries can be transported as cargo both in freighter and passenger aircraft under certain provisions.

Since high density shipments of lithium batteries is still considered a possible risk, ICAO continues working to find a suitable solution to appropriately address these risks with the aim of improving the packaging and shipping provisions contained in the Technical Instructions for the Safe Transport of Dangerous Goods by Air.

EASA meanwhile issued the following recommendation:

“Operators are responsible for the acceptance, loading, and actual transport of dangerous goods in accordance with the Technical Instructions.
Until safer methods of packaging and transporting are established and implemented, EASA strongly recommends that operators, before engaging in the transport of lithium batteries/cells as cargo in passenger or freighter aircraft, conduct a safety risk assessment in order to establish whether the risk is manageable.
Such an assessment should contain information on the types and quantities of lithium batteries/cells being transported, as well as on their state of charge, and consider the very limited capability of aeroplanes cargo compartment fire protection systems to control a lithium battery fire. In performing the assessment, the possibility that lithium batteries/cells may be affected by fires originating from other sources shall be considered.
EASA also recommends National Aviation Authorities to include this element in their oversight programme.”

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EASA recommends better pilot training for manual flight at high altitude

The European Aviation Safety Agency  (EASA) issued recommendations regarding the training of pilots for unreliable airspeed indications at high altitude and the manual handling of the aircraft at high altitude.

This recommendation was issued following accidents and incidents, Air France flight 447 among others, in which  the autopilot and autothrottle/autothrust disconnected following a loss of airspeed indication en route at high altitude. This led to a reversion to manual control and the temporary or permanent loss of control of the flightpath by the flight crew, particularly when operating close to the aircraft’s maximum operating altitude.

Recommendations:
EASA strongly recommends that operators and training organisations of aeroplanes with max cruising altitude above FL300 provide pilots with briefing material, theoretical knowledge and practical training on the following elements, at the earliest possible opportunity and regularly thereafter, during their recurrent training.
EASA strongly recommends that the same elements are included, by ATOs, in initial type rating training for the same category of aeroplanes.

  • Basic flight physics principles concerning flight at high altitude, with a particular emphasis on the relative proximity of the critical Mach number and the stall, pitch behaviour, and an understanding of the reduced stall angle of attack when compared with low altitude flight (see EASA SIB 2015-07).
  • Interaction of the automation (AP, FD, ATHR) and the consequences of failures inducing disconnection of the automation.
  • Consequences of an unreliable airspeed indication at high altitudes and the need for the flight crew to promptly identify the failure and react with appropriate (minimal) control inputs to keep the aircraft in a safe envelope.
  • Degradation of FBW flight control laws/modes and its consequence on aircraft stability and flight envelope protections, including stall warnings.
  • Practical training, using appropriate simulators, on manual handling at high altitude for all pilots in normal and in non-normal flight control laws/modes, with particular emphasis on pre-stall buffet, the reduced stall angle of attack when compared with low altitude flight and the effect of pitch inputs on the aircraft trajectory and energy state.
  • The requirement to promptly and accurately apply the stall recovery procedure, as provided by the aircraft manufacturer, at the first indication of an impending stall.
  • Procedures for taking over and transfer manual control of the aircraft, especially for FBW aeroplanes with independent side-sticks.
  • Task sharing and crew coordination in high workload/stress conditions with appropriate call-out and acknowledgement to confirm changes to the aircraft flight control law/mode.

More information:

EASA issues recommendations to prevent loss of fan cowl doors on A320

 

Lost cowlings on a BA A319 in May 2013 (AAIB)

Lost cowlings on a BA A319 in May 2013 (AAIB)

The  European Aviation Safety Agency (EASA) issued a Safety Information Bulletin, recommending operators of A320 aircraft to take measures to avoid non- or improper closing of fan cowl doors.

There have been numerous incidents involving the loss of fan cowl doors during the take-off phase, especially on Airbus A320 aircraft. In all reported incidents, analysis shows that the latches of the fan cowl doors were either unlocked or not properly hooked and secured. This condition remained undetected during the exterior walk-around preceding departure, leading to air scooping and subsequent cowl separation.

Airbus is currently working on a new design solution for the A320 family fleet, improving the identification of any fan cowl door not properly closed and latched. That modification is expected to be the subject of an Airworthiness Directive (AD).

In the mean time EASA recommends owners and operators to amend their pre-take-off procedures to ensure that all maintenance actions involving the opening/closing, removal and re-installation, or replacement of an fan cowl door is brought to the attention of the flight crew of the affected aeroplane before the next flight of that aeroplane.

In addition, EASA recommends design approval holders to consider amending the existing fan cowl door opening and closing procedures in the applicable aircraft maintenance manual (AMM) to make a record in the aircraft logbook each time these procedures have been applied and to communicate to operators to emphasize that applying these procedures is essential to avoid further events.

More information:

 

EASA advises airlines to monitor flights and manage risk in ITCZ to prevent loss of control

ITCZ between over the Atlantic on 20 August 2010 (NOAA)

ITCZ between over the Atlantic on 20 August 2010 (NOAA)

The European Aviation Safety Agency (EASA) advises airlines to apply flight monitoring en risk management strategies regarding operations in the Inter-Tropical Convergence Zone (ITCZ) to prevent loss of control accidents.

The accident involving Air France flight AF447 in June 2009 highlighted the risks of operations in the ITCZ. The Airbus A330 suffered a loss of control accident when the flight crew reacted inappropriately on the icing of the pitot probes while flying near cumulonimbus clouds in the ITCZ. All 228 on board died in the accident.

EASA now issued a Safety Information Bulletin, advising the airlines as follows:

When operating in adverse convective weather and the ITCZ area, operators should thoroughly determine their exposure to ITCZ risks and ensure that efficient mitigating actions are continually and consistently taken, based on data-driven strategies, thereby actively preventing accidents resulting from LOC-I (loss of control in-flight). Safety management principles should apply to all aspects of flight operations in adverse convective weather and the ITCZ with a view to implementing risk mitigation strategies and proactively taking preventive actions. Particular attention should be paid to precursors of LOC-I. 

The recommendations for operators focus on Safety risk management; Flight planning and dispatch; In-flight procedures; and Competency of personnel.

The recommendations issued in the EASA bulletin are not mandatory.

More information:

EASA issues bulletin on the prevention of hazardous low speed at high altitude cruise

EASA

The  European Aviation Safety Agency (EASA) issued a safety information bulletin, reminding flight crew of the dangers of low speed at high altitude cruise.

A recently published interim report on a July 2014 accident involving an MD-83 Mali, prompted EASA to issue a bulletin to remind flight crews of some basic flight physics principles to better manage the airplane speed (Mach number) when flying at high altitudes to prevent entry into upset situations such as stall.

Investigators think the MD-83 accident occurred when pressure sensors became obstructed by icing while en route at FL310. Due to the incorrect pressure values, the auto-throttle tried to maintain a lower thrust than was necessary. The aircraft lost speed and developed a tendency to descend.  The autopilot, engaged in altitude hold mode, then attempted to raise the nose in order to maintain altitude.  The aircraft ultimately stalled.

The bulletin concludes that, when in cruise,

– if continuous Mach decrease cannot be stopped after the maximum available thrust has been applied, and
– if the Mach/airspeed indication can be considered reliable,

flight crews should establish the aeroplane in a reasonable descent to recover the initial targeted Mach. Then after a descent has been initiated, appropriate actions to mitigate the risk of air-to-air collision should be taken (ATC advised, TCAS monitoring etc.). Return to the previous cruise altitude should be initiated only after reaching the optimum Mach for climb and only then in coordination with ATC.

Failure of the flight crew to take the decision to descend in due time will result in a stall with significant altitude loss and a potential loss of control of the aeroplane. The initiation of a controlled descent manoeuvre is the correct action to be taken by the flight crew.

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