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France recommends ground ice detection system following fatal takeoff accident of Premier 1A jet
5 May 2014

France recommends ground ice detection system following fatal takeoff accident of Premier 1A jet

Radar plots and position of the wreckage (BEA)

Radar plots and position of the wreckage (BEA)

The French accident investigation bureau, BEA, recommends EASA to study the possibilities of ground ice detection systems following the fatal accident involving a Premier 1A corporate jet in March 2013.

The Hawker Beechcraft 390 Premier IA jet, registered VP-CAZ,  was parked overnight on the platform at Annemasse Airport in France. The temperature was -2°C and humidity was 98% with fog or low clouds as the pilot prepared for a 5-minute VFR flight to Genève-Cointrin Airport (GVA). One passenger was seated in the cockpit, another passenger was seated in the passenger cabin.

The pilot started the takeoff from runway 12 at 08:38. Rotation occurred 19 seconds later. Several witnesses reported seeing the airplane with a high nose-up pitch attitude, with a low rate of climb. Three seconds after the rotation the “Bank Angle” warning, indicating excessive bank, and then the stall warning, was recorded several times on the cockpit voice recorder. Several witnesses saw the airplane turn sharply to the right and then to the left.
Fifteen seconds after the rotation, the left main landing gear struck the roof of a house about 500 m from the threshold of runway 30 at Annemasse. The aircraft then collided with the ground. During the impact sequence, all three elements in the landing gear and the left wing were torn away from the rest of the airplane. It then slid along the ground for a distance of about 100 m before hitting a garden shed, a low wall and some trees in the garden of a second house. A post-impact fire erupted. Both occupants seated in the cockpit were killed.

BEA concluded: “The pilot’s insufficient appreciation of the risks associated with ground-ice led him to take off with contamination of the critical airframe surfaces. This contaminant deposit then caused the aerodynamic stall of the aeroplane and the loss of control shortly after lift-off.”

Investigators noted among others that Annemasse Airport was not equipped with anti-icing/de-icing facilities. A recommendation was issued to the regulator DGAC to “define criteria intended to make it mandatory for aerodrome operators to have de-icing/anti-icing facilities at aerodromes.”

Additionaly BEA recommends EASA to “make  changes to the training requirements for pilots so as to include periodic  reminders on the effects of contaminants such as ice on stall and loss of control on takeoff.”

Citing 32 takeoff accidents since 1989, attributed to contaminated wings, BEA also recommends EASA, in coordination with the FAA and the other non-European civil aviation authorities, to “study the technical and regulatory means to put in place in order to install systems for the detection of frozen contaminants on the critical surfaces of aircraft.”

More information:

 

NTSB issues urgent safety recommendation to improve oversight of operator in Alaska

Cessna 208B Grand Caravan N12373 crashed in Alaska in November 2013.

Cessna 208B Grand Caravan N12373 crashed in Alaska in November 2013.

The U.S. National Transportation Safety Board (NTSB) issued an urgent safety recommendation to the Federal Aviation Administration (FAA) regarding the oversight of air operators in Alaska owned by HoTH, Inc., after six recent accidents and one incident.

These operators include Frontier Flying Service; Hageland Aviation Services, Inc.; and Era Aviation, which may do business as Ravn Alaska, Ravn Connect, and Corvus Airlines.

The NTSB issued an urgent safety recommendation to the FAA to conduct a comprehensive audit of the regulatory compliance and operational safety programs in place at HoTH, Inc., operators. The NTSB also issued a second, non-urgent safety recommendation that the FAA conduct a comprehensive audit of its own oversight of these Alaska-based operators. The oversight audit should be conducted by FAA units that are based outside of Alaska, the NTSB recommended.

While the operator and the FAA have made several recent changes designed to improve safety and oversight, the NTSB believes that, due to the breadth of the issues identified during its investigations, today’s recommendations are necessary to ensure the safe operation and effective oversight of the operators owned by HoTH, Inc.

More information:

NTSB issues recommendations to address MD-11 bounced landing susceptibility

Accident sequence of a FedEx MD-11 at Narita, 2012 (JTSB)

Accident sequence of a FedEx MD-11 at Narita, 2012 (JTSB)

The U.S. NTSB issued seven safety recommendations, aimed at providing long term solutions for reducing the risk of MD-11 landing accidents.

The McDonnell Douglas MD-11 airplane was involved in fourteen hard landing accidents since 1994, leading to several safety recommendations. The last recommendations were issued on July 12, 2011, while two accident investigations were still underway. These recommendations addressed the need for improved recurrent training and operational guidance for MD-11 pilots. The NTSB believed that the actions described in those recommendations would provide near-term improvements to reduce the risk of MD-11 landing accidents.
The seven new recommendations are aimed at providing longer term solutions for further reducing the risk of MD-11 landing accidents.

The NTSB reviewed data from multiple MD-11 hard landing accidents and identified factors that might have contributed to the severity of these hard landing accidents, including the following:

  • the MD-11’s high landing speed, which increases the difficulty of a properly timed and executed flare because it must be initiated within a narrow timeframe; 
  • the airplane’s geometry, which places the cockpit far ahead of the center of gravity and the main landing gear, reducing pilot awareness of wheel-ground contact; 
  • the MD-11’s automatic reduction of thrust during the landing flare, which could lead to a delay in adjusting thrust or pitch overcontrol during landings with excessive sink rates; and 
  • the airplane’s use for long-range cargo flights, which reduces the opportunities for pilots to maintain landing proficiency compared with transport-category pilots who do not fly such routes.

The interaction of all of these factors might increase the MD-11’s susceptibility to a late flare, a bounced landing, and improper column inputs by the pilot after a bounce, which could lead to overload of the main gear and the potential for catastrophic structural overload, a hull loss, and injuries and/or fatalities, according to the NTSB.

The NTSB issued the following recommendations to the Federal Aviation Administration (FAA):

  • Work with Boeing to (1) assess the effectiveness of flare cueing systems to assist MD-11 pilots in making timely and appropriate inputs during the landing flare, (2) provide a formal report on the findings of the assessment, and (3) if the assessment shows that flare cueing systems could be useful to MD-11 pilots, provide copies of the report to all US operators of MD-11 airplanes and encourage them to install such a system on these airplanes. (A-14-004)
  • Work with Boeing to (1) assess methods for providing weight-on-wheels cueing to MD-11 pilots to enhance pilot awareness of bounced landings and facilitate proper pilot reaction and effective control inputs when bounced landings occur, (2) provide a formal report on the findings of the assessment, and (3) if the assessment shows that the weight-on-wheels cueing methods could be useful to MD-11 pilots, provide copies of the report to all US operators of MD-11 airplanes and encourage them to provide a means for weight-on-wheels cueing for these airplanes. (A-14-005)
  • Work with Boeing to (1) evaluate the effect of brief power increases on simulated MD-11 landing distances, (2) adjust the values in published MD-11 landing distance tables accordingly, and (3) provide the adjusted values to MD-11 operators. (A-14-006)
  • Reconvene the MD-10/MD-11 flight standardization board to determine whether currency requirements should be strengthened for MD-11 pilots. (A-14-007)

The NTSB issued the following recommendations to the Boeing Company:

  • In collaboration with the Federal Aviation Administration, (1) assess the effectiveness of flare cueing systems to assist MD-11 pilots in making timely and appropriate inputs during the landing flare, (2) provide a formal report on the findings of the assessment, and (3) if the assessment shows that flare cueing systems could be useful to MD-11 pilots, provide copies of the report to all US operators of MD-11 airplanes and encourage them to install such a system on these airplanes. (A-14-008)
  • In collaboration with the Federal Aviation Administration,(1) assess methods for providing weight-on-wheels cueing to MD-11 pilots to enhance pilot awareness of bounced landings and facilitate proper pilot reaction and effective control inputs when bounced landings occur, (2) provide a formal report on the findings of the assessment, and (3) if the assessment shows that the weight-on-wheels cueing methods could be useful to MD-11 pilots, provide copies of the report to all US operators of MD-11 airplanes and encourage them to provide a means for weight-on-wheels cueing on these airplanes. (A-14-009)
  • In collaboration with the Federal Aviation Administration,(1)evaluate the effect of brief power increases on simulated MD-11 landing distances, (2) adjust the values in published MD-11 landing distance tables accordingly, and (3) provide the adjusted values to MD-11 operators. (A-14-010)

More information:

 

ATR-72 flight deck overheat occurrence highlights crew’s response and smoke procedures

Flight track of GE-5111 (ASC)

Flight track of GE-5111 (ASC)

The  Aviation Safety Council published its final report of the investigation into a flight deck overheat incident on an ATR-72, highlighting the crew’s response and their failure to identify origin of the hot air.

On July 1st 2013, Trans Asia Airways flight GE5111, an ATR 72-500 aircraft, took off from Taipei Song-Shan Airport for Kaohsiung Airport. On board were 72 passengers and four crew members.

During climb, the cockpit temperature began to rise due to hot air that was blown out of the air conditioning vent. A white vapor like moisture appeared. When the aircraft had reached an altitude of 4,000 feet, a master caution sounded and the “OVERHEAT AIR” was illuminated on the instrument panel. The captain instructed first officer to request Taipei Approach radar vectors back to Song-Shan Airport. At 5,300 feet, the flight crew had not yet started the Engine #1 bleed overheat procedures. Meanwhile the master warning continuously sounded and the Electric Smoke light illuminated. The captain disengaged the autopilot and instructed the first officer to request an emergency landing. A Pan pan was declared.
Both flight crew believed there was no electrical smoke therefore memory items were not executed and oxygen masks and goggles were not donned. When the aircraft descended through 3,000 feet, the crew opened the avionics vent exhaust. The vapor disappeared and the warning light was no longer illuminated. The temperature came back to normal level. The aircraft landed safely without further incident.

The Aviation Safety Council concluded that the probable cause of this occurrence was:
“Hot air was continuously vented from air condition outlet, due to malfunctioning Pack #1 duct temperature sensor and temperature limiter that caused the modulating valve kept opening in the occurrence flight; as a result, temperature in the cockpit remained high. The flight crew did not shut off pack #1 immediately which enabled to stop hot air from continuously flowing into the cockpit.”

Three safety recommendations were issued to ATR:

  1. Use the FSF research as a reference to review the appropriateness and completeness of the design philosophy of ATR smoke procedures, including: use bigger font that are more distinguishable, evaluate oxygen mask and goggle application as required or set items, evaluate adding diversion as an option in the procedure and list the operation consideration during an emergency landing situation.
  2. Review the deviation between Flight Operation Manual and Flight Crew Training Manual regarding flight crew task sharing principles during abnormal and emergency situation.
  3. Review the emergency procedures in Flight Operation Manual that do not include smoke elimination, revise as appropriate so that flight crew can execute smoke procedures more efficiently.

More information:

 

FAA issues safety alert to inform Cessna Citation operators of sensitive aileron trim controls

approximate impact attitude of the accident Citation II (NTSB)

approximate impact attitude of the accident Citation II (NTSB)

The U.S.  Federal Aviation Administration (FAA) issued an alert to inform Cessna Citation operators of sensitive aileron trim controls. 

The Safety Alert for Operators (SAFO) was issued following tests of the Citation aileron trim system that were conducted after a fatal accident in 2007.
In June 2007, a Cessna 550 Citation II airplane being operated by an air ambulance operator crashed shortly after takeoff, killing the two pilots and four passengers. A National Transportation Safety Board (NTSB) investigation revealed that a misuse of aileron trim, which caused the pilot to lose control of the aircraft, was a contributing factor in the accident.
The NTSB issued several recommendations to the FAA to evaluate the Citation’s aileron trim deflection and sensitivity.

Subsequently, in July 2010, Cessna and the Federal Aviation Administration (FAA) conducted flight tests to evaluate the sensitivity of the aileron trim system. These tests found that the aileron trim system’s sensitivity is appropriate for its intended use.
Due to the complexities of the aileron trim system, the FAA says it is imperative that operators adhere to aircraft limitations and standard operating procedures (SOP). Pilots flying Citation CE-500 type aircraft should follow the manufacturer’s recommended procedures for the use of aileron trim including verifying that aileron trim is set properly prior to takeoff. When airborne, pilots should exercise caution when using aileron trim, avoiding excessive trim. Operators are recommended to verify that their CE-500 training programs are consistent with the manufacturer’s recommended procedures for the use of the aileron trim system.

More information:

 

Russia recommends landing gear inspection of Boeing 737’s

File photo of the main undercarriage of a Boeing 737-300 (photo: H.Ranter/ASN)

File photo of the main undercarriage of a Boeing 737-300 (photo: H.Ranter/ASN)

The Russian Ministry of Transport recommended Russian airlines to conduct a one-time inspection of the landing gear shimmy damper and on Boeing 737 for the presence of possible fatigue cracks.

The recommendation was issued following several incidents involving fatigue fractures of Russia Boeing 737 main landing gear torsion links.
The most recent incident occurred on January 4, 2014 when the torstion link hinge on the right hand main landing gear of an Aurora Boeing 737-200 cracked on landing at Magadan, Russia.
There were no injuries and the airplane suffered minor damage.
During the investigation three previous incidents were discovered since 2002:

  • 30 April 2008 – Boeing 737-347 VP-BBL of Moscow Airlines suffered a shimmy damper failure after landing at Barcelona, Spain.
  • 24 October 2011 – Boeing 737-347 EI-CDE of Rossiya suffered torsion link hinge failure and shimmy damper failure on landing at Prague, Czech Republic.
  • 12 March 2013 – Boeing 737-42C VP-BTH of Globus suffered oscillations of the left hand main gear on landing at Sochi, Russia.

These incidents prompted the ministry to issue the recommendation.

More information:

Ireland urges Boeing to review pitot heater failure warning system of Boeing 737-800

Boeing 737NG pilot probes, two on the first officer's side, one on the captain's side (photo: Aviation Safety Network)

Boeing 737NG pilot probes, two on the first officer’s side, one on the captain’s side (photo: Aviation Safety Network)

The Irish Air Accident Investigation Unit (AAIU) issued safety recommendations to Boeing and the FAA following occurrences of undetected pitot heater failures on Boeing 737-800 aircraft.

The recommendations stemmed from an investigation that the AAIU conducted into the causes of a serious incident involving a Boeing 737-800 on January 7, 2012.  A Ryanair flight from  East Midlands Airport (EGNX), United Kingdom to Riga, Latvia was descending in poor weather conditions with moderate snow when the indicated airspeed (IAS) readings began to diverge. The flight crew decided, following evaluation, that the IAS displayed on the First Officer’s side was incorrect. Airspeed disagreement and other warnings then activated. Following completion of checklists an ILS approach to runway 18 was commenced with Air Traffic Control actively monitoring the aircraft. During the approach both the autopilot and autothrottle disconnected and the approach was continued hand flown. During the later stages of the approach the stall warning (stick shaker) activated on the First Officer’s side and this continued until after the landing.

Subsequent maintenance action found that, although the pitot heater on the First Officer’s side had failed due to a short circuit, the pitot heater failure warning had not activated because the design of the warning system may not detect failures of this nature.
The operator reported that it had 20 events in 2012 of unannounced pitot heat failures. The life analysis of these failures indicated that the pattern of pitot tube failures showed no trend that would allow determination of the life of pitot probes.

As a result of the investigation, two Safety Recommendations were issued to the Boeing regarding the design of the pitot heater failure warning system and the guidance provided to flight crew. A further Safety Recommendations is issued to the Federal Aviation Administration (FAA) regarding the Failure Modes and Effects Analysis (FMEA) of the Boeing 737-800.

More information:

 

Airbus A320 gear up landing accidents prompt tougher inspections

The right landing gear of flight 063 only partially extended. (photo: ANSV)

The right landing gear of flight 063 only partially extended. (photo: ANSV)

Two recent Airbus A320 gear up landing accidents in Italy prompted EASA to demand tougher inspections. At the same time, the Italian accident investigation board ANSV issued four safety recommendations to EASA.

ANSV is currently investigating two accidents involving Airbus A320 passenger planes at Roma-Fiumicino Airport (FCO) in 2013. On June 8 an Wizzair A320 encountered problems when the crew selected the gear down during the approach to Rome-Ciampino Airport.  The left main gear only partially extended and remained stuck. An emergency landing was carried out at Fiumicino Airport.

On September 29, an Airbus A320 operated by Alitalia developed similar problems, this time with the right main gear only partially extending on approach to Rome. This aircraft also made an emergency landing at Fiumicino Airport.

Preliminary investigation results of the Alitalia plane indicate that the right hand main gear actuator was jammed. An X-Ray analysis revealed the presence of heavy debris in the damping housing. A retaining ring was found ‘out of the design position’. An analysis of DFDR data showed that the undercarriage locked down without delay on previous flights. No fault messages were found.

Several airworthiness directives have been issued since a similar occurrence involving a United Airlines A319 at Newark in January 2010. EASA now issued a new AD that retained the requirements of EASA AD 2011-0069R1 and AD 2013-0132-E, which are superseded, but with reduced inspection intervals, and requires replacement or modification, as applicable, of the affected MLG door actuators as terminating action for the monitoring, repetitive checks and inspections.

At the same time, ANSV issued four safety recommendations to EASA. Amongst others, ANSV recommends EASA to require additional checks of the hydraulic system of the landing gear doors when replacing an actuator, to make sure that there is no contamination present. ANSV also recommends X-Ray inspections of actuators.

 

Boeing warns of GEnx engine icing risk on 747-8 and Dreamliner aircraft

Damage to  high pressure compressor stages 8 and 9 after ice ingestion on the B747-8 aircraft (photo: FAVT)

Damage to high pressure compressor stages 8 and 9 after ice ingestion on a B747-8 aircraft (photo: FAVT)

Boeing issued a warning to airlines operating Boeing 747-8 and 787 Dreamliner aircraft equipped with General Electric GEnx engines. Those aircraft have a risk of engine icing problems, and airlines are advised to avoid flying in specific weather circumstances.

This move was prompted by several icing incidents this year. Five Boeing 747-8s and one 787 suffered a temporary loss of thrust while flying at high altitude in icing conditions. In the notice sent to airlines, Boeing prohibits the aircraft from flying at high attitude within 50 nautical miles of thunderstorms that may contain ice crystals.

General Electric and Boeing are working on software modifications to the engine control system, which they hope will eliminate the problems.

One of the incidents was probably an event on July 31, 2013 when an AirBridgeCargo 747-8 diverted following the in-flight shut down of two engines over Russia due to the ingestion of ice clumps and engine surges.

More information:

Report: Long touchdown of ERJ-190 on wet runway causes runway excursion and nosegear collapse

The E190 came to rest off the side of the runway (photo: ASC)

The E190 came to rest off the side of the runway (photo: ASC)

Taiwanese accident investigators reported that the crew of an  Embraer ERJ-190 did not apply the best deceleration procedures after landing long on a wet runway, leading to a runway excursion and nose gear collapse.

On Augst 17, 2012, a Mandarin Airlines Embraer ERJ-190, registration B-16825, departed Taipei-Sung Shan Airport on a domestic service to Magong (also known as Makung). The flight was cleared to land on runway 20. Runway length available on that runway was 6890 feet and the runway surface was wet. The airplane crossed the runway threshold at an altitude of about 22 feet. It descended slowly, touching down on the main wheels at 2830 feet past the runway threshold. The flight crew felt that the deceleration was not what they expected and intentionally steered the plane to the left side of the runway.
Just prior to reaching the runway end, they steered the plane onto the grass. The nose landing gear was ruptured and fuselage skin was damaged due to colliding with the concrete base of four taxiway lights.

The airplane sustained substantial damage but there were no injuries to the 104 passengers and six crew members.

Findings related to probable causes:

During landing phase, the flight crew early flare the aircraft, did not timely retract the thrust lever to idle position. The flight crew continued holding to the control column and did not initiate a go around or reject landing after the aircraft landed beyond the touchdown zone. After landing, the flight crew did not apply the best deceleration procedures, incorrectly considered the aircraft encountered hydroplaning and intentionally controlled the aircraft out of the runway to the grass field when approaching the end of runway. The aircraft hit the handholds of the taxiway edge lights during landing roll and damaged the nose landing gear.

This accident also highlighted the need for airports to follow the rules and recommended practices of ICAO Annex 14  ‘Civil Aerodrome Design and Operation Standards’. At Magong measures should be taken to prevent an aircraft wheel from striking a hard vertical face in the case of a runway excursion. Magong Airport also has an uncovered ditch, 85 meters from runway centerline, parallel runway 02.

The Aviation Safety Council (ASC) issued seven safety recommendations.

More information: