Safety: March 2009 Archives

Anyone know anymore about this one? And ideally have the original pictures, which my contact doesn't have? (Better still - the CVR tape!) Clearly it's a Delta Connection Bombardier CRJ of some flavour and equally clearly the crew have a story to tell their children, (which fortunately I guess they will have the option of having.)

I don't know how recent it was.

   

The UK AAIB has finally put out an initial bulletin on the happily non-fatal loss of the Bond Helicopters Eurocopter EC225 Super Puma in the North Sea last month. Most of it confirms the semi-official version of events which has been pretty well-circulated in the offshore helicopter community. But there's some very interesting additional information.

The NTSB has just issued an update on the investigation of the Colgan Air Q400 loss at Buffalo. Full text below. Several interesting hints at where this is going. Basically it is looking rather more as if this investigation will be looking hard at some of the more nuanced factors like training, scheduling, as well as the specifics of how the crash finally occurred - important though that obviously is.

Here's my take on some key pointers:

• icing looking less pertinent
• nothing wrong with the aircraft
  
• Colgan training operation of interest
• Colgan (and perhaps industry) scheduling practices of interest
• experience levels of interest (Capt 3,379hr total with 109 on type, F/O 2,220 total with 772 on type)
  
• sterile cockpit procedures may be pertinent
• questions about Buffalo ILS system not looking relevant
• previously unrevealed recent Colgan Q400 stick-shaker incident at Burlington, Vt being looked at

Feel free to comment if you disagree (or agree) with me after you've read the document below.

The International Federation of Airline Pilots Associations (IFALPA) is angry about the jailing in Italy of the Tunisian crew of the ATR 72 that ditched in August 2005. And so am I.

The Italian court also jailed seven Tuninter managers including execs and various maintenance staff. None of them were in court and I'm not clear what the likelihood is of their serving their sentences.

Obviously I wasn't in court either and I don't know what the evidence was against the ground staff. But it's clear that the pilots were convicted in large part because of their alleged mishandling of the situation, and that much was made of their alleged praying when they should have been doing other things.

It's impossible to ignore the history of landing-related accidents to the MD-11 and MD-10 series of aircraft. Plus at least one DC-10 loss that may be relevant. Some of these bear remarkable resemblances to today's accident at Narita. Others may be pertinent for knock-on reasons. I find it hard to think of a comparable pattern of serious, related accidents to a single type - particularly one not even built in large numbers. Much discussion of landing the MD-11 here.


Martinair DC-10 at Faro, Portugal 21 December 1992

FedEx MD-11 at Anchorage 4 November 1994

FedEx MD-11 at Anchorage 16 May 1996

Alitalia MD-11 at Chicago 19 August 1994

FedEx MD-11 New York Newark 31 July 1997

China Airlines MD-11 Hong Kong 23 August 1999 and here

FedEx MD-11 Subic Bay 17 October 1999

Eva Air Taipei 22 November 2001

FedEx MD-10 Memphis 18 December 2003

FedEx MD-11 Memphis 19 September 2004

UPS MD-11 Louisville 7 June 2005

FedEx MD-10 Memphis 28 July 2006

My colleague David Learmount is wondering what the recent series of accidents to US-registered aircraft means.

Today's horrible loss of the FedEx MD-11 at Tokyo is prompting everyone in the industry to talk about two things: the challenging nature of landings in the Boeing (but McDonnell Douglas-designed) MD-11, and the frequently difficult wind conditions at Tokyo Narita.

This video below, showing another FedEx MD-11 landing at Narita indicates just how demanding the approach to the airport can be. I don't know if this is to the same runway, but you get the idea. Below that is the video of today's accident, which you've probably seen already.

A tired old line, but the cliche "if you think safety's expensive, try having an accident" occasionally gets some supporting data. In this case it comes in the prospectus for a newly launched rights issue from SAS, which puts a price on the loss of revenue from the Spanair Boeing MD-82 crash in August last year.

I hope this is not a sign of things to come. The US National Transportation Safety Board (NTSB) has been behaving very oddly with respect to the fuel-icing issue on Boeing 777s thrown up by the British Airways crash at Heathrow last year.

At best they've been plain bloody rude to their UK equivalents, at worst they're committing the cardinal sin of dragging politics into safety. On this occasion I'm discounting the cock-up theory.

The question is: why did the NTSB release its own high-profile findings on this UK investigation 24 hours before the actual investigating authority - the UK Air Accidents Investigation Branch (AAIB) - put out its own highly detailed report?

As mentioned last week, the recent loss of the  Bond Helicopters Eurocopter EC225 Super Puma in the North Sea involved the proverbial perfectly serviceable aeroplane. A version of events apparently sourced from an official or quasi-official document on the early investigation findings is now public and it's no surprise to see that pilot disorientation features high on the agenda.

A perennial, and seemingly insoluble, hazard in the tough environment of UK offshore operations. Here's the document below - I'd stress that I don't know precisely what it is, (and can't easily find out as I'm on the road), but nobody's so far questioning that it is an authoritative account of what is believed to have happened.

The accident came two years after the horrific loss of an earlier model of Super Puma a Eurocopter SA365N Dauphin in the sea on the other side of the UK. Disorientation, though in markedly different circumstances, played a crucial role there too.

An interim report on the Qantas Airbus A330 upset last October is out today. As you'll perhaps recall the investigation is focusing on the ADIRU issues and their underlying causes. You can read the whole thing here. However, I encourage you to take a look at the excerpt below containing the pretty detailed account of what happened to the 303 passengers - particularly the ones who were not strapped in, 91% of whom were injured.


I realise this was not turbulence - but the same point applies. If you do nothing else to protect yourself in an aircraft, strap in.

There's a new FAA airworthiness directive out today stemming from the British Airways Boeing 777 crash on short finals to Heathrow last year, and now taking in additional evidence from a similar incident involving just one engine last November, plus a heap of research by Boeing and Rolls-Royce. Details below.

Thanks to the commenter Dicks Airbus who posted the bulletin text in the comments on my earlier post.

Just to clarify, here it is again:

FROM: THE BOEING COMPANY TO: MOM [MESSAGE NUMBER:MOM-MOM-09-0063-01B] 04-Mar-2009 05:29:01 AM US PACIFIC TIME Multi Operator Message This message is sent to all 737-100,-200,-300,-400,-500,-600,-700,-800,-900,-BBJ customers and to respective Boeing Field Service bases, Regional Directors, the Air Transport Association, International Air Transport Association, and Airline Resident Representatives. SERVICE REQUEST ID: 1-1228079803 ACCOUNT: Boeing Correspondence (MOM) DUE DATE: 10-Mar-2009 PRODUCT TYPE: Airplane PRODUCT LINE: 737 PRODUCT: 737-100,-200,-300,-400,-500,-600,-700,-800,-900,-BBJ ATA: 3400-00 SUBJECT: 737-800 TC-JGE Accident at Schiphol Airport, Amsterdam - 25 February 2009 REFERENCES: /A/ 1-1222489391 Dated 25 February 2009 Reference /A/ provides Boeing's previous fleet communication on the subject event. The US NTSB, FAA, Boeing, the Turkish DGCA, the operator, the UK AAIB, and the French BEA continue to actively support the Dutch Safety Board's (DSB) investigation of this accident. The DSB has released a statement on the progress of the investigation and has approved the release of the following information. While the complex investigation is just beginning, certain facts have emerged from work completed thus far: - To date, no evidence has been found of bird strike, engine or airframe icing, wake turbulence or windshear. - There was adequate fuel on board the airplane during the entire flight. - Both engines responded normally to throttle inputs during the entire flight. - The airplane responded normally to flight control inputs throughout the flight. The Digital Flight Data Recorder (DFDR) data indicates that the crew was using autopilot B and the autothrottle for an ILS (Instrument Landing System) approach to runway 18R at Amsterdam Schiphol airport. During the approach, the right Low Range Radio Altimeter (LRRA) was providing accurate data and the left LRRA was providing an erroneous reading of -7 to -8 feet. When descending through approximately 2000 feet the autothrottle, which uses the left radio altimeter data, transitioned to landing flare mode and retarded the throttles to the idle stop. The throttles remained at the idle stop for approximately 100 seconds during which time the airspeed decreased to approximately 40 knots below the selected approach speed. The two LRRA systems provide height above ground readings to several aircraft systems including the instrument displays, autothrottle, autopilots and configuration/ground proximity warning. If one LRRA provides erroneous altitude readings, typical flight deck effects, which require flight crew intervention whether or not accompanied by an LRRA fault flag, include: - Large differences between displayed radio altitudes, including radio altitude readings of -8 feet in flight. - Inability to engage both autopilots in dual channel APP (Approach) mode - Unexpected removal of the Flight Director Command Bars during approach - Unexpected Configuration Warnings during approach, go-around and initial climb after takeoff - Premature FMA (Flight Mode Annunciation) indicating autothrottle RETARD mode during approach phase with the airplane above 27 feet AGL. There will also be corresponding throttle movement towards the idle stop. Additionally, the FMA will continue to indicate RETARD after the throttles have reached the idle stop Boeing Recommended Action - Boeing recommends operators inform flight crews of the above investigation details and the DSB interim report when it is released. In addition, crews should be reminded to carefully monitor primary flight instruments (airspeed, attitude etc.) and the FMA for autoflight modes. More information can be found in the Boeing 737 Flight Crew Training Manual and Flight Crew Operations Manual. Operators who experience any of the flight deck effects described above should consult the troubleshooting instructions contained in the 737 Airplane Maintenance Manual. Further, 737-NG operators may wish to review 737NG-FTD-34-09001 which provides information specific for the 737-NG installation. Initial investigations suggest that a similar sequence of events and flight deck indications are theoretically possible on the 737-100/-200/-300/-400/-500. Consequently the above recommendations also apply to earlier 737 models.

This morning the Dutch investigators are holding a press conference on the Turkish Airlines Boeing 737-800 crash at Amsterdam last week and I understand that later Boeing will release a safety bulletin. From a reliable source, the contents of the Boeing bulletin will include the points below. Regrettably they don't reflect well on the pilots, who are dead of course - but I'd caution that there is a long investigation still to come.

• no evidence of fuel shortage, birdstrike, icing, windshear, wake turbulence, or engine, system or control malfunction
• the first officer was initially flying the aircraft and was inexperienced in airline operations
• autopilot and autothrottle were in use
• the aircraft was initially high and fast on the approach and at about 2,000ft above ground the throttles were pulled to idle
• the authrottle went to "retard" mode and the throttles then stayed at idle for about 100 seconds during which time the speed fell to 40kt below reference speed
• the aircraft descended through the glideslope with the captain talking the first officer through the before landing checklist
• the stick shaker activated at about 400ft above ground and the first officer increased power
• the captain took control and as the first officer released the throttles they moved to idle due to being in "retard" mode
• after six seconds the throttles were advanced but as the engines responded the aircraft hit the ground in a slightly nose-high attitude
• throughout the episode the left-hand radio altimeter read negative seven feet altitude, but the right-hand radalt worked correctly

Boeing will warn crews about fundamentals like flying the aircraft, monitoring airspeed, monitoring altitude, and will give advice about radalt issues.

The Dutch news site Hart van Nederland has a passenger's video of the immediate aftermath of the Turkish Airlines 737 accident at Amsterdam last week. I don't recall ever seeing anything quite like this before. Not sure that it tells us anything investigation-wise, but captivating viewing I have to admit.

Seems that the North Sea helicopter pilot community has been fairly well briefed on the initial findings of the investigation of the loss of the Bond Helicopters EC225 two weeks ago. As I'm sure most of them suspected, it doesn't look as if there was anything wrong with the aircraft.