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Aviation Human Factors Industry News

December 14, 2005

Vol. I, Issue 6


Cockpit rule violated in Chicago accident
Dec 14, 2005, 19:00 GMT

CHICAGO, IL, United States (UPI) -- The pilot of a Southwest Airlines flight that skidded off a runway at Chicago’s Midway Airport last week had engaged a braking system the airline forbids.

National Transportation Safety Board investigators said they found the autobrake switch in the 'maximum' position on the Boeing 737 flight panel after it landed Thursday in a heavy snowstorm and skidded onto a busy street.

Southwest`s policy is for pilots to brake manually, rather than allow an automatic function to kick in when the wheels touch the ground, the Chicago Sun-Times said Wednesday.

Federal Aviation Administration, NTSB and Southwest officials would not comment or provide documents regarding requests or plans to change Southwest`s flight operation procedures regarding autobrakes.

Meanwhile, the 6-year-old boy who was killed in the accident, Joshua Woods, was to be buried Wednesday in Schererville, Ind.

Probable Cause/Contributing Factors:

Ignored AD Causes Fatal Crash
Hughes 269A accident Louisburg, North Carolina, May 14, 2004. Onboard, one pilot, one passenger. Fatalities: one passenger. The flight was conducted as part of a drug-eradication program, according to the pilot. The National Transportation Safety Board (NTSB) noted that the pilot was not able to show he was FAA certificated or that he had obtained helicopter training, and that this was a contributing factor in the accident.

After takeoff, the pilot told the NTSB, "he felt two vibrations and then heard a loud bang from the back of the helicopter. He stated the helicopter yawed to the right, and he entered an autorotation and maneuvered toward a small clearing in the wooded area. The main rotor blades struck a pine tree and impacted the ground on the helicopter's left side."

The NTSB found that, though the helicopter had undergone an annual inspection two months prior, there was no record of compliance with an old airworthiness directive--AD80-05-05 on the tailboom saddle fitting. The NTSB investigators found that the helicopter's saddle attachment was broken and the "tailboom support fitting was fractured as a result of fatigue initiated at the base of a large corrosion pit on the forward wall's tip surface." This surface, which was in direct contact with the tailboom, was only partially covered by paint and contained extensive pitting damage. The NTSB determined that the accident's probable cause was "fatigue failure of the tailboom saddle fitting, which resulted in loss of aircraft control, and there was non-compliance to an airworthiness directive requiring inspection of the saddle fitting."

The NTSB report is available at: www.ntsb.gov/ntsb/brief.asp?ev_id=20040519X00615&key=1

Vacuum Pump Failure is Fatal
Piper PA32R-300, inflight breakup, near Rachel, Texas, September 9, 2004. Onboard, one commercial pilot. Fatalities: one. The Piper Lance was being flown on a night cargo run. The National Transportation Safety Board (NTSB) found that the vacuum pump had failed, causing a loss of suction to the gyroscopic instruments.

The NTSB reported that the Piper's vacuum pump had been overhauled and installed on May 7, 2004, slightly less than 300 tachometer hours prior to the accident flight. A measurement of the wear on the pump's vanes, however, showed that the vanes probably had been operating for approximately 1,380 hours, based on pump manufacturer Parker-Hannifin's vane-wear rule-of-thumb of 0.025 inches of wear per 100 hours of operation.

The NTSB report noted that Parker-Hannifin reiterated its recommendation that this particular model vacuum pump--a 211CC--be replaced after 500 hours of operation or six years from the date of manufacture.

The NTSB report on this accident is available at: www.ntsb.gov/ntsb/brief.asp?ev_id=20040928X01501&key=1

B-nuts Cause Engine Losses
National Transportation Safety Board investigator Edward Malinowski is concerned about two engine failures in turbocharged Cessna 210s caused by loose turbocharger pressure oil line B-nuts.

The first accident occurred on March 2, 1999. The loss of oil caused the engine to seize and the propeller bolts to fail, allowing the propeller to fall off. On September 27, 2004, an engine failure resulted in a forced landing and substantial damage to the airplane and serious injuries to a flight instructor. Malinowski has investigated both cases and found other cases in FAA records. He hopes to spread the word about this problem so that mechanics are aware of the loose B-nut problem.

Crisis in Aviation….

When will the nation stop coffins from flying as aircrafts, ensuring that no aging, sometimes disused, and ill-maintained aircrafts are allowed to fly in the nation's airspace?

When will the nation stop corrupt and inept public officials from running the aviation sector at all levels?

When will a minister resign honorably in the face of multiple accidents and monumental loss of lives under his watch? When will we have strong no-nonsense leadership in the aviation sector to check the deep-seated rot within the system?

When will the nation do the much-needed consolidation of the aviation sector such that well-capitalized and efficient airlines operate in the nation's airspace?
When will the nation fully deregulate aviation business while stringently regulating and policing the sector to ensure full compliance with global safety standards while ensuring competition such that airlines can charge appropriate prices to meet the huge maintenance and compliance costs without having to
cut corners?

When will we fully equip the nation’s  airports with modern facilities to meet global standards? An airport management system without the right radars, technology and modern navigational equipments cannot belong to a nation that prides itself as the giant of Africa with $30 billion in foreign reserves.

When will the nation allow the right professionals to lead, manage and maintain airport facilities, equipment and technology?

What best practice do we have to train and retrain airport and airspace managers such that they are at the cutting edge of modern technology and management ethos?

What strategies are being put in place to ensure efficient and prompt search and rescue in the event  of accidents and other emergencies?

In the face of growing threat of terrorism and sabotage, when will the nation secure its airports to ensure that Nigerians are not exposed to unnecessary risks? This question becomes more important in view of the recent experience in which former Bayelsa Governor jumped bail in London and entered Nigeria through the airport with the connivance of aviation authorities and security officials who may have looked the other way?

Two Nigerian airlines grounded after crashes

14 December 2005 09:41

President Olusegun Obasanjo has grounded two private domestic Nigerian airlines after two deadly plane crashes killed 224 people in seven weeks.

He also announced a review of all aircraft flying in Nigeria. Blaming corruption for some of the industry's troubles, he said two experts from the International Civil Aviation Organisation will be brought in "to ensure the integrity of the inspection".

Obasanjo announced the groundings on Tuesday after meeting airline carriers and government regulators to discuss public concern over aviation accidents.

During the meeting, which was broadcast live on state television, Obasanjo read what appeared to be a February intelligence report detailing safety problems at the two grounded airlines, including planes experiencing landing-gear trouble. It was not clear why those concerns had not been acted upon earlier.

Attempts to reach officials at the grounded airlines were not immediately successful on Tuesday.

One of the carriers grounded, Sosoliso Airlines, operated the 32-year-old McDonnell Douglas DC-9 that crashed on Saturday in the southern city of Port Harcourt, killing 107 people, most of them schoolchildren heading home for the holidays. The plane's previous owner, Serbia's JAT Airways, said it did not meet European standards.

The second grounded airline, Chanchangi Airlines, operated a plane that skidded off the runway in the main city of Lagos earlier this year and another craft that developed problems shortly after taking off from Abuja earlier this month and had to return to the capital.

On October 22, a passenger jet crashed shortly after taking off from the main city of Lagos, killing all 117 people on board. There has been little indication of what could have caused the crash. That plane's carrier, privately owned Bellview Airlines, was not grounded on Tuesday.

"People are asking: When will this stop? How will this stop? And we have to answer these questions," Obasanjo said as Tuesday's meeting began, speaking to representatives of local and international airlines and government and emergency officials in the capital, Abuja.

Obasanjo on Monday ousted two senior officials in Nigeria's aviation ministry.

Aviation Minister Babalola Borishade told meeting participants on Tuesday that flight facilities in the country have long been in decay.

Despite great oil riches as one of the world's top petroleum producers, wasteful and corrupt rule by military juntas has left much of Nigeria's public infrastructure in tatters.

"The greatest bane of the aviation industry is corruption," Obasanjo said as he closed Tuesday's meeting. "Corruption leads to death and we are not going to have any more of it. It is not a matter of prayer alone. It is also a matter of action and we will start the action from here today."

Obasanjo, elected in 1999 to end military rule, has vowed to weed out official corruption in a government often cited as among the world's most corrupt.

Serbia's state-owned JAT, which in 2002 sold the DC-9 that crashed on Saturday to Sosoliso, said Monday that the craft was built in 1973 and did not meet European standards when it was sold, due to loud noise levels produced by the jet's two engines.

Sosoliso's MD, Oscar Ikwuemesi, however, insisted that the company's aircraft were safe.

Sosoliso was established in 1994 and began domestic flights in 2000. The airline now flies to six Nigerian cities.

Saturday's flight took off from the capital, Abuja, and crashed as it tried to land in Port Harcourt. Three people survived. Among those onboard were 71 teenagers from a Catholic boarding school in Abuja, heading home for the Christmas holidays. -- Sapa-AP

696 feet of runway rendered useless
Published December 14, 2005

Light poles, utility lines and other obstacles prevent planes from using the first 696 feet of the already short runway at Midway Airport where a Southwest Airlines Boeing 737 skidded and crashed in a swirling snowstorm last week, city and federal officials said Tuesday.

Landing a big plane on the remaining 5,826 feet of the 6,522-foot runway requires precision even in good weather. But touching down safely in sloppy, icy conditions on Midway's Runway 31 Center, where the accident occurred, tests the abilities of an airline's best pilots, according to veteran aviators.

Swept along by a gusting tail wind while being told by air-traffic control that the aircraft braking ability on the runway was dicey, the captain of Southwest Flight 1248 descended fast on Thursday, according to an account culled from radar tapes under review by the National Transportation Safety Board.

Data from the onboard flight recorder indicate that the plane touched down harder than normal--reflecting an apparent attempt by the captain to hit the intended runway-landing markings dead-on so the maximum amount of remaining runway was available to stop the plane. The hard landing also explains the previously reported bounce that the plane made before sliding across the concrete, crashing through barriers after racing through a dangerously short runway protection zone and exiting the airport.

"When you break out of the clouds on a snowy night like that, you don't try to do a nice squeaky smooth landing. You plant the plane down onto the runway," said Robert Mark of Evanston, a former airline and corporate pilot who flew for the original Midway Airlines.

The Southwest plane came to rest on Central Avenue after hitting several vehicles and spearing a fire hydrant. A child inside one of the cars was killed and 10 people were injured in the worst accident in the airline's history.

Investigators who are re-creating the flight's events say they don't know whether the captain hit the landing mark--696 feet from the edge of the runway--or floated farther down the runway before touching down.

"A lot of issues involving the runway and runway safety are being looked at," said Keith Holloway, safety board spokesman.

Midway air-traffic controllers told investigators that blowing snow prevented them from seeing where the plane landed on the runway.

Obstacles on and off the airport, coupled with the angle of the plane's descent on an instrument-guided glide slope, prevent pilots from using the full length of the runway during landings.

It is called a displaced threshold, meaning the landing zone is at a point that is not the physical end of the runway--in this case, 696 feet away. The portion of the runway displaced may be used for takeoffs only. Landing aircraft may use the displaced area when touching down on the opposite end of the runway.

The opposite end of 31 Center, called 13 Center, allows for 6,059 feet of landing space--233 feet more for pilots to use. The extra distance would have been helpful in the case of Flight 1248, but 13 Center was not the landing configuration in use.

Holloway said the safety board is probing to determine why 13 Center was not used.

Runway 13 Center met the minimum requirements of a 300-foot cloud ceiling during the snowstorm. But the runway was 500 feet under the 5,000-foot minimum visual range for that runway. A minimum visual range is the distance a pilot sitting on the runway would be able to see straight ahead, according to officials at the Federal Aviation Administration.

Runway 31 Center requires a minimum runway visual range of 4,000 feet.

Some veteran Midway pilots, who asked not to be identified, questioned the FAA explanation, saying rules are often stretched a bit at the Southwest Side airport to allow for what is known as a "Midway mile."

These pilots said the extra 233 feet in stopping distance would have been more than worth giving up the 500 feet visually for the pilots of Flight 1248.

Meanwhile, the FAA reopened Runway 31 Center at 6:30 p.m. Tuesday for the first time since the accident. Equipment that aligns planes on the middle of the runway was damaged in the crash.

In addition, Chicago aviation officials responded to criticism from the FAA that the city isn't doing enough to improve safety on the edges of Midway runways.

The Tribune reported Tuesday that the FAA ordered city airport officials early last year to come up with a better plan to prevent planes from overrunning runways. The city submitted a study that the FAA rejected as unacceptable, but airport officials did not follow up with new recommendations.

Longtime FAA standards call for obstacle-free safety zones at the margins of runways. The safety zones are supposed to be at least 1,000 feet long and 500 feet wide.

Most of the runway safety areas at Midway, which opened in 1927 next door to a Chicago public school, measure less than 100 feet long.

Almost 700 homes and more than 100 businesses would be uprooted if the city complied with the FAA standards, said Erin O'Donnell, a deputy Chicago aviation commissioner who manages Midway.

"We are not going to go on an aggressive land-acquisition program (to build runway safety areas)," O'Donnell said. "Instead of busting up stable neighborhoods, the city will continue to work with the FAA
to find the appropriate technologies and safety measures at an airport that has been hailed as one of the safest in the nation."

She pointed out that an FAA report in 2000 on runway safety never specifically called for Midway officials to build safety zones, and in fact called the zones impractical at the space-constrained airport.

The FAA, however, did not take Midway off the hook. The FAA report said the city needs to conduct a detailed study of alternatives to provide a safety net to minimize the damage, deaths and injuries caused by a plane skipping off a runway.

A number of options exist, ranging from pits filled with soft, crushable concrete to stop out-of-control planes, to barrier systems that more gently absorb the impact of a crash.

O'Donnell pledged the city would step up its review to remove objects from runway perimeters and from surrounding streets that could endanger airline passengers and vehicle occupants in a crash, and it will explore emerging technologies.

"There is no magical solution at airports with short runways today. But I am confident" answers will be found, she said.

Airlines highlight safety record despite outsourcing

Associated Press

ATLANTA - Despite the airline industry's ongoing economic woes and increased reliance on outsourcing, its safety record has never been better.

Financially stressed carriers have cut jobs as they outsource work they used to do themselves, displacing veteran mechanics. Also, thousands of experienced pilots have taken early retirement.

Delta Air Lines Inc. has hired vendors in Miami and Vancouver, British Columbia, to handle its aircraft overhauls. Striking Northwest mechanics were replaced en masse.

About 53 percent of U.S. airline maintenance is now performed by non-airline workers, a dramatic increase from about 33 percent in 1990, according to the Transportation Department's inspector general. The outsourced work is valued at $37 billion a year, The Atlanta Journal- Constitution reported Sunday.

Unions warn that replacements are poorly trained.

"We're developing a gypsy work force of aircraft mechanics and technicians who have far less experience than the people they're replacing," said Dave Suplee, an International Association of Machinists safety director.

But Marshall Filler, managing director for the Aeronautical Repair Station Association, a trade group representing firms that perform contract maintenance work, said the airline industry's recent safety record showed such fears were a "red herring."

Not counting the four Sept. 11-related crashes, airlines since 1998 have chalked up an unusually safe stretch, based on the rate of fatal accidents per million departures. During that span, the highest annual rate was 0.196 in 2003, when 21 passengers died in a US Airways Express crash. The lowest was in 2002, when there were no fatalities.

Atlanta-based Delta expects to lower maintenance costs 34 percent through outsourcing and reducing its own work force.

Historic safety record

By Marion Blakey

Last June, USA TODAY said aviation "is experiencing its safest period in history." So it is disappointing that the newspaper continues an editorial position that ignores how the nation's airline safety program got to this point.

The reason the commercial fatal accident rate for air travelers is one in every 15 million passenger flights is that the Federal Aviation Administration (FAA) has changed the way it oversees air carriers as the airline business has changed. We have 2,980 field inspectors conducting nearly 225,000 inspections a year. But more important, we have a system that allows us to ensure that airlines and maintenance facilities, regardless of location, are taking the necessary steps to operate safely.

Nearly a decade ago, the FAA took bold steps to move away from a "checklist" approach toward a risk-based system that emphasizes quality assurance programs and self-audits. The FAA has more proprietary information from airlines and operational data from pilots and aircraft recorders than it has ever had. These tools enable our inspectors to analyze data, spot safety trends and prioritize risks before accidents happen and to help carriers adjust their safety programs as their business changes.

Repair-station oversight is a good example of why this approach is the most effective. The average domestic repair station undergoes more than 30 audits a year by the FAA, aircraft operators and internal management. For foreign repair stations, the number of audits jumps to 74 a year, including oversight by international civil aviation authorities.

In countries where we have Bilateral Aviation Safety Agreements, we also have procedures to ensure that foreign inspectors place appropriate emphasis on FAA regulations when conducting reviews of work done on U.S. aircraft. These stations must also renew their FAA certificates every 12 to 24 months. They can lose their certificates if they do not meet our standards.

USA TODAY vastly underestimates the enormous effort and singular focus by the FAA and the industry to achieve a historic safety record. Some risk is inherent in any form of transportation, but in aviation, we are striving to reduce it by continuous improvement.

Travelers should be assured that the FAA will never rest, will remain vigilant, and will continue to deliver effective safety oversight.

Marion Blakey is administrator of the Federal Aviation Administration.