NTSB cites ATC error as probable cause of near mid-air collision over Gulfport-Biloxi International Airport

January 21, 2012

The NTSB cited an operational error by a tower air traffic controller as the probable cause of a near mid-air collision involving a commercial jetliner and a small private plane over the Gulfport-Biloxi Airport.

On Sunday, June 19, 2011, at 12:35 p.m. CDT at Gulfport-Biloxi International Airport, a Cessna 172 was cleared for takeoff on runway 18 by the tower air traffic controller. Sixteen seconds later, the same air traffic controller cleared an Embraer 145, a commercial passenger flight, for takeoff on runway 14, the flight path of which intersects the flight path of runway 18.

While both airplanes were about 300 feet above the airfield, the Embraer passed in front of the Cessna. The closest proximity between the two planes was estimated to be 0 feet vertically and 300 feet laterally.

The Embraer 145, N13929, operated as ExpressJet flight 2555 (dba Continental/United Express) was carrying 50 passengers and 3 crewmembers, and was bound for Houston Bush Intercontinental Airport (IAH) where it landed uneventfully.

The Cessna 172P Skyhawk, N54120, operated on a local  instructional flight carrying an instructor and a student.

No one in either airplane was injured in the incident.

More information:

 


Pakistani court rejects Airblue accident investigation report

January 20, 2012

The Peshawar High Court in Pakistan rejected the inquiry report of the fatal Airblue Airbus A321 accident, judging it incomplete.

On December 20, 2011,  the inquiry report into the fatal Airblue Airbus A321 accident was submitted to the Peshawar High Court in Pakistan. The investigators concluded that the crew had violated procedures during an attempted approach to land at Islamabad in inclement weather.

The Peshawar High Court on January 20  rejected the report, stating it was incomplete and inconclusive in several aspects that were mandatory for the inquiry.  The court issued orders to the Civil Aviation Authority to constitute a board to “revisit the findings from the starting point up to the crash, within three months.”

Additionally, the chief justice called for an inquiry on the performance of Pakistan International Airlines (PIA) “regarding its crew, flying fleet, communication system, lights, landing, taking off and fitness certificates”.  He added that experts should also check the capabilities of the captains and crew members and submit its report to the court within 90 days.

Source: The News International, The Express Tribune, Dawn


Loss of control and poor CRM cited in fatal Ethiopian Boeing 737 accident near Lebanon

January 17, 2012

Flight ET409 flight profile

The Lebanese Ministry of Public Works & Transport released their investigation progress report regarding the January 2010 fatal accident involving a Ethiopian Flight 409 off the coast of Beirut.

On January 25, 2010 a Boeing 737-8AS (WL) passenger jet, registered ET-ANB, was destroyed in an accident 6 km southwest off Beirut International Airport (BEY), Lebanon. All 82 passengers and eight crew members were killed. The airplane operated on Ethiopian Airlines flight ET409 from Beirut International Airport (BEY) to Addis Ababa-Bole Airport (ADD).

The flight departed at night on an instrument flight plan. Low clouds, isolated cumulonimbus (CB) and thunderstorms were reported in the area. After take-off ATC (Tower) instructed ET 409 to turn right on a heading of 315°. ET 409 acknowledged and heading 315° was selected on the Mode Control Panel (MCP). As the aircraft was on a right turn, Control suggested to ET 409 to follow heading 270° “due to weather”. However, ET 409 continued right turn beyond the selected heading of 315° and Control immediately instructed them to “turn left now heading 270°”. ET 409 acknowledged, the crew selected 270° on the MCP and initiated a left turn.
ET 409 continued the left turn beyond the instructed/selected heading of 270° despite several calls from ATC to turn right heading 270° and acknowledgment from the crew. ET 409 reached a southerly track before sharply turning left until it disappeared from the radar screen and crashed into the sea about five minutes after the initiation of the take-off roll. The flight recorder data revealed that ET 409 encountered during flight two stick shakers for a period of 27 and 26 seconds. They also recorded 11 “Bank Angle” aural warnings at different times during the flight and an over-speed clacker towards the end of the flight. The maximum recorded AOA was 32°, maximum recorded bank angle was 118° left, maximum recorded speed was 407.5 knots, maximum recorded G load was 4.76 and maximum recorded nose down pitch value 63.1°.

Probable causes:

  1. The flight crew’s mismanagement of the aircraft’s speed, altitude, headings and attitude through inconsistent flight control inputs resulting in a loss of control.
  2. The flight crew failure to abide by CRM principles of mutual support and calling deviations hindered any timely intervention and correction.

Contributing factors:

  1.  The manipulation of the flight controls by the flight crew in an ineffective manner resulted in the aircraft undesired behavior and increased the level of stress of the pilots.
  2.  The aircraft being out of trim for most of the flight directly increased the workload on the pilot and made his control of the aircraft more demanding.
  3.  The prevailing weather conditions at night most probably resulted in spatial disorientation to the flight crew and lead to loss of situational awareness.
  4.  The relative inexperience of the Flight Crew on type combined with their unfamiliarity with the airport contributed, most likely, to increase the Flight Crew workload and stress.
  5.  The consecutive flying (188 hours in 51 days) on a new type with the absolute minimum rest could have likely resulted in a chronic fatigue affecting the captain’s performance.
  6.  The heavy meal discussed by the crew prior to take-off has affected their quality of sleep prior to that flight.
  7.  The aircraft 11 bank angle aural warnings, 2 stalls and final spiral dive contributed in the increase of the crew workload and stress level.
  8.  Symptoms similar to those of a subtle incapacitation have been identified and could have resulted from and/or explain most of the causes mentioned above. However, there is no factual evidence to confirm without any doubt such a cause.
  9.  The F/O reluctance to intervene did not help in confirming a case of captain’s subtle incapacitation and/or to take over control of the aircraft as stipulated in the operator’s SOP.

More information:


Hong Kong CAD issues final report on A340 attempted taxiway takeoff

January 14, 2012

Chart of runway 07L and taxiway A at Hong Kong

The Hong Kong Civil Aviation Department released the final investigation report into the serious incident involving an Airbus A340 that attempted to take off from a taxiway.

The serious incident occurred on November 27, 2010. The incident flight involved a Finnair Airbus A340-313X which operated on flight AY070 from Hong Kong-Chek Lap Kok International Airport (HKG/VHHH) to Helsinki-Vantaa Airport (HEL/EFHK).

The incident occurred at night time and in good visibility conditions. One of the runways was closed for maintenance.  The north runway (07L/25R) remained operational with runway 07L in use for both arrivals and departures.

Flight 070 was cleared by ATC to taxi on taxiway B westbound for departure on runway 07L. When the aircraft was approaching the western end of taxiway B, ATC cleared the aircraft for take-off on runway 07L. The aircraft took the normal right turn at the end of taxiway B towards runway 07L but then took a premature right turn onto taxiway A, a taxiway parallel to and in between the runway-in-use and taxiway B. With the help of the Advanced Surface Movement Guidance and Control System (A-SMGCS) provided in the Control Tower, ATC observed that the aircraft commenced take-off roll on taxiway A. On detecting the anomaly, ATC immediately instructed the pilot to stop rolling and the aircraft was stopped abeam Taxiway A5, approximately 1400 metres from the beginning (western end) of taxiway A.

The following causal factors were identified:

  1. A combination of sudden surge in cockpit workload and the difficulties experienced by both the Captain and the First Officer in stowing the EFB computers at a critical point of taxiing shortly before take-off had distracted their attention from the external environment that resulted in a momentary degradation of situation awareness.
  2. The SOP did not provide a sufficiently robust process for the verification of the departure runway before commencement of the take-off roll.
  3. The safety defence of having the First Officer and the Relief Pilot to support and monitor the Captain’s taxiing was not sufficiently effective as the Captain was the only person in the cockpit trained for ground taxi.

Progress report: TSB Canada classifies Resolute Bay Boeing 737 accident as CFIT

January 5, 2012

In a progress report of their investigation into a fatal Boeing 737 accident at Resolute Bay, the Transportation Safety Board of Canada currently classified the accident as a Controlled Flight Into Terrain (CFIT) occurence.

On 20 August 2011, a First Air Boeing 737-210C aircraft (registration C-GNWN) was being flown as a charter flight from Yellowknife, North West Territories, to Resolute Bay, Nunavut.  At 11:42, during the approach to Runway 35T, First Air Flight 6560 impacted a hill at 396 feet above sea level (asl) and about 1 nautical mile east of the midpoint of the Resolute Bay Airport runway which, itself, is at 215 feet asl. The aircraft was destroyed by impact forces and an ensuing post-crash fire. Eight passengers and the four crew members suffered fatal injuries. Three passengers suffered serious injuries.

The investigators have complete the field phase of the  investigation. With regards to the weather, it was reported that in the hours before the accident, the weather in Resolute Bay was variable with fluctuations in visibility and cloud ceiling. Forty minutes before the accident, the visibility was 10 miles in light drizzle with an overcast ceiling at 700 feet above ground level (agl). A weather observation taken shortly after the accident, reported visibility of 5 miles in light drizzle and mist with an overcast ceiling of 300 feet agl.

The weather conditions required the crew to conduct an instrument approach using the aircraft flight and navigation instruments. The crew planned to conduct an instrument landing system (ILS) approach to Runway 35T. This instrument approach provides guidance down to weather minimums of 12 mile visibility and a ceiling of 200 feet agl.

The crew initiated a go-around 2 seconds before impact. At this time, the flaps were set to position 40, the landing gear was down and locked, the speed was 157 knots and the final landing checklist was complete.

Another aircraft successfully completed an ILS approach to Runway 35T approximately 20 minutes after the accident. NAV CANADA conducted a flight check of the ground based ILS equipment on 22 August 2011; it was reported as serviceable.

The technical examination of the aircraft at the accident site revealed no pre-impactproblems. Analysis of the flight data recorder information and examination of the engines at the site indicate the engines were operating and developing considerable power at the time of the accident. Analysis of the aircraft flight and navigational instruments is ongoing.

More information:


Report: Serious runway confusion incident at Amsterdam-Schiphol Airport

December 21, 2011

The Dutch Safety Board published the final report of their investigation into a serious runway confusion incident at Amsterdam-Schiphol Airport involving a Boeing 737-300.

On February 10, 2010 KLM flight KL1369 was cleared for takeoff on runway 36C at Amsterdam-Schiphol International Airport (AMS/EHAM). Instead, the crew took off from the parallel taxiway B.

At the time of the incident, about 20:30,  it was dark and it was snowing. The airplane had just been de-iced and was instructed to taxy down taxiway Alpha towards runway 36C. This meant that the crew had to use taxiway Alpha in the opposite direction, contrary to published procedures. Air traffic control is allowed to use this taxiway in the opposite direction if deemed necessary. This is sometimes the case when an aircraft leaves the Juliet platform after de-icing, just like KL1369.

The crew were very familiar with the airport and did not use a taxiway map although they were supposed one. The air traffic controller then offered the flight to enter the runway through intersection W-8. At that time a preceding Boeing 747 had taxied the wrong way and  was blocking the taxiway. The KLM flight crew accepted the offer because this also meant an opportunity for an expedited takeoff.

At that point the crew started losing positional awareness. The workload increased because the an entry in the FMS now had to be changed because the crew had anticipated using  intersection W-9. Meanwhile the captain was distracted by radio communications between the air traffic controller and the pilot of the Boeing 747. The crew had to cross parallel taxiway Bravo to enter runway 36C. However, they turned directly onto Bravo and initiated their takeoff roll. The crew did not notice their error and continued their takeoff, passing within about 300 metres of a Boeing 737-400.

It appears that the taxiway leading from taxiway Bravo to runway 36C was covered with a thin layer of snow, possibly obscuring the taxiway lights. Also, visibility of the lights of runway 36C was degraded because the lighting pattern matched that of the lights along the highway parallel to the runway.

Taxi routes of KL1369 (blue) and the preceding Boeing 747, flight CAL5420 (yellow)

More information:

Final report (in Dutch)


Report: In-flight upset of Airbus A330 near Australia

December 19, 2011

The Australian Transport Safety Bureau (ATSB) issued the final report of their investigation into an in-flight upset accident involving an Airbus A330 in 2008.

On 7 October 2008, an Airbus A330-303 aircraft, registered VH-QPA and operated as Qantas flight 72, departed Singapore on a scheduled passenger transport service to Perth, Western Australia. While the aircraft was in cruise at 37,000 ft, one of the aircraft’s three air data inertial reference units (ADIRUs) started outputting intermittent, incorrect values (spikes) on all flight parameters to other aircraft systems. Two minutes later, in response to spikes in angle of attack (AOA) data, the aircraft’s flight control primary computers (FCPCs) commanded the aircraft to pitch down. At least 110 of the 303 passengers and nine of the 12 crew members were injured; 12 of the occupants were seriously injured and another 39 received hospital medical treatment.

Although the FCPC algorithm for processing AOA data was generally very effective, it could not manage a scenario where there were multiple spikes in AOA from one ADIRU that were 1.2 seconds apart. The occurrence was the only known example where this design limitation led to a pitch-down command in over 28 million flight hours on A330/A340 aircraft, and the aircraft manufacturer subsequently redesigned the AOA algorithm to prevent the same type of accident from occurring again.

Each of the intermittent data spikes was probably generated when the ADIRU’s central processor unit (CPU) module combined the data value from one parameter with the label for another parameter. The failure mode was probably initiated by a single, rare type of internal or external trigger event combined with a marginal susceptibility to that type of event within a hardware component. There were only three known occasions of the failure mode in over 128 million hours of unit operation. At the aircraft manufacturer’s request, the ADIRU manufacturer has modified the LTN-101 ADIRU to improve its ability to detect data transmission failures.

At least 60 of the aircraft’s passengers were seated without their seat belts fastened at the time of the first pitch-down. The injury rate and injury severity was substantially greater for those who were not seated or seated without their seat belts fastened.

The investigation identified several lessons or reminders for the manufacturers of complex, safety‑critical systems.

More information:


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