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

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:

• Complete incident report
• The accident docket, which contains statements from the pilots, the airport diagram, and other investigation related documents

 

Pakistani court rejects Airblue accident investigation report

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

EASA orders inspection of A380 for cracks in wing rib feet

The European Aviation Safety Agency (EASA) issued an Airworthiness Directive (AD), ordering inspection of certain Airbus A380 aircraft for the possible presence of cracks in the wing rib feet.

The AD states:

Following an unscheduled internal inspection of an A380 wing, some rib feet have been found with cracks originating from the rib to skin panel attachment holes (Type 1 cracks according to Airbus All Operator Telex (AOT) terminology).

Further to this finding, inspections were carried out on a number of other aeroplanes where further cracks have been found. During one of those inspections, a new form of rib foot cracking originating from the forward and aft edges of the vertical web of the rib feet has been identified (Type 2 cracks according to Airbus AOT terminology). The new form of cracking is more significant than the original rib foot hole cracking. It has been determined that the Type 2 cracks may develop on other aeroplanes after a period of time in service.

This condition, if not detected and corrected, could potentially affect the structural integrity of the aeroplane.

For the reasons described above, this AD requires a Detailed Visual Inspection (DVI) of certain wing rib feet. This AD also requires reporting the inspection results to Airbus.

This AD is considered to be an interim action to immediately address this condition. As a result of the on-going investigation, further mandatory actions might be considered.

The cracks were discovered by Airbus engineers while performing repair work to a Qantas A380 that had suffered an uncontained engine failure near Singapore’s Changi Airport. Singapore Airlines also discovered some cracks in on the L-shaped feet of the wing ribs. The feet attach the rib, a vertical fixture, to the cover of the wing.

On January 9th a spokesman for the Australian Licensed Aircraft Engineers Association demanded that all A380 aircraft should be grounded for inspections. Airbus reported that all planes were safe to fly and that the cracks did not pose a safety threat.

More information:

• A380 wing cracks ‘really is not a safety issue’: head engineer (Sydney Morning Herald, 6 Jan 2012)
• Singapore Air Checks A380s After Cracks Found (Bloomberg, 20 Jan 2012)
• EASA AD 2012-0013

FAA assigned Curaçao and Sint Maarten Cat. 2 safety rating

The U.S. Department of Transportation’s Federal Aviation Administration (FAA) announced that Curaçao and Sint Maarten do not comply with international safety standards set by the International Civil Aviation Organization (ICAO), based on an assessment of each country’s civil aviation authority.

As a result, the FAA has assigned both Curaçao and Sint Maarten an International Aviation Safety Assessment (IASA) Category 2 rating. With a Category 2 rating, Curaçao and Sint Maarten air carriers will not be allowed to establish new service to the United States, but can continue existing service. Both countries were previously part of the Netherlands Antilles, which had a Category 1 rating.

A Category 2 rating means a country either lacks laws or regulations necessary to oversee air carriers in accordance with minimum international standards, or that its civil aviation authority – equivalent to the FAA for aviation safety matters – is deficient in one or more areas, such as technical expertise, trained personnel, record keeping or inspection procedures.

As part of the FAA’s IASA program, the agency assesses the civil aviation authorities of all countries with air carriers that operate or have applied to fly to the United States and makes that information available to the public. The assessments determine whether or not foreign civil aviation authorities are meeting ICAO safety standards, not FAA regulations.

Countries with air carriers that fly to the United States must adhere to the safety standards of ICAO, the United Nations’ technical agency for aviation that establishes international standards and recommended practices for aircraft operations and maintenance.

More information:

• www.faa.gov/about/initiatives/iasa/

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

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:

• Investigation Report Ethiopian 409 Accident – Boeing 737-800 25th January 2010 Beirut – Lebanon
• ASN Accident Description

Hong Kong CAD issues final report on A340 attempted taxiway takeoff

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.

French pilot: 6 months suspended sentence in accident case

A French pilot was received a six months suspended sentence for causing an accident in Pau, France that killed one man on the ground.

On January 25, 2007 a Fokker 100 passenger jet, operated by French carrier Régional, overshot the end of the runway at Pau following an aborted takeoff. Upon crossing a road, the left main landing gear struck the cabin of a truck, killing the driver.

The BEA investigation concluded that “the accident resulted from a loss of control caused by the presence of ice contamination on the surface of the wings associated with insufficient consideration of the weather during the stopover, and by the rapid rotation pitch, a reflex reaction to a flight of birds.” BEA also noted as one of the contributing factors, that there was “limited awareness within the [French] aviation community regarding the risks associated with the icing on the ground and changes in the performance of the aircraft involved in this phenomenon”.

The pilot in command of the flight was being charged with  homicide and unintentional injuries. A criminal court in Pau decided on a six months suspended sentence and a 20.000 Euro fine for the airline.

Source: Sud-Ouest (3-1-2012)

More information:

• ASN Accident description

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

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 ¹⁄₂ 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:

• TSB Progress report A11H0002
• ASN Accident Description

Crew members grounded after testing positive on alcohol tests

Crew members in India and the Netherlands were grounded after testing positive for alcohol.

In Mumbai, India pre-flight alcohol tests on New Year’s Eve showed that three cabin crew members and one co-pilot were under the influence of alcohol. The Indian Directorate General of Civil Aviation (DGCA) reported that “At present, they cannot operate a flight for three months. We are going through records of previous offenders. If any of them feature in that list, their licence would be cancelled.”

The DGCA had conducted similar surprise checks on December 25, 2011. However, none of 333 flight attendants and pilots tested then were found to be under the influence of alcohol.

On January 2, 2012 a cabin attendant of a U.S. airline was not allowed to fly when a test showed a blood alcohol concentration of 0,48 permille (0.048 percent) with a legal limit of 0,2 permille. She was fined 1000 Euros and grounded for twelve hours.

Sources: Hindustan Times; De Volkskrant

 

ASN releases airliner safety statistics 2011

The Aviation Safety Network today released the 2011  airliner accident statistics showing a total of 507 airliner accident fatalities, as a result of 28 fatal multi-engine airliner accidents.

The year 2011 was a very safe year for civil aviation, Aviation Safety Network data show. The second safest year by number of fatalities and the third safest year by number of accidents. Also, 2011 marked the longest period without a fatal airliner accident in modern aviation history. This record period now stands at 80 days and counting (by January 1).

Over the year 2011 the Aviation Safety Network recorded a total of 28 fatal airliner accidents, resulting in 507 fatalities and 14 ground fatalities. The number of fatalities is lower than the ten-year average of 764 fatalities.
The worst accident happened on January 9, 2011 when an Iran Air Boeing 727 crashed while on approach to Orumiyeh, Iran, killing 77.

The number of accidents involving passenger flights was relatively high with nineteen accidents as compared to the ten-year average of 16 accidents.

Seven out of 28 accident airplanes were operated by airlines on the E.U. “black list” as opposed to six out of 29 the year before. The E.U. added a total of nine airlines to the “black list” and removed three airlines based on improved safety records.

In 2011 Africa showed a continuing decline in accidents: 14% of all fatal airliner accidents happened in Africa. Although this is still out of sync compared to the fact that the continent only accounts for approximately 3 percent of all world aircraft departures. Russia suffered a very bad year with six fatal accidents.

The Aviation Safety Network is an independent organisation located in the Netherlands. Founded in 1996. It has the aim to provide everyone with a (professional) interest in aviation with up-to-date, complete and reliable authoritative information on airliner accidents and safety issues. ASN is an exclusive service of the Flight Safety Foundation (FSF). The figures have been compiled using the airliner accident database of the Aviation Safety Network, the Internet leader in aviation safety information. The Aviation Safety Network uses information from authoritative and official sources.

More information:

http://aviation-safety.net/database/year.php?year=2011

Harro Ranter
the Aviation Safety Network
http://aviation-safety.net/
e-mail: hr@aviation-safety.net