ASN releases preliminary airliner safety statistics 2011

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

Caveat: This press release shows the figures as of December 27, 2011. Final statistics will be released on January 1, 2012.

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 75 days and counting (by December 27).

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

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

Cypriot court clears five defendants of wrongdoing in Helios accident case

Five defendants, accused of manslaughter in connection with the fatal Helios Airways Boeing 737 accident 2005  have been acquitted by a Court in Cyprus.

The Helios airplane crashed in Greece after all 121 aboard had become unconscious because the cabin had not pressurized. It was being argued that the defendants in the case did not prevent the aircraft to be flown by a captain and a co pilot who were described as inadequate or unsuitable, which  resulted in an unsafe flight. The defendants were Helios’ chief executive, the managing director, the operations manager, the chief pilot and Helios Airways itself as a legal entity. A total of 238 charges were made to each of the defendants.

“The fundamental link that connects the chain (of events) is missing, the connection between alleged negligence by the accused with the crash is also missing. Consequently, we conclude that there is no proof that the accused have violated any of their duties and/or that the violation of their duties was the cause of the damage,” the court ruling said as quoted by the Famagusta Gazette.

Source: Famagusta Gazette, Cyprus Mail.

More information:

• ASN Accident Description of Helios Flight 522

 

Report: Poor CRM, violation of procedures caused fatal A321 accident in Pakistan

The Pakistan Civil Aviation Authority (CAA) completed its investigation into the accident involving an Airblue Airbus A321 in July 2010 that killed 152 all occupants.

Flight ABQ202 had departed Karachi International Airport (KHI) on a domestic service to Islamabad, Pakistan. Weather at Islamabad was poor with deteriorating visibility. A PIA flight had landed on the third attempt to land and a flight om China had returned. ABQ202 was cleared for a Runway 12 Circling Approach procedure. During the approach the captain descended below Minimum Descent Altitude (MDA) (i.e. 2,300 ft instead of maintaining 2,510 ft), losing visual contact with the airfield. The captain then decided to fly a non-standard self-created PBD-based approach, thus transgressing out of the protected airspace by an distance of 4.3 NM into the Margalla Hills area.
The captain did not take appropriate action following calls from Air Traffic Controller. He also did not respond to 21 EGPWS warnings related to approaching rising terrain and pull up.
The airplane flew into the side of a mountain. The First Officer remained a passive bystander in the cockpit and did not participate as an effective team member failing to supplement and compliment or to correct the errors of his captain assertively due to the captain’s behaviour in the flight. The report said that during initial climb, the captain tested the knowledge of the First Officer and used harsh words and a snobbish tone, contrary to the company procedure/norms. The question/answer sessions, lecturing and advices by the captain continued with intervals for about one hour after takeoff. After the intermittent humiliating sessions, the FO generally remained quiet, suffered from underconfidence, became submissive and subsequently did not challenge the captain for any of his errors, breaches and violations.

Source:  Dawn,  The Express Tribune, The News International

Report: Serious runway confusion incident at Amsterdam-Schiphol Airport

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)

FAA issues final rule on pilot fatigue

The U.S.  Federal Aviation Administration (FAA) issued a final rule that overhauls commercial passenger airline pilot scheduling to ensure pilots have a longer opportunity for rest before they enter the cockpit. The National Transportation Safety Board (NTSB) was pleased with the new rule but also voiced concerns on the limitation to Part 121 carriers.

Fatigue has been on the NTSB’s Most Wanted List of transportation safety improvements since 1990. The Department of Transportation identified the issue of pilot fatigue as a top priority during a 2009 airline Safety Call to Action following the crash of Colgan Air flight 3407. The FAA launched an effort to take advantage of the latest research on fatigue to create a new pilot flight, duty and rest proposal, which the agency issued on September 10, 2010. This proposed rule is now final.

The NTSB reacted in a statemtent, saying that, “while this is not a perfect rule, it is a huge improvement over the status quo for large passenger-carrying operations. Yet, we are extremely disappointed that the new rule is limited to Part 121 carriers. A tired pilot is a tired pilot, whether there are 10 paying customers on board or 100, whether the payload is passengers or pallets.”

The estimated cost of this rule to the aviation industry is $297 million but the benefits are estimated between $247- $470 million. Covering cargo operators under the new rule would be too costly compared to the benefits generated in this portion of the industry. Some cargo airlines already have improved rest facilities for pilots to use while cargo is loaded and unloaded during night time operations. The FAA encourages cargo operators to opt into the new rule voluntarily, which would require them to comply with all of its provisions.

Key components of this final rule for commercial passenger flights include:

Varying flight and duty requirements based on what time the pilot’s day begins.
The new rule incorporates the latest fatigue science to set different requirements for pilot flight time, duty period and rest based on the time of day pilots begin their first flight, the number of scheduled flight segments and the number of time zones they cross. The previous rules included different rest requirements for domestic, international and unscheduled flights. Those differences were not necessarily consistent across different types of passenger flights, and did not take into account factors such as start time and time zone crossings.

Flight duty period.
The allowable length of a flight duty period depends on when the pilot’s day begins and the number of flight segments he or she is expected to fly, and ranges from 9-14 hours for single crew operations. The flight duty period begins when a flightcrew member is required to report for duty, with the intention of conducting a flight and ends when the aircraft is parked after the last flight. It includes the period of time before a flight or between flights that a pilot is working without an intervening rest period. Flight duty includes deadhead transportation, training in an aircraft or flight simulator, and airport standby or reserve duty if these tasks occur before a flight or between flights without an intervening required rest period.

Flight time limits of eight or nine hours.
The FAA limits flight time – when the plane is moving under its own power before, during or after flight – to eight or nine hours depending on the start time of the pilot’s entire flight duty period.

10-hour minimum rest period.
The rule sets a 10-hour minimum rest period prior to the flight duty period, a two-hour increase over the old rules. The new rule also mandates that a pilot must have an opportunity for eight hours of uninterrupted sleep within the 10-hour rest period.

New cumulative flight duty and flight time limits.
The new rule addresses potential cumulative fatigue by placing weekly and 28-day limits on the amount of time a pilot may be assigned any type of flight duty. The rule also places 28-day and annual limits on actual flight time. It also requires that pilots have at least 30 consecutive hours free from duty on a weekly basis, a 25 percent increase over the old rules.

Fitness for duty.
The FAA expects pilots and airlines to take joint responsibility when considering if a pilot is fit for duty, including fatigue resulting from pre-duty activities such as commuting. At the beginning of each flight segment, a pilot is required to affirmatively state his or her fitness for duty. If a pilot reports he or she is fatigued and unfit for duty, the airline must remove that pilot from duty immediately.

Fatigue Risk Management System.
An airline may develop an alternative way of mitigating fatigue based on science and using data that must be validated by the FAA and continuously monitored.

In 2010, Congress mandated a Fatigue Risk Management Plan (FRMP) for all airlines and they have developed these plans based on FAA guidance materials. An FRMP provides education for pilots and airlines to help address the effects of fatigue which can be caused by overwork, commuting, or other activities. Airlines will be required to train pilots about the potential effects of commuting.

Required training updates every two years will include fatigue mitigation measures, sleep fundamentals and the impact to a pilot’s performance. The training will also address how fatigue is influenced by lifestyle – including nutrition, exercise, and family life – as well as by sleep disorders and the impact of commuting.

The final rule has been sent to the Federal Register for display and publication. It is currently available at: http://www.faa.gov/regulations_policies/rulemaking/recently_published/media/2120-AJ58-FinalRule.pdf, and will take effect in two years to allow commercial passenger airline operators time to transition.

Russia revokes AOC of Dagestan Airlines for safety reasons

Dagestan Airlines Tupolev Tu-154, (c) Dmitriy Pichugin

The Russian Federal Air Transport Agency Rosaviatsia revoked the Air Operator Certificate of Dagestan Airlines following safety issues and lack of financial resources.

Russian regional carrier Dagestan Airlines has been under scrutiny since an accident in December 2010. Two passengers died when a Tupolev 154 crashed during an  emergency landing at Moscow-Domodedovo Airport, Russia.

The Interstate Aviation Committee found significant violations in the organization of flight operations of the airline, aircraft maintenance, pilot training, issues of work and rest hours of crews, and other shortcomings in the airline, having a systemic character. The Commission also found that there were counterfeit parts installed on the accident plane.

During 2011 the airline did not show progress in dealing with those issues. Ramp inspections carried out by foreign aviation authorities revealed gross violations of flight safety and lack of a timely management response to the comments received. In particular, the inconsistencies identified at Ras al-Khaimah Airport (UAE) and Istanbul (Turkey) on a Tu-154 passenger jet showed a recurrence of  safety findings. For instance, the pilot’s proficiency in the English language was insufficient.

During an audit in December quality deficiencies were again identified. The results of the audit showed that the  management of Dagestan Airlines was unable to correct systemic weaknesses in the airline, which negatively affects the state of the safety of its aircraft and poses a direct threat to life and health of the passengers, according to Rosaviatsia.

These findings, and the fact that the airline is experiencing a significant shortage of financial resources, forced Rosaviatsia to revoke the airline’s AOC.

The airline was established in February 1927 as the Makhachkala department of Aeroflot, North Kavkaz Civil Aviation Directorate. In 1994, following the split-up of Aeroflot, it became known as Makhachkala Air Enterprise. In 1996, the company was rebranded as Dagestan Airlines.

 

Report: In-flight upset of Airbus A330 near Australia

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:

• ATSB Report

This week marked the longest period without a fatal airliner accident

This week marked the longest period without a fatal airliner accident 1) in modern aviation history. As of today, Saturday December 17, 2011 , there have been no fatal airliner accidents since October 13.  An accident-free period of 65 days and counting.

On October 13 a DHC-8 turboprop airplane crashed in a forest near Madang, Papua New Guinea, killing 28 passengers. Three crew members and one passenger survived the accident. This accident marked the start of the longest period without a fatal airliner accident since 1945 according to Aviation Safety Network data.

The previous longest period was in 1985. Sixty-one days passed between a Fokker F-27 turboprop accident in Burma (4 fatalities) on October 12 and the December 12 tragedy involving a McDonnell Douglas DC-8 of Arrow Air that crashed on takeoff from Gander, Canada, killing all 256 on board.

The average period between two fatal airliner accidents since 2002 is twelve days.

 

1) ASN defines an airliner accident as: “An occurrence associated with the operation of a commercial multi-engine airplane model, with a certificated maximum passenger configuration of 14 or more passengers,  which takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, in which a person on the airplane is fatally injured and the airplane is damaged beyond repair.”

 

 

Report: Incorrect take-off data causes A340-500 tailstrike and runway overrun at Melbourne

The incorrect entry of take-off weight data that resulted in the tailstrike and runway overrun of an Emirates Airbus A340 aircraft in 2009 was not a unique event. Similar events continue to occur throughout the world, according to the Australian Transport Safety Bureau (ATSB).

The ATSB published the final report of its investigation into a 20 March 2009 accident, when flight EK407, with 18 crew and 257 passengers, sustained a tailstrike and overran the runway end on departure from Melbourne Airport.  The aircraft became airborne in the grass clearway but struck a light and several antennae, which damaged and disabled the instrument landing system for the airport.
The flight crew climbed the aircraft to 7,000 ft and circled over Port Phillip Bay, Victoria, while jettisoning fuel to reduce the aircraft’s weight. The flight crew then returned the aircraft to Melbourne for an uneventful landing on runway 34.

The ATSB found that the accident resulted from the use by the crew of incorrect take-off performance parameters. The initial error was likely due to mistyping, when a weight of 262.9 tonnes, instead of the intended 362.9 tonnes, was entered into a laptop computer to calculate the aircraft’s take-off settings. The error passed through several subsequent checks without detection.

Although a number of contributing factors were identified, the ATSB determined that there were two primary factors in the development of the accident as follows:

• the flight crew did not detect the erroneous take-off weight that was used for the take-off performance calculations, and
• the flight crew did not detect the degraded take-off performance until very late in the take-off roll.

More information:

• ATSB Investigation Report
• ATSB Study: Take-off performance calculation and entry errors: A global perspective

ATSB animation of the occurrence.

NTSB issues safety recommendations following B737 tailwind landing accident

The NTSB has issued four safety recommendations and reiterated one older recommendation to prevent runway excursion accidents following tailwind landings.

On December 22, 2009, American Airlines flight 331, a  Boeing 737-800, N977AN, ran off the departure end of runway 12 after landing at Kingston-Norman Manley International Airport (KIN), Jamaica. The aircraft landed approximately 4,000 feet down the 8,911-foot-long, wet runway with a 14-knot tailwind component and was unable to stop on the remaining runway length. After running off the runway end, it went through a fence, across a road, and came to a stop on the sand dunes and rocks above the waterline of the Caribbean Sea adjacent to the road. No fatalities or postcrash fire occurred.

The investigation, being conducted by the Jamaica CAA, is still ongoing. The NTSB, being part of the investigation, decided to issue the following recommendations to the Federal Aviation Administration (FAA):

 

Require principal operations inspectors to review flight crew training programs and manuals to ensure training in tailwind landings is (1) provided during initial and recurrent simulator training; (2) to the extent possible, conducted at the maximum tailwind component certified for the aircraft on which pilots are being trained; and (3) conducted with an emphasis on the importance of landing within the touchdown zone, being prepared to execute a go-around, with either pilot calling for it if at any point landing within the touchdown zone becomes unfeasible, and the related benefits of using maximum flap extension in tailwind conditions. (A-11-92)

Revise Advisory Circular 91-79, “Runway Overrun Prevention,” to include a discussion of the risks associated with tailwind landings, including tailwind landings on wet or contaminated runways as related to runway overrun prevention. (A-11-93)

Once Advisory Circular 91-79, “Runway Overrun Prevention,” has been revised, require principal operations inspectors to review airline training programs and manuals to ensure they incorporate the revised guidelines concerning tailwind landings. (A-11-94)

Require principal operations inspectors to ensure that the information contained in Safety Alert for Operators 06012 is disseminated to 14 Code of Federal Regulations Part 121, 135, and 91 subpart K instructors, check airmen, and aircrew program designees and they make pilots aware of this guidance during recurrent training. (A-11-95)

The National Transportation Safety Board also reiterates the following recommendation to the Federal Aviation Administration and reclassifies it “Open—Unacceptable Response”:
Require all 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to accomplish arrival landing distance assessments before every landing based on a standardized methodology involving approved performance data, actual arrival conditions, a means of correlating the airplane’s braking ability with runway surface conditions using the most conservative interpretation available, and including a minimum safety margin of 15 percent. (A-07-61)

This recommendation, A-07-61, was issued following the December 2005 runway excursion accident involving a Boeing 737-700 at Chicago-Midaway Airport.

More information:

• NTSB Safety Recommendations A-11-92 through -95 (PDF)