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:


Crew members grounded after testing positive on alcohol tests

January 3, 2012

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

January 1, 2012

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


ASN releases preliminary airliner safety statistics 2011

December 28, 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

December 23, 2011

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.

SourceFamagusta Gazette, Cyprus Mail.

More information:

 


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

December 22, 2011

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

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)


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