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

 

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)

NTSB issues recommendations on accessibility of flight deck fire extinguishers

Fire damage on the captain's windshield of this Boeing 757 (photo: NTSB)

The National Transportation Safety Board (NTSB) issued three safety recommendations on flight crews’ ease of access to fire extinguishers while oxygen masks are donned.

These recommendations were made following the Boards investigation into an incident in which the crew of a Boeing 757 were face with a fire at the windshield heat terminal connection in the cockpit. The flight crew diverted to Washington Dulles International Airport, VA, and landed without further incident. No evacuation was conducted, and none of the 7 crewmembers or 105 passengers sustained injuries.
In addition to the factors that led to the fire, NTSB’s investigation of this incident revealed a safety issue concerning 14 CFR Part 121 flight crews’ ability to readily access fire extinguishing equipment while wearing the oxygen masks and goggles that they are instructed to don at the first indication of smoke, fire, or fumes. During postincident interviews, the flight crewmembers of the incident flight indicated that they immediately donned oxygen masks and smoke goggles in accordance with the United Airlines Boeing 757 Smoke, Fire or Fumes checklist.
The captain reported that he left his seat because the flames were in front of him and he needed to immediately reach the fire extinguisher, located on the back wall of the cockpit next to the jumpseat.
The captain stated that, as he moved toward the fire extinguisher, his oxygen mask and smoke goggles were “torn off” because he had reached the end of the hose attached to the oxygen mask. He removed the fire extinguisher, put the mask and goggles back on, and discharged the extinguisher until it was empty. The captain reported that the fire was suppressed but reignited within seconds and that, as he moved toward the cockpit door to retrieve a second extinguisher from the cabin crew, his mask and goggles came off again. He retrieved the extinguisher, put his mask and goggles back on, and discharged the extinguisher, fully extinguishing the fire.

Therefore, the National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration:

Require that the length of oxygen mask hoses in the cockpits of airplanes used in 14 Code of Federal Regulations Part 121 operations be increased, as necessary, to allow flight crews access to all required emergency equipment in the cockpit, as 6 well as to additional emergency equipment provided by the cabin crew via the cockpit door, while oxygen masks are donned. (A-11-79)

Amend Advisory Circular 120-80, “In-Flight Fires,” to provide clear guidance to flight crews concerning the type of breathing equipment to wear when combating a cockpit fire, taking into consideration the limitations of portable protective breathing equipment in both passenger and cargo operations. (A-11-80)

Amend Advisory Circulars 20-42D, “Hand Fire Extinguishers for Use in Aircraft”; 25-17A, “Transport Airplane Cabin Interiors Crashworthiness Handbook”; and 25-22, “Certification of Transport Airplane Mechanical Systems” to indicate that hand fire extinguishers in the cockpit must be reachable by at least one flight crewmember while wearing an oxygen mask. (A-11-81)

More information:

• NTSB Safety Recommendations A-11-79 through -81
• NTSB Incident Report

 

NTSB: Fatal Alaska accident involving Ted Stevens caused by pilot’s temporary unresponsiveness

The airplane wreckage (photo: NTSB)

The U.S. NTSB concluded their investigation into the cause of the August 2010 fatal accident involving a DHC-3T Turbine Otter in Alaska.  Former U.S. Senator Ted Stevens was among the five fatalities. 

On August 9, 2010, the single-engine, turbine-powered, amphibious float-equipped de Havilland DHC-3T airplane, N455A, impacted mountainous, tree-covered terrain about 10 nautical miles northeast of Aleknagik, Alaska. The airline transport pilot and four passengers received fatal injuries, and four passengers received serious injuries.
The flight was operated by GCI Communication Corp. from a GCI-owned private lodge on the shore of Lake Nerka and was en route to a remote sport fishing camp about 52 nm southeast on the Nushagak River.

Marginal visual flight rules were reported at Dillingham Airport, Dillingham, Alaska, about 18 nm south of the accident site.

The National Transportation Safety Board determined that the probable cause of this accident was the pilot’s temporary unresponsiveness for reasons that could not be established from the available information. Contributing to the investigation’s inability to determine exactly what occurred in the final minutes of the flight was the lack of a cockpit recorder system with the ability to capture audio, images, and parametric data.

The NTSB noted that fatigue, stress or a  medical condition could have been a factor in the pilot’s temporary unresponsiveness.  However, there is insufficient evidence to determine whether these factors played a role in the accident.

More information:

• NTSB Accident Synopsis
• NTSB Board meeting presentations
• ASN Accident Description

NTSB investigates ATC incident at Chicago-O’Hare

The National Transportation Safety Board (NTSB) is investigating an air traffic control incident involving two regional jets that occurred on Monday, May 16, 2011 at Chicago O’Hare International Airport.

At approximately 09:35, ExpressJet Airlines flight 6075, an Embraer ERJ-145, was cleared for takeoff on runway 32L at Chicago-O’Hare (ORD), en route to Buffalo, NY (BUF).  SkyWest Airlines flight 6958, a Canadair CRJ-200 (N905SW), arriving at O’Hare from Muskegon, MI (MKG), was cleared to land on runway 9R.   Aircraft approaching runway 9R cross runway 32L at low altitude before landing. Because of the timing of the two operations, the SkyWest flight nearly overflew the departing ExpressJet flight.

A supervisor on duty in the tower noticed the traffic on the runway and the traffic on the approach and instructed the controller handling the SkyWest flight to direct the pilot to go around.  The SkyWest pilot discontinued the initial approach as instructed.  The ExpressJet flight continued takeoff  roll and departed without further incident.  The SkyWest flight returned a few minutes later and landed.  There were no injuries or damage to either aircraft.

Safety Board investigators are reviewing radar data, air traffic control audio recordings, and statements provide by the pilots of the aircraft involved. Preliminary radar information provided to the Safety Board by the Federal Aviation Administration indicates that the SkyWest aircraft crossed runway 32L approximately 225 feet above the ExpressJet aircraft when the two aircraft were laterally less than 480 feet apart.

More information:

• NTSB press release
• FAA airport diagram of ORD

NTSB cites crew actions in ATR-42 cargo flight crash in Texas

The accident airplane (photo: FAA)

The crash of an ATR-42  cargo airplane while on approach to landing at Lubbock, Texas, was caused by the flight crew’s failure to maintain a safe airspeed, which put the plane into an aerodynamic stall at an altitude too low from which to recover, the NTSB determined.

Poor crew resource management, flawed decision-making and human fatigue were cited as contributing factors to the crash that left the captain seriously injured and the first officer with minor injuries.

On January 27, 2009, at 4:37 a.m. CST, an ATR 42-320 (N902FX) operating as Empire Airlines flight 8284 between Ft. Worth and Lubbock, was on an instrument approach when it crashed short of the runway. The airplane, which was registered to Federal Express Corporation (FedEx) and operated by Empire Airlines, Inc., was substantially damaged.

The aircraft, which had departed Ft. Worth about 84 minutes before the accident occurred, encountered icing conditions while en route to Lubbock. And although the airplane accumulated some ice during the flight that degraded its performance, the NTSB determined that the aircraft could have landed safely had the airspeed been maintained.

During the approach into Lubbock, at about 1400 feet above the ground and about 90 seconds from the runway, the captain indicated a flight control problem saying, “We have no flaps.” Although the crewmembers had been trained to perform a go-around and refer to a checklist if a flap problem occurred during an approach, the captain chose to continue the approach as he attempted to troubleshoot the flap anomaly while the first officer flew the plane. Neither flight crewmember adequately monitored the airspeed, which decayed to the extent that the stick shaker activated, which warned of an impending aerodynamic stall.

The captain continued the unstabilized approach even though he received additional stick shaker activations and an aural “pull up” warning from the terrain awareness and warning system (TAWS). At that point, the plane was descending at a rate of over 2,000 ft per minute.

Although procedures for responding to either the stick shaker or the TAWS warning require the immediate application of maximum engine power, the captain did not apply maximum power until 17 seconds after the TAWS warning. Seconds after maximum power was applied, the airplane entered an aerodynamic stall and crashed.

The NTSB also uncovered significant issues related to icing. Empire Airlines had dispatched the airplane into icing conditions that were outside the airplane’s certification envelope. Although this practice was not prohibited by the Federal Aviation Administration (FAA), the NTSB has longstanding concerns about operations in freezing drizzle/freezing rain and as a result of this investigation made a safety recommendation to address the issue.

Among the nine safety recommendations that the NTSB made to the FAA were:

• improve crew resource management training to encourage first officers to more assertively voice their concerns and teach captains to develop a leadership style that supports first officer assertiveness;
• prohibit operators of pneumatic boot-equipped airplanes from dispatching them into icing conditions that are outside of those that the airplane was certified for;
• educate pilots and dispatch personnel on the dangers of flight in freezing precipitation;
• develop a method to quickly communicate flight information regarding the number of persons aboard and the presence of hazardous materials to emergency responders;
• provide guidance on monitoring and ensuring the operability of emergency response and mutual aid gates during winter operations;
• require all operators of ATR 42 and ATR 72 series airplanes to be equipped with an aircraft performance monitoring system;
• improve flight simulator fidelity to more accurately model aerodynamic degradations resulting from airframe ice accumulation and ensure that flight crews are trained on them;
• and require all ATR 42 aircraft to be equipped with a flap asymmetry annunciator light.

More information:

• Synopsis of the NTSB report
• NTSB Board Meeting
• NTSB Accident Docket

NTSB releases factual information regarding 2010 plane crash involving former Senator Stevens

The airplane wreckage (photo: NTSB)

As part of its continuing investigation into the August 9, 2010 aviation accident in Alaska, the U.S. National Transportation Safety Board (NTSB) made the accident docket available to the public.

Both former U.S. Senator Ted Stevens of Alaska and former NASA Administrator Sean O’Keefe were among the eight passengers aboard the DHC-3T Turbine Otter aircraft that crashed northeast of Aleknagik. The pilot and four passengers, including Senator Stevens, were killed. The other four passengers were seriously injured.

The accident docket contains NTSB factual reports including: operations, meteorology, survival factors, powerplants, aircraft performance, human performance, airworthiness, and a synopsis of medical records.
Also included are exhibits, interview transcripts, photographs, and other documents from the on-going investigation. Additional material will be added to the docket as it becomes available.

The information released is factual in nature and does not provide any analysis. A determination of findings, probable cause, and recommendations will be released during the public NTSB Board Meeting on May 24, 2011.

More information:

• NTSB Accident Docket
• ASN Accident Description

NTSB investigation A380 wing clipping incident at New York-JFK (w/video)

The U.S. NTSB is investigating a wing clipping incident that occurred on April 11, 2011 at 20:25 local time.

An Air France Airbus A380, registered F-HPJD and a Comair CRJ701ER, registered N641CA, both sustained minor damage in a ground collision occurrence at New York-John F. Kennedy International Airport, NY (JFK/KJFK).
The Airbus A380 was operating as flight AF007 to Paris-Charles de Gaulle Airport with 485 passengers and 25 crew onboard. It taxied to the departure runway when the port wing of AF007 clipped the tail of the CRJ, spinning it through almost 90 degrees.
The CRJ, Comair Flight 293 was taxiing to the gate following a flight from Boston. There were 52 passengers and 4 crew onboard. No injuries were reported.

More information:

• NTSB media release
• FAA airport diagram of JFK (incident reportedly happened near taxiways A and M)
• ASN incident description

NTSB progress report on United Airlines 497 runway excursion at New Orleans

The National Transportation Safety Board continues to make progress in its investigation of United Airlines flight 497, which returned to the airport on April 4, 2011, in New Orleans, shortly after take-off due to automated warnings of smoke in the equipment bay. The airplane’s nose wheel exited the side of runway 19 upon completing the landing roll and an emergency evacuation was conducted.

The NTSB team, comprised of 3 NTSB investigators and representatives from the designated parties and advisors, arrived on scene April 4 to document and examine the aircraft and retrieve the data and voice recorders. Two other NTSB investigators, specializing in operational factors and maintenance factors, traveled to various locations to review pertinent documentation and records and conduct interviews.

After documenting the condition of the equipment in the electronics bay, investigators applied limited electrical power to various systems on the airplane. At this time, the preliminary examination has not revealed any signs of burning, indications of smoke or other anomalous system findings.

The NTSB operations group completed interviews of the flight crew yesterday. The crew indicated that, at about 4000 feet, the airplane’s electronic centralized aircraft monitoring (ECAM) system provided an autothrottle-related message, then an avionics smoke warning message, accompanied by instructions to land. Despite receiving this message, neither crew member recalled smelling smoke or fumes during the flight.

The captain indicated that he used the electronic checklist for the avionics system smoke warning indication, which included shutting down some of the airplane’s electrical system. The crew reported that the first officer’s display screens went blank, the ECAM messages disappeared, the cockpit to cabin intercom stopped functioning, and the air-driven emergency generator deployed. The captain said that he took control of the airplane at this point and managed the radios while the first officer opened the cockpit door to advise the flight attendants of the emergency and their return to New Orleans airport.

The crew also noted to investigators that they requested runway 10 for landing, but were told the runway was not available due to the presence of construction vehicles. The captain said that he was able to use the airspeed, altimeter, and attitude information on his primary flight display during the return to the airport, and that he ordered an evacuation after landing.

As previously reported, the airplane’s forward right slide did not properly inflate during the emergency evacuation. After examining the evacuation slides, investigators found that the aspirator for the forward right-hand slide was partially blocked. The aspirator component is the mechanism for inflating the slide during an emergency evacuation. Investigators have retained the slide for further evaluation.

Preliminary reports provided to investigators suggest that the flight attendants did not smell or see smoke in the cabin, but observed the cabin lights turn off and the intercom system cease to function during the flight. Interviews of the cabin crew will be conducted after the investigators complete their on-scene work to more thoroughly document the cabin crew’s observations and communications throughout the flight and emergency evacuation.

The cockpit voice recorder (CVR) and flight data recorder (FDR) arrived at NTSB headquarters in Washington, D.C. on April 5 and were successfully downloaded. The CVR is of good quality and captured approximately 7 minutes and 30 seconds of the incident flight. The FDR contained in excess of 25 hours of data and captured approximately 18 minutes of data relevant to the incident flight. Both the CVR and FDR stopped recording data prior to landing.

Investigators will remain on scene to complete their evaluation of the airplane and documentation of other factors in the incident.

Cracks found on three Southwest 737’s; Boeing planes Serice Bulletin

The U.S. National Transportation Safety Board (NTSB) provided an update regarding the continuing investigation into the mid-air rupture of the fuselage skin on Southwest Airlines flight 812 that occurred on Friday, April 1st. The aircraft made an emergency landing in Yuma, Arizona.

On April 3, mechanics from Southwest Airlines, under the supervision of NTSB investigators, removed a section of the ruptured fuselage skin from Friday’s accident. The segment will be transported to NTSB headquarters in Washington, D.C. for in-depth analysis.

In addition, NTSB investigators conducted additional inspections of other portions of the lap joint along the fuselage of the accident airplane and found evidence of additional cracks.

The past few days, Southwest Airlines has been conducting additional non destructive testing inspections on 79 of their 737 airplanes. Additional crack indications in the lap joints have been identified on 3 airplanes.

The NTSB, along with the other investigative parties – FAA, Boeing, and Southwest Airlines – has been working to determine what actions might be necessary to inspect any similar airplanes.
As a result of the findings to date and the results of the Southwest Airlines inspections, Boeing has indicated that they will be drafting a Service Bulletin to describe the inspection techniques that they would recommend be accomplished on similar airplanes.

While the specifics of the Service Bulletin are being developed, the focus is to require inspection of the left and right lap joints on all similar 737 airplanes that have comparable cycles (takeoffs and landings) as the accident airplane. Once the Service Bulletin is released by Boeing, the FAA will make a determination whether to make it mandatory for all similar 737 airplanes.

A check by ASN of the Service Difficulty Reports of the accident airplane, N632SW, revealed that 38 reports were related to the Fuselage (cracks, damage, corrosion of for example stringer clips and frames).

About three of those reports were from roughly the fuselage section were the rupture occorred  (Body Station 685-727).

The last report is dated March 27 at an aircraft total time of 48722 hours and 39768 cycles.

More information:

• Southwest Airlines media releases
• NTSB media release
• SDRs of N632SW (MS Excel)