11 DEC 2008 _______________________________________ *NTSB and Brazil release clashing reports on Amazon crash *NTSB: Loss of “effective air traffic control” at root of 2006 Legacy 600, Gol 737 collision *French BEA releases final report on A340 engine test accident at Toulouse *Violation of test procedures led to Toulouse A340-600 crash *Boeing confirms 787 first flight pushed back to 2Q 2009 *ANZ buys two repair shops in Australia *************************************** NTSB and Brazil release clashing reports on Amazon crash The National Transportation Safety Board and the Brazilian Air Force released clashing reports yesterday on the cause of a 2006 midair collision over the Amazon jungle that killed 154 people. While Brazil's report placed roughly equal blame on Brazilian air traffic controllers and the two Long Island pilots involved in the crash, the NTSB assigned the blame on what it called "systemic shortcomings" of the Brazilian air traffic control system. The NTSB's findings are a boost for Joseph Lepore of Bay Shore and Jan Paladino of Westhampton Beach, who were at the controls of an ExcelAire executive jet that collided with a Boeing 737 over the Amazon jungle. All aboard the Boeing were killed. David Rimmer, executive vice president of ExcelAire, based in Ronkonkoma, said the Brazilian Air Force report took "the easy way out" to minimize its role. "I was on the airplane, so it's a personal thing for me," he said. "Brazilian air traffic control pointed two aircraft at each other for an hour ... [Brazil's] report is a cover-up of Brazilian air traffic control's systemic problems." The Brazilian report sharply criticized the American pilots, concluding that they were not prepared for the flight, that they unintentionally turned off a transponder and that they were late in realizing that they were having trouble communicating with air traffic control. The report also faulted air traffic controllers, saying they failed to follow proper procedure when they lost radio contact with the executive jet and when its collision avoidance system stopped functioning. The NTSB, which participated in Brazil's investigation because an American-made Boeing was involved, disagreed with Brazil's conclusions: "Even though the body of the [Brazil] report acknowledges safety deficiencies with [air traffic control], these deficiencies are not sufficiently ... reflected in the conclusions or cause of the accident." The NTSB concluded that air traffic control caused the accident by giving two planes "clearances which directed them to operate in opposite directions on the same airway at the same altitude resulting in a midair collision." The NTSB recommended upgrades for cockpit warnings when a plane's collision avoidance system is not functioning. There is no evidence that the American pilots turned off the transponder - or that its failure was reflected on the cockpit display, Rimmer said. The pilots' lawyer, Joel Weiss of Uniondale, said the Brazil report represented a conflict of interest because the investigating agency and air traffic control are both branches of the country's Air Force. Reached by phone, Joseph Lepore's mother, Anna Lepore, said she does not read news reports about the crash. "Joe doesn't talk about work at home anymore," Lepore, of Bay Shore, said in Italian. "I hope everything turns out well for everyone - for everyone." Camila Viegas-Lee contributed to this story. BLAME GAME The National Transportation Safety Board and the Brazilian Air Force yesterday released dueling reports about the cause of a 2006 midair collision over the Amazon that killed 154 people. THE BRAZILIAN AIR FORCE Placed equal blame on the Brazilian air traffic controllers and two American pilots flying one of the planes THE NTSB Criticized the Brazilian report, saying it downplayed "systemic shortcomings" in Brazilian air traffic control Concluded that the cause of the crash was air traffic control, which gave two planes clearances that "directed them to operate in opposite directions on the same airway at the same altitude resulting in a midair collision." http://www.newsday.com/news/printedition/longisland/ny-liexcel115960415dec11 ,0,1564955.story ************* NTSB: Loss of “effective air traffic control” at root of 2006 Legacy 600, Gol 737 collision The US National Transportation Safety Board (NTSB) has determined that "numerous individual and institutional ATC factors" are the most likely causes of the fatal head-on collision between an Embraer Legacy 600 business jet and a Gol Transportes Aéreos 737-800SPF passenger jet at 37,000ft over Brazil's Amazon region on 29 September 2006. All 154 passengers and crew on board Gol Flight 1907 were killed after the damaged aircraft plunged to the forest floor. The Legacy, flown by US-based air taxi operator Excelaire, was controllable and landed at a nearby military airfield with no injuries to the crew and passengers. The aircraft was being delivered from Embraer's plant in southern Brazil to the US at the time of the crash. NTSB and representatives from several US companies, including Honeywell, ACSS and Boeing, participated in the investigation which was headed by the Brazilian Centro de Investigação e Prevenção de Acidentes Aeronáuticos (Cenipa). "The evidence collected during this investigation strongly supports the conclusion that this accident was caused by N600XL and GLO1907 following ATC clearances which directed them to operate in opposite directions on the same airway at the same altitude resulting in a midair collision," the NTSB states in comments appended to the Cenipa final report. "The loss of effective air traffic control (ATC) was not the result of a single error, but of a combination of numerous individual and institutional ATC factors which reflected systemic shortcomings in emphasis on positive air traffic control concepts." NTSB also addresses the transponder issue on the Legacy Jet. "Contributing to the accident was the undetected loss of functionality of the airborne collision avoidance system technology as a result of the inadvertent inactivation of the transponder on board N600XL," the board explains. "Further contributing to the accident was inadequate communication between ATC and the N600XL flight crew." In May 2007 NTSB asked FAA to require that collision avoidance systems include an audio warning and enhanced visual alert to inform pilots of the "loss of collision avoidance system functionality, for any reason". As currently built and certified, the units display a message only. Following in the release of that recommendation FAA in September 2007 issued a warning to US operators of Embraer ERJ commuter jets and Legacy business jets that they could accidentally deactivate the type's transponder by placing their feet on the footrests located directly below the instrument panel, an action that would render the aircraft invisible to the collision avoidance system of an approaching aircraft. The NTSB in its comments says that though the footrest guard is "designed to prevent unintended interactions" with the control interface for the collision avoidance system, during "in flight deck observations conducted by the NTSB and FAA, it was observed that pilots might misuse the footrests since, in certain forward seat positions, there appeared to be a very comfortable resting position that involved resting the feet on top of the footrest guards rather than inside the designated footrest areas." The report continues, "This position allowed the resting pilot to remain within easy reach of the primary flight controls but, unfortunately, located the captain's right foot in the area of the [control interface] so it could make unintended contact [with the transponder] without the captain's awareness. "It can not be determined exactly how the accident crew commanded the transponder to standby, but the possibility of an unexpected use of the footrest guard, along with other possibilities discussed in the report, serve as important reminders of human ergonomic considerations at preventing inadvertent contacts in actual flying situations," says NTSB. While the US team "has no substantial disagreement" with the facts gathered by Cenipa and "generally concurs" that the safety issues involved in this accident are related to ATC, operational factors, and the loss of in-flight collision avoidance technology, the NTSB report states that "interpretations, conclusions, and understandings of the relationship between certain factual items and the demonstrated risk differ in a number of respects." The Cenipa report was initially published today. "This investigation has identified many safety issues for ATC operations, but these issues need to be further highlighted. Even though the body of the [Cenipa] report acknowledges safety deficiencies with ATC, these deficiencies are not sufficiently supported with analysis or reflected in the conclusions or cause of the accident," the NTSB states. "These deficiencies include a lack of timely ATC action after the loss of N600XL's transponder and two-way radio communication, and features of the ATC software that may have aggravated deficiencies in altitude clearance awareness for N600XL," according to the board. Source: Air Transport Intelligence news ************* French BEA releases final report on A340 engine test accident at Toulouse The French Bureau d'Enquêtes et d'Analyses published the final report of their investigation into the Airbus A340-600 accident at Toulouse Airport in November 2007. A ground crew was conducting pre-delivery engine and brake tests when the airplane ran into a concrete containment wall. The accident was occurred because the tests were carried out without chocks and the engine power reached the limits of the parking brake. When the aircraft moved forward the engineer was caught by surprise and he focused on the braking system instead of reducing engine thrust. (BEA) BEA f-cj071115 (aviation-safety.net) ************** Violation of test procedures led to Toulouse A340-600 crash Investigators have determined that an Airbus A340-600 collided with a test-pen wall in Toulouse after it was powered up while unchocked, and an attempt to steer the aircraft out of danger reduced the effect of the brakes. The test crew failed to reduce the engine thrust as the jet surged forward, attempting instead to stop the aircraft by pressing the brake pedals and turning the nose-wheel sharply to the right. It smashed into the pen wall, seriously injuring four of the nine people on board. A division of the French Bureau d'Enquetes et d'Analyses, which conducted the inquiry, has released its final report into the accident, stating that "lack of detection and correction" of test-procedure violations helped lead to the accident. It points out that procedures for the test, aimed at checking for oil leaks, were not correctly followed, noting that the engines were all operating at high power and the aircraft was left unchocked. Detailing the events leading to the collision, it says the aircraft arrived in the test-pen at 14:19 on 15 November last year and underwent routine engine tests for about 1hr 40min. Just before 16:00 the power of the Rolls-Royce Trent 500 engines was increased to an engine pressure ratio of 1.25 - with the thrust levers corresponding to a position between maximum continuous thrust and maximum take-off thrust. All four engines were operating. While the parking brake was on, registering 2,600psi, the inquiry says the applied thrust was around the limit of the parking-brake capacity. At the time of the accident an Airbus employee was occupying the right-hand seat of the jet while an Abu Dhabi Aircraft Technologies technician was in the left-hand seat. Flight-recorder data shows that, shortly after 16:02, the person in the left-hand seat warned that the aircraft was moving. The ground speed began gradually increasing to 4kt over the next few seconds and, after a second call that the aircraft was moving, the recorder registered pedal-braking and the deactivation of the parking brake. Brakes on the A340-600 are linked to two hydraulic circuits: the 'green' normal circuit and the 'blue' alternate. The parking brake is on the blue circuit and only applies to the left- and right-hand main undercarriage bogies, not the centre bogie. If the parking brake is released and the brake pedals applied, the 'green' circuit comes into play. The pedals act on all three main bogies. Recorder data shows that 'green' circuit brake pressure on the A340 rapidly rose to 2,500psi while the 'blue' circuit pressure dropped. About seven seconds after the first movement warning the nose-wheel was turned sharply right. Activating the nose-wheel steering inhibits braking on the central bogie, becoming completely ineffective past 20° of steering. The aircraft swung 37° to the right but continued to accelerate, its speed increasing from 4kt to 31kt in seven seconds, before the aircraft struck the test-pen wall, demolishing its forward fuselage. The jet was written off. In its report into the accident, the BEA says the aircraft and its braking system functioned correctly, but states that the nose-wheel steering "limited the effectiveness" of the brakes. "Surprise led the ground-test technician to focus on the braking system, so he did not think about reducing the engines' thrust," it adds. Only after the collision with the wall were the throttle levers retarded to the idle position. Source: Air Transport Intelligence news ************** Boeing confirms 787 first flight pushed back to 2Q 2009 Boeing today confirmed a further six-month delay for the 787 programme, blaming the 57-day strike by machinists and an unexpected requirement to replace thousands of fasteners. The new schedule moves first flight from the fourth quarter of 2008 to the second quarter of 2009. The first delivery to launch customer All Nippon Airways shifts from the third quarter of 2009 to the first quarter of 2010. Counting previous delays, the programme is now running nearly two years behind schedule. "We will overcome this set of circumstances as we have others in the past, and we understand clearly what needs to be done moving forward," said Pat Shanahan, Boeing's VP for the 787 programme. First flight preparations include finalizing and incorporating engineering changes and completing systems testing, qualifications and certification. Boeing is continuing to evaluate how the delay will impact the long-awaited production ramp-up for the 787 and new delivery dates for customers. The financial impact of the delay is also still under review, Boeing said, and will be released "at a later date". Last month, Boeing acknowledged discovering that it needed to replace thousands of fasteners on each 787 currently in production because of a quality assurance breakdown. That admission came immediately after about 27,000 members of the International Association of Machinists and Aerospace Workers (IAM) returned from a 57-day strike. Both events conspired to ruin the 787 programme's comeback from a system-wide production breakdown that caused a previous delay of 18 months. Source: Air Transport Intelligence news ************ ANZ buys two repair shops in Australia Air New Zealand (ANZ) is expanding its maintenance operations in Australia through the purchase of small aviation services providers Tenix Aviation and Masling Industries. The Star Alliance carrier says in a statement that it has acquired South Australia-based Tenix Aviation and New South Wales-based Masling Industries. Tenix, which employs 60 people, provides gas turbine, airframe, avionics, propeller component and spare parts services to the general aviation industry and to regional airlines. It is headquartered at Adelaide Airport and also has operations at Parafield Airport and Darwin. Masling Industries employs 11 people and is based at Cootamundra. It specialises in component overhaul and repair of gas turbine engine accessories for helicopters and fixed-wing aircraft. ANZ says the purchases are part of its "continued diversification" and the businesses will operate under its Australian-based aerospace engineering services company subsidiary, TAE. Tenix Aviation will be re-named TAE Aviation but the Masling Industries name will be retained. Source: Air Transport Intelligence news *************