Flight Safety Information April 6, 2010 - No. 069 In This Issue NTSB Letter Urges FAA To Improve SAR Responses Jet sheds engine cover during takeoff Man threatens to down Qantas jet with his mind FAA's Oversight Of Air Carrier Inspections Continues To Be Ineffective ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ NTSB Letter Urges FAA To Improve SAR Responses To Downed Aircraft Says Communications Problems Hamper Speedy Rescue Of Crash Survivors In a letter to FAA Administrator Randy Babbitt, the NTSB says the FAA should work to improve communications between it and the Air Force Rescue Coordination Center (AFRCC), which has responsibility for initiation and coordination of SAR activities in the domestic United States. The letter cites a case in which a Piper PA-38-112, N9247T crashed into trees and rising mountainous terrain at Amicalola Falls State Park in Dawsonville, Georgia. The pilot was attempting to stay below overcast cloud conditions. The certificated commercial pilot, the sole occupant, eventually died as a result of the accident, and the airplane sustained substantial damage. The flight originated from Habersham County Airport, Cornelia, Georgia, about 1400 local time, destined for Lunken Field, Cincinnati, Ohio. Evidence indicates that the pilot likely survived the accident and activated an emergency transponder code but died before the airplane was located. Shortly after the crash, the letter says, controllers at the Atlanta Air Route Traffic Control Center (ZTL) noticed an unidentified stationary radar target about 50 nm north of Atlanta. Beginning about 1534, the target transmitted transponder code 7700, which is a dedicated emergency code reserved for use by aircraft in distress, and its use by the accident pilot caused a special flashing "EMRG" alert to appear on ZTL radar displays. About 1552, the ZTL traffic management coordinator (TMC) notified the AFRCC of ELT reports and observation of the 7700 code. During the call, the TMC stated that there were "numerous ELT reports...north of Atlanta" and that he did not believe that an incident number had been assigned. The AFRCC controller replied that an incident had been reported south of Atlanta. The TMC noted that the reports he was calling about were north of Atlanta and that "...we actually show an emergency beacon flashing north of the airport." (In using the term "emergency beacon," the TMC was attempting to communicate the observation of a 7700 emergency transponder signal, which provides more specific location information than ELT reports and indicates more definitively that an emergency has actually occurred.) At the AFRCC controller's request, the TMC provided the information in the ELT reports, and the call concluded. The AFRCC controller did not provide an incident number to the TMC, which would have indicated that she understood that the TMC's report indicated a new incident. Rather, she associated the report with the incident south of Atlanta. Once the report for the incident south of Atlanta was closed, that also ended any activity related to the ELT reports and radar observations north of Atlanta provided by ZTL's TMC. As a result, no SAR effort was begun for N9247T until family members reported the accident airplane missing the following day. As there was evidence that the pilot survived the crash, this was a critical SAR failure. Based on the family's report of the missing airplane, the Dayton, Ohio, Flight Service Station (FSS) issued an Alert Notice (ALNOT) about 1247. According to the AFRCC's mission log, the AFRCC began attempting to locate the airplane immediately upon receipt of the ALNOT. Air searchers located the airplane about 49 hours after the accident, and the ground team arrived shortly afterward. The team reported that the pilot was deceased. The NTSB says that the lack of standard phraseology for communications between FAA and AFRCC personnel about particular observations, such as the observation of an emergency 7700 transponder code, clearly hindered the SAR effort in this event. For example, the AFRCC controller also did not understand that the TMC's report of "an emergency beacon flashing north of the airport" indicated that ZTL was observing a 7700 emergency code on radar. If the AFRCC controller had understood that ZTL was forwarding not only ELT reports but also a radar observation of an emergency 7700 code north of Atlanta, she likely would have recognized that two separate events were occurring and assigned a new incident number to the emergency 7700 code instead of associating the new information with the previous ELT reports south of Atlanta. The NTSB recommends that the FAA develop, in conjunction with the AFRCC, specific phraseology for communicating about the location, time, and nature of ELT signals and emergency beacon codes. The NTSB further recommends that the FAA amend FAA Order 7110.65, "Air Traffic Control," to prescribe the use of the phraseology requested in Safety Recommendation A-10-1. The NTSB further recommends that the FAA provide training for all FAA personnel who may be required to interact with the AFRCC, ensuring that personnel understand the AFRCC's incident reporting process and recognize that new incidents are always assigned a unique incident number. FMI: www.ntsb.gov, www.faa.gov Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Jet sheds engine cover during takeoff Sheet metal covering an engine fell from a jet taking off at Newark Liberty International Airport today, forcing the plane to land and temporarily closing a runway, NorthJersey.com reports. The engine cover from JetBlue Flight 507 forced the Fort Lauderdale-bound jet to return to the airport. No one was injured, a Port Authority spokeswoman told the website. The runway was closed for about an hour as crews cleaned up fragments from the cover, which keeps debris out of the engine. No other flights were affected, the spokeswoman said. http://content.usatoday.com/ Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Man threatens to down Qantas jet with his mind A QANTAS passenger had to be restrained by flight stewards after he threatened to bring down the plane with the power of his mind. The man, believed to be under the influence of drugs or alcohol, was said to be delusional and threatening to use the power of his mind to bring the plane down, reports ABC's Nick Luchinelli, who was onboard the flight. Stewards on flight QF31 from Sydney to Singapore handcuffed the man's arms and legs for the rest of the flight. Singaporean police boarded the flight after passengers disembarked. The man is being held by police for questioning. Meanwhile, Qantas passengers on a flight from Los Angeles to Brisbane arrived 17 hours late after two of the airline's jumbo jets reported technical problems. The original Boeing 747 and a replacement jet failed to start, further delaying the flight's departure. http://www.theaustralian.com.au/ [http://r20.rs6.net/tn.jsp?et=1103275273839&s=6053&e=001ZvsL4yRheBkdOCWtNZKCAqkSEwbboG4rrc6-l5okfhOah6SYn0csqzS6EN9KvK-rYp6L5fGYmfABFLq6it2rDDCsIxqXHjPjWiIWYXyzwSvteYx56zt2N1gVT83v3VJY] Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ FAA's Oversight Of Air Carrier Inspections Continues To Be Ineffective April 6, 2010 - DOT's Inspector General's Office testified before congress, Subcommittee on Transportation, in their report they indicated the FAA's oversight of the Air Transportation Oversight System (ATOS) inspections continues to be ineffective at the national level in large part because the FAA does not collect data on all overdue inspections or fully utilize the data it already collects. In response to DOT 2008 recommendation, the FAA established a process to compile inspection data at the national level and distribute quarterly reports to alert regional managers to overdue inspections. However, FAA's data tracking efforts still lack accountability in two key areas. First, FAA does not monitor completion of a key group of inspections, those identified as scheduled, but not yet assigned. From June 2008 through June 2009, 237 scheduled inspections were left unassigned and uncompleted-and none were being tracked by FAA to completion. While local oversight offices rescheduled some of the inspections, they were not projected for completion for as much as 4 years beyond the original inspection date. Unless the FAA holds regional managers accountable for ensuring that local inspection offices complete these inspections, they will continue to lapse beyond the minimum inspection intervals established by FAA. Inspecting air carrier programs at required time intervals is critical to validate the levels of risk that might exist in air carrier programs. Second, the FAA's quarterly inspection status reports do not include any trend analyses or cumulative data roll-up from the rest of the year that could help identify offices where inspections are habitually late. Moreover, regional managers stated that they did not find the Headquarters reports useful and, in many cases, were already tracking the progress of their local oversight offices in completing assigned inspections using locally developed systems. Yet, those systems were not monitoring the 237 overdue inspections identified during DOT review to completion. The FAA introduced (ATOS) in 1998 as its new tool for conducting air carrier safety inspections. ATOS was a major shift in FAA's oversight system as it moved beyond the traditional inspection method of simply checking an air carrier's compliance with regulations to identifying and assessing safety risks to preclude accidents. FAA initially implemented ATOS at 10 of the Nation's largest passenger air carriers. Over the past 7 years, DOT has reported on a number of weaknesses within ATOS. In 2002, DOT recommended that FAA establish strong national oversight and accountability to ensure consistent ATOS field implementation. Today, all Part 121 passenger air carriers in the United States are being inspected using ATOS. In 2005, DOT again recommended that FAA strengthen its national oversight of field offices by establishing policies and procedures to ensure air carrier inspections are conducted in a timely and consistent manner. More recently, in 2008, DOT recommended that FAA implement a process to track field office inspections and alert the local, regional, and Headquarters offices to overdue inspections. To conduct this review, DOT obtained and analyzed ATOS inspection data and interviewed FAA Flight Standards Division (Headquarters) and regional managers to evaluate their role and effectiveness in analyzing data and ensuring timely completion of inspections. ATOS is FAA's approach to air carrier safety oversight. FAA inspectors assigned to local oversight offices use ATOS to conduct surveillance of air carrier operations and maintenance programs at more than 100 Part 121 air carriers in the United States. ATOS is designed to allow FAA inspectors to use data to focus their inspections on areas posing the greatest safety risks and adapt their inspection plans in response to changing conditions within air carriers' operations. ATOS helps inspectors assess air carriers across three primary areas: · System Design: Inspectors evaluate air carriers' policies and procedures to determine if their operating systems comply with safety regulations and standards. System design evaluations are required every 5 years. · Performance: Inspectors determine whether an air carrier is following its FAA-approved procedures and that those procedures and operating systems are working as intended. Performance evaluations are conducted at prescribed intervals depending on the likelihood of failure in air carrier programs. · Risk Management: Inspectors examine air carrier processes dealing with hazards and associated risks that are subject to regulatory control (e.g., enforcement actions and rulemaking). FAA uses these analyses as a basis to target resources towards the most at-risk programs. The frequency of performance evaluations is based on the significance of the program to an air carrier's operations. Inspections of high-criticality maintenance programs, such as Airworthiness Directive Management, are performed every 6 months; lower-criticality programs, such as Carry-On Baggage or Service Difficulty Reports, are inspected every 12 or 36 months, respectively. Since ATOS is an automated oversight system, results of inspections and decisions made by managers to mitigate risk levels are collected and organized in a centrally located repository within ATOS. This allows Headquarters and regional officials to monitor the current status of all ATOS inspections. FAA headquarters does not use inspection status data to hold local oversight offices accountable for completing ATOS inspections. Inspections are automatically scheduled in ATOS based on intervals established within the system, and it is the responsibility of local oversight office managers to assign inspectors to complete these inspections. However, DOT review of inspection data indicates that not all scheduled inspections are being assigned, including those with increased levels of risk. For example, four local oversight offices that transitioned to ATOS since 2006 have yet to complete any scheduled system design or performance inspections for 10 air carrier operations programs. At the time of DOT review, these inspections were unassigned. In DOT June 2008 report, DOT recommended that FAA implement a process to monitor field office inspections and alert local, regional, and Headquarters management to overdue inspections. In response, the FAA developed a process to track the status of ATOS inspections. In July 2008, the FAA Headquarters ATOS Division Manager began sending quarterly inspection status reports-commonly referred to as the Quarterly ADI Completion Report-to regional managers. However, DOT analysis of FAA's quarterly inspection status reports showed that FAA Headquarters only tracks the status of assigned inspections for timely completion. Unassigned inspections pose a greater problem for FAA because managers have not committed inspector resources to complete these inspections. Once these inspections become past due, there is no sense of urgency to complete them. FAA Headquarters officials also use the quarterly reports during FAA's "Dashboard" meetings. DOT found 237 instances where ATOS inspections were unassigned and not completed at the required interval. For example, DOT review of ATOS data disclosed 11 inspections that were at least 90 days past due but not yet rescheduled. In other instances, FAA did reschedule unassigned inspections. FAA officials acknowledged that not all scheduled ATOS inspections will be completed at the required interval. They informed DOT that in a risk-based oversight system such as ATOS, it is not practical or desirable to complete all inspections just for the sake of completing inspections. Therefore, Headquarters officials do not hold local oversight offices accountable for completing unassigned inspections because doing so would impede the time inspectors need to perform quality inspections for those areas that pose greater risk. While DOT agreed that higher-risk air carrier programs warrant being inspected ahead of lower-risk programs, some of the unassigned inspections were identified by inspectors as "high risk" programs but not inspected. Additionally, ensuring that all areas, regardless of risk, are inspected is a critical step toward identifying and monitoring risk levels before system failure occurs. Quarterly inspection status reports consistently pointed to a lack of inspector resources as the main reason scheduled inspections have gone unassigned and uncompleted. Headquarters officials acknowledged that they are aware of the resource issues cited by the regions, but they have not addressed this problem. DOT analysis showed that a lack of inspector staffing was cited in 70 percent of the 237 unassigned inspections over a 1-year period. FAA's efforts to effectively oversee all inspections at a national level will require a process that tracks unassigned inspections to ensure that they are rescheduled and completed in a timely manner. FAA could maximize the results of this process by monitoring reasons cited by local oversight offices for failing to assign inspections. This would allow FAA to better ensure repetitive resource issues are resolved that may be impeding timely completion of ATOS inspections. DOT analysis showed, the FAA's quarterly reports is not an effective analytical tool because it only reflects inspection completion data for the past calendar quarter and does not include any trend analyses or cumulative data roll-up that could be useful in identifying problem offices where inspections are habitually late. As a result, FAA Headquarters does not readily know if uncompleted inspections-whether assigned or unassigned-in that quarter would be scheduled and completed in the following quarters. http://avstop.com/ [http://r20.rs6.net/tn.jsp?et=1103275273839&s=6053&e=001ZvsL4yRheBlWpi6xU8pQHEJd5IoDplnShBD47iaRLyfYrF9HNQfUteP_6Ju_PQSL5xYLHS9Dbtg2ac6WBEobpGUVVanMu-0fWdTi1ZlxyDA=] Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC