Flight Safety Information MAY 7, 2010 - No. 089 In This Issue FAA Won't Revoke Licenses Of 2 U.S. Pilots Involved In Brazilian Accident Turkish 737 stalled as faulty altimeter triggered thrust cut Australia's Rex Saab 340 skids off runway at Mount Gambier Cathay agrees with Hong Kong govt report on A330 high-speed landing... Submarine signal analysis moves AF447 search to new site United States Society of Air Safety Investigators 2010 Seminar ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ FAA Won't Revoke Licenses Of 2 U.S. Pilots Involved In Brazilian Accident "Insufficient Evidence" To Take Revocation Action In Mid-Air Collision The FAA has denied a request from two Brazilian congressmen to revoke the pilots licenses of two U.S. pilots who were involved in an accident in Brazil in 2006. Joseph Lepore of Bay Shore, NY, and Jan Paladino of Westhampton Beach, NY, were flying an Embraer Legacy jet over the Amazon when it collided with a 737. The larger airplane went down in the jungle, killing all 154 people on board. The FAA sent a letter April 27th saying there was "insufficient evidence" to take a revocation action against the two pilots. The Associated Press reports that Brazilian Congressman Milton Monti released a statement Wednesday saying he was "deeply unhappy and surprised with the negative response given by the (FAA)." Monti said Brazilian Authorities had given the FAA "irrefutable proof" that the Legacy pilots were negligent and incompetent. Monti said the decision was an "affront to Brazilians and to the victims' families," and that he would appeal to the Intermerican Court of Justice. However, the pilot's attorney, Joel Weiss, said the FAA acted appropriately. He said that the request was "utterly partisan," and that the pilots "violated no rules whatsoever." Weiss contends that Brazilian air traffic controllers put "two competent flight crews on a collision course." However, a Brazilian Air Force report from 2008 indicates that the Legacy pilots may have inadvertently disengaged the airplanes collision avoidance system and transponder. FMI: www.faa.gov Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Turkish 737 stalled as faulty altimeter triggered thrust cut Dutch investigators have concluded that an incorrect reading of the radio altimeter led a Turkish Airlines Boeing 737-800's autothrottle to command a thrust reduction in both engines to 'idle', before the aircraft crashed short of touchdown at Amsterdam Schiphol last year. Pilots of the aircraft did not notice the autothrottle's switch to 'retard flare' mode - normally engaged below 27ft on approach - because the 737, having intercepted the localiser later than normal, at 5.5nm from runway 18R, had to descend from 2,000ft to align with the glidepath. This descent manoeuvre, says the Dutch Safety Board, "obscured" the mode change and the aircraft's subsequent behaviour. But the investigation also states that the aircraft's approach was not stabilised at 1,000ft, because the pilots were late in completing preparations, and that the crew should have executed a go-around. The right-hand autopilot continued to follow the glideslope, resulting in the aircraft attempting to maintain height with idle engine thrust. The nose-up pitch and falling airspeed eventually resulted in the aircraft's stalling - its stick-shaker activated at 460ft - and the crew failed to recover the situation in the remaining height. Turkish Airlines normally requires both autopilots to be activated for an instrument approach. But an attempt to engage the left-hand autopilot was unsuccessful. During the approach the first officer, who was operating as the flying pilot under supervision from a third 'safety' pilot, was using only the right-hand radio altimeter with the right-hand autopilot engaged. His displays did not register the incorrect reading from the left-hand radio altimeter, which had switched to an indication of minus 8ft. The inquiry was unable to explain the reason for the malfunction, although it says the radio altimeter started reading incorrectly almost as soon as the aircraft took off from Istanbul. Crucially, while the first officer was using information from the right-hand systems, the left-hand radio altimeter is the primary provider of information to the autothrottle. The final investigation report states that this feature is a "relic" from the 737's certification in which the original design prioritised provision of information to the captain's position. Changes in cockpit roles in the interim have resulted in pilots having an "incomplete, or even incorrect, mental model" of automated flight controls. Although the left-hand radio altimeter was reading erroneously, the reading was not recognised as a failure, meaning there was no automatic transfer to the right-hand system. The faulty altimeter continued to feed the autothrottle, resulting in the reduction of engine thrust. Along with the three pilots, flight TK1951 had four cabin crew and 128 passengers on board. Nine of the occupants, including four crew members, were killed in the 25 February 2009 crash. Source: Air Transport Intelligence news "Dutch Safety Board (DSB) Issues Accident Report on February 25, 2009 Accident of a Boeing 737-800 at Amsterdam Schiphol Airport (EHAM)" http://www.ntsb.gov/Aviation/Netherlands-EHAM.htm Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Australia's Rex Saab 340 skids off runway at Mount Gambier A Regional Express (Rex) Saab 340 skidded off the runway yesterday while landing at Mount Gambier Airport after a flight from Adelaide. None of the 31 passengers and three crew members on board were hurt in the incident, which happened at 08:10hr. The Australian regional carrier says the aircraft had "landed normally" but "during the final stage of the landing roll the crew experienced a pull to the left and the aircraft came to a halt partially off the left side of the runway". Local media reports say a wheel of the aircraft may have locked during the landing. The aircraft was not damaged during the incident, and will be checked by Rex Engineering before being returned to service, says the airline. Source: Air Transport Intelligence news Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Cathay agrees with Hong Kong govt report on A330 high-speed landing Cathay Pacific Airways says a report issued by Hong Kong authorities on an A330-300 high-speed landing last month is "consistent" with its understanding of the incident. The aircraft had landed at a ground speed of 230kt at Hong Kong International Airport on 13 April after flying from Surabaya. The high-speed landing deflated the aircraft's tyres and injured 57 passengers. Yesterday, Hong Kong's Civil Aviation Department (CAD) issued a preliminary report on the incident, revealing that the aircraft's monitoring system had reported problems with the twin Rolls-Royce Trent 700 engines at least five times throughout the flight. Both engines were reported to have stalled while the aircraft was preparing for landing, prompting the pilot to send out a Mayday signal. "The report's account of the incident is consistent with our understanding of the sequence of events leading to the landing. We will continue to co-operate fully with the CAD in its ongoing investigations," says Cathay. Experts from the airline are assisting a team of international aviation officials in the investigations, which are expected to take more than a year to complete, says the CAD. "We look forward to the final report which we believe will determine the cause of the emergency. This will enable us to ensure that all necessary steps are taken to avoid a recurrence of such an incident," says Cathay. Source: Air Transport Intelligence news Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Submarine signal analysis moves AF447 search to new site French investigators are to extend the search for a crashed Air France Airbus A330 to a new location, south of the current region under examination. The decision follows new analysis by the French Navy of audio signals detected by the nuclear submarine Emeraude which was brought in to assist the search for flight AF447 days after its loss on 1 June 2009. France's Bureau d'Enquetes et d'Analyses states that the information was originally picked up during the first phase of the search in the South Atlantic. "These [analysis] results were obtained very recently and made it possible to define a zone of a few dozen square kilometres in which the aircraft wreckage may be found," it adds. "Given this latest information, the BEA has decided to extend the searches to this zone." Three separate search efforts have been organised since the A330 crashed while en route from Rio de Janeiro to Paris, the third of which has been exploring a clearly-defined rectangular area north of the aircraft's last known position. But the BEA says that the latest information will focus the search on a location two hours' sailing time to the south of the area currently being scoured. Search efforts are set to start in this area on 7 May. The search team is using a single surface vessel, supported by autonomous underwater vehicles, for the work. The BEA is to provide an update on progress on 10 May. Source: Air Transport Intelligence news Back to Top [http://r20.rs6.net/tn.jsp?et=1103372331139&s=6053&e=001IM77unNtIYQXUSjUcPP2nUTtjX_wTfJHo58e8cPN9iwO2Zsk-rGxlJR8P_LZt16HRxhnI3U4eliAb1gTXNB8TFSex0U6zhVw] ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ United States Society of Air Safety Investigators 2010 Seminar "Learning From Investigations" The United States Society of Air Safety Investigators (USSASI) is pleased to announce the 2010 USSASI seminar! This two-day seminar (June 21-23) at the National Aircraft Accident Investigation School, Oklahoma City, OK, is intended to provide air safety professionals an opportunity to update professional knowledge and network with other air safety professionals. Attendees have the opportunity to participate in one of three breakout sessions! Choose from General Aviation, Commercial Aviation, or Helicopter Operations. Presenters are current investigators and air safety professionals who will share their lessons learned and discuss accident trends over the last decade, case studies, and current issues. Three workshops will also be offered to provide attendees an opportunity to enhance their skills and develop a few new ones! Attendees will choose one of three workshops: Bloodbourne Pathogens, Crash Survivability/Emergency Evacuation, or Aircraft Crash Laboratory/Boneyard. Lunch and coffee breaks will be provided on Tuesday and Wednesday. Tuesday evening is free night. Business casual attire recommended. For more information, please click here http://www.rotor.com/rotornews/May%2010/USSASI%20Registration-2.pdf [http://r20.rs6.net/tn.jsp?et=1103372331139&s=6053&e=001IM77unNtIYTmp1-EBlGTjSLNbMB5iULoQntDrPTQqKV2Q67buJkEC6QomjLhJkXTd81Ire7SpnmAnJYR9v4JH11-jZvNBya41HJLfDrAaK_byjsm7jKUuQPO9cKS6hMf_wl3Ot_AdmRrdon9y7kfNBqhBB6byB1wkeZDSzLX7ueyZ9NG6CPHag==] Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC