Flight Safety Information January 14, 2011 - No. 011 In This Issue Crash report angers Poles and shakes ties with Russia 17 years of FAA delay on NTSB air safety recommendations Boeing 737 Runway Excursion A320 Runway Excursion DGCA risked safety with crew cut? Carson Helicopters breaks silence about NTSB accident report EtQ to Host Aviation Safety Management System Summit Crash report angers Poles and shakes ties with Russia WARSAW - The crash last spring of a plane carrying Poland's president and other top officials outside the Russian city of Smolensk unexpectedly drew Poland and Russia closer together. Now, Russia's report on the crash is driving the longtime antagonists apart again - and dividing Polish politicians as well. Polish Prime Minister Donald Tusk cut short a trip Thursday to return to Warsaw, where he attempted to contain the anger building here over the report's findings, published a day earlier. The Russian investigators blamed Polish pilots for the crash, which killed President Lech Kaczynski and 95 others, and suggested they were pressured into attempting a landing by a Polish general who had been drinking on the flight. Good relations with Russia are too important to throw away, Tusk said. At the same time, he said, "the alternative to truth is a lie, and these relations can't be built on a lie." He said he does not contest the "reasons" for the crash, as identified in the report, but wants to address its "circumstances," which he said the report ignores, including Smolensk's airport being kept open despite bad weather and the possible role of Russian air traffic controllers. Tusk said he wants to open negotiations with Russia over a rewrite. "It's not about some false symmetry," he said. "It's important for Polish-Russian relations to have common agreement and get rid of all doubts." That brought a swift retort from Polish opposition lawmakers. Tusk was acting too late and attempting too little, said Stanislaw Wziatek of the Democratic Left Alliance. He accused the prime minister of "wishful thinking" and said he should have started pressuring the Russians before the inquiry's report was released. "Now it's too late for a common stance," he said. If Poland's concerns are not recognized by the Russians, "it will be a slap in the face for Poland," said Grzegorz Napieralski, a colleague of Wziatek's. He accused Tusk of trying to score political points by grandstanding over the report without actually attempting to refute it. The Poles agreed, however, that the inquiry had begun in a spirit of solidarity, but that over the summer the Russians had grown less and less cooperative. In Moscow on Thursday, Russian Transport Minister Igor Levitin derided Poland's response, suggesting it was cherry- picking the evidence to shift some blame to Russian air controllers when there were decisive grounds for finding the pilots in error. http://www.washingtonpost.com Back to Top 17 years of FAA delay on NTSB air safety recommendations After investigating more than 140,000 aviation accidents, the National Transportation Safety Board has fact-based authority for its recommendations on how to make the skies safer. Unfortunately, the Federal Aviation Administration doesn't always pay heed. Case in point: Even though nine people died in glider-aircraft collisions over the past 20 years, FAA has still not followed NTSB's 2008 recommendation to require gliders to carry transponders so that air traffic controllers and other pilots can "see" them in the sky. Nor has FAA followed through on other recommendations that would establish a national transponder code specifically for gliders, ensure that air traffic controllers know the new code, and develop guidelines for "the prompt installation and approval of transponders" on gliders. Apparently, the FAA just doesn't do prompt. NTSB's oldest "open" recommendation, made 17 years ago when Bill Clinton was president, urged FAA to require that pilots get ongoing training to take immediate evasive action whenever warned by the Traffic Collision and Alerting System in the cockpit. TCAS sounds a warning whenever it thinks another aircraft has gotten too close. NTSB "believes it is crucial for flight crews to be able to quickly evaluate, interpret, and execute" TCAS commands, and that because response time is literally a matter of seconds, training should be ongoing and not limited to pilots' initial orientation. But FAA has still not formally implemented this commonsense recommendation. Like transponders, TCAS is designed to keep planes a safe distance apart. A close call last March in San Francisco illustrates why ongoing pilot training is necessary. The crew of a United Boeing 777 headed to Beijing with 181 people aboard reported seeing the underside of a small private plane that had been cleared by air traffic controllers just seconds after hearing their TCAS alarm go off. The planes came within 300 feet of colliding. The good news is that of 787 TCAS activations reported to NTSB between March 2010 and January 2011, when NTSB started collecting its own cockpit collision-avoidance data, only a "handful" are considered worrisome, a board spokesman told The Washington Examiner. The bad news? "The fact that separation of aircraft had to be maintained by the flight crews in response to an anti-collision warning rather than by air traffic control may warrant further inquiry," the spokesman said. TCAS' importance in preventing mid-air collisions was heightened on Dec. 21, when Department of Transportation Inspector General Calvin Scovel issued a report to Congress noting a "cascading effect" of serious flaws -- including software glitches -- in NextGen, the FAA's new $2.1 billion air traffic control system. Scovel pointed out that numerous gaps remain between another federal aviation advisory committee's recommendations and FAA's actions to date. Late last month, FAA published a proposed Airworthiness Directive in the Federal Register that would require flight operators to upgrade TCAS units that failed in tests over high-density airports because it "could compromise separation of air traffic and lead to subsequent mid-air collisions." If FAA acknowledges the importance of on-board collision avoidance technology, why has it not implemented NTSB's recommendations on glider transponders and TCAS training, which both have the same goal? An FAA spokeswoman told The Examiner that the TCAS issue is part of a "major rewrite" of training rules for pilots and dispatchers, but did not explain why this process has taken 17 years. By coincidence, FAA is now operating on its 17th extension since its last reauthorization bill expired in 2007. NTSB is a purely investigative agency with no power to force FAA to follow any of its recommendations, but members of Congress have a lot of leverage over the aviation agency. The question is, will they use it before another tragedy happens. http://washingtonexaminer.com/ Back to Top Boeing 737 Runway Excursion Status: Preliminary Date: 10 JAN 2011 Type: Boeing 737-2T5 Operating for: Africa-Air Charter Leased from: Safair Registration: ZS-SGX C/n / msn: 22396/730 First flight: 1981-01-16 (30 years ) Crew: Fatalities: 0 / Occupants: Passengers: Fatalities: 0 / Occupants: Total: Fatalities: 0 / Occupants: Airplane damage: Substantial Location: Hoedspruit AFB (HDS) (South Africa) Phase: Taxi (TXI) Nature: Domestic Non Scheduled Passenger Departure airport: Hoedspruit Airport (HDS) (HDS/FAHS), South Africa Destination airport: Johannesburg-O.R. Tambo International Airport (JNB) (JNB/FAJS), South Africa Narrative: A Boeing 737-2T5 passenger jet, registered ZS-SGX, sustained substantial damage in an accident at Hoedspruit AFB (HDS), South Africa. There were no fatalities. The airplane operated on a flight from Hoedspruit Airport (HDS) to Johannesburg-O.R. Tambo International Airport (JNB). The accident happened at night when the plane was taxied for a runway 18 departure. Taxiway A leads to runway 18 and has several entries to runway 18. The crew possibly intended to use full runway length of the runway and were planning to take taxiway C to enter the runway. However the crew missed taxiway "C" and continued straight ahead. The taxiway ends up on a tar road and doesn't lead back to any taxiway. The crew attempted to turn the aircraft using reverse thrust but it ran off the taxiway backwards into the bush. www.aviation-safety.net Back to Top A320 Runway Excursion Status: Preliminary Date: 10 JAN 2011 Time: 22:02 Type: Airbus A320-216 Operator: AirAsia Registration: 9M-AHH C/n / msn: 3427 First flight: 2008-02-14 (2 years 11 months) Engines: 2 CFMI CFM56-5B6/P Crew: Fatalities: 0 / Occupants: 6 Passengers: Fatalities: 0 / Occupants: 123 Total: Fatalities: 0 / Occupants: 129 Airplane damage: Substantial Location: Kuching Airport (KCH) (Malaysia) Phase: Landing (LDG) Nature: Domestic Scheduled Passenger Departure airport: Kuala Lumpur Subang International Airport (KUL) (KUL/WMKK), Malaysia Destination airport: Kuching Airport (KCH) (KCH/WBGG), Malaysia Flightnumber: 5218 Narrative: An AirAsia Airbus A320-216 passenger jet, registered 9M-AHH, sustained substantial damage in a runway excursion accident at Kuching Airport (KCH), Malaysia. All 123 passengers and six crew members survived. The airplane operated on flight AK5218 from Kuala Lumpur Subang International Airport (KUL) to Kuching Airport (KCH). The flight landed on Kuching's runway 25 in heavy rain around but skidded to the right and went off the side of the runway. It came to rest in the grass with the nose gear dug in or collapsed. According to AirAsia the aircraft landed at 20:02. Media reports indicate the accident happened around 22:00, which seems more likely given the scheduled departure time of AK5218 of 19:40. Weather about the probable time of the accident, 22:00 (14:00 UTC) was reported as: WBGG 101400Z 36010KT 2000 +TSRA FEW015CB SCT020 BKN150 25/24 Q1007 TEMPO 1000 +TSRA= [14:00 UTC: Wind 360 degrees at 1 knots, Visibility 2000m; Heavy thunderstorm with rain; Few clouds with cumulonimbus 1,500 ft., scattered clouds 2,000 ft., broken clouds 15,000 ft; Temperature 25°C, Dewpoint 24°C; 1007 hPa; Temporary visibility 1000m] www.aviation-safety.net Back to Top DGCA risked safety with crew cut? (India) If you are flying Air India, pay full attention to pre-flight safety instructions. If there is an emergency, you may find that there is no flight attendant at the exit that you have rushed to. The door will be open and the inflatable slide deployed, but no one will be there to monitor and speed up the evacuation. In a December 30, 2010 order, A K Sharan, joint director-general of civil aviation, allowed Air India to operate some of its aircraft with fewer flight attendants than what is deemed safe by other airlines and countries. Air India can operate its Boeing 777-200 LR with a minimum of five attendants instead of eight, Boeing 747-400 flights with nine instead of 12 and Boeing 777-300 ER with seven instead of 10 cabin crew members. In these aircraft, three flight attendants will each be in charge of two exit doors that are opposite each other at an average distance of 15 feet. It means that unlike other aircraft and airlines, in these Air India aircraft, every exit will not be manned by a cabin crew member during an emergency. ''In a fully occupied wide-body aircraft like the Boeing 747 or B777, it's essential to have a trained cabin crew member at each exit,'' said Ed Galea, director, Fire Safety Engineering Group, University of Greenwich, London. ''Expecting a single cabin crew member to safely and efficiently operate two exits in an exit pair of a wide-body aircraft is unrealistic and can compromise the safety of passengers and crew in the event of an accident.'' Bharat Bhushan, director-general of civil aviation, unavailable for comment. An Air India spokesperson said, ''Air India doesn't do anything without the express consent of the authorities.'' He added that the airline has a zero-tolerance policy towards safety violations. Capt M Ranganathan, an air safety expert, said, ''Before the aviation regulator permits a degraded operation, they should have demanded a safety assessment from the airline to ascertain whether the fewer cabin crew members can evacuate the aircraft within 90 seconds.'' An airline source said, ''No mock drills or safety assessment was carried out.'' The primary responsibility of a cabin crew member is flight safety and an emergency evacuation is the most testing job. An emergency evacuation is a procedure carried out on land or water in event of a fire, engine failure, explosion, crash-landing, ditching or any such accident/incident. During such emergencies, chances of survival often depend on speed of evacuation. http://timesofindia.indiatimes.com/ Back to Top Carson Helicopters breaks silence about NTSB accident report Charging the National Transportation Safety Board with trying to make his company a scapegoat for the 2008 helicopter crash that killed nine people, the president of Carson Helicopters Inc. rejects the board's conclusion that excess weight and lack of oversight caused the accident. In an open letter released Wednesday morning, company president Franklin Carson in Perkasie, Pa., said the firm has, until now, maintained silence to allow the investigation to proceed. But the board's "arbitrary and one-sided" hearing last month in Washington, D.C., forced the company to go public, he said. "Carson is extremely sorry this accident occurred and grieves for the accident victims and their families," he wrote. "We have done our best to do the right thing by the families and will continue to do so as we pursue the root cause of this accident. "We will not, however, stand silently by while the NTSB ignores an ongoing safety of flight issue by trying to make Carson a scapegoat," he added. The Aug. 5, 2008, crash in Northern California killed nine people, including seven firefighters from Jackson and Josephine counties. The accident occurred on a nearly 6,000-foot-high mountaintop near Weaverville, Calif., while the Sikorsky S-61N helicopter was ferrying out firefighters battling the Iron 44 fire in the Trinity Alps Wilderness. Carson said the board ignored testimony by co-pilot William "Bill" Coultas, 46, of Cave Junction, that the crash was caused by the loss of power in the No. 2 engine shortly during takeoff. They also ignored Coultas' actual air temperature at the scene to fit "their preconceived narrative," he wrote. Higher temperatures can reduce a helicopter's lifting ability. Coultas, the only surviving crew member, expressed similar concerns in an interview with the Mail Tribune immediately following the NTSB hearing last month. Moreover, the NTSB lost the aircraft's fuel control unit early in the investigation and failed to investigate that loss, Franklin Carson wrote. The NTSB stands by its full report and completed investigation, board spokeswoman Bridget Serchak indicated in an e-mail to the Mail Tribune on Wednesday. "... These materials together represent the sum of NTSB's response and position on this investigation," she wrote. "Any party to an NTSB investigation is permitted to file a petition for reconsideration and we would respond through standard NTSB procedures," she added. The board's investigators said the helicopter firm deliberately understated the helicopter's weight by more than 1,000 pounds in order to make it appear the aircraft could safely carry a heavier payload. That helped the firm win a Forest Service firefighting contract, they said. The NTSB report concluded that both the Forest Service and the Federal Aviation Administration failed to notice a deliberate understatement by Carson of the helicopter's weight. The NTSB's full accident report, covering some 500 pages, can be viewed at www.mailtribune.com/ntsbfinalreport. Franklin Carson countered that the NTSB did not properly explore contaminants inside the fuel control unit and refused to participate in flight tests which demonstrated the aircraft had sufficient power to fly that day. Further, the primary NTSB investigation team had no relevant helicopter experience to properly investigate the accident, he wrote. "For months, Carson believed that important evidence had been mishandled and was then ignored by the NTSB investigators in order to close the investigation as quickly as possible," he wrote. "We brought our concerns to the NTSB's attention on numerous occasions." When the board held a news conference on Dec. 7, 2010, stating that the main cause of the accident was Carson's alleged use of false charts and weights, "I knew that my faith in a fair and impartial investigation had been ill-founded," he added. The NTSB concluded that the firm, whose Pacific Northwest office is in Merlin, deliberately understated the weight of its Sikorsky. That, along with lapses in safety oversight by federal agencies, resulted in the crash, it said. The deadliest helicopter crash involving working firefighters in U.S. history killed firefighters David Steele, 19, Ashland; Shawn Blazer, 30, Medford; Scott Charlson, 25, Phoenix; Matthew Hammer, 23, Grants Pass; Edrik Gomez, 19, Ashland; Bryan Rich, 29, Medford; and Steven "Caleb" Renno, 21, Cave Junction. Command pilot Roark Schwanenberg, 54, of Lostine, and check pilot Jim Ramage, 63, of Redding, Calif., also died. Ramage was a U.S. Forest Service employee. Coultas was seriously injured along with local firefighters Richard Schroeder Jr., Jonathan Frohreich and Michael Brown. All of the firefighters were employed by Grayback Forestry Inc. of Merlin. Both the Coultas and Schwanenberg families have sued General Electric and its parent company, United Technology, as well as Sikorsky and Columbia Helicopters, citing engine failure, among other things, as the cause of the deadly crash. http://www.mailtribune.com/ Back to Top EtQ to Host Aviation Safety Management System Summit EtQ, Inc., is pleased to announce its first-ever Aviation Safety Management System (SMS) Summit to be held on February 1, 2011 at the Tempe Mission Palms Hotel in Tempe, AZ. This summit is a free event designed to provide professionals in the aviation industry with knowledge to help them in their SMS initiatives. It will feature sessions on key SMS topics from world-renown aviation experts and is ideal for Aviation Safety Professionals who wish to learn more about how to incorporate a simple, yet effective, risk-based Safety Management System. Topics will include: · What technologies are available to automate the SMS · How some companies are currently automating their SMS · How to bring about convergence of Quality and Safety systems under a single platform "EtQ is offering this seminar to provide those in the Aviation industry with information on the enterprise SMS as well as provide insight into how technology can help them in their SMS journey," stated Morgan Palmer, Chief Technology Officer at EtQ. "We look forward to meeting with the Aviation community and in dissecting the enterprise SMS- from its various technology enablers to a look into its past, present, and future." EtQ's SMS Summit will include sessions led by Bill Voss, President and CEO of the Flight Safety Foundation; Morgan Palmer; and case studies presented by Peter Blake, Senior Vice President of Safety of Korean Air; and Callie Choat, Director of Safety Assurance and Environmental Programs at US Airways. For more information or to register for EtQ's free SMS Summit, visit us at http://www.etq.com/smssummit/. About EtQ EtQ is the leading Enterprise Quality, Environmental Health and Safety, and Compliance Management software for identifying, mitigating, and preventing high-risk events through integration, automation, and collaboration. EtQ for Aviation is an integrated Aviation Safety Management System that has been pre-configured to specifically address the needs of the Aviation industry and maintain compliance to the standards set by regulatory bodies such as the International Civil Aviation Organization (ICAO) as well as Government Regulatory agencies such as Transport Canada and the Federal Aviation Administration (FAA). EtQ uses best in class, integrated modules and enterprise application integration to manage and measure quality and compliance processes and execute organizational change. Key modules within the product include Job Safety Analysis, Accidents and Safety Reporting, Risk Register, Failure Mode and Effects Analysis (FMEA), Document Control, Corrective and Preventive Action (CAPA), Audits, Risk Management, Employee Training, Enterprise Reporting, and more. With its world-class flexible workflow, collaborative platform, EtQ has developed a unique niche to support enterprises involved in various compliance management initiatives such as ISO 9001:2008, ISO/TS 16949, ISO 14001, AS 9001, TL 9000, OHSAS 18001, RoHS, Sarbanes-Oxley, and similar standards for compliance and regulatory management. EtQ has been providing compliance solutions to a variety of markets for over 15 years. For more information or to schedule a virtual demo, contact EtQ Inc., at 800-354-4476 or 516-293-0949, or e-mail us at info(at)etq(dot)com. Visit us on the Web at http://www.etq.com. Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC