Flight Safety Information April 18, 2011 - No. 078 In This Issue FAA gives tired controllers an extra hour to rest Taking a harder look at planes' age Indian arrests reveal corruption in granting of pilot licenses The cost of aviation safety NTSB Report Details How Close United Airlines Flight 889 Came To A Midair Report: Canadair RJ uncommanded roll on takeoff in icing conditions Report: LOT B767 Erroneous instrument indications resulting in airspeed and altitude deviations In-flight mobile connectivity appears headed to United States ATR 72 in-flight upset traced to rudder maintenance fault Pacific Blue pilot faces fine, imprisonment JFK Collision Raises Concerns About Safety With Big Aircraft GRADUATE SURVEY REQUEST FAA gives tired controllers an extra hour to rest WASHINGTON (AP) - The government said Sunday it is giving air traffic controllers an extra hour off between shifts so they don't doze off at work, a problem that stretches back decades. But officials rejected the remedy that sleep experts say would make a real difference: on-the-job napping. "On my watch, controllers will not be paid to take naps. We're not going to allow that," Transportation Secretary Ray LaHood said. That's exactly the opposite of what scientists and the Federal Aviation Administration's own fatigue working group say is needed after five cases disclosed since late March of sleeping controllers. The latest one occurred just before 5 a.m. Saturday at a busy regional radar facility that handles high altitude air traffic for much of Florida, portions of the Atlantic Ocean and the Caribbean Sea. Several other countries, including Germany and Japan, permit controllers to take sleeping breaks and they provide quiet rooms with cots for that purpose. "Given the body of scientific evidence, that decision clearly demonstrates that politics remain more important than public safety," said Bill Voss, president of the Flight Safety Foundation of Alexandria, Va. "People are concerned about a political backlash if they allow controllers to have rest periods in their work shifts the same way firefighters and trauma physicians do." It has been an open secret in the FAA dating to at least the early 1990s that controllers sometimes sleep on the job. Toughest are the midnight shifts, which usually begin about 10 p.m. and end about 6 a.m. Scientists say it would be surprising if controllers didn't doze sometimes because they are trying to stay awake during the time of day when the body naturally craves sleep. Studies show that 30 percent to 50 percent of night-shift workers report falling asleep at least once a week while on the job, according to Dr. Charles Czeisler, chief of sleep medicine at Brigham and Women's Hospital in Boston. Six of eight present and former controllers interviewed by The Associated Press acknowledged they briefly fell asleep while working alone at night at least once in their careers. Most of the controllers asked not to be identified because they didn't want to jeopardize their jobs or the jobs of colleagues. Much more common is taking a nap on purpose, they said. On midnight shifts, one controller will work two positions while the other one sleeps and then they switch off, controllers said. The unsanctioned arrangements sometimes allow controllers to sleep as much as three hours or four hours out of an eight-hour shift, they said. The FAA does not allow controllers to sleep at work, even during breaks. Controllers who are caught can be suspended or fired. But at many air traffic facilities the sleeping swaps are tolerated as long as they don't affect safety, controllers said. "It has always been a problem," said former controller Rick Perl, who retired last year. In 1991, a Denver television station caught controllers leaving a regional radar center during midnight shifts to sleep in their cars, sometimes for as long as five hours. A former internal watchdog at the Department of Transportation, Mary Schiavo, recalled her office investigating a similar incident in Texas during the early 1990s. The problem of tired controllers was raised by the National Transportation Safety Board after a 2006 crash of a regional airliner in Lexington, Ky., that killed 49 of the 50 people aboard. The lone controller in the airport tower was wrapping up a schedule that compressed five eight-hour shifts into four days. He cleared a regional jet for takeoff and failed to notice the plane make a wrong turn onto a runway that was too short. The board cited pilot error as the cause of the accident, but noted the controller had slept only two of the previous 24 hours. The board also cited other incidences of mistakes by tired controllers. They include a controller who ordered a passenger jet to take off directly into the path of another jet at Chicago's O'Hare International Airport in 2006, and a controller who cleared a cargo jet for takeoff on a closed runway in Denver in 2001. An FAA and National Air Traffic Controllers Association working group, relying on sleep research by NASA, the Air Force, the Mitre Corp. and others, recommended in January letting controllers take naps for as long as 2 ½ hours on midnight shifts. They also recommended that controllers be allowed to sleep during the 20- to 30-minute breaks they receive every few hours during day shifts. Instead, the FAA's new rules will give controllers at least nine hours off between shifts, compared with eight now. That also was recommended by the working group, but a summary of their report notes the extra hour will likely result in only a "slight improvement" on midnight shifts. Controllers won't be able to swap shifts to get a long weekend unless there's at least nine hours off from the end of one shift to the start of the other, the FAA said. More managers will be on duty during the early morning hours and at night to remind controllers that nodding off is unacceptable. "We're going to make sure that controllers are well-rested. We're going to increase the rest time by an hour," LaHood said on "Fox News Sunday." Back to Top Taking a harder look at planes' age Passengers are more worried about planes' age after roof tears open in Southwest Boeing 737. How old is too old for an airplane? (AP) Most travelers don't think twice about it - although there's something unsettling about easing into your seat and finding the armrest still has an ashtray built in. But passengers may be more worried than usual after a 5-foot hole opened in the roof of a 15-year-old Southwest jet earlier this month. Southwest quickly grounded 79 of its older Boeing 737s for inspections. A well-maintained plane can fly for decades. Older planes do need more repairs, but experts say an aircraft's age has never been the cause of a passenger death. Pilot training and fatigue, as well as frequency of aircraft maintenance, are larger safety issues. The average age of jets flown by U.S. airlines is 11 years, slightly above the world average of 10 but far shy of the 28 for Venezuela's fleet - the oldest of any country with more than a handful of jets. Theoretically, a jet could continue flying indefinitely as long as an airline maintained it, says Bill Voss, president and CEO of the Flight Safety Foundation. The costs would eventually be prohibitive, though. Deciding when to mothball an airplane is usually a matter of the economics of the individual airline. Older planes need more frequent inspections, and bigger and costlier repairs. That means less time in the sky carrying paying passengers. Besides being cheaper to maintain, newer planes offer substantial fuel savings, and passengers enjoy features like personal TVs. "Aircraft become impractical a long time before they become unsafe," Voss says. Nearly one out of every four planes flown today by U.S. airlines is more than 15 years old. That's about the same share as a decade ago, according to aviation consulting firm Ascend. The government requires more frequent inspections as an airplane or certain parts get older. The Federal Aviation Administration doesn't set a mandatory retirement age for planes. Age isn't the only factor when it comes to safety. Each takeoff and landing cycle - and the pressurization and depressurization associated with it - adds stress to the skin of the plane. Aircraft that fly short, frequent routes go through more of these cycles than planes flying long distances. In 1988, a 19-year-old Aloha Airlines Boeing 737-200 that had made frequent, short hops among the Hawaiian islands lost a large part of its roof. Corrosion and metal fatigue were to blame. On April 1, a Southwest Boeing 737-300 with 118 people on board rapidly lost cabin pressure just after takeoff from Phoenix after the plane's fuselage ruptured, causing a 5- foot tear. Passengers reached for oxygen masks as the pilots quickly brought the plane down to an altitude with more oxygen in the air before making an emergency landing at an Arizona military base. No one was seriously injured. While the incident is still being investigated, the jet had been pressurized and depressurized 39,000 times in its 15 years and metal fatigue is suspected. Cracks were subsequently found on five other Southwest jets with more than 30,000 cycles. That came as a shock to the industry. Boeing engineers had forecast that the planes wouldn't need to be inspected for metal fatigue until at least 60,000 cycles. "It reminds us that as much we know about metal structures, we haven't figured it all out yet," Voss says. Flying is the safest form of public transportation. John M. Cox, an aviation safety consultant and former commercial pilot, says regulators do a good job of making sure airlines perform proper maintenance. "A '55 Chevy in the right hands could go hundreds of thousands of miles," he says. But that isn't much comfort to some passengers. After all, if the Chevy breaks down, you simply pull off to the side of the road. Emily Kahn of Portland, Ore., says she now does more research before booking a flight and is willing to pay more for a newer model of plane. "When the magazine rack in front of me is falling apart, it's not the best feeling in the world," Kahn says. "It makes me think they aren't spending enough time inspecting this plane." Of the 5,363 jets used by U.S. airlines today, almost 1,300 are more than 15 years old and 235 of them were built before 1988, the year the government banned smoking on most domestic flights. At least one site, airfarewatchdog.com, provided travelers this week with instructions on how to find the type of plane assigned to a route. "If you have a choice, why not go with a newer model?" founder George Hobica says. Passengers can check the make and model of a plane by entering the flight number on sites such as flightaware.com and flightstats.com. The airlines also usually provide that information on their websites. However, aircraft can be changed at the last minute. And none of the sites specify the age or maintenance history of a specific plane. Some airlines have much younger fleets than others. Virgin America, which only started service in August 2007, is flying planes that average just 3.4 years. Allegiant Air, which bought MD-80s once flown by Aeromexico and SAS Scandinavian Airlines, has an average fleet age of 21.5 years. Ascend aviation analyst Andy Golub notes that Allegiant picked up its used jets for bargain prices, meaning the company has plenty of cash on hand. "They have more than enough money to make sure that those aircraft are superbly maintained," Golub says. Even within an airline, there can be big differences. Delta Air Lines has an average fleet age of 16 years. Its 737-700s average less than two years old. But it also has more than 30 DC-9s that date back to the 1970s. They are the oldest commercial passenger planes flown today by a U.S. airline. Delta plans to retire those jets next year. Not even new planes have spotless safety records, of course. The last two U.S. fatal airline crashes - a Continental Express flight to Buffalo, N.Y., and a Delta Connection flight out of Kentucky - were both on relatively new planes, one and five years old respectively. Back to Top Indian arrests reveal corruption in granting of pilot licenses NEW DELHI - An Indian pilot made news here in January when she landed an Airbus 320 passenger plane on its nose wheel. Investigators soon discovered several alarming things: Parminder Kaur Gulati had not only made that dangerous mistake before, she also had earned her senior pilot's license through fake grades. Worse still, she had plenty of company. A government-ordered investigation has exposed a nationwide network of flight schools, aviation officials and others routinely forging grade sheets, fudging logbooks and accepting bribes. The revelation that some unqualified aspirants have made it into the cockpit is just one of a string of scandals that have roiled India in the past six months, but it is among the most serious, potentially endangering the lives of thousands. "It is worrying that people could get away with it for so long," said E.K. Bharat Bhushan, India's director general of civil aviation, showing files of fraudulent grade sheets. "These look so real. It really shakes you." Bhushan said he would not describe India's skies as unsafe, noting, "These are only a handful of our 8,000 certified pilots." Still, 29 pilots - including Gulati - have lost their licenses and 14 people have been arrested in the wake of the January incident, as officials comb through files from the past five years, scrutinizing the grades of more than 1,700 pilots and auditing 40 flight schools. India's airline industry expanded rapidly during that period. From 2009 to 2010 alone, passenger traffic grew by 19 percent. There were more than 51 million domestic passengers last year, and many of them used the numerous low-fare airlines that have sprung up. The boom also triggered a rush among India's youths for lucrative jobs as pilots. "So many flying schools opened in the boom time," Bhushan said. "There was a lot of competition, but hardly any oversight." To graduate from an Indian aviation school, students must log 200 hours of flying time, then pass four written tests. That qualifies them for a commercial pilot's license, which allows them to work as a co-pilot. To take command of an aircraft, they have to fly 1,500 hours and take additional written tests, which officials say 30 percent of candidates pass. "The questions in the tests are theoretical, irrelevant and chosen by bureaucrats who have never touched the controls of the aircraft," said a senior pilot who works for government-owned Air India and spoke on the condition of anonymity to avoid jeopardizing his job. "This is why so many resort to faking their test results. It's a well- oiled machinery. Flying hours cannot be fudged without the active connivance of aerodrome officials, aviation fuel suppliers, flying instructors and government officials. The rot affects the entire system - from top to the bottom." Pilots suspended in the past month worked for Air India and the private airlines SpiceJet and IndiGo, Gulati's employer. "We have busted two organized gangs from six cities that ran this racket of fudging test marks and booked them for cheating and forgery," said Ashok Chand, deputy commissioner of police in New Delhi's crime department. "The pilots' licenses have been canceled, but the court has granted them bail." Chand said the average bribe paid by aspiring pilots for a forged grade sheet was about $15,000. In India, cheating carries a maximum sentence of seven years in prison. The civil aviation minister, Vayalar Ravi, told the Parliament that a committee has been formed to develop tougher standards for verifying pilots' test grades and licenses. He also said that online testing may soon be an option, as part of the effort to limit the opportunities for tampering. The committee's report is expected by the end of the month. Priya Subramanian, from the southern city of Chennai, wanted to be a pilot and spent the past year checking out flying schools nationwide. "I visited six flying academies. It was so frightening because some of them are just operating out of one or two dilapidated, empty rooms. There is no runway, no aircraft most of the time," she said. "I often wondered about how dangerous it can be to fly in India. When the scandal hit the headlines, I was not surprised at all." Subramanian, 33, said she has put her dream of flying on hold until the government addresses the corruption in the system. In the past two years, the Civil Aviation Ministry also caught 57 pilots who reported drunk for work. The country's last major air accident was in May 2010, when a plane overshot a table- top runway upon landing, killing 158 people. The pilot was not Indian. http://www.washingtonpost.com/ Back to Top The cost of aviation safety Congress should help, not cut, the FAA and make sure it's properly staffed A pilot of a medical flight preparing to land Wednesday at Reno-Tahoe International Airport tried to contact the air traffic controller on duty. It was just after 2 a.m., and the pilot didn't receive a response. While the pilot circled, the regional air traffic control center in Oakland tried to reach the controller as well, both on the radio and by phone. No luck. Citing concern for a "pretty sick patient" on board, the pilot finally told regional controllers at 2:13 a.m. that he needed to land and made it down safely. FAA officials said the controller was asleep. It was the latest in a rash of incidents of sleeping or unresponsive controllers on overnight shifts. The FAA has reported incidents in Washington, D.C., Seattle, Tennessee and Texas over the past few months. Transportation Secretary Ray LaHood said he was outraged and said the problem "will not stand on my watch." That's good. This can't continue. On Wednesday, the agency immediately ordered 27 towers that are staffed overnight with one air traffic controller to add a second controller. The FAA is also conducting a top-to-bottom review of the nation's air traffic control centers and has reinforced nighttime safety procedures. On Thursday, the head of the agency's air traffic control centers resigned. FAA Administrator Randy Babbitt said the incidents "have rightly caused the traveling public to question our ability to ensure their safety." It should go without saying that air traffic controllers have to be awake during their shifts, but safety experts say that can be especially difficult when it's slow during an overnight shift. As USA Today reported Thursday, research shows that workers on midnight shifts are prone to more errors because of sleep issues. The FAA should address such fatigue in its review. At the very least, putting a second controller on duty overnight should help improve safety with extra backup, especially in case of an illness or emergency. But it's unclear what that will do to FAA's current staffing levels, which have seen a recent decrease. Air traffic controllers are already considered overworked and stressed. Congress should help the agency with staffing, but don't count on Republicans in the House of Representatives. For example, Rep. John Mica, chairman of the House Transportation and Infrastructure Committee, complained that the FAA was wasting money with a second overnight controller. The House previously passed a bill that would cut $4 billion from the FAA's budget - Republicans said it wouldn't affect safety. Mica said the agency could "do more with less." What does that mean? Fewer controllers working longer hours? There will certainly be efficiencies the FAA can find, but safety isn't a place where doing more with less typically works. The FAA said the budget cuts would, if nothing else, set back the implementation of a nationwide system designed to improve the air traffic control system. Republicans need to take responsibility. Budget cuts look good on paper, but what about the real-life effects? http://www.lasvegassun.com/news/2011/apr/15/cost-aviation-safety/ Back to Top NTSB Report Details How Close United Airlines Flight 889 Came To A Midair April 18, 2011 - United Airlines Flight 889 (N216UA) had just departed San Francisco Airport, California for Beijing, China with 268 onboard on March 27, 2010, when an operational error occurred at the San Francisco Airport Traffic Control Tower (SFO ATCT). Flight 889 (UAL889), a Boeing 777 and a Cessna 182 (N9870E) transiting the SFO class B surface area southbound toward Palo Alto, California, passed within approximately 480 feet laterally and 300 feet vertically of each other over San Bruno, California. Both aircraft were under control of SFO ATCT at the time of the incident. The crew of UAL889 filed a near-midair collision report and a Traffic Alert and Collision Avoidance System (TCAS) report following the incident. There was no damage reported to either aircraft, and no injuries to passengers or crew. According to a company report filed by the crew of UAL889, the SFO local controller cleared the flight for takeoff from runway 28L on the MOLEN 3 departure with clearance to climb to 3,000 mean sea level (MSL). The flying First Officer reported after the landing gear was retracted at approximately the runway end, and at 1,100 MSL, he heard the tower controller report traffic at 1 o'clock. This was followed immediately by the TCAS "TRAFFIC TRAFFIC" warning. According to the TCAS, the target was at 1,400 MSL. The pilots visually acquired a light high wing airplane in a hard left turn at their 1 o'clock position. Both crew members reported seeing only the underside of the airplane. Distance to the airplane described as slant range was 200-300 feet. The First Officer's response was to push forward on the yoke to level the airplane. The other airplane disappeared from view through the 3 o'clock position. The First Officer then looked back into the cockpit at which time TCAS annunciated "ADJUST VERTICAL SPEED", followed by a "DESCEND, DESCEND" command. The First Officer stated he complied with a push over to comply. The climb on MOLEN 3 was then continued. N9870E was operating from the area of the city of San Francisco southbound along US 101, a freeway that passes just west of SFO. The pilot contacted the SFO local controller at 1809:34, reporting level at 1,600 feet. The controller instructed the pilot to, "...keep highway 101 off your left side," and the pilot acknowledged. The route the pilot was following is a commonly used transition through the SFO class B surface area. UAL889 was a scheduled part 121 passenger flight operating from San Francisco, California, to Beijing, China. The pilot was instructed to taxi to runway 28L for departure. At 1810:10, the local controller cleared UAL889 into position and hold on the runway. At 1811:47, UAL889 was cleared for takeoff. At 1812:50, the local controller transmitted, "70 echo traffic off the departure end climbing out of 500 heavy triple 7." The pilot of N9870E responded, "70E in sight." The controller then continued, "70E maintain visual separation pass behind that aircraft." The pilot responded, "70E pass behind 'em." At 1813:03, the controller transmitted, "United 889 heavy traffic's uh just ahead and to your right has you in sight Cessna 1,500 they're maintaining visual separation." At 1813:13, the controller continued, "United 889 heavy traffic's no factor contact Norcal departure." The pilot of UAL889 responded, "OK, that set off the TCAS...that was...that...we need to talk." At 1813:47, UAL889 transmitted, "All right, trip...889's going to uh departure," and the controller acknowledged. At 1815:23, the pilot of UAL889 recontacted SFO tower to request a discrete frequency to contact the tower on. The controller instructed the pilot to contact the tower on 128.65, and the pilot acknowledged. At 1817:59, the controller-in-charge spoke with UAL889 on 128.65, advising the pilot, "...that was a VFR transition, and uh he was ahead and to your right, he had you in sight, he had visual, and he was instructed to pass behind you." The pilot responded, "Well, his uh flight path was definitely gonna be uh converging with ours and uh there was uh less than uh 500 feet separation between the aircraft if you could uh pull the tapes and uh pull any you know uh radar sweeps we'd appreciate it." The controller replied, "...understand - he did have visual with you. We'll uh we'll do that though, you can uh get that number from your ops if you want to call." The pilot requested the number, and the controller again stated that they would need to get the number from UAL operations. The pilot acknowledged and the contact concluded. The CIC logged the incident as a quality assurance review item in the Daily Record of Facility Operations. He also advised the front-line manager, who was out of the cab working on documentation of two previous incidents, of the United pilot's complaint. While still in flight, the captain of UAL889 recontacted the tower through UAL operations to discuss the incident further. The captain stated that she was very upset over the incident because of the close proximity of the Cessna, the lack of warning from the tower, and the TCAS alert indicating that the two aircraft were separated by only 200 feet vertically and horizontally. She questioned the tower's procedures and the separation standards applicable to the encounter, and stated that she would be filing paperwork on the incident. SFO ATCT did not initially file an operational error report on the incident. After review by service area and FAA headquarters management, the facility was directed to file an operational error report based on non-compliance with paragraph 7-2-1 of FAA Order 7110.65, and did so on April 5, 2010. Radar data for this report was obtained from the ASR-9 sensor located at Oakland, California, about 8 miles northeast of SFO. Two graphics showing an overview of the paths of the two aircraft and a close view of their minimum separation, have been entered in the docket. The applicable separation standard between VFR and IFR aircraft in class B airspace is either 1.5 miles laterally or 500 feet vertically. At closest point of approach, the aircraft were separated by about 480 feet laterally and 350 feet vertically, resulting in a minimum slant range distance between UAL889 and N9870E of about 600 feet. The local controller was assigned to SFO ATCT in 1999 and was qualified on all control positions in the tower. Asked about any unusual circumstances on the day of the incident, the local controller noted that he had been controller-in-charge earlier that morning when another controller had an operational error. Reporting of that incident and the associated paperwork required the attention of the front-line manager (supervisor) on duty and resulted in the supervisor being occupied with administrative duties outside the tower cab for almost the whole shift. That effectively reduced available staffing because the controllers then had to fill the CIC position as well as the control positions. Just before the incident, the radar coordinator asked the local controller if she should accept a handoff from Northern California TRACON on Cessna N9870E. As UAL889 was the only runway 28 departure pending, he told her to take the handoff. The Cessna reported over Hunter's Point (north of the airport), and the local controller instructed the pilot to keep highway 101 off of his left side as he proceeded southbound. The ground control position then began verbally coordinating with the radar coordinator regarding an aircraft that would be taxiing around the west end of runways 28L/R "after the guy on the runway." (UAL889) Ground control then amended the request to cross two aircraft instead of one. The local controller looked at the west end taxiway to check on the positions of the crossing aircraft and then cleared UAL889 for takeoff. He then looked back at taxiway Z to make sure that the taxiing aircraft were holding short of the runways while UAL889 departed. The local controller then looked at the radar display and realized there was a conflict between N9870E and UAL889. He pointed out the departing United aircraft as traffic to the Cessna pilot and instructed him to pass behind it. When interviewed, the local controller stated that after he recognized the conflict and told the Cessna to turn behind the departure, he believed that he had successfully resolved the problem. When the crew of UAL889 requested another frequency to talk to the tower on, the local controller advised the CIC that the pilot was upset about the transition traffic, they had gotten "too close," and the pilot wanted to talk to someone about it. The crew was given a spare frequency to use, and did contact the CIC to ask about the incident. The local controller stated that his normal scan when clearing an aircraft for takeoff is to scan the runway, check the radar display, then go back to the runway. He said that in this instance, he was distracted by the ground controller's taxi coordination and missed checking the radar display until after the departure was rolling. The local controller stated that the tower has a procedure for using a flight strip as a reminder that there are aircraft on the transition route. It is his normal practice to physically place the reminder strip on top of the flight strips for runway 28 departures, but in this case he did not use his normal procedure and he was not sure exactly where he placed the strip. The radar coordinator was assigned to SFO ATCT on November 23, 2008. She was still in training, and was certified on all positions except local control and cab coordinator. She described the duties of the radar coordinator as coordinating with NCT, coordinating with the ground control position about the use of taxiway Z at the west end of runways 28L/R, serving as a second set of eyes for local control, taking handoffs, scanning strips, and updating proposed departure times to prevent flight plan timeouts. The radar coordinator had been on position about two minutes at the time of the incident. She was engaged in coordinating a request from ground control to cross the west end of runways 28 with one or two aircraft. It was an extended exchange, and somewhat confusing because there was training in progress at GC. The trainee asked for one thing, and then the instructor changed it. The coordination was done verbally directly between the radar coordinator and the ground controllers, not on the interphone, so it was all audible to the local controller and may have momentarily distracted him. When the coordination with GC concluded, the radar coordinator reported hearing the local controller instructing N9870E to "...pass behind..." someone. She looked at the radar display and recognized the conflict. UAL889 had just acquired a radar tag after departure. With the training in progress and other activity in the cab, she stated that, "...it was pretty loud up there." When the radar coordinator took over the position, she did receive a recorded position relief briefing that included information on the Cessna, but she did not recall exactly what was said. Transition traffic is a normal part of the relief briefing, and she was aware of the Cessna when she took over the position. She last remembers seeing the aircraft "...pretty far north" in the tower's airspace, maybe near the Hunter's Point area or Candlestick Park. The controller-in-charge was assigned to SFO ATCT in 1991, and was qualified on all positions in the tower cab. When interviewed, he described the CIC's duties as "...answer the phones, watch the operation, deal with breaks, and perform other administrative duties." Around the time of the incident, the CIC was essentially occupied with administrative duties, and was not monitoring the operation. There is no local requirement for the CIC to directly monitor control positions. The CIC first became aware of the incident shortly after UAL889 departed, when the local controller told him that the pilot would be calling on frequency 128.65 about a Cessna. The CIC looked at the radar display and saw the Cessna about halfway between SFO and San Carlos. UAL889 was off the edge of the radar display by then. The pilot of UAL889 did call on the spare frequency to request information on the incident. During that discussion, the CIC asked the local controller if traffic had been issued, if the Cessna had the B777 in sight, and if visual separation had been applied. The local controller responded affirmatively to all three questions. The CIC advised the pilot of that information, and the conversation concluded. After this incident, SFO ATCT management and controllers initiated a review of the event and the circumstances leading up to it. The following actions were taken: The supervisor on duty on the day of the incident conducted a Quality Assurance Review, examining radio and radar recordings, interviewing the local controller involved, and identifying opportunities for improvements. The Air Traffic Manager discussed the incident with both pilots via telephone, and met with the captain of UAL889 at the tower. The facility produced a "Summary Report" of the incident, itemizing the existing SFO ATCT procedures that should have prevented it - including the ability to exercise more control over transitions, assistance to the local controller by the radar coordinator, use of memory aids, direct supervisor or CIC monitoring of the local control position, and better control over the timing of runway 28 takeoff clearances vs. transitioning aircraft. SFO ATCT also implemented short-term follow-up actions, including: Face-to-face supervisory briefings on new mandatory procedures for increasing awareness of runway 28 departures, including verbal announcements in the tower cab, mandatory use of memory aids, and focus on the radar coordinator's responsibility to assist the local controller. Team briefings on this and similar past incidents, including a replay of the UAL889 event. A Safety Risk Analysis panel that included an open discussion between management and controllers on all aspects of the UAL889 event and possible corrective or mitigating actions. Issuance of an Operational Notice revising coordination and control procedures for VFR transition traffic through the SFO class B surface area. Establishing a panel to review and discuss the current transition corridor, including representatives from the tower, SFO Airport, FAA Flight Standards, Northern California TRACON, Air Transport Association, the Aircraft Owners and Pilots Association, and the National Air Traffic Controllers Association. Coordinating with other FAA facilities having a stand-alone class B airspace position, such as LaGuardia and Newark, to discuss such operations and determine whether such a position would be beneficial at SFO. http://avstop.com/April_2011/ Back to Top Report: Canadair RJ uncommanded roll on takeoff in icing conditions The CRJ shortly before Stick pusher activates AIBN Norway published the final report of their investigation into an serious incident involving a Cimber Air Denmark Canadair CRJ200LR Regional Jet, January 2008. During take-off, immediately after lift-off, the aircraft suddenly lost lift on the right wing. The wing dropped, sending the aircraft into an uncontrolled 40-degree bank. The stall protection system activated, and the crew regained control On 31 January 2008, at 17:21 hours, a serious aircraft incident took place during take- off from runway 19L at Oslo Airport Gardermoen (ENGM). A Canadair CRJ200LR aircraft with two pilots and two cabin crew members on board suddenly lost lift on the right wing, causing the wing to drop and sending the aircraft into an uncontrolled 40-degree bank immediately after lift-off. The stall protection system activated, and the crew regained control and continued as scheduled to Copenhagen. The investigation has shown that prescribed de-icing took place 15 minutes prior to departure, and that the wings were not cold-soaked in advance. Weather conditions were temperature at freezing, 15 kt wind and continuous precipitation in the form of aggregated, wet snowflakes. The runway was covered by slush and wet snow which had fallen after the runway had been cleared of snow and sanded 30 minutes earlier. Unintentionally, due to distraction, the system for heating the leading edge of the wing was not switched on prior to take-off. The nose wheel was lifted from the ground at the correct speed, but at a higher than recommended rotation rate. This incident is one in a number of similar cases. From 2002 to 2008, six CL-600 series aircraft were involved in accidents during winter conditions. The wing of the aircraft type has proven to be especially sensitive to contamination on the leading edge. After the accidents, a number of measures have been implemented to ensure that the wing is clean during take-off, and to ensure that the pilots use the correct take-off technique. The AIBN believes that the safety measures that have been introduced have not resulted in a definitive solution to the problem. When the de-icing fluid runs off during take-off, it is essential that the leading edge of the wing is heated. On take-off from contaminated runways, spray from the nose wheel will envelop the aircraft's wing root. This source of contamination hits an aerodynamically critical area on the wing, and comes in addition to the precipitation which can adhere to the wing and disturb the airflow. The AIBN believes that it is not sufficient to depend solely on "soft" safety barriers such as check lists and memory when the position of one switch (Wing Anti-Ice ON) can be critical to prevent a catastrophic accident during take-off. Technical or physical safety barriers in the form of design changes, automatic systems or automatic warning systems are, in the opinion of the Accident Investigation Board, necessary to obtain adequate reduction in accident risk. Alternatively, more severe restrictions for winter operations with the affected aircraft models must be introduced. The Accident Investigation Board issues four safety recommendations. www.aviation-safety.net Back to Top Report: LOT B767 Erroneous instrument indications resulting in airspeed and altitude deviations TSB Canada published the final report of their investigation into an occurrence involving a LOT Polish Airlines Boeing 767-300, June 2009. Erroneous instrument indications resulted in airspeed and altitude deviations. The LOT Polish Airlines Boeing 767-300 (registration SP-LPA) operating as LOT 2 departed from Chicago-O'Hare International Airport (ORD) and was destined for Warsaw (WAW), Poland. At 22:03 Eastern Daylight Time, while the aircraft was in level cruise flight in the vicinity of North Bay, Ontario, Canada the captain's airspeed indicator suddenly increased above the maximum operating speed, and an overspeed warning was triggered. The flight crew reduced thrust to flight idle and initiated a climb. As the aircraft slowed, the overspeed warning stopped. The flight crew maintained the nose-up attitude with the reduced thrust setting but the captain's indicated airspeed suddenly increased again, causing a second overspeed warning. As the flight crew reacted to the second overspeed warning, a simultaneous activation of the stick shaker occurred. During the incident the aircraft climbed from 33 000 to 35 400 feet above sea level (asl) and then descended to approximately 27 900 feet asl. The crew diverted to the Toronto/Lester B. Pearson International Airport where the aircraft landed safely. There was no damage to the aircraft and none of the 10 crew members and 206 passengers were injured. Findings as to causes and contributing factors: 1.There was a fault within the phase locked loop (PLL) circuitry of the ADC which resulted in sudden and erroneous airspeed and altitude indications on the captain's instruments. 2.The readings on the captain's instruments were not compared to those on the first officer's or the standby instruments. Consequently, the crew believed the captain's instruments to be correct and made control inputs that resulted in significant altitude and airspeed deviations. Findings as to risk: 1.LOT Polish Airlines initial and recurrent flight training syllabus does not include practical training for an overspeed warning event. Consequently, flight crews may respond improperly and exacerbate the situation. 2.Although revision 5 of the Boeing SB 767-34A0332 requires changes to chapters of the FCOM, it does not specify what the changes should be. Therefore some manuals may not be properly amended, thereby increasing the risk of crews being ill-informed of the status of the aircraft they operate. 3.The LOT Polish Airlines FCOM incorrectly states that the IAS DISAGREE and ALT DISAGREE EICAS messages will not be displayed on the occurrence aircraft during an unreliable airspeed incident. This increases the risk of a crew misidentifying a problem. 4.The installation of CVRs with less than 2 hours of recording capacity creates the risk that relevant information will not be available to accident investigators and that significant safety issues may not be identified. 5.During the initial examination and disassembly of the ADC, it was noted that there was a large build-up of dust and dirt inside the unit, which could cause an increase in the internal temperature. Other finding: In the hold, with thrust at idle, the flight crew did not monitor the airspeed. In an attempt to maintain altitude, the autopilot increased the angle of attack until the stick shaker activated. During the recovery, the crew allowed the aircraft to climb through the flight's cleared altitude, resulting in a loss of separation. www.aviation-safety.net Back to Top In-flight mobile connectivity appears headed to United States In-flight mobile connectivity providers are cautiously optimistic of breaking into the US market after lawmakers dropped language from proposed FAA Reauthorisation legislation that would have imposed a permanent federal ban on the technology. At present, the use of mobile phones in flight is disallowed by the Federal Communications Commission (FCC) and the FAA. In an effort to ensure that a permanent federal ban remained in place, Representative Peter DeFazio and other lawmakers in 2008 introduced the "Hang-Up Act" to more formally prohibit wireless voice communications during flights, including voice over Internet protocol (VoIP), while ignoring wired voice communications. Hang-Up Act language was later added to FAA Reauthorisation legislation, but now both chambers of Congress have opted not to include the language in their respective bills. The Senate version of FAA Reauthorisation legislation has affirmed the current regulatory process - that the FAA and FCC can address in-flight connectivity when an airline application occurs by being silent about connectivity in its bill. Meanwhile, the House version of the FAA bill "has done a total reversal from the previous Congress where it advocated a ban", notes Carl Biersack, executive director of In-flight Passenger Communications Coalition (IPCC), a lobbying group established by industry rivals AeroMobile and OnAir, as well as Panasonic Avionics, Inmarsat and Rockwell Collins. The House wants three things, notes Biersack - a study on international deployment; a public comment period where all stakeholders can input their thoughts and concerns; and finally a report to Congress. Each of these three steps have a specified date for performance/execution based on the date of final passage and enactment of the FAA bill. "There should be a new FAA Reauthorisation bill from what I can see by the end of May and the House and Senate versions of that bill do not include any Hang-Up Act legislation whatsoever," says AeroMobile vice president, regulatory and programmes Kevin Rogers. An OnAir spokeswoman says: "The final version of a FAA Reauthorisation bill when adopted, is expected to include provisions mandating the FAA to conduct a study on the impact of cell phones for voice communications aboard aircraft. Such provisions will mark a significant milestone towards formulating a regulatory framework to enable certification and licensing of cell phone use (including voice communications) aboard aircraft." But could Hang-Up Act legislation be introduced in standalone form? Rogers believes that is "highly unlikely", noting that House transportation and infrastructure committee chairman John Mica is among the "strong supporters of what we're about". Before mobile connectivity can be brought on board US aircraft, however, the FCC must open a notice of proposed rulemaking (NPRM). As such, a change in FCC regulation could take "18 months or longer", notes Rogers. However, he adds: "I would say things are slightly better. No doubt work needs to be done with the telcos [telecommunications companies] to make sure there is no concern with regard to ground interference, which was their primary concern [when the FCC opened a NPRM on the matter in the middle of the last decade]." Adds AeroMobile CEO Pal Bjordal: "This provides the telcos with incremental revenue." Even though in-flight mobile connectivity has been offered in other parts of the world for years, the topic has proven a touchy one in the US. When DeFazio introduced his bill, he said the public "doesn't want to be subjected to people talking on their cell phones on an already over-packed airplane" and some studies have supported his claims. Detractors say DeFazio's proposal sought to "legislate manners". Rogers notes that it could take "18 months or longer" to get a change in FCC regulation, once the agency opens a NPRM. "There is light at the end of the tunnel," he says. Says OnAir: "Definitive steps should be taken by the FCC on its own initiative or in response to petitions from private parties including US airlines, effecting changes to the rule currently prohibiting communications with cellular phones on-board aircraft. More so as increased use of cellular service on international carriers continues to spark competition, underscored by the fact that passengers on planes offering in-flight connectivity prefer cellular services to Wi-Fi." Biersack says: "If either the House or Senate version of in-flight connectivity is enacted into law then airline passengers in America will have won the right to have a communication connectivity choice. After action by the FAA and the FCC, airlines in American airspace will have won the right to offer a passenger option that has a growing marketplace demand as reflected in overseas deployment and a usage that compliments the flying experience." ATI and Flightglobal understand that at least one US carrier is keen to offer AeroMobile in-flight mobile connectivity to passengers. Source: Air Transport Intelligence news Back to Top ATR 72 in-flight upset traced to rudder maintenance fault Investigators are warning ATR operators that a crucial rudder component could be installed incorrectly in the turboprop, after the crew of an Air Contractors aircraft experienced serious control problems after take-off from Edinburgh a month ago. UK Air Accidents Investigation Branch inspectors determined that the twin-engined aircraft had undergone routine maintenance on its rudder immediately before the 15 March flight. As the ATR 72-200 reached flight level 230, travelling through 185kt, it rolled 5-10° left while the rudder trim indicated fully-right. The co-pilot, flying, disengaged the autopilot and applied aileron and right rudder in a bid to correct the roll and side-slip. Some 15-20° of right bank was necessary to hold the heading constant. The crew requested vectoring to return to Edinburgh. "The co-pilot had to operate the control wheel with both hands in order to maintain directional control," says the AAIB. "The commander operated the power levers in the latter stages of the final approach." Neither of the two pilots, the only occupants of the ATR, was injured. The aircraft involved was a 21-year old airframe, serial number 183. The AAIB found that the maintenance at Edinburgh had involved disassembling the rudder's travel limitation unit, a system which reduces rudder deflection at speeds above 185kt. Two cams form part of the engaging mechanism to reduce rudder authority. While the left-hand cam had been correctly installed, the right-hand cam had been transposed through 180°. "Neither an independent inspection nor an operational test of the [limitation unit] was performed," says the AAIB, even though a test of the unit after removal or installation is required by the aircraft maintenance manual. The incorrect assembly was only discovered after the incident and the AAIB says that the maintenance manual does not indicate that the cam can be installed wrongly, which can lead to uncommanded rudder input in flight. It has urged ATR to inform operators of the potential problem and to revise testing procedures in the maintenance manual. The AAIB states that ATR "intends to take the necessary actions" in response to the investigation. Source: Air Transport Intelligence news Back to Top Pacific Blue pilot faces fine, imprisonment for aircraft endangerment New Zealand's Civil Aviation Authority has laid two charges against a Pacific Blue pilot in command of a Boeing 737-800 flight who failed to comply with his carrier's visual flight rules. The CAA says one of the charges against the pilot is unnecessary endangerment under section 44 of the Civil Aviation Act. If convicted, the offence carries a fine of up to NZ$10,000 ($7,930) or up to 12 months in jail, according to the CAA. It declines to specify the nature of the second charge. "The investigation concluded that the airline's procedures and operating conditions were breached in this take off event in June 2010, and that safety was compromised as a result," says CAA director Steve Douglas. The pilot was in command of Pacific Blue flight DJ89 on 22 June 2010 when the flight became delayed and departed Queenstown for Sydney approximately 18 minutes before twilight, the carrier says. Queenstown, on New Zealand's South Island, required flights to operate under visual flight rules since the airport did not have approach and runway lighting. Pacific Blue required its flights to takeoff no later than 30 minutes before twilight, ensuring adequate time for aircraft to make a safe return around the mountainous terrain in the event of a problem. That is more stringent than the CAA's rule requiring flights to take off before twilight. The Queenstown air traffic control tower gave DJ89 takeoff clearance, a spokeswoman for ATC provider Airways New Zealand says. "The tower was able to give clearance as the flight was within civil evening twilight. It was operating within CAA limits." Electing to ignore internal company rules, however, "was ultimately the pilot's decision". The CAA is not pressing charges against the flight's first officer or the airline. "I am satisfied that Pacific Blue had the appropriate procedures in place for operations conducted at Queenstown," Douglas says. The pilot has been stood down from duty pending a court ruling, a spokesman for Virgin Blue says. Pacific Blue is a New Zealand-based subsidiary of the Virgin Blue Group. The spokesman did not know the nationality of the pilot, who requested to have his name suppressed. "We note no action is being taken against the company and as the matter relating to the captain of that flight is now before the court, it would be inappropriate to make any further comment at this time," the spokesman says. Queenstown Airport is currently installing approach, runway, and passenger area lighting, a spokeswoman says. It expects to complete the installation this year. The airport already has precision approach path indicators available. The case is due to be heard in the Queenstown District Court. Source: Air Transport Intelligence news Back to Top JFK Collision Raises Concerns About Safety With Big Aircraft The April 11 mishap at a taxiway intersection at New York's John F. Kennedy International Airport, in which the wingtip of a taxiing Airbus A380 struck the tail of a Bombardier CRJ700 regional jet and spun the smaller aircraft nearly 90 deg., is raising some big questions. More precisely, the incident raises questions about how to ensure safe ground operations of really big commercial aircraft. The incident occurred at nighttime, and the Air France A380 crew, taxiing to a runway for takeoff, may not have noticed that the regional jet, operated by Delta Connection carrier Comair, had stopped instead of proceeding to its gate, especially with the light rain, darkness, reflections of light and glare, suggests Kevin Hiatt, a former Delta Air Lines pilot who is now executive vice president of the Alexandria, Va.-based Flight Safety Foundation. No one was injured, but the mishap drew wide media coverage and Internet saturation, largely because of a video showing the strike and spin. Inevitably, size-related safety questions arose. An Air France A380's wingtip was damaged when it struck a Delta Connection CRJ700's horizontal stabilizer at JFK Airport April 11. The Airbus A380 is the biggest of the commercial airplanes, with dimensions that include a wingspan of nearly 262 ft, (80 meters), about 50 ft. wider than on a Boeing 747-400. But the conversation also included Boeing's 747-8, a freighter with a wingspan of 225 ft., about 13 ft. longer than on a 747-400. The FAA sets design standards that govern how an airport must be configured to safely accommodate aircraft with certain dimensions. A 747, for example, operates under Design Group V standards. The A380 and 747-8 are supposed to operate under Design Group VI standards, which call for wider taxiways and more separation from the service road. Some of those standards are intended to reduce the risk of aircraft bumping into each other while moving on the ground. But those standards are much easier to accomplish if an airport is starting from scratch; it might not be feasible or practical to implement them at an existing airport, particularly one with limited space. That is why many airports have applied for waivers from the Group VI standards by submitting alternative proposals for maintaining an acceptable level of safety, which must be accompanied by safety studies. The FAA has granted more than dozen waivers for airports that committed to precautions such as restricting which taxiways and ground routes the larger aircraft can take, or perhaps adjusting what other aircraft can do while the bigger aircraft are on the move. One of those airports is Kennedy, so it is not surprising that the incident draws the waivers into question. It is not a trivial concern for safety-or the airplane manufacturers, which need the waivers so their aircraft can operate at more airports. The idea of the A380, after all, is to provide more capacity at congested airports, and many more of the airplanes will be flying in the coming years, serving airports with a lot of moving pieces. "Kennedy is one of those places where things are always moving and always changing," says Hiatt, who flew for Delta for more than 26 years In reality, however, both Airbus and Boeing probably can rest easy. The NTSB investigation is likely to focus as much on the Air France crew and ground control as on the waivers, if not more so. But the incident should create more caution. "I don't think really it's a systemic problem, but I do think it's an issue that needs to be looked at," Hiatt says of the movements of aircraft with larger wingspans. "You have to make sure those big guys have the proper clearance." Dick Marchi, a senior adviser for Airports Council International-North America, suggests controllers, who devote more attention to runway clearance, might be given more responsibility for taxiways. So, is this incident indicative of a big problem? Based on the evidence seen so far, it is not yet. But a little more vigilance would be helpful, lest it become one. http://www.aviationweek.com Back to Top GRADUATE SURVEY REQUEST April 18, 2011 Dear Safety Director or Manager, I am a student in the Master of Aeronautical Science Program at Embry-Riddle Aeronautical University working on my Graduate Capstone Project on air carrier safety management systems (SMS). I am inviting you to participate in my research project to survey scheduled air carriers to find the differences between adopters and non-adopters of SMS. The survey should take no more than ten minutes of your time to complete. I hope that my findings from the survey will offer insights into the levels of safety between air carriers who have implemented SMS and those who have not. If you choose to participate in my survey, please follow this link to zoomerang.com to answer the survey questionnaire: http://www.zoomerang.com/Survey/WEB22C8RMK8PCA/ This website is utilized as a tool to collect and disseminate data only. I do not endorse the website, nor have benefitted in any way from its use. I assure that your responses and participation in this survey will remain anonymous. If you are interested in receiving a copy of the results, please send an email to me at terasakr@my.erau.edu. Your participation in this survey will provide valuable information regarding safety management systems for scheduled air carriers. Thank you for your time and consideration. Sincerely, Richard J. Terasaki Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC