Flight Safety Information May 25, 2011 - No. 107 In This Issue Investigators unable to determine cause of crash that killed Ted Stevens Early Reports of Pilot Error in Air France Crash Are Condemned Runway accidents a global issue FAA, AFA Team Up For Passenger Safety Airbus Plans Higher Max Takeoff Weight For A380 Indonesia bans MA-60 aircraft from three airports FAA investigates 2 more snoozing air traffic controllers Investigators unable to determine cause of crash that killed Ted Stevens A month before he flew a plane carrying former U.S. senator Ted Stevens into an Alaskan mountain last summer, pilot Terry Smith seemed so unfocused on one occasion that an aviation museum staff member worried that he was unfit to fly their planes, according to testimony Tuesday before the National Transportation Safety Board. "There's something wrong with Terry," the staff member said, according to the testimony. The employee reported that he found the veteran Alaskan pilot "staring into space" like an "Alzheimer's patient" as he was about to fly a plane at the Alaska museum. Witnesses also testified about concerns that a 2006 stroke might have affected Smith's cognitive abilities. At the end of the hearing, however, the NTSB was unable to determine what caused Smith to go off course and fly into the side of mountain last summer, killing Stevens (R-Alaska) and four others. "We just didn't have enough weight behind any of the possible scenarios to draw a conclusion," said NTSB Chairwoman Deborah A.P. Hersman. The plane crashed into a remote, rugged mountainside Aug. 9 while flying Stevens and a party of friends and colleagues from a log-cabin lodge on Lake Nerka to a camp where the silver salmon were running. Smith, Stevens, Washington lobbyist William "Bill" Phillips Sr. and an executive with the telecommunications company that owned the lodge and her teenage daughter died in the crash. All four of the survivors - former Stevens staff members Sean O'Keefe and Jim Morhard, O'Keefe's college-age son, Kevin, and Phillips's 13-year-old son Willy - were seriously injured. According to the testimony presented at the two-hour hearing, Smith was alert and conversant during lunch prior to the flight, took off with eight passengers on board and flew a normal path on a familiar route and then inexplicably turned into the mountainside. Alarms went off in the cockpit about five seconds before impact, and Smith tried without success to put the plane into a steep climb. The sound on a system that would have given an alarm 30 seconds before the crash had been turned down. Three autopsies on Smith failed to provide any evidence he had suffered a stroke or a seizure. But investigators did not rule out either possibility. Kevin O'Keefe was asleep in the co-pilot's seat, and none of the other survivors was positioned to observe Smith in the minutes before the crash. Michael A. Garber, an NTSB investigator, said Smith had suffered from disorientation and confusion after suffering a stroke at age 58. "He had to relearn certain skills having to do with driving and flying," Garber said. Investigators said Smith also had experienced three "life events" in the weeks leading up to the crash. He had retired for the second time after a long career in commercial aviation in Alaska, his daughter had married, and a son-in-law had been killed in an airplane accident. Citing reports that stress might have resulted in fatigue, Garber said, "We do know that sleep deprivation can increase the risk of a seizure." The NTSB was critical of the process by which the Federal Aviation Administration cleared Smith to return to flying after his 2006 stroke. NTSB staff investigator Michael A. Garber told the board that the FAA restored Smith's license to pilot commercial planes without fully evaluating whether he was fit to fly. He said the FAA relied solely on the word of a flight surgeon who was "out of his element" in evaluating a patient who FAA officials knew had cognitive problems for months after the stroke. FAA spokesman Les Dorr said the agency has revised procedures to require more stringent evaluation of pilots who suffer strokes. "We're confident that since we've changed the policy no post-stroke pilots have been certified," Dorr said. Hersman also was critical of the FAA for declining to follow an NTSB recommendation to require inexpensive on-board video recorders on small planes. "Technology is moving faster than the FAA moves," she said. http://www.washingtonpost.com/local/investigators-unable-to-determine-cause-of- crash-that-killed-ted-stevens/2011/05/24/AFyQ6hAH_story.html Back to Top Early Reports of Pilot Error in Air France Crash Are Condemned The main pilots' union at Air France and relatives of the 228 people who died in the Atlantic crash of Air France Flight 447 two years ago strongly condemned reports Tuesday suggesting that crucial errors by the jet's crew might have led to the disaster. (NYT) In recent days, a series of reports have surfaced in the European and American news media purporting to describe details that accident investigators have gleaned from the data contained in the plane's so-called black boxes, which was successfully downloaded last week. Some of those reports, citing anonymous sources, have suggested that the data indicates that the crew reacted to a cascade of system failures on the Airbus A330-200 jet exactly as they had been trained to do, while others have said there was evidence that the pilots failed to follow standard procedures. "Every day there's a new leak," said Jean-Louis Barber, president of the Air France branch of France's main pilots' union, Syndicat National des Pilotes de Ligne, which represents 80 percent of Air France's pilots. "It is inconsistent, it is scandalously damaging and it is preventing investigators from doing their work." For the past week, technical investigators at the nation's Bureau of Investigations and Analyses, or B.E.A., have been poring over more than 1,300 pieces of flight data and two hours of cockpit voice recordings. The bureau is expected to publish a brief chronology of the events captured on the recorders on Friday, but a fuller analysis of the probable causes of the accident is not expected before the end of July. A criminal inquiry led by a Paris magistrate is also under way, though experts said it would take several months to reach any conclusions. Air France and Airbus have been placed under formal investigation for involuntary manslaughter - a step short of being charged. Late Monday, The Wall Street Journal reported that the Air France pilots apparently became distracted by inconsistent airspeed readings as the plane entered extreme turbulence and failed to properly address other flight systems as they sought to troubleshoot the problem. The report, which cited unnamed people familiar with investigators' preliminary findings, suggested that problems with the airspeed sensors led the plane's autopilot to disengage and that the pilots then allowed the plane to slow down dangerously and stall. Meanwhile, a report over the weekend by the German magazine Der Spiegel cited an anonymous expert as saying Flight 447 did not encounter any increased turbulence. The report said that the plane shuddered after the airspeed sensors failed and that the plane's two co-pilots, and not its captain, were at the controls. A B.E.A. spokeswoman declined to comment on Tuesday. Representatives for Airbus and Air France said they would not respond before the publication of the chronology on Friday. Robert Soulas, whose daughter and son-in-law died in the crash, said he found the recent volley of news media reports "deplorable." "This is extremely upsetting for the families," said Mr. Soulas, a spokesman for Entraide et Solidarité AF447, a group representing relatives of 60 of the victims. "I am thinking in particular of the families of the pilots who are being anonymously accused and cannot defend themselves." Back to Top Runway accidents a global issue Co-operation Urged; Aviation accidents often don't have single cause Runway accidents, the leading cause of aviation deaths, must decrease worldwide just to stay stable, said Nancy Graham on Tuesday. The director of the air navigation bureau of Montreal-based International Civil Aviation Organization (ICAO) told The Gazette after hosting the Global Runway Safety Symposium that the rate of accidents is stable, but "that's why we have a problem. As our traffic grows, we can expect these runwayrelated accidents to grow as well, unless we act now." Runway incursions and excursions are "the No. 1 killer in commercial aviation today" and the biggest single cause of accidents, she told the symposium. An incursion is generally defined as an object - generally another aircraft - on the runway that's not supposed to be there. An excursion is overshooting a runway. Between 35 and 40 per cent of all accidents in the past five years were related to runway operations, and 18 per cent the result of incursions or excursions. Accidents in aviation are hardly ever caused by a single action or occurrence, but by a series of events that cause a chain reaction. That's why it's critical, Graham added, for all industry stakeholders - including airports, airlines, plane-makers, navigation service providers, navigational aids designers, pilots, air traffic controllers and national regulatory agencies - to work together more closely. "Airport and aircraft operators, associations representing pilots and air traffic controllers, aircraft and avionics manufacturers, air navigation service providers and regulators all have important roles to play in developing effective runway safety solutions. "One of ICAO's main challenges will be to establish higher levels of co-ordination between these groups (for) sharing of information and best practices related to runway accidents." A major hurdle, though, is the long-standing problem of sharing data on accidents and incidents. Countries have been reluctant to share information for fear of possible lawsuits that would cross national boundaries. For instance, in countries such as France that operate under the Napoleonic code, when an inquiry is launched, a parallel criminal investigation can also be opened that could expose foreigners to criminal charges. Graham said that the three-day symposium grouping all the main participants is meant to "knock off the early bits," but that all the spadework and specific progress will have to come during seven regional meetings around the world over the next three years. She stressed that air travel remains the safest mode of transportation - there were about 700 aviation-related deaths in 2009, but out of 2.5 billion passengers. "We're always focusing on trying to make that zero," she said. North America and Europe remain the safest regions for flying in general, and for incursions specifically, but Africa "has its percentage of issues; it's not as good as what we want to see." She said that no airport or airline triggers a cautionary red flag in terms of safety. Christiane Beaulieu of Aéroports de Montréal said there were 26 incursions in 2009- 2010 at Pierre Elliott Trudeau International Airport, out of about 210,000 aircraft movements. None resulted in accidents, injuries or deaths. "Risks vary from state to state and from region to region. That is another reason why we need to tap the experience and expertise of all segments of the world aviation community, to come up with the best solutions." www.montrealgazette.com FAA, AFA Team Up For Passenger Safety Washington D.C -- As the summer travel season begins, Federal Aviation Administration Administrator Randy Babbitt and Association of Flight Attendants International President Veda Shook this week outlined a series of safety tips for air travelers of all ages to keep in mind when they board an airplane. "Millions of people will take to the skies this summer, and we are doing everything we can to keep air travelers as safe as possible," said U.S. Transportation Secretary Ray LaHood. "Passengers can help us by taking a few simple steps to keep themselves and their loved ones safe." Digital Daily - subscribe to our daily newsletter "We're calling on passengers to take an active role in aviation safety," said Administrator Babbitt. "We are committed to safety and we are asking every passenger to take just a few minutes to follow our safety tips and, most importantly, pay attention to your flight and cabin crews." Travelers can make their flight even safer by following these guidelines: * Pay attention to the flight attendant safety briefing at the beginning of your flight and read the safety briefing card. * Buckle up. Keep you and your family safe by wearing a seat belt at all times while seated. * Use an approved child safety seat or device if your child weighs less than 40 pounds. * Prevent in-flight injuries by following your airline's carry-on restrictions. * When it's time, turn off your personal electronic device. "As first responders in the cabin, a flight attendant's foremost responsibility is to help protect the safety and security of our passengers. Through comprehensive training and extensive experience, flight attendants are well equipped to ensure passengers arrive at their destination safely and securely," said Shook. http://www.ksee24.com/home/122536259.html Back to Top Airbus Plans Higher Max Takeoff Weight For A380 Airbus has finalized an A380 design package available to airlines allowing them to fly the aircraft farther or with more payload. The design changes are available as an option to airlines and boost the maximum takeoff weight of the aircraft by four metric tons to 573,000 metric tons. The change would enable the aircraft to fly 120 nm farther or carry the equivalent of 20 more passengers. Airbus is now in discussions with airlines about who want to take the option. The new weight variant is available starting in 2013, says program chief Alain Flourens. The upgraded version introduces a slight modification to the wing twist on the A380 to improve efficiency, features a number of weight savings and, in some areas, slight reinforcements. "We simply sharpened our pencil." No engine changes were required to achieve the higher performance, says the Airbus official. Nevertheless, Rolls-Royce and Engine Alliance are looking at upgrades to introduce to their powerplant offerings on the A380, although Mary Ellen Jones, president of the General Electric/Pratt & Whitney joint venture, says right now Engine Alliance remains in the evaluation stage. Meanwhile, Airbus is preparing for flight certification of new Koito Industries seats for Singapore Airlines, and deliveries will restart in a few weeks. Flourens notes that progress in production is clearly being made, but concedes that seat issues and supply bottlenecks on the Trent 900 following last year's uncontained engine failure on a Qantas A380 that has eaten up spares supplies will mean deliveries are heavily backloaded in the second half. Lead time for production, however, is significantly down, he stresses. Production, meanwhile, is set to continue ramping up, with a goal of reaching three aircraft per month next year from about 2.5 aircraft per month this year. http://www.aviationweek.com Back to Top Indonesia bans MA-60 aircraft from three airports JAKARTA (AFP) - Indonesia has banned Chinese-made MA-60 aircraft from using three airports for safety reasons, after one of the planes crashed and killed 25 people earlier this month, an official said Wednesday. The turbo-prop plane operated by state-owned Merpati Nusantara airlines crashed into the sea as it approached an airport in Kaimana district of West Papua province during heavy rain on May 7. Air transport director general Herry Bhakti said authorities decided to ban the aircraft from landing at three airports with difficult approaches. "The airports are in Ruteng in West Nusa Tenggara province, Ende and Waingapu in East Nusa Tenggara. Those airports have high obstacle rates. They demand lot of manoeuvring to get there," he said. The official said the cause of the crash was still being investigated but it was already clear that Merpati pilots needed supplementary training on the MA-60s. Simulators for the aircraft -- manufactured by Xi'an Aircraft Industrial Corporation -- are not yet available in Indonesia, he added. Indonesia's aviation authorities have insisted the aircraft are safe and have rejected calls from lawmakers to ban them altogether. But President Susilo Bambang Yudhoyono has ordered a review of the government's decision to buy 15 MA-60s for some $220 million. The deal has been shrouded in controversy amid allegations of kickbacks and questions about the planes' air-worthiness. Yudhoyono said on May 12 the public needed "clear explanations" from Merpati directors, the state-owned enterprises minister and the transport minister. The investigator of the accident said that they had yet to reach a conclusion on the cause of the accident. "We are still trying to gather the plane's wreckage from the sea," transportation safety committee official Masruri said. The vast Indonesian archipelago relies heavily on air transport but the country has one of Asia's worst air safety records. The European Union banned Indonesian airlines from its airspace in June 2007 due to safety concerns, but lifted the ban for some carriers after two years. Merpati remains on the blacklist. Back to Top FAA investigates 2 more snoozing air traffic controllers, including one in Fort Worth WASHINGTON (AP) -- The Federal Aviation Administration is investigating two more cases of air traffic controllers falling asleep on the job, including one in Fort Worth, the agency's top administrator disclosed to Congress on Tuesday. Both incidents occurred in January at radar centers that handle high-altitude air traffic, FAA Administrator Randy Babbitt said. The Fort Worth controller was observed with his eyes closed while he was supposed to be working at the FAA's facility just south of Dallas/Fort Worth Airport. He was reprimanded. The other was found sleeping at his workstation in Los Angeles and has been suspended pending the outcome of disciplinary proceedings, the FAA said later in a statement. At the hearing before the Senate Commerce, Science and Transportation aviation subcommittee, a government watchdog said a surge in errors by air traffic controllers appears to reflect a real increase, not just better reporting, as FAA officials claim. Transportation Department Inspector General Calvin Scovel said there has been a 39 percent increase in errors at air traffic control facilities that handle aircraft at high altitudes even though there's been no change in recent years in automated error- counting equipment at those facilities. "That would indicate an absolute increase," Scovel said. Overall, errors in which planes come too close in the air increased 53 percent from 2009 to 2010. The controllers' job is to keep aircraft at safe distances. The increase in errors, as well as a series of incidents in March and April in which controllers fell asleep or made high-profile mistakes, has raised concerns in Congress about the safety of the air traffic system. Babbitt, also testifying, attributed the increase to policy changes that encourage controllers to disclose errors without fear of punishment and to an automated reporting system being phased in at regional radar centers that handle airport approaches and departures. However, errors disclosed under the voluntary, nonpunitive reporting program aren't counted in the FAA's official error tally. That means they can't account for the increase in errors, Scovel said. Scovel also urged that the FAA be guided by medical science when deciding whether to allow controllers scheduled nap breaks during overnight shifts -- something sleep scientists recommend. Babbitt and Transportation Secretary Ray LaHood have said paying controllers to sleep on the job is unacceptable. It would be "cold comfort" to the family of a victim of a crash caused by controller error that the controller wasn't allowed to sleep on the job, Scovel said. Greg Belenky, a sleep expert at Washington State University, said all night shift workers suffer from fatigue no matter how employers try to manipulate schedules. The only solution that works, he said, is brief naps during night shifts. The head of the controllers union said a large increase in new controllers who need on- the-job training is partly responsible for the increase in errors. The FAA plans to hire 11,000 controllers through 2019. All those new controllers have to receive on-the-job training from current controllers, placing a serious strain on air traffic operations, according to testimony by Paul Rinaldi, president of the National Air Traffic Controllers Association. Babbitt disagreed. About 25 percent of controllers are in training, down significantly compared with the last few years and more in line with the norm, he said. www.star-telegram.com/2011/05/24/3100962/faa-investigates-2-more- snoozing.html#ixzz1NMz6o2zV Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC