Flight Safety Information September 18, 2017 - No. 186 In This Issue Incident: Eurowings A319 at Hamburg on Sep 14th 2017, smoke in cockpit EVAS - Cockpit Smoke Protection Incident: Ryanair B738 at London on Sep 15th 2017, dropped nose wheel Incident: Fiji B737 over Pacific on Sep 15th 2017, problems with crew oxygen Incident: Royal Wings B733 at Aqaba on Sep 17th 2017, runway excursion on landing Flight To Seattle Diverts To Sacramento After In-Flight Emergency Britten-Norman BN-2A-26 Islander damaged by fire during maintenance (Bahamas) ANA Boeing 737-500 from Nagoya/Chubu Centrair to Fukuoka returned to Centrair due to a burnt smell ATR 72-500 hit a catering truck (Manchester, UK) British Airways jet evacuated in Paris after 'direct threat' Did Airbus Underestimate A320 Capacitor Threat? FAA using outdated information on aircraft evacuations This Famous Airline Just Diverted a Transatlantic Flight To Drop Off One of Its Pilots New Zealand jet fuel shortage leaves passengers stranded Ryanair loses 140 pilots to Norwegian Air as travel chaos continues The Tragic Crash of Flight AF447 Shows the Unlikely but Catastrophic Consequences of Automation NTSB Releases Icon A5 Fatal Accident Report Former pilot says contaminated air on planes is 'like breathing car exhaust fumes' Northrop Grumman nears deal to purchase Orbital ATK AUVSI Names Tracy Lamb as Vice President of Regulatory and Safety Affairs SpaceX's Dragon capsule successfully returns from 12th ISS resupply mission Why Choose AvSax? CHC Safety & Quality Summit - 2017 (September 27-29; Grapevine, TX) Incident: Eurowings A319 at Hamburg on Sep 14th 2017, smoke in cockpit A Eurowings Airbus A319-100, registration D-ABGS performing flight EW-7778 from Hamburg (Germany) to Prague (Czech Republic), was climbing out of Hamburg's runway 23 when the crew stopped the climb at about 4500 feet reporting smoke in the cockpit and returned to Hamburg for a safe landing on runway 23 about 10 minutes after departure and taxied to the apron. The passengers disembarked normally. Airport police reported an overheated air conditioning system was identified as source of the smoke. The passengers were taken to hotels and have been rebooked onto other flights the following day. The occurrence aircraft had replaced the aircraft scheduled to perform the flight on schedule and departed Hamburg with a delay of 5.5 hours only to land back 10 minutes later. http://avherald.com/h?article=4ae60c9d&opt=0 Back to Top Back to Top Incident: Ryanair B738 at London on Sep 15th 2017, dropped nose wheel A Ryanair Boeing 737-800, registration EI-DLV performing flight FR-7384 from London Stansted,EN (UK) to Copenhagen (Denmark) with 182 passengers and 6 crew, was climbing out of Stansted's runway 22 when the crew stopped the climb at FL170 after ATC told them they had lost a wheel on departure. The crew decided to divert to East Midlands,EN (UK), where the aircraft landed safely on runway 27 without the left nose wheel. The airline confirmed the aircraft dropped the left hand nose wheel after takeoff and diverted to East Midlands. The passengers disembarked normally and will be taken to Copenhagen by a replacement aircraft. The UK AAIB have dispatched a team of investigators to East Midland and have opened an investigation into the occurrence. A replacement Boeing 737-800 registration EI-EVW is estimated to reach Copenhagen with a delay of 4.5 hours. http://avherald.com/h?article=4ae60802&opt=0 Back to Top Incident: Fiji B737 over Pacific on Sep 15th 2017, problems with crew oxygen A Fiji Airways Boeing 737-700, registration DQ-FJF performing flight FJ-430 from Auckland (New Zealand) to Suva (Fiji), was enroute at FL340 about 350nm north of Auckland when the crew descended the aircraft to FL100, turned around and returned to Auckland due to a problem with the crew oxygen supply. The aircraft landed safely back in Auckland about 2:10 hours after departure. The airline reported the aircraft returned due to a problem with an air valve. The passengers were rebooked onto the next two flights, the remaining passengers were brought to hotels and are going to reach Suva the following day. http://avherald.com/h?article=4ae635e3&opt=0 Back to Top Incident: Royal Wings B733 at Aqaba on Sep 17th 2017, runway excursion on landing A Royal Wings Boeing 737-300 on behalf of Royal Jordanian, registration JY-SOA performing flight RJ-6888 from Amman to Aqaba (Jordan) with 126 people on board, landed at Aqaba at about 08:25L (05:25Z) but went off the paved surface of the runway and came to a stop of soft ground. There were no injuries, the aircraft sustained minor damage. The passengers disembarked onto soft ground via stairs and were bussed to the terminal. The airline confirmed a runway excursion disabling the aircraft to continue the flight to Dubai (United Arab Emirates) as scheduled. The aircraft sustained minor damage to its exterior. The passengers disembarked normally and were taken to hotels to await continuation of the flight to Dubai. The airport reported the aircraft was unable to stop before the end of the runway and overran the end of the runway. Related NOTAM: A0264/17 - AD WILL BE CLOSED DUE TO DISABLED AIRCRAFT ON THE RUNWAY. 17 SEP 17:02 2017 UNTIL 18 SEP 05:00 2017. CREATED: 17 SEP 17:03 2017 http://avherald.com/h?article=4ae7b1c1&opt=0 Back to Top Flight To Seattle Diverts To Sacramento After In-Flight Emergency SACRAMENTO (CBS13) - A Compass Airlines flight operating as Delta Connection flying to Seattle, Washington from Orange County, California declared an in-flight emergency and diverted to Sacramento International Airport on Sunday afternoon, according to an airline spokesperson. The flight left Orange County Airport at approximately 1:15 P.M. and according to flight tracking website FlightRadar24 just after 3 P.M. crossed over the California-Oregon border and turned back towards Sacramento International Airport. The Aircraft landed about 30 minutes later in Sacramento. According to Sacramento International Airport spokesperson Laurie Slothower, fire crews were alerted and inspected the aircraft shortly after an uneventful landing and then gave the approval to have it taxi to a gate. No injuries were reported. According to a Compass Airlines spokesperson, the in-flight emergency was declared "out of an abundance of caution due to a possible mechanical issue." The airline says that passengers from flight 5795 will be put on another aircraft scheduled to leave at approximately 8:20 P.M. and flown to Seattle. http://sacramento.cbslocal.com/2017/09/17/flight-to-seattle-diverts-to-sacramento-after- in-flight-emergency/ Back to Top Britten-Norman BN-2A-26 Islander damaged by fire during maintenance (Bahamas) Status: Date: Wednesday 13 September 2017 Type: Britten-Norman BN-2A-26 Islander Operator: Golden Wings Charter Registration: C6-FYP C/n / msn: 2015 First flight: 1979 Crew: Fatalities: 0 / Occupants: 0 Passengers: Fatalities: 0 / Occupants: 0 Total: Fatalities: 0 / Occupants: 0 Airplane damage: Substantial Airplane fate: Written off (damaged beyond repair) Location: Nassau-Lynden Pindling International Airport (NAS) ( Bahamas) Phase: Standing (STD) Nature: - Departure airport: - Destination airport: - Narrative: A Britten-Norman BN-2A-26 Islander was damaged by fire while undergoing routine maintenance in a hangar at Nassau's Lynden Pindling International Airport, Bahamas. The owner reported that the fire originated in a fuel tank. https://aviation-safety.net/database/record.php?id=20170913-0 Back to Top ANA Boeing 737-500 from Nagoya/Chubu Centrair to Fukuoka returned to Centrair due to a burnt smell (Japan) Date: 18-SEP-2017 Time: ca. 09:15 LT Type: Boeing 737-54K Owner/operator: All Nippon Airways - ANA Registration: JA303K C/n / msn: 28991/3017 Fatalities: Fatalities: 0 / Occupants: 131 Other fatalities: 0 Airplane damage: Unknown Location: near Chubu Centrair International Airport (NGO/RJGG) - Japan Phase: Initial climb Nature: Domestic Scheduled Passenger Departure airport: Nagoya/Chubu Centrair International Airport (NGO/RJGG) Destination airport: Fukuoka Airport (FUK/RJFF) Narrative: A Boeing 737-500 as flight ANA/NH435 from Nagoya/Chubu Centrair to Fukuoka returned to Centrair due to a burnt smell coming from the air conditioning duct just after take off at 09:15 LT. The airplane landed safely at 09:27 LT. No personal injuries were reported among 126 passengers and 5 crew members. https://aviation-safety.net/wikibase/wiki.php?id=199775 Back to Top ATR 72-500 hit a catering truck (Manchester, UK) Date: 17-SEP-2017 Time: 09:50 a.m. Type: ATR 72-500 (72-212A) Owner/operator: Aurigny Air Services Registration: G-COBO C/n / msn: 852 Fatalities: Fatalities: 0 / Occupants: 60 Other fatalities: 0 Airplane damage: Minor Location: Manchester Airport (MAN/EGCC) - United Kingdom Phase: Pushback / towing Nature: Domestic Scheduled Passenger Departure airport: Manchester Airport (MAN/EGCC) Destination airport: Guernsey Airport, Channel Islands (GCI/EGJB) Narrative: Aurigny Air Services flight GR671, an ATR 72-500 was cancelled when the plane hit a catering truck during push back from the gate at Manchester Airport, U.K. There were no personal injuries. https://aviation-safety.net/wikibase/wiki.php?id=199749 Back to Top British Airways jet evacuated in Paris after 'direct threat' A British Airways jet was evacuated at Terminal 2 in Charles de Gaulle airport in Paris because of a "direct threat" Sunday morning, officials said. The plane took off four hours after the incident. File photo by Wikimedia Commons/Fyodor Borisov Sept. 17 (UPI) -- A British Airways jet was evacuated Sunday at Charles de Gaulle airport in Paris because of a "direct threat," officials said. Flight BA303 was due to take off 7:25 a.m. Sunday bound for Heathrow in London when the incident occurred. Passengers waited on the tarmac near Terminal 2 as security personnel and sniffer dogs searched bags and aircraft. Police and fire engines surrounded the plane on the tarmac. British traveler James Anderson, 20, posted on Twitter, "Apparently an individual has made a direct threat to this aircraft." After the plane was cleared, he tweeted: "Our pilot was an absolute credit to @British- Airways. Extremely calm and composed, handled the situation wonderfully." The Airbus 320 took off at 11:10 a.m., a British Airways spokeswoman confirmed. "The safety and security of our customers and crew is always our top priority," the airline said in a statement. "Additional security checks are being carried out as a precaution. We would never operate a flight unless it is safe to do so." French police said evacuation of the plane was triggered by a "false alarm." The security threat came two days after an explosion rocked a crowded London subway car, injuring at least 29, in what officials say was a terror attack. https://www.upi.com/Top_News/World-News/2017/09/17/British-Airways-jet-evacuated- in-Paris-after-direct-threat/8961505658401/ Back to Top Did Airbus Underestimate A320 Capacitor Threat? WASHINGTON-Pilots of an EasyJetAirbusA320-200 climbing out from Edinburgh, Scotland, on a flight to Hamburg, Germany, in 2016 donned their oxygen masks and declared an emergency after an acrid electrical smell permeated the cockpit and entered the cabin. The aircraft, which was flying on the afternoon of Nov. 28, 2016, diverted to Newcastle, England. The pilots were able to land safely once the smoke had cleared, a new report by the UK's Air Accident Investigation Branch (AAIB) shows. None of the 172 passengers and six crewmembers were injured. The culprit-a faulty capacitor in the electronics bay under the cockpit floor-turned out to be the root cause of two previous static inverter failures for EasyJet. The first was in August 2014, followed by another in January 2015. The static inverters, standard equipment on the A320 since 1999, provide power to three electrical outlets in the cockpit. Pilots can use the outlets for charging electronic flight bags and other devices. The failure was narrowed down to one capacitor that was overheating and failing. The problematic part had not received a targeted "quality screening prior to fitment," according to the AAIB. What EasyJet did not know at the time was that Airbus had been aware of a broader problem with the capacitors. There had been eight previous failures, seven of which had caused diversions. Eight months earlier, the airframer had issued a relatively benign technical follow-up (TFU) notification that does not require any operator action. One month before the incident, the inverter's manufacturer issued a Vendor Service Bulletin (VSB), alerting customers that it would fix the problematic inverters for free. EasyJet, however, was not aware of either bulletin. Because TFUs were not mandatory and sent to help airlines improve aircraft operation, the carrier did not include the notifications in its maintenance management software, AMOS. What AMOS did import were more pressing alerts, including airworthiness directives from regulators, service bulletins (SB) and Operator Information Transmissions (OIT) from Airbus. Since no follow- up actions were required for the TFU, EasyJet "did not conduct regular reviews of TFUs as part of its airworthiness control processes," the AAIB said. Another large UK-based Airbus A320 operator told the AAIB it also did not include TFUs as part of its routine technical document review process. Easyjet had also not registered with the inverter manufacturer to receive updates. "The operator advised [the AAIB] that it relied predominantly upon communications from the aircraft manufacturer to identify VSBs that required follow-up action," the AAIB said. Airbus' on-site representatives did not inform EasyJet of the TFU and VSB until three days after the incident. Rather than an "information" bulletin-which was not ingested into AMOS-Airbus could have opted for an OIT. It uses this method to "communicate quickly to operators" information on in-service events, or findings that have substantial implications on the Airbus fleet. The airframer had begun developing an OIT in September, but did not issue the document to all operators until mid-December, after the EasyJet inciden. In early December, EasyJet asked Airbus why the cause of the static inverter failures was communicated via TFU, rather than through an Alert Operator Transmission, OIT or SB. It considered all of those more appropriate communication methods in relation to the "severity of the outcome," the AAIB said. EasyJet noted that the "failure of the capacitor due to overheating resulting in a smoke smell event should be classified as a safety issue, and hence should have been clearly communicated to the operators." In response, Airbus said that after its initial analysis of the eight failures, it determined that a TFU, combined with vendor-issued VSB, were "the most appropriate means" of communicating the information related to the overheating of the static inverter capacitor 306. "The analysis had taken into account aspects such as failure mode, availability of crew procedures and impact on airworthiness and safety," the AAIB said about Airbus' response. As of early December, Easyjet had removed all of the problematic static inverters from its fleet, including spares. It modified its procedures so that the engineering department would review all TFUs "on a routine basis," the AAIB said. The carrier also planned to review how it handles VSBs. Airbus said it will release an SB later this year to "assist operators in identifying and rectifying any of the affected static inverters," the AAIB said. Along with being standard on the A320, the inverters are options on Airbus A330, A340 and A380 models. www.avationweek.com Back to Top FAA using outdated information on aircraft evacuations, report says Tests on whether passengers can safely exit an aircraft in an emergency have failed to account for the ever-shrinking size of airline seat space, posing a potential safety risk, according to a report by the Daily Beast. According to an investigation by Daily Beast reporters, the tests conducted by the Federal Aviation Administration (FAA) are outdated and do not account for either the smaller seating configuration in coach (economy) or the larger size of the average airline passenger in the US. The report adds that modern coach seating also does not meet FAA standards for safe seating of flight attendants in emergency situations. Reporters based their conclusions on a review of more than 900 pages of federal airline documents and regulations. The FAA and aircraft manufacturer Boeing have conducted emergency-egress testing using tighter seating configurations, but refused to make their data public, the Daily Beast reported. Some of the findings reflect charges made in a lawsuit filed by the airline passenger group Flyers Rights, which has asked the federal courts to compel the FAA to review and update its safety protocols involving seating. A judge in that case agreed that there was "a plausible life-and-death safety concern" and ordered the FAA to respond to the group's petition. The judge also rejected the agency's contention that seat dimensions were unimportant to testing emergency evacuations. https://www.businesstraveller.com/business-travel/2017/09/18/faa-using-outdated- information-aircraft-evacuations-report-says/ Back to Top This Famous Airline Just Diverted a Transatlantic Flight To Drop Off One of Its Pilots Yes, of course it delayed the flight. Why do it at all? Hang on, where are we going again? CREDIT: Getty Images Absurdly Driven looks at the world of business with a skeptical eye and a firmly rooted tongue in cheek. You're getting ready to sit back and relax. London to Boston is a long flight. But you're flying Virgin Atlantic. It's an airline at least try and make the experience enjoyable. Unless you happen to get a piece of foam, instead of a seat. Suddenly, you're given a note. (It was obtained by the fine One Mile At A Time blog.) The note is signed by the airline's Customer Relations Duty Manager. It reads: "Your flight to Boston will be operating via Manchester today. In order for us to ensure our customers are able to fly from Manchester to New York today, we need to fly one of our pilots to Manchester. We have looked at other options to achieve this, but this is the only option available to use. You will remain on board the aircraft during our short stop in Manchester Airport. I apologize for any inconvenience and disruption this may cause to your journey." Ah. Oh. What? This all happened on Friday. Manchester is around 200 miles from London. British Airways flies there quite a lot. Couldn't the pilot have flown up there on another flight, without having to drag all the passengers from a completely different flight along for the ride? Wouldn't, say, a helicopter have been quicker and caused less disruption? Don't Virgin own trains? Doesn't this sound a touch bonkers? As it turned out, the Boston flight suffered a 1 hour and 36 minute delay. Moreover, it surely cost the airline quite some cash to do this. So why, oh, why? Virgin's logic is a joy to behold. It told me that there had been a "last-minute pilot sickness." Yes, when that pilot sickness gets around it can be contagious. Just ask the 200 Air Berlin pilots who simultaneously fell ill last week. "While we appreciate this caused an one hour and 30 minute delay to customers onboard the VS11 to Boston, it was necessary to ensure 228 passengers on the VS127 from Manchester could also make their journey as planned," said an airline spokesman. Also? Some Virgin passengers didn't make their journey as planned, so that some other Virgin passengers could? Alrighty. The spokesman added that the airline had "investigated every possible option to relocate our pilot." I asked what some of these options might have been. Virgin told me it looked at "trains, public transport and scheduled flights on competitor airlines before this action was taken. It's unclear whether the Boston passengers received any compensation. Or even a little extra ice cream. "We would like to thank the customers onboard the VS11 for their patience and understanding in these exceptional circumstances," said Virgin. Exceptionally annoying to some, I imagine. https://www.inc.com/chris-matyszczyk/virgin-atlantic-just-diverted-a-transatlantic- flig.html Back to Top New Zealand jet fuel shortage leaves passengers stranded Planes grounded at Auckland airport Thousands of airline passengers were stranded in Auckland on Monday after a burst pipeline cut jet fuel supplies to New Zealand's largest airport. The damaged pipeline is Auckland Airport's only source of jet fuel. The disruption is expected to last at least a week as work continues to repair the pipe, the operator said. Fuel supplies have been rationed and airlines are looking to refuel in Australia and elsewhere to keep long-haul services running. According to Auckland Airport, which sees about 18 million passengers a year, oil companies are responsible for the transport and supply of fuel used by airlines, and that supply has been reduced. Air New Zealand said fuel supplies at the airport were down to 30% of normal capacity, forcing some long-haul flights to make additional refuelling stops at airports in Australia and the Pacific. The carrier said about 2,000 passengers are affected by cancellations on Monday. As well as Air New Zealand, Qantas, Cathay Pacific and Emirates said that some flights had been affected by the fuel shortage. At least 27 international and domestic flights were cancelled over the weekend. Pipe repairs Teams are working around the clock to fix the pipeline after damage from a digger caused it to burst last Thursday, operator Refinery New Zealand said. But the firm said the repairs to build a new section of pipe, which have been complicated by safety concerns and heavy rains, will take a least a week. The pipeline should return to service between 24 September and 26 September, the firm said. That is likely to spell more pain for passengers and airlines. The pipe also supplies petrol and diesel to drivers in Auckland, but the country's energy minister Judith Collins said it was unlikely that motorists would be inconvenienced, as fuel was being trucked in from the refinery. http://www.bbc.com/news/business-41303112 Back to Top Ryanair loses 140 pilots to Norwegian Air as travel chaos continues So far in 2017 Ryanair has lost 140 pilots to Norwegian Air, as passengers continue to be affected by the budget airline's plans to scrap up to 50 flights a day until the end of October. As the airline battles to fill positions, it is understood that Ryanair has commenced offering pilots a €10,000 "signing-on bonus" the Irish Independent reports. The airline has blamed a number of factors including changes to staff rosters and air traffic control strikes for the cancellation of dozens of flights for the next six weeks. However the Irish Independent reports that recruitment problems are also affecting the low-cost airline. Earlier this month Norwegian Air confirmed it's to open a new pilot base in Dublin later this year, which will initially include around 40 pilots. Norwegian's Ireland-based unit - Norwegian Air International (NAI) - already has a head office at Dublin Airport, which is headed by Tore Jenssen, and which employs over 80 people. At Dublin airport today a dozen Ryanair flights in or out of the airport have been cancelled, something which is being replicated in airports around Europe. In total just under 400,000 passengers across Europe could be affected by the cancellations in the coming days and weeks. "We will cancel 40 to 50 flights daily for the next six weeks, (less than 2pc of our schedule) with a slightly higher number this weekend as we begin to implement these cancellations" Ryanair's Kenny Jacobs said. http://www.independent.ie/business/irish/ryanair-loses-140-pilots-to-norwegian-air-as- travel-chaos-continues-36141910.html Back to Top The Tragic Crash of Flight AF447 Shows the Unlikely but Catastrophic Consequences of Automation The tragic crash of Air France 447 (AF447) in 2009 sent shock waves around the world. The loss was difficult to understand given the remarkable safety record of commercial aviation. How could a well-trained crew flying a modern airliner so abruptly lose control of their aircraft during a routine flight? AF447 precipitated the aviation industry's growing concern about such "loss of control" incidents, and whether they're linked to greater automation in the cockpit. As technology has become more sophisticated, it has taken over more and more functions previously performed by pilots, bringing huge improvements in aviation safety. In 2016 the accident rate for major jets was just one major accident for every 2.56 million flights. But while overall air safety is improving, loss of control incidents are not. In fact, they are the most prevalent cause of fatalities in commercial aviation today, accounting for 43% of fatalities in 37 separate incidents between 2010 and 2014. Loss of control typically occurs when pilots fail to recognize and correct a potentially dangerous situation, causing an aircraft to enter an unstable condition. Such incidents are typically triggered by unexpected, unusual events - often comprising multiple conditions that rarely occur together - that fall outside of the normal repertoire of pilot experience. For example, this might be a combination of unusual meteorological conditions, ambiguous readings or behavior from the technology, and pilot inexperience - any one or two of which might be okay, but altogether they can overwhelm a crew. Safety scientists describe this as the "Swiss cheese" model of failure, when the holes in organizational defenses line up in ways that had not been foreseen. These incidents require rapid interpretation and responses, and it is here that things can go wrong. Our research, recently published in Organization Science, examines how automation can limit pilots' abilities to respond to such incidents, as becoming more dependent on technology can erode basic cognitive skills. By reviewing expert analyses of the disaster and analyzing data from AF447's cockpit and flight data recorders, we found that AF447, and commercial aviation more generally, reveal how automation may have unanticipated, catastrophic consequences that, while unlikely, can emerge in extreme conditions. Automation on the Flight Deck Commercial aircraft fly on autopilot for much of the time. For most pilots, automation usually ensures that operations stay well within safe, predictable limits. Pilots spend much of their time managing and monitoring, rather than actively flying, their aircraft. Cockpit automation, sometimes called the "glass cockpit", comprises an ensemble of technologies that perform multiple functions. They gather information, process it, integrate it, and present it to pilots, often in simplified, stylized, and intuitive ways. Through "fly-by-wire," in which pilot actions serve as inputs to a flight control system that in turn determines the movements of the aircraft's control surfaces, technology mediates the relationship between pilot action and aircraft response. This reduces the risk of human errors due to overload, fatigue, and fallibility, and prevents manoeuvers that might stress the airframe and endanger the aircraft. Automation provides massive data-processing capacity and consistency of response. However, it can also interfere with pilots' basic cycle of planning, doing, checking, and acting, which is fundamental to control and learning. If it results in less active monitoring and hands-on engagement, pilots' situational awareness and capacity to improvise when faced with unexpected, unfamiliar events may decrease. This erosion may lie hidden until human intervention is required, for example when technology malfunctions or encounters conditions it doesn't recognize and can't process. Imagine having to do some moderately complex arithmetic. Most of us could do this in our heads if we had to, but because we typically rely on technology like calculators and spreadsheets to do this, it might take us a while to call up the relevant mental processes and do it on our own. What if you were asked, without warning, to do this under stressful and time-critical conditions? The risk of error would be considerable. This was the challenge that the crew of AF447 faced. But they also had to deal with certain "automation surprises," such as technology behaving in ways that they did not understand or expect. Loss of AF447 AF447 was three and a half hours into a night flight over the Atlantic. Transient icing of the speed sensors on the Airbus A330 caused inconsistent airspeed readings, which in turn led the flight computer to disconnect the autopilot and withdraw flight envelope protection, as it was programmed to do when faced with unreliable data. The startled pilots now had to fly the plane manually. A string of messages appeared on a screen in front of the pilots, giving crucial information on the status of the aircraft. All that was required was for one pilot (Pierre-Cédric Bonin) to maintain the flight path manually while the other (David Robert) diagnosed the problem. But Bonin's attempts to stabilize the aircraft had precisely the opposite effect. This was probably due to a combination of being startled and inexperienced at manually flying at altitude, and having reduced automatic protection. At higher altitudes, the safe flight envelope is much more restricted than at lower altitudes, which is why pilots rarely hand- fly there. He attempted to correct a slight roll that occurred as the autopilot disconnected but over-corrected, causing the plane to roll sharply left and right several times as he moved his side stick from side to side. He also pulled back on the stick, causing the plane to climb steeply until it stalled and began to descend rapidly, almost in free-fall. Neither Bonin nor Robert, nor the third crew member (Marc Dubois, the captain) who entered the cockpit 90 seconds into the episode, recognized that the aircraft had stalled despite multiple cues. In the confusion, Bonin misinterpreted the situation as meaning that the plane was flying too fast and actually reduced the thrust and moved to apply the speedbrakes - the opposite of what was required to recover from the stall. Robert overruled him and attempted to take control, but Bonin continued to try and fly the plane. He and Robert made simultaneous and contradictory inputs, without realizing that they were doing so. By the time the crew worked out what was going on, there was insufficient altitude left to recover, and AF447 crashed into the ocean, with the loss of all 228 passengers and crew. The AF447 tragedy starkly reveals the interplay between sophisticated technology and its human counterparts. This began with the abrupt and unexpected handover of control to the pilots, one of whom, unused to hand flying at altitude, made a challenging situation much worse. A simulation exercise after the accident demonstrated that with no pilot inputs, AF447 would have remained at its cruise altitude following the autopilot disconnection. With the onset of the stall, there were many cues about what was happening available to the pilots. But they were unable to assemble these cues into a valid interpretation, perhaps because they believed that a stall was impossible (since fly-by-wire technology would normally prevent pilots from causing a stall), or perhaps because the technology usually did most of the "assembling" of cues on their behalf. The possibility that an aircraft could be in a stall without the crew realizing it was also apparently beyond what the aircraft system designers imagined. Features designed to help the pilots under normal circumstances now added to their problems. For example, to avoid the distractions of false alarms, the stall warning was designed to shut off when the forward airspeed fell below a certain speed, which it did as AF447 made its rapid descent. However, when the pilots twice made the correct recovery actions (putting the nose- down), the forward airspeed increased, causing the stall alarm to reactivate. All of this contributed to the pilots' difficulty in grasping the nature of their plight. Seconds before impact, Bonin can be heard saying, "This can't be true." Implications for Organizations This idea - that the same technology that allows systems to be efficient and largely error- free also creates systemic vulnerabilities that result in occasional catastrophes - is termed "the paradox of almost totally safe systems." This paradox has implications for technology deployment in many organizations, not only safety-critical ones. One is the importance of managing handovers from machines to humans, something which went so wrong in AF447. As automation has increased in complexity and sophistication, so have the conditions under which such handovers are likely to occur. Is it reasonable to expect startled and possibly out-of-practice humans to be able to instantaneously diagnose and respond to problems that are complex enough to fool the technology? This issue will only become more pertinent as automation further pervades our lives, for example as autonomous vehicles are introduced to our roads. Second, how can we capitalize on the benefits offered by technology while maintaining the cognitive capabilities necessary to handle exceptional situations? Pilots undergo intense training, with regular assessments, drills, and simulations, yet loss of control remains a source of concern. Following the AF447 disaster, the FAA urged airlines to encourage more hand-flying to prevent the erosion of basic piloting skills and this points to one avenue that others might follow. Regular, hands-on engagement and control builds and maintains system knowledge, enabling operators, managers, and others who oversee complex systems, to identify anomalies, diagnose unfamiliar situations, and respond quickly and appropriately. Structured problem-solving and improvement routines that prompt one to constantly interrogate our environment can also help with this. Commercial aviation offers a fascinating window into automation, because the benefits, as well as the occasional risks, are so visible and dramatic. But everyone has their equivalent of autopilot, and the main idea extends to other environments: when automation keeps people completely safe almost all of the time, they are more likely to struggle to reengage when it abruptly withdraws its services. Organizations must now consider the interplay of different types of risk. More automation reduces the risk of human errors, most of the time, as shown by aviation's excellent and improving safety record. But automation also leads to the subtle erosion of cognitive abilities that may only manifest themselves in extreme and unusual situations. However, it would be short-sighted to simply roll back automation, say by insisting on more hand- flying, as that would increase the risk of human error again. Rather, organizations need to be aware of the vulnerabilities that automation can create and think more creatively about ways to patch them. * Nick Oliver is a professor at the University of Edinburgh Business School, United Kingdom who researches lean and resilient forms of organization. His latest book is Crisis, Resilience and Survival: Lessons from the Global Auto Industry (2016). * Thomas Calvard is lecturer at the University of Edinburgh Business School. His research focuses on sense-making processes around diversity and technology in organizations. * Kristina Poto?nik is a senior lecturer at the University of Edinburgh Business School. She researches the factors that determine individual, team, and organizational performance, with a particular focus on creativity and innovation. https://hbr.org/2017/09/the-tragic-crash-of-flight-af447-shows-the-unlikely-but- catastrophic-consequences-of-automation Back to Top NTSB Releases Icon A5 Fatal Accident Report On May 8, the first fatal crash of an Icon A5 light sport amphibious airplane occurred during a new-employee familiarization flight for a recently hired engineer. The NTSB took just one day shy of three months to release the final report on the accident. Most accident reports take a year or more to complete. The precise path of the accident flight is known because the A5 is equipped with two sources of data; one is a flight data monitoring device that captures information from the flight data computer, and a second is part of the A5's 100-hp Rotax 912IS Sport powerplant's electronic engine control unit. The data showed that the pilot and his passenger took off just before 9 a.m. in good VFR weather from Nut Tree Airport in Vacaville, Calif., in N184BA, A5 Serial Number 7, one of the company's training airplanes with 182.7 hours flying time logged since it was manufactured last year. Icon conducts pilot training at Lake Berryessa, about a 15-minute flight from the company headquarters and assembly facility at Nut Tree. The company has another flight training facility in Tampa, Fla. The recorded data showed that after departing Runway 2 at Nut Tree, the A5 climbed to a GPS altitude of 3,700 feet while flying north toward Lake Berryessa, then began descending as it neared the lake. After crossing the shore near Monticello Dam, the A5 descended to 450 feet GPS altitude (the lake's elevation can range to more than 400 feet msl; its spillway is 440 feet msl). Flying over the water, the A5 proceeded in a northerly direction, but then at 9:07:30 entered Little Portuguese Canyon. There is no outlet for this canyon, and the terrain surrounding the canyon rises steeply. According to the NTSB, "The areas of rising terrain that surrounded Little Portuguese Canyon varied between 780 and 1,420 feet msl. The accident site was located about 0.35 nautical mile (nm) from the tops of 1,200-foot-high ridges to the west, 0.36 nm from the 1,050-foot-high ridges to the east, and 1.34 nm from the 1,200-ft-high ridges to the north. In addition, Little Portuguese Canyon narrowed in width from about 700 feet at the opening to about 300 feet near the accident site and 240 feet near the farthest northern area of the canyon." To fly to the more open area of Lake Berryessa, before entering Little Portuguese Canyon it would have been necessary to make a 90-degree turn to the left followed by a 90- degree right turn to fly into the wide open lake recreation area. According to the NTSB, when the A5 entered Little Portuguese Canyon, it was at 450 feet GPS altitude and 54 kias, as logged by the airplane's recording devices. Twenty seconds later, power was added and the airplane climbed while turning slightly to the east, followed by a left turn to the west. The NTSB's depiction of the recorded data shows the A5 flying toward the right side of Little Portuguese Canyon then turning sharply left before hitting terrain on the left side of the canyon (as viewed from the entry to the canyon). After reaching a maximum GPS altitude of 506 feet, the A5 descended. "The airplane struck terrain at 09:08:06 at 470 feet GPS altitude and 66 knots indicated airspeed," according to the NTSB. The data shows that at the time of the accident the power was at maximum, landing gear was up and the flaps were not deployed. LOW-ALTITUDE MANEUVERING "A witness, who was in a boat on Lake Berryessa near the entrance to Little Portuguese Canyon, reported seeing the airplane flying about 30 to 50 feet above the lake at what appeared to be between 30 to 40 mph," the NTSB wrote in its report. "The witness stated that the engine was running smoothly and that the airplane was level. The airplane passed by his position flying in a northerly direction and entered Little Portuguese Canyon. The witness reported hearing the engine 'rev up and accelerate hard' as the airplane approached the right side of the canyon 'in what appeared to be an effort to climb out of' the canyon. Subsequently, the airplane climbed to about 100 feet above ground level and then entered a left turn as it began to quickly descend. The witness stated that it appeared that the pilot attempted to make a 'U-turn in the air' just before the airplane flew beyond his field of view. The witness stated that he heard the sound of impact shortly after losing sight of the airplane." The NTSB found "no evidence of any preexisting mechanical malfunctions that would have precluded normal operation [of the A5]." In its final report, the NTSB wrote, "It is likely that the pilot mistakenly thought the canyon that he entered was a different canyon that led to the larger, open portion of the lake. Additionally, it is likely that, once the pilot realized there was no exit from the canyon, he attempted to perform a 180-degree left turn to exit in the direction from which he entered. Based upon performance information outlined in the Pilot's Operating Handbook for the accident airplane, the airplane's altitude above the water's surface and its indicated airspeed, and the ridge line elevations in the area adjacent to the accident site, the airplane would have not been able to climb out of the rising terrain that surrounded the area, which led to his failure to maintain clearance from terrain." The probable cause of the accident was: "The pilot's failure to maintain clearance from terrain while maneuvering at a low altitude. Contributing to the accident was the pilot's mistaken entry into a canyon surrounded by steep rising terrain while at a low altitude for reasons that could not be determined." Although the NTSB doesn't release identities of those involved in accidents, Icon Aircraft founder and CEO Kirk Hawkins issued a statement following the release of the final report (the pilot and passenger names had been released shortly after the accident). At the controls of the A5 was Jon Karkow, lead engineer on the A5 program and well known in the aerospace industry for his 21 years working at Scaled Composites. The passenger was Cagri Sever, who had recently been hired by Icon. "I want to thank the NTSB for its professionalism and thoroughness in this process; this is an important step in reaching closure for the families of Jon and Cagri as well as the Icon team after such a traumatic loss. Jon and Cagri were both extraordinary individuals and are missed tremendously. Cagri had recently joined Icon as a star engineering leader from Ford Motor Company. Jon was a legendary aircraft designer, test pilot and unsung hero in aviation. He was a founding member of the Icon team, the lead aero engineer on the A5 and a core part of Icon's DNA. The A5 reflects not only his genius, but it also represents his love for flying in its purest form. It was his final gift to aviation. The Icon family is committed to carrying the flag forward in Jon and Cagri's honor." https://www.ainonline.com/aviation-news/general-aviation/2017-09-10/ntsb-releases- icon-a5-fatal-accident-report Back to Top Former pilot says contaminated air on planes is 'like breathing car exhaust fumes' CONTAMINATED cabin air on planes is like "sticking a pipe from your exhaust into your car", a former pilot and leading researcher has warned. Dr Susan Michaelis said air crew and frequent fliers are being let down by gaps in health and safety regulation which allow the regulators to "turn a blind eye" to the hazard of chronic exposure to low doses of poisonous chemicals in cabin air, as well as high-dose "fume events" which can leave pilots disorientated. She said it would take a catastrophic air crash for the industry to act. Dr Michaelis, of Stirling University's Occupational and Environmental Health Research group, is among the speakers at a major four-day conference on aircraft cabin air in London, starting tomorrow [Tues]. She will argue that cabin air safety falls into a "gap" between the Civil Aviation Authority (CAA), which regulates air traffic, and the Health and Safety Executive (HSE) which enforces occupational health. She said: "It's for the CAA to take the lead on hazardous substances on aircraft, but the CAA does not have expertise in this area. The HSE does but they don't get involved - they leave it to the CAA. "In other words, the protections that are there under the occupational health and safety regulations in Europe are not being applied to the aircraft contaminated air problem: that is, oil and fluids leaking into the aircraft breathing air supply. They [the CAA] just turn a blind eye." Her comments come as EasyJet announced it will fit filters to stop toxic fumes entering its passenger cabins and cockpits. The airline told the Sunday Times that "health concerns" had led it to begin work with an aerospace company to develop a new system. It is thought to be the first time that an airline has acknowledged the potential risk of "aerotoxic syndrome", which could also affect frequent flyers. Ms Michaelis said that since the CAA was funded by airlines there was no incentive to tackle an issue which could leave them liable to compensation claims or redesign costs. Ms Michaelis said: "The airline industry would need a major accident [to do anything about it]. "But you cannot have a cost-benefit analysis where you say 'is it going to cost more to fix the problem than if we lost the aircraft with all the people on board?' - that's not acceptable. "I'm sure the people that might be in some future accident would not agree that it's acceptable to breathe contaminated air. "It's like sticking a pipe from your exhaust into your car and saying 'what's the problem?' - it's stupidity." Ms Michaelis worked as a commercial pilot in Australia until she was medically retired, aged 34, in 1997 after eventually becoming too ill to fly. She has since specialised in researching the issue. In June, she was the lead author on the first in-depth study on the cabin air contamination, published in a World Health Organisation journal, which concluded that it was a "clear occupational and public health issue with direct flight-safety consequences". Ms Michaelis said: "Almost every flight I would get in the air, I would turn the air supply on, and that's when I would start to get headaches, fatigue, nausea, difficulty concentrating, and airway irritation. "Then when I got outside the aircraft I would recover. Once back inside the aircraft, I would go downhill. "On several occasions the air was so bad that couldn't stay flying the aircraft - I had to go and sit outside [the cockpit] to recover. I was effectively incapacitated." A spokesman for the CAA said: "Our priority is always the safety of passengers and crew and we continue to work with airlines, manufacturers and international regulators to drive improvements in safety standards across the industry. "We understand the concerns that have been raised about cabin air quality and we take very seriously any suggestions that people have suffered ill health from flying. "We rely on guidance from scientific experts based on the results of a number of independent studies and evidence reviews - including government commissioned research. "Long-term ill health due to any toxic effect from cabin air is understood to be unlikely, although such a link cannot be ruled out." HeraldScotland: Analysis: Pilot felt dizzy, nauseous and had tunnel vision as he landed plane IT has been described as "big tobacco all over again". Critics say that just as the cigarette companies in the 1950s dodging a link between smoking and lung cancer, so airlines and the aviation authorities they fund are today loathe to own up to a problem with contaminated cabin air in case they find themselves saddled with costly redesigns and compensation claims from sickened employees. The controversy relates to the use of "bleed-air" to pressurise and ventilate aircraft cabins and cockpit, which has been standard design on passenger jets since the 1950s. All commercial planes - with exception more recently of the Boeing 787 Dreamliner - use the bleed-air system, which means the air breathed by passengers and crew is contaminated by low-level concentrations of poisonous chemicals coming from the engines which have been linked to infertility, cancer and harm to unborn babies. These include compounds called organophosphates, which have been blamed for causing various neurological symptoms such as numbness, memory loss, mobility problems, and headaches in thousands of pilots and cabin crew worldwide. Dr Michaelis' own study, published in the WHO journal Public Health Panorama, found that in a sample of 274 UK-based pilots, 36 had either died or experienced chronic ill health leading to a permanent loss of fitness to fly, while a total of 172 reported some type of health problem. Diagnoses included chronic fatigue, gastrointestinal problems and neurological disorders. The study also examined 15 so-called "fume events" - serious chemical leaks into the cockpit - which had occurred on flights in Australia, Germany, the UK and US. It found that a third of cases resulted in "full or partial incapacitation" of both pilots. One notorious case in Germany in 2010 saw both the captain and co-pilot of a Germanwings plane overcome by fumes on approach to Cologne which left them nauseous, dizzy, suffering from tunnel vision, concentration problems and severe tingling. By the time they put on oxygen masks and recovered some control, the plane was travelling too fast for an autopilot landing and the captain - despite feeling unwell - had to land the aircraft manually. Both pilots, who described feeling in a "dream-like" state during the landing, were subsequently signed off sick for six months. However, recent research by the European Aviation Safety Authority (EASA) found that air quality on the flights it tested was similar or better than that observed in normal indoor environments, such as homes and hospitals. Critics insist that safe standards on the ground are not necessarily the same in a pressurised environment at altitude, where the chemicals have been heated. The debate looks far from settled. http://www.heraldscotland.com/news/ Back to Top Northrop Grumman nears deal to purchase Orbital ATK: source FILE PHOTO: A UAV helicopter build by Northrop Gruman is on deck aboard the soon to be commissioned littoral combat ship USS Coronado during a media tour in Coronado, California April 3, 2014. REUTERS/Mike Blake/File Photo NEW YORK (Reuters) - U.S. defense contractor Northrop Grumman Corp (NOC.N) is poised to announce a purchase of missile and rocket maker Orbital ATK Inc (OA.N) as soon as Monday, a person familiar with the transaction said on Sunday. The deal would come as the firing of missiles by North Korea in recent months has focused attention on missile defense systems. With Orbital's stock market value of $6.3 billion and $1.4 billion of long-term debt, the deal's final value will likely exceed $7.7 billion. Northrop Grumman declined to comment. Orbital did not immediately respond to a request for comment. Orbital's rocket motors, missiles and electro-optical countermeasure product lines would enlarge Northrop's offerings to its largest customer, the U.S. Department of Defense, analyst Byron Callan of Capital Alpha Partners LLC said in a research note on Sunday. The deal is noteworthy not only because it boosts Northrop's exposure to missile defense, but also because the company has not bought a large rival in many years. It would also represent a departure from a focus of returning earnings to shareholders. Orbital ATK has contracts with NASA as well as the U.S. Army and the deal would give Northrop more than $4.4 billion in annual revenue according to Orbital's 2016 financials. Despite infrequent strategic mergers, Northrop has not shied away from bold corporate actions to please investors. In 2011 Northrop spun off its Huntington Ingalls Industries (HII.N) shipbuilding business to shareholders. In 2009, it sold its government services business, TASC. Northrop's last buying spree more than a decade ago included the 2002 purchase of TRW Inc for about $7.8 billion. Based on Friday's closing stock price, Northrop was valued at $46.5 billion. The acquisition price could exceed $7.5 billion if a typical premium was attached to it, the Wall Street Journal said in a report published earlier on Sunday. Another reason for the deal could be the Pentagon's efforts to rebuild missiles defenses. The Air Force had asked the defense industry last summer for proposals to replace the aging nuclear cruise missiles and intercontinental ballistic missile system as the military moved ahead with a costly modernization of its aging atomic weapons systems. In August, Northrop received a $328 million contract to continue developing a replacement of the aging Minuteman III intercontinental ballistic missile system for the U.S. Air Force. Northrop is also the prime contractor for the B-21 bomber as well as the maker of the Global Hawk unmanned aerial vehicle. Orbital is a subcontractor for composite structures on the B-21, and Callan of Capital Alpha Partners said the deal might spark concerns at the Pentagon because of vertical integration within that program. So far this year Orbital's stock has increased 25 percent as investors have eyed an increase in U.S. defense spending. Earlier in September, aerospace supplier United Technologies Corp (UTX.N) agreed to buy avionics and interiors maker Rockwell Collins Inc (COL.N) in $30 billion deal that would be the largest in the industry's history. http://www.reuters.com/article/us-orbital-atk-northrop-grumman/northrop-grumman- nears-deal-to-purchase-orbital-atk-source-idUSKCN1BS0YB?il=0 Back to Top AUVSI Names Tracy Lamb as Vice President of Regulatory and Safety Affairs The Association for Unmanned Vehicle Systems International (AUVSI) today announced it has named Tracy Lamb, an experienced pilot of manned and unmanned aircraft and a recognized aviation safety expert, as vice president of Regulatory and Safety Affairs and chief pilot. As a former international airline pilot and senior flight instructor, Lamb has more than 7,000 flight hours, including more than 4,200 hours flying the Boeing 737. She has also piloted charter and corporate aircraft, flying missions that have included passenger and freight transport, aeromedical, and surveying. In addition, Lamb is licensed to operate unmanned aircraft systems. Lamb is widely recognized as an authority on aviation safety. She is a certified ISO 9000:2008 lead auditor and has conducted audits and inspections of fixed wing, rotary wing, and UAS operators and maintenance organizations around the world. Most recently, she has developed safety and risk-management programs for UAS. "We're pleased that Tracy is joining our team. She is an accomplished and experienced pilot and aviation safety expert, and she will represent AUVSI at the FAA and at international regulatory organizations," said Brian Wynne, AUVSI's president and CEO. "As chief pilot, Tracy will share her expertise and knowledge with AUVSI members and develop training and certification programs to help increase safe and responsible operations throughout the UAS community." Most recently, Lamb was manager of Safety Data Analysis for the Bristow Group. Previously, she was Global Remote Piloted Aircraft Systems RPAS Safety Manager for SGS North America, where she was also a commercial aviation advisor and safety auditor. While at SGS, she led the development of Standards and Best Practices for Unmanned Aircraft Operations, which enabled accurate and systematic operational safety auditing of UAS operations. Earlier in her career, Lamb worked at Virgin Australia Airlines, Ansett Aviation Training Centre of Excellence and several large flight training organizations. Lamb earned a bachelor's degree in applied science and aviation and a master's degree in business management and human factors at Griffith University in Melbourne, Australia. She is currently studying for a doctorate in safety and risk management at Royal Melbourne Institute of Technology University. Her academic work has included developing the first risk-management computer program for the drone industry. For more information, visit www.AUVSI.org. http://uasweekly.com/2017/09/15/auvsi-names-tracy-lamb-vice-president-regulatory- safety-affairs/ Back to Top SpaceX's Dragon capsule successfully returns from 12th ISS resupply mission SpaceX has confirmed that the Dragon capsule used to ferry cargo including supplies and experimentation material has returned to Earth as planned, with a successful splashdown in the Pacific Ocean. The Dragon went up to the International Space Station on SpaceX's CRS-12 resupply mission, which launched in August. Dragon brought a number of experimental payloads to the ISS, including a supercomputer built by HPE that is designed to test whether software hardening alone, without any additional hardware changes vs. a standard supercomputer configuration, can keep the computer operating as intended in the harsh conditions of space. Dragon was also loaded up with experimental results and other cargo during its month- long stay at the ISS, and with good splashdown and proper deployment of its parachutes after re-entry, those should be intact and ready for Earth-based researchers to analyze. This is the 12th successful ISS resupply mission SpaceX has conducted using one of its Dragon cargo capsules. The capsule used this time around is also intended to be the last brand new capsule SpaceX employs for this purpose - from now on, it hopes to only use refurbished Dragons used on previous missions. SpaceX first re-used a Dragon capsule back in June of this year, and while the company later said that its first attempt really didn't actually save it any money vs. using a new one, it hopes to gain efficiencies over time by turning around Dragon for repeat use more quickly and easily. https://www.yahoo.com/finance/news/spacex-apos-dragon-capsule-successfully- 143649023.html Curt Lewis