Flight Safety Information November 13, 2018 - No. 230 In This Issue Incident: American B763 near Orlando on Nov 10th 2018, loss of cabin pressure Incident: Nordstar B738 at Norilsk on Nov 12th 2018, flaps problems Incident: France B773 near Irkutsk on Nov 11th 2018, smoke in crew rest area EVAS - Cockpit Smoke Protection Raytheon Hawker 850XP - Emergency Landing - Nose Gear Collapse (Minn). Gulfstream 690C Commander - Forced Landing (South Carolina) NTSB: fatal Metroliner crash due loss of control after pilot continued into adverse weather. WHAT WE CAN LEARN FROM LION AIR 610 737 Pilots Not Told of MAX Design Change That Could Factor in Lion Air Crash U.S. Pilots Maintain Boeing Never Warned of System Linked to 737 Crash in Indonesia HOW TO LAND A 'COMPLETELY UNCONTROLLABLE' PASSENGER JET Sumwalt Sees Growing Data Role for NTSB Officials Are Investigating Why a Las Vegas Airport Controller Suddenly Went Silent Decades battling for veteran status, WWII women pilots fight for their place in Texas history Tata in active talks to buy majority stake in Jet Airways Want A Private Jet? Mexico's Next President Has One Up For Sale ISASI Update...Periodic News from the International Society of Air Safety Investigators Develop your career with our Fundamentals of Accident Investigation course.- Cranfield DTI Training Workshops Scheduled in Canada and the U.S. Investigation in Safety Management Systems from SCSI November/December Issue of FAA Safety Briefing Incident: American B763 near Orlando on Nov 10th 2018, loss of cabin pressure An American Airlines Boeing 767-300, registration N379AA performing flight AA-376 from Miami,FL to Philadelphia,PA (USA), was enroute at FL390 about 15nm north of Orlando,FL (USA) when the crew received indications the cabin altitude was climbing shortly followed by indicating the right hand pack had tripped offline. The crew descended the aircraft to FL310, attempted to control the cabin pressure manually but needed to continue the descent to FL240. While descending towards FL240 the cabin altitude warning triggered and the passenger oxygen masks were released, the crew initiated an emergency descent to 10,000 feet and diverted to Charlotte,NC (USA) for a safe landing. According to information The Aviation Herald received the aircraft had suffered a similiar problem on the previous day's flight AA-376 when the right hand pack tripped offline at the top of climb at FL390, the crew descended to FL310 and later FL250 but was able to control the cabin pressure by continually switching the right pack off and on while the aircraft continued to destination. Maintenance replaced a temperature control valve, subsequent tests showed no faults and the aircraft was returned to service, completed one flight (AA1450 from Philadelphia to Miami) and suffered the occurrence on the second flight after maintenance. https://flightaware.com/live/flight/AAL376/history/20181110/2045Z/KMIA/KPHL http://avherald.com/h?article=4c032a35&opt=0 Back to Top Incident: Nordstar B738 at Norilsk on Nov 12th 2018, flaps problems A Nordstar Boeing 737-800, registration VQ-BNG performing flight Y7-103 (dep Nov 11th) from Moscow Domodedovo to Norilsk (Russia) with 183 passengers and 6 crew, was on approach to Norilsk when the crew stopped the descent at 900 meters due to a problem with the flaps and entered a hold. After working the checklists the aircraft continued for a safe landing on Norilsk's runway 19 about 20 minutes later. The aircraft was unable to depart for the return flight prompting West Siberia's Transport Prosecution Office to look into the occurrence. The occurrence aircraft remained on the ground for 13 hours, then positioned back to Moscow. http://avherald.com/h?article=4c032739&opt=0 Back to Top Incident: France B773 near Irkutsk on Nov 11th 2018, smoke in crew rest area An Air France Boeing 777-300, registration F-GSQC performing flight AF-116 (dep Nov 10th) from Paris Charles de Gaulle (France) to Shanghai Pudong (China) with 282 passengers and 16 crew, was enroute at 9800 meters/FL321 about 160nm south of Irkutsk (Russia) in Mongolian Airspace when the crew decided to divert to Irkutsk reporting flight attendants had reported the smell of smoke in the crew rest area, a short time later the crew reported light smoke had become visible in the crew rest area and the smoke detector in the aft galley had triggered. The aircraft landed safely on Irkutsk's runway 30 about 30 minutes later. The passengers and crew were taken to hotels. Rosaviatsia reported the aircraft did not sustain any damage. A replacement Boeing 777-300 registration F-GSQB positioned from Paris Charles de Gaulle to Irkutsk as flight AF-7676, but did not depart Irkutsk so far about 19 hours after landing. The occurrence aircraft is still on the ground in Irkutsk about 36 hours after landing in Irkutsk. http://avherald.com/h?article=4c032467&opt=0 Back to Top Back to Top Raytheon Hawker 850XP - Emergency Landing - Nose Gear Collapse (Minn.) Date: 12-NOV-2018 Time: 18:31 Type: Raytheon Hawker 850XP Owner/operator: Emerald Cloud LLC Registration: N403CT C/n / msn: 258818 Fatalities: Fatalities: 0 / Occupants: 6 Other fatalities: 0 Aircraft damage: Unknown Location: Minneapolis-St Paul International Airport (KMSP), Minneapolis, MN - United States of America Phase: Landing Nature: Executive Departure airport: Raleigh-Durham Int'l (KRDU) Destination airport: Range Regional (KHIB) Narrative: The aircraft experienced a diversionary emergency landing at Minneapolis-St Paul International/Wold- Chamberlain Airport (KMSP) in Minneapolis, Minnesota, and subsequent nose gear collapse. The airplane sustained unreported but apparent minor damage and the six occupants onboard were not injured during the incident. https://aviation-safety.net/wikibase/wiki.php?id=217678 Back to Top Gulfstream 690C Commander - Forced Landing (South Carolina) Date: 12-NOV-2018 Time: 14:07 Type: Gulfstream 690C Jetprop 840 Owner/operator: C&C Flying LLC Registration: N840JC C/n / msn: 11676 Fatalities: Fatalities: 0 / Occupants: 1 Other fatalities: 0 Aircraft damage: Written off (damaged beyond repair) Location: Grand Strand, Horry County, Myrtle Beach, SC - United States of America Phase: Landing Nature: Unknown Departure airport: Greater Cumberland Rgnl (KCBE) Destination airport: Myrtle Beach Int'l (KMYR) Narrative: The aircraft sustained substantial damage during an apparent force landing to Atlantic Ocean beach terrain short of the approach end of Runway 36 at Myrtle Beach International Airport (KMYR), Myrtle Beach, South Carolina. The sole pilot onboard the airplane was seriously injured. https://aviation-safety.net/wikibase/wiki.php?id=217673 Back to Top NTSB: fatal Metroliner crash due loss of control after pilot continued into adverse weather Status: Final Date: Monday 5 December 2016 Time: 22:22 Type: Swearingen SA227-AC Metro III Operator: Key Lime Air Registration: N765FA C/n / msn: AC-765 First flight: 1990 Total airframe hrs: 23296 Engines: 2 Garrett TPE331-11U-611G Crew: Fatalities: 1 / Occupants: 1 Passengers: Fatalities: 0 / Occupants: 0 Total: Fatalities: 1 / Occupants: 1 Aircraft damage: Destroyed Aircraft fate: Written off (damaged beyond repair) Location: 5,5 km (3.4 mls) ESE of Camilla, GA ( United States of America) Phase: En route (ENR) Nature: Cargo Departure airport: Panama City-Northwest Florida Beaches International Airport, FL (ECP/KECP), United States of America Destination airport: Albany-Southwest Georgia Regional Airport, GA (ABY/KABY), United States of America Flightnumber: LYM308 Narrative: A Swearingen Metro cargo plane, operating Key Lime Air flight LYM308, was destroyed during a descent and subsequent inflight breakup near Camilla, Georgia, USA. The pilot, the sole occupant, was killed. The aircraft departed Panama City, Florida at 20:54 CST (02:54 UTC Dec. 6) on a flight to Albany Airport, Georgia. En route the air traffic controller advised the pilot of moderate to extreme precipitation along his planned route of flight and suggested a route of flight that would have had the pilot fly to the northeast for 70 nautical miles to avoid the most severe weather. The pilot responded that he did have enough fuel for such a diversion, but concluded that he would "see what the radar is painting" after the descent to 3,000 mean sea level (msl). Shortly thereafter, the pilot advised the controller that he intended to divert the flight to Tallahassee International Airport (TLH), Florida. The airplane then descended from 7,000 feet msl to 3,700 feet msl before radar and radio contact was lost. The wreckage was scattered over a large area that included a cotton field and dense forest. The debris field was about 2,640 feet in length and 1,500 feet in width. Probable Cause: PROBABLE CAUSE: "The pilot's decision to initiate and continue the flight into known adverse weather conditions, which resulted spatial disorientation, a loss of airplane control, and a subsequent in-flight breakup" Accident investigation: Investigating agency: NTSB Status: Investigation completed Duration: 1 year and 11 months Accident number: ERA17FA066 Download report: Final report https://aviation-safety.net/database/record.php?id=20161205-0 Back to Top Back to Top WHAT WE CAN LEARN FROM LION AIR 610 By Captain Shem Malmquist A FSI Commentary Editors Note: While the Lion Air 610 investigation continues, it's important to remember that hindsight bias is no substitute for understanding potential combination system failure events. We welcome reader response to Captain Malmquist's commentary. On October 29, 2018, Lion Air flight 610, a Boeing 737 Max 8, crashed shortly after takeoff from Soekarno- Hatta International Airport in Jakarta, enroute to Depati Amir airport. The aircraft was brand new, only having been in service for two months. The day prior to the accident flight maintenance had been performed due to an airspeed and altitude indication problem and an elevator feel differential pressure light illuminated. There were also reported problems with the angle of attack sensing system. In signing the items off, a term familiar to most pilots was used, terms such as "test on ground ok" and "test on ground satisfied". In the immediate aftermath of the accident, Boeing sent out a bulletin which was quickly adopted by FAA as an airworthiness directive to follow the Runway Stabilizer non-normal checklist. The bulletin stated that in the event of erroneous angle of attack data the stabilizer may trim nose down in increments lasting up to ten seconds. The runway trim exercise is commonly taught in simulators. It is a simple matter, in the Boeing, to counter the trim movement with control column input, and then shut off the stabilizer trim switches thus removing electrical power from the system. In these simulator events it is just one system, the stabilizer trim, that has gone wrong. The motor has gotten "stuck" in the "on" position, and that is driving the stab trim motor. Just remove the power. However, the Boeing bulletin points to something a bit different. Here we can now have a faulty sensor input into a computer system that misleads the system to do the wrong thing. This was not something that could affect earlier models of the B-737. It appears that the feature to add nose-down trim was new to the Max 8 version. It also now appears, based on recent reports, that few pilots flying the aircraft were aware that the aircraft had an angle of attack protection feature built into its trim system. We do not yet know what other systems might be impacted here. Many systems are connected to the angle of attack sensor, including flight instruments and warning systems. If, as reported, the pilots were not aware of the system functionality, it would not be surprising to find that they reacted incorrectly to it. We will learn more as the investigation progresses. In the meantime, there have already been multiple articles and comments indicating that the issue here was pilot competency. I would like to remind all pilots that these types of accidents are rarely due to lack of pilot skill. It is all too easy, as pilots, to think "I would not have done that." The response seems obvious with the clarity of hindsight bias. Part of this arrogance stems from the way we train. In the simulator the events we see are fairly simplistic. They rarely involve one system failing in a subtle way, cascading into multiple other systems. In 1974 a Northwest Airlines Boeing 727 crashed after stalling due to blocked pitot tubes due to ice. Many wondered how an experienced flight crew might not recognize that they were stalling, after all, it was well known that one outcome of iced pitot tubes could be that the airspeed increases with climb, much like an altimeter. The higher indicated speeds led to the crew pulling the nose up to try to prevent an overspeed, but shouldn't that have been obvious? As outlined in the NTSB report, the Board suspected that the elevator feel pitot tubes were also blocked. This creates a confusing situation where the airspeed indication is increasing, and that can be coupled with the control forces acting as if the plane is flying faster as well. This then mixes with overspeed warnings as well as stall warnings. A very confusing situation. We do not know, yet, all that the Lion Air crew had to contend with. We do know that these combination failure events can lead to a situation that can be very difficult to sort out. We also know it is hard for a pilot to handle a situation where the airplane is doing something outside of what they know to be possible. Instead of this being another "I would not have done that" conversation, use it instead to start delving into your aircraft systems. Knowledge is power. In this case, knowledge can keep you alive. Captain Shem Malmquist is a veteran 777 captain and accident investigator. He is coauthor of Angle of Attack: Air France 447 and The Future of Aviation Safety and teaches an online high altitude flying course with Beyond Risk Management and Flight Safety Information. He can be reached at shem.malmquist@gmail.com Back to Top 737 Pilots Not Told of MAX Design Change That Could Factor in Lion Air Crash By: Christine Negroni How concerned are 737 MAX pilots about their new airplane? Plenty concerned. Over the weekend, two U.S. operators of Boeing's newest model narrowbody were sending out memos with details of a new system unique to the MAX called the Maneuvering Characteristics Augmentation System, which may have contributed to the fatal crash of Lion Air Flight 610 last month in Indonesia. This memo had to be sent because until last week this system was a secret to the men and women who fly the plane. The MCAS on the Boeing 737 Max was added as part of its Federal Aviation Administration certification. Pilots at American Airlines, which has 16 MAX-8s in its fleet and at Southwest with 26, were told over the weekend that the MCAS was added, "to enhance pitch characteristics during steep turns with elevated load factors and during flaps up flight at airspeeds approaching stall." Pilots have been abuzz over the Lion Air accident and what appears to have been the pilots' inability to pull out of an airplane-induced nose-over on October 29. The din got louder when Boeing sent a Service Bulletin to operators and the Federal Aviation Administration followed up with an Emergency Airworthiness Directive nine days later. "This is the first description you, as 737 pilots, have seen. It is not in the AA 737 Flight Manual Part 2, nor is there a description in the Boeing FCOM (flight crew operations manual)," says the letter from the pilots' union safety committee. "Awareness is the key with all safety issues." The APA told pilots an update to the airline's and Boeing's crew manual would be added soon. Pilots of any version of the 737 could encounter situations in which the elevator trim puts the airplane in a nose down position unexpectedly. It is something for which they train in the simulator. What makes the addition of the MCAS to the 737 MAX problematic for pilots, is not knowing about it. "Events that happen seemingly for no reason can be very difficult to deal with. That's the whole reason we learn about systems in ground school and practice responding to their failures in the sim, to make a mental blueprint that acts as a vaccination against unexpected issues," said John Gadzinski, a 737 MAX pilot and the president of Four Winds Aerospace Safety Corp. "There's a huge dissonance here. At best we're trained so that when the airplane tells us to do something, we do it. There's an enormous part of your brain that wants to trust what the airplane is telling you and to all of a sudden to be told, 'Wow, in this case, the airplane - which is the most advanced version of the most trusted airplane in the world - can't be trusted,' that's kind of a big deal. That's a huge deal." http://christinenegroni.com/737-pilots-not-told-of-max-design-change-that-could-factor-in-lion-air-crash/ Back to Top U.S. Pilots Maintain Boeing Never Warned of System Linked to 737 Crash in Indonesia By Alan Levin and Mary Schlangenstein Two U.S. pilots' unions say the potential risks of a safety feature on Boeing Co.'s 737 Max aircraft that has been linked to a deadly crash in Indonesia weren't sufficiently spelled out in their manuals or training. Boeing and the Federal Aviation Administration issued directives last week telling flight crews about the system, which is designed to provide extra protection against pilots losing control. That prompted aviators, unions and training departments to realize that none of the documentation for the Max aircraft included an explanation of the system, the union leaders said. "We don't like that we weren't notified," said Jon Weaks, president of the Southwest Airlines Pilots Association. Dennis Tajer, a 737 captain and spokesman for the Allied Pilots Association at American Airlines Group Inc., said his union's members were also concerned. The complaints from pilot union leaders at Southwest Airlines Co. and American are significant because of the size of those carriers' 737 fleets and their Max purchases. Southwest is the largest operator of the 737 Max and has the most on order with 257 of the jets yet to be delivered. American, the world's largest airline, has outstanding orders for 85 of the planes. "This is not about silos and layers of bureaucracy, this is about knowing your airplane," Tajer said. "We will always be eager and aggressive in gaining any knowledge of new aircraft." A bulletin from APA to American's pilots said details about the system weren't included in the documentation about the plane. "This is the first description you, as 737 pilots, have seen," it said. "The companies and the pilots should have been informed," Weaks said. "It makes us question, 'Is that everything, guys?' I would hope there are no more surprises out there." Boeing said it is confident in the safety of the 737 Max family of jets. "We are taking every measure to fully understand all aspects of this incident, working closely with the investigating team and all regulatory authorities involved," the company said in a statement by email. "Safety remains our top priority and is a core value for everyone at Boeing." Few details have been released about the underlying causes of the Lion Air crash Oct. 29 in the sea near Jakarta, but Indonesian investigators say that an erroneous sensor prompted the plane's computers to push the aircraft into a steep dive. A new safety measure added on the Max models to prevent pilots from losing control is what caused the plane to point downward, according to the FAA and Boeing. A long-standing procedure taught to pilots could have halted the dive, according to the regulator and the manufacturer. The FAA ordered airlines to add an explanation into flight manuals. Indonesia's National Transport Safety Committee is continuing to search for the plane's crash-proof cockpit voice recorder under the sea, it said Monday. The investigative agency plans to release a preliminary report between Nov. 28 and 29, a month after the crash, as mandated by international treaty. The FAA, which certified the plane, said in a statement it couldn't comment on the matter while the investigation in Indonesia remains open. The FAA's emergency directive required that U.S. carriers revise flight manuals and said the agency "will take further action if findings from the accident investigation warrant." While the design of the Max has been under a spotlight since the accident, other factors in the crash could eclipse it in importance. They include questions about how maintenance was performed after problems arose on at least three prior flights of the Lion Air jet and the actions of the pilots on its last flight. When Boeing designed its latest version of the 737, it added the new safety feature to combat a loss of lift, which is a leading contributor to the loss-of-control accidents that by far cause the most crash deaths around the world. Known as the Maneuvering Characteristics Augmentation System, it was added "to compensate for some unique aircraft handling characteristics," according to a bulletin sent by Southwest's flight operations division to its pilots on Nov. 10. Sharp Dive When the system senses the plane is close to losing lift on the wings, it automatically commands a lowering of the nose to counteract the risk. However, the chief sensor used to predict a loss of lift - known as an angle-of- attack vane - was malfunctioning on the Lion Air flight. It essentially tricked the system into ordering a sharp dive. Pilots are drilled on how to cut power to the so-called trim system if the plane starts to dive or climb on its own, but that procedure was never linked directly to a malfunctioning angle-of-attack sensor in training or the documentation. "At the present time, we have found no instances of AOA anomalies with our 737 Max 8 aircraft," the APA bulletin said, referring to angle of attack as AOA. "That is positive news, but it is no assurance that the system will not fail." Because the system is only designed to operate in rare conditions while pilots are manually flying, "pilots should never see" the system in operation, according to the Southwest memo. As a result, Boeing chose not to include a description of it in the extensive manuals it prepared for the Max models, said the memo. That reasoning doesn't make sense, said Roger Cox, a retired investigator with the U.S. National Transportation Safety Board and a former airline pilot. Flight crews have a right to be concerned that details about the new system weren't included in manuals and the short training courses they were required to take before flying the upgraded 737, Cox said. "I would be pretty pissed" about not being told, he said. "This is important systems information that pilots should know about." https://www.insurancejournal.com/news/national/2018/11/13/507297.htm Back to Top HOW TO LAND A 'COMPLETELY UNCONTROLLABLE' PASSENGER JET Pilots are trained to follow a simple creed when something goes wrong: Aviate, navigate, and communicate, in that order.MARINA LYSTSEVA/TASS/GETTY IMAGES THE TROUBLE STARTED almost immediately. A few minutes after taking off from Lisbon on Sunday, the pilots of an Air Astana Embraer 190 jet called Mayday. "We have flight control problems," he told air traffic control, asking for a path to the sea for an emergency landing. "We have six people on board," one pilot said a few minutes later, according to an audio recording available via LiveATC.net. "Airplane is completely uncontrollable." Those six included three pilots and three engineers, according to FlightGlobal, who were taking the aircraft from Portugal, where it had been undergoing maintenance, to Kazakhstan, where Air Astana is based. In the first portion of the flight, the Embraer traced the sort of flight path you'd draw if you took your Spirograph on a roller coaster. Eventually, the pilots regained control and, escorted by a pair of fighter jets, flew south to an airport with good weather and landed safely. "Due to technical reasons the crew decided to perform an unplanned landing," Air Astana said in a statement on Twitter. The investigation into what happened is just beginning, but the loss of control points to a few possibilities, says Shawn Pruchnicki, a former airline pilot who teaches aviation safety, human factors, accident investigation, and complex aircraft operation at Ohio State University's Center for Aviation Studies. The plane's control surfaces (the flaps, ailerons, and so on) could have frozen, or the power control units that move them might have failed. It might be related to the plane's recent maintenance, or the timing could be coincidental. Pilots are trained to follow a simple creed when something goes wrong: Aviate, navigate, and communicate, in that order. In a loss-of-control situation, Pruchnicki says, aviating means figuring out what systems are working and how you can use them to stay level. Flight 1388 followed a wild course during its harrowing flight. (Note FlightRadar24 tracked the plane using 'multilateration,' which isn't perfectly precise. "Try to maintain control of the aircraft at all times, using whatever means you have to," Pruchnicki says. "There are some aerodynamic techniques that can be used for an airplane that is seemingly out of control that really sharp pilots, especially those with acrobatic training, can attempt to regain control." Imagine you're stuck banking steeply to the right and losing altitude, and the ailerons (those flappy bits on the wings) are frozen. In normal flight, the pilot uses the rudder to point the nose right or left. Here, with the plane at an angle, the pilot could step on the left pedal to move the rudder, pulling the nose up and maintaining altitude. "The airplane will still stay 90 degrees"-tilted to the right, that is-"but it'll be controllable in a different axis." Or say you're having trouble turning: Changing how much power goes to each engine might help. The Brazilian-made Embraer 190's engines sit under its wings, so applying thrust can pitch the plane up a bit. The point is, pilots have lots of tools at their disposal. When one tool malfunctions, pilots have to get creative with how they use the others. The Air Astana pilot's request for directions to the ocean-"We need vectoring to the sea please, we will be ditching"-indicate that at that moment, he didn't think he could reach an airport or even a large field. The ocean's swells can make things tricky, but "it might be the best choice, out of some really crappy choices." At least you won't hit any buildings, and you don't have to worry about lining up with a runway. An hour after calling Mayday, the pilot announced he had control of the plane and could maintain a set heading and altitude. By this point, they were accompanied by a pair of F-16 fighter jets scrambled by the Portuguese air force, which led the Embraer south toward the airport in Beja. Even when your navigation systems are working, that kind of guidance is helpful because it gives you one less thing to worry about. "All of this takes a lot of mental bandwidth, and it's nice to have a jet that you can just fly next to," Pruchnicki says. "That way the burden is shifted onto them. It's good crew resource management." Remember that aviating-maintaining control of the plane-comes before navigating. (The fighter pilots can also take a look at the parts of the plane you can't see and maybe figure out what's wrong.) Once at Beja, the Embraer's crew needed three approaches to get onto the ground, but safely touched down at around 3:30 in the afternoon. https://www.wired.com/story/air-astana-flight-1388-portugal-loss-control/ Back to Top Sumwalt Sees Growing Data Role for NTSB National Transportation Safety Board chairman Robert Sumwalt believes his agency will increasingly turn to data use for its safety activities but he does not expect it will have a role in monitoring individual operator's data in real-time. "We are trying to get more savvy on [data]," said Sumwalt. "We have not been out there mining data in the past. We are going to be postured to mine data more to look for trends." He noted other organizations are already engaged in such activity, such as the Aircraft Owners and Pilots Association's Air Safety Institute, which examines trends for data and reports those findings in its Joseph T. Nall report. He also believes access to data from flight data monitoring equipment is "very valuable" to the agency's investigations, adding he is a strong proponent of flight operational quality assurance (FOQA) programs. Having said that, Sumwalt added the NTSB will not mine for real-time data. "That is not what our congressional mandate is. That is not going to be a function of NTSB," he said. "But from personal experience, I think data should be mined and monitored in-house." He added that data-sharing programs such as ASIAS are helpful, but it is not the role of government to look at an individual operator's data. Sumwalt also last week reported improving aviation safety statistics overall, with the number of accidents in 2017 down by 19 to 1,316 and the number of fatalities declining from 412 in 2016 to 350 last year. Air taxis were in involved in 43 accidents, resulting in 15 fatalities. Reiterating the strong safety improvements in Part 121, which resulted in no fatal accidents in a nine-year period until the Southwest Airlines fatal accident on April 17, Sumwalt said concerns still remain for business aviation. Accidents involving professionally flown Part 91 and 135 operations produced 77 fatalities during the same nine-year period. He agreed with remarks presented by NTSB's Office of Aviation Safety director John DeLisi at the recent Bombardier Safety Standdown that business aviation could benefit in three key areas: safety management systems, flight-data monitoring programs, and mandatory controlled flight into terrain prevention training. https://www.ainonline.com/aviation-news/business-aviation/2018-11-12/sumwalt-sees-growing-data-role- ntsb Back to Top Officials Are Investigating Why a Las Vegas Airport Controller Suddenly Went Silent (LAS VEGAS) - Federal and airport authorities said Friday they are investigating why an air traffic controller became incapacitated and went silent while working a night shift alone in the tower at busy McCarran International Airport in Las Vegas. "No safety events occurred during this incident," the Federal Aviation Administration said in a statement about what officials said amounted to a 40-minute span during which the female controller slurred words and then apparently lost consciousness shortly before midnight Wednesday. "An air traffic controller at the Las Vegas tower became incapacitated while on duty," the agency said. It did not identify the controller or the cause of her incapacitation. Airport director Rosemary Vassiliadis issued a statement saying that initial findings echoed the FAA assessment. Five inbound aircraft remained airborne during the incident, and aircraft on the ground held positions or communicated between themselves to maintain safety while moving, the FAA said. Air traffic recordings available on the internet show commercial airline pilots having trouble understanding the controller during radio communications about approaches to land, clearances to take off and directions for taxiing. Some begin talking between themselves about something being amiss. At one point, the controller sounds sleepy and apologizes over the radio, saying she is "choking a little bit." Minutes later, she misstates an aircraft's call numbers. Finally, her microphone opens to the sound of coughing and grunting. She does not respond to a pilot's inquiry before the sound of a male voice is heard in the room asking if the woman is all right. Officials said a male controller who had been on break was summoned to return to the tower. Paramedics responded. The FAA said the woman was put on administrative leave, and the agency ordered two controllers to be in the tower during busy hours. "The FAA is deeply concerned by the incident, is thoroughly investigating what occurred, and is taking immediate steps to modify its overnight shift staffing policies," the agency statement said. McCarran is among the 10 busiest airports in the U.S. in passenger volume. The unidentified controller worked for a little more than an hour before trouble began and communicated with pilots of 29 aircraft before she was replaced, the FAA said. National Air Traffic Controllers Association chief Paul Rinaldi issued a statement praising the work of thousands of union members around the country and promising cooperation in the FAA investigation "so that all of the facts are known." http://time.com/5451938/las-vegas-airport-controller-silent/ Back to Top Decades battling for veteran status, WWII women pilots fight for their place in Texas history AUSTIN - After decades fighting to be recognized as veterans, women pilots who flew during World War II are now fighting to retain their place in Texas history. On Tuesday, the Texas State Board of Education is expected to vote on sweeping changes to what is taught in history classes. Among the dozens of people and groups the board has proposed cutting to "streamline" the curriculum are the Women Airforce Service Pilots, or WASP, the more than 1,000 Fly Girls trained in West Texas to be the first American women to fly military aircraft. It took the pilots more than three decades to win the right to call themselves veterans. And now, their descendants are gearing up for this new fight. They want their stories taught in Texas classrooms, and have amassed thousands of signatures in support. "I'd not want to have to tell the family of WASP Cornelia Fort, a woman who survived the attack on Pearl Harbor, who joined the WASP, who was the first woman pilot to die in service of her country, that the State Board of Education is removing her story from the curriculum," Ann Hobing, president of the National WASP WWII Museum in Sweetwater, said Friday. "Children can be inspired by this group of women 75 years ago. What better example to show that a legacy can truly live on than to be required in textbooks?" Elaine D. Harmon Elaine Harmon never demanded recognition. But her family has fought for years to make sure she gets it. Like many others among Women Airforce Service Pilots, Harmon signed up to fly because she saw it as part of her duty as an American citizen. The military needed to free up male pilots for combat missions overseas and recruited women to fill in for them at home, ferrying personnel and cargo, flying drones, towing targets during live fire drills, and more. More than 25,000 women applied. Only 1,830 were accepted. And just 1,074 completed the training program, most at Avenger Field in Sweetwater, about 180 miles west of Fort Worth. Women like Harmon flew more than 60 million miles in the 16 months the program existed. But, when it was disbanded in 1944, the women in the WASP program were sent home without the recognition afforded male civilian pilots. They didn't receive benefits and were denied the right to call themselves veterans. The 38 who lost their lives in the line of duty weren't given military funerals and their families were prohibited from placing the American flag over their caskets. This all began to change in 1977. That year, more than three decades after their service ended, Congress finally voted to extend veterans status to the pilots. And in 2009, Harmon stood by President Barack Obama when he awarded the Women Airforce Service Pilots the Congressional Gold Medal, the country's highest civilian award. When she died six years later, Harmon left her family a handwritten request to be laid to rest among her fellow veterans at Arlington National Cemetery. But, yet again, she was almost denied recognition. The women who were part of the WASP program could only be interred at cemeteries run by the Department of Veterans of Affairs, the Army told her family, not those, like Arlington National Cemetery, which are run by the Army. Unacceptable, her family decided. After a protracted battle, in which her granddaughter Erin Miller visited 150 offices on Capitol Hill, Harmon's family won the ability to heed her final wish. More than a year after her death, Harmon was inurned at Arlington National Cemetery. Miller's next battlefield is the State Board of Education. This week, she'll travel to Austin to tell board members her grandmother's story. "It's baffling to me that Texas would want to remove these women from the curriculum," Miller said. "Putting a line through them ... It's just absolutely devastating to me and to my family. "They were already forgotten about once." Muriel Lindstrom Segall Muriel "Mimi" Lindstrom Segall climbs into a plane during her service a Women Airforce Service Pilot during World War II. Segall's son, Lindy, will be testifying before the Texas State Board of Education on Tuesday, Nov. 13 in the hopes of reversing the board's decision to cut the WASP from the public school social studies curriculum. (Courtesy of Lindy Segall) Muriel "Mimi" Lindstrom Segall was a girl of the West. She fell in love with flying when she took it as an elective in college, around the time she fell in love with her future husband. He graduated with a diploma in one hand and a commission in the other. And although she didn't have to serve, she wanted to, so she signed up to be a WASP. Segall flew three different bombers during her service, and after the war, she and her husband continued to fly together for the next 55 years. She died in 1999. Her son, "Lucky" Lindy Segall, has dedicated himself to making sure the stories of the WASP are not lost. He helped curate a exhibit about his parents at the Bullock Texas State History Museum, has given talks around the state and even wrote a screenplay about these women pilots. Most recently, he's supported the development of a WASP musical called Sweetwater. And this week, he'll be in Austin. As a substitute teacher, Segall said, he understands the pressure educators are under to check off everything required in the curriculum. He doesn't want to push that the pilots be recognized - something his mother also never demanded - but he hopes her story can persuade the education board to recognize their value. "I've always believed that you ask yourself the question, 'Are you merely a resident of a country, city or state, or are you a citizen?'" Segall said. "They knew everybody had to step up. There was complete unity of thought and they didn't complain. They did their job. "And, to me, that spells citizenship." This week Under state guidelines, fourth-grade students can learn about up to 70 different people and groups. Same with seventh graders. From kindergarten through high school, the current social studies curriculum includes nearly 450 people and groups. Some, like George Washington, are required reading; others, like Hillary Clinton and Helen Keller, are recommended. Teachers have long complained about the breadth of the curriculum, known as the Texas Essential Knowledge and Skills, or TEKS. They worry their students are asked to learn about so many people that they're resorting to rote memorization of names and dates instead of real learning. So, earlier this year, before they finished their regular review of the social studies TEKS, the Texas State Board of Education tried to tackle this problem. The members nominated a group of teachers, administrators and parents who volunteered to find ways to cut the curriculum. This group came up with a rubric ranking each historical figure or group and then recommended eliminations. Keller and Clinton didn't make the cut. Neither did Stonewall Jackson or a group of prominent Confederate leaders including John Reagan, whose name is on a building on the Texas Capitol grounds. The WASP program was cut from the second-grade history curriculum; teachers had been recommended to teach students about these pilots as part of a lesson on Americans "who have exemplified good citizenship." But when the volunteer group ranked them using the rubric, the Women Airforce Service Pilots received just 6 points out of a possible 20 and were put on the chopping block. The board agreed. In September, board members voted to cut the WASP and a few dozen other historical figures from the curriculum. The board will take its final vote on the curriculum this week. Board Chairwoman Donna Bahorich reiterated that this review, which state lawmakers asked for a few years ago, was meant to streamline the curriculum to give teachers more time and flexibility in the classroom. She expects some changes to be made this week but doesn't know which ones based on public feedback. Member Marty Rowley, who represents the Sweetwater area, said he'll support adding the WASP back in. "I plan to support these courageous women's inclusion in the standards as an outstanding example of citizenship while our country fought for freedom in World War II," Rowley said Friday. "They are not only an interesting story of citizens stepping up to serve their country, they also serve as role models to elementary students of strong female leadership." Hobing, the WASP museum president, said she's contacted all 15 board members and, as of Friday, had gathered 3,200 signatures supporting reversal of the decision. Ideally, she would like to see the pilots' story be required reading. "They defied all that adversity. They wanted to serve their country," Hobing said. "That is an extremely good example of what citizenship means and how individual people can come together to make a difference." https://www.dallasnews.com/news/education/2018/11/12/after-decades-battling-veteran-status-wwii- women-pilots-fight-place-texas-history Back to Top Tata in active talks to buy majority stake in Jet Airways NEW DELHI/MUMBAI, Nov 13 (Reuters) - Indian conglomerate Tata Sons is in active talks to acquire a controlling stake in Jet Airways, four people aware of the talks told Reuters, in what could potentially be a lifeline for the debt-laden carrier. Tata is very interested in Jet but it is not at a stage of conducting due diligence or looking through non-public data, said two of the people, who spoke on condition of anonymity as the discussions are private. One potential deal structure could include Tata taking over Jet's assets including the planes, leases, pilots and slots but not the whole company, one of the people said. The first step is to see if the economics are viable, if it makes sense from the cost and strategy perspective, and if Tata can make it work with its other aviation businesses, the person said. Tata already owns and operates two airlines in the country: full-service carrier Vistara, which is in partnership with Singapore Airlines Ltd, and low-cost carrier AirAsia India in combination with AirAsia Group Bhd. The talks come as a mix of rising oil prices, a weak rupee, low fares and competition has seen profit dive in the world's fastest-growing aviation market, which is clocking 20 percent annual passenger growth. Jet, founded by entrepreneur Naresh Goyal, is struggling to make payments to creditors including aircraft lessors and employees, and has seen its share price plunge 70 percent so far this year. The airline said on Monday it would cut flights on less profitable routes and add capacity to more lucrative markets as part of a broader consolidation plan to reduce costs and boost revenue after it reported its third consecutive quarterly loss. Any investment by Tata in Jet is, however, contingent to Goyal stepping down so that Tata has the power to take the decisions necessary to turn the airline around, the people said. Goyal owns 51 percent of the airline while 24 percent is held by Etihad Airways. "A lot of deal structures are possible and being explored," said one of the people. "The only structure that is not viable is one with Goyal in it." Mint newspaper earlier on Tuesday reported, citing two people directly aware of developments, that Tata was conducting due diligence on Jet Airways as it considered buying a controlling stake. Shares in Jet were up 3.6 percent in afternoon trade. https://www.nasdaq.com/article/tata-in-active-talks-to-buy-majority-stake-in-jet-airways-20181113-00165 Back to Top Want A Private Jet? Mexico's Next President Has One Up For Sale Mexico's presidential plane, a Boeing 787-8 Dreamliner called the Jose Maria Morelos y Pavon, arrives at Benito Juarez International Airport in Mexico City in February 2016, when it was brand new. The airplane was one of the most expensive presidential airplanes in the world. Mexico's next president is trying to sell it. Hector Vivas/LatinContent/Getty Images The Boeing 787-Dreamliner is big, luxurious, nearly new - just two years old. It's downright presidential, since it was built to transport a head of state. The president-elect of Mexico doesn't want it. Not even a little. But that doesn't mean he can't praise it. In fact, he has a whole sales pitch. "It's not just efficient and modern," President-elect Andrés Manuel López Obrador, who's widely known by his initials, AMLO, told reporters on Friday. "It's a comfortable plane, with a bedroom, a restaurant, lots of space." If you set it up like a passenger jet you could fit 280 people, he notes. Plus, it's famous! And if you want it, it's yours. For a price. López Obrador ran for office as a leftist populist who said he'd crack down on corruption and slash his own salary - while also capping other public officials' pay and eliminating perks of government employment. Ditching the presidential jet, purchased by his predecessors for a pricey $218 million, was one of his campaign promises. As he approaches his inauguration in December, he says he hasn't changed his mind. In fact, López Obrador has decided to sell - or rent out - a whole slew of airplanes and helicopters owned by the federal government. "We aren't going to use this fleet," he stated firmly in August. The profits from selling or leasing out the planes and helicopters would be directed to social programs, he said. At a press conference on Friday, López Obrador asked the gathered journalists to help him get the word out to potential buyers. https://www.npr.org/2018/11/12/667113109/want-a-private-jet-mexicos-next-president-has-one-up-for-sale Back to Top ISASI Update Periodic News from the International Society of Air Safety Investigators No. 34, November 2018, Esperison (Marty) Martinez, Editor ISASI Executive Office Incumbents Retain Seats The Ballot Certification Chairman and Nominating Committee Chairman certified the election of the 2018 Executive Officers, U.S. Councilor, and the International Councilor. Those elected for a two year term are as follows: President, Frank Del Gandio; Vice President , Ron Schleede; Secretary, Chad Balentine; Treasurer Robert (Bob) MacIntosh; U. S. Councilor, Eugene (Toby) Carroll, Jr.; and International Councilor, Caj Frostell. All were incumbents and were returned to their positions. ISASI 2018 'Truly International' President Frank Del Gandio characterized ISASI 2018 as "...truly international" citing the record setting 46 countries represented at the Society's annual Accident Investigation and Prevention Seminar. Barbara Dunn, ISASI's Seminar Chairperson added that the overall programs were exceptionally well received by all 287 attendees, including 33 companions. President Del Gandio added that the support provided by General Civil Aviation Authority, UAE for the event held in Dubai Oct 29-Nov 2 was evident in the well orchestrated event which included a day of tutorials attended by 103 and an optional tour day, attended by 50. He noted that attendees expressed pleasure with the seminar's venue as it permitted opportunity for more outdoor activity encouraging interaction among them. He concluded; "ISASI 2018 proved to be an exceptional platform for the discussion of The Future of Aircraft Accident Investigation." Plans are underway for ISASI 2019 - September 1-6 at The Hague. Its Theme: "Future Safety: Has The Past Become Irrelevant?" Capt. M.A. Aziz Receives Lederer Award ISASI's 2018 Lederer award was presented to Capt. Mohammad A, Aziz (Middle East Airlines, Ret.) for his efforts to establish and grow MENASASI and a lifetime spent to improve aviation safety through investigation. The presentation was made before 250 attendees at the Society's 49th annual International Accident Investigation and Prevention Seminar Awards Banquet held in Dubai, UAE, in late October. List of Winners Recipients of the ISASI Jerome F. Lederer Award * 2017 - Mr. Chan Wing Keong * 2016 - Eugene "Toby" Carroll * 2015 - Ladislav Mika (Ladi) * 2014 - David King * 2013 - Frank S. Del Gandio and Myron P. "Pappy" Papadakis * 2012 - Dr. Curt Lewis * 2011 - Paul-Louis Arslanian * 2010 - Michael Poole * 2009 - Capt. Richard B. Stone * 2009 - Australian Transport Safety Bureau * 2008 - Don Bateman * 2007 - Tom McCarthy * 2006 - Richard H. Wood * 2005 - John D. Rawson * 2004 - Ron Chippindale (deceased 2/12/08) * 2003 - Caj Frostell * 2002 - Ronald L. Schleede * 2001 - John Purvis and The Transportation Safety Board of Canada * 2000 - Nora Marshal * 1999 - Capt. James McIntyre (deceased 11/19/01) * 1998 - A. Frank Taylor * 1997 - Gus Economy * 1996 - Burt Chesterfield * 1995 - Dr. John K. Lauber * 1994 - U.K. Aircraft Accidents Investigation Branch * 1993 - Capt. Victor Hewes * 1992 - Paul R. Powers * 1991 - Eddie J. Trimble * 1990 - Olof Fritsch * 1989 - Aage A. Roed (deceased 1/25/03) * 1988 - H. Vincent LaChapelle * 1987 - Dr. Carol A. Roberts * 1986 - Geoffrey C. Wilkinson * 1985 - Dr. John Kenyon Mason * 1984 - George B. Parker * 1983 - C.O. Miller (deceased 10/20/03) * 1982 - C.H. Prater Houge * 1981 - Dr. S. Harry Robertson * 1980 - John Gilbert Boulding * 1979 - Gerard M. Bruggink * 1978 - Allen R. McMahan * 1977 - Samuel M. Phillips ISASI Gains ARCM Status Daniel Barafani, Latin America ISASI Latin America Regional President, reports that ISASI has been granted "Special Observer" status in the MG Regional Cooperation Mechanism (ARCM) of South America which has the mission of "supporting States, upon request, on all matters relating to aircraft accidents and incident investigations." The main objective of the ARCM is to improve and achieve an appropriate level of cooperation between the countries of the SAM region, taking into account the capabilities of each State, through the respective agencies responsible for aircraft accident investigation in order to help achieve the goals set in the Declaration of Bogotá. In its Special Observer status, ISASI can facilitate collaboration and cooperation to AIG organizations of the ARCM member States, not only in the investigation technical area but also in training and exchange of information. Member states include: Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Guyana, Panamá, Paraguay, Perú, Suriname, Uruguay, and Venezuela. Larry Fogg Granted Life Membership ISASI President Frank Del Gandio has granted Larry L. Fogg Life Membership status in ISASI as he meets the requirements of reaching age 70 and having paid dues for at least five years. The new status recognizes Larry as a "member in good standing for life" as he is no longer required to pay membership dues. In a letter forwarding Larry his "Life" membership identification card, President Del Gandio wrote: "We hope you will continue to enjoy and participate in the Society's activities. Congratulations and thank you for your support and interest in the International Society of Air Safety Investigators." Lederer Award Committee Seeks 2019 Nominations The Jerome F. Lederer Awards Committee Chairman, Gale Braden, seeks new 2019 nominations. No new nominations for the award were received in 2018. "Usually we get one to three per year. Surely there are some deserving investigators among us," Braden said. He urged ISASI members to "nominate a person or persons you believe deserves consideration for this award." This award, ISASI's highest recognition for individual or group efforts to promote or improve air safety through investigations, was established in honor of Jerome F. Lederer for his many significant contributions to aviation safety during his lifetime. Each year, at the Society's annual seminar, ISASI presents The Jerome F. Lederer Award to the winner. The award recognizes positive advancement in the art and science of air safety investigations. To be considered for the 2019 Jerome F. Lederer Award, nominations must be received by the committee chairman on or before May 31, 2019 "The criterion for the award is quite simple," Braden said. The Lederer Award recognizes outstanding contributions to technical excellence in accident investigation. Any member of the Society in good standing may submit nominations. The award can be given to a group of people, an organization, or an individual, and the nominee does not have to be an ISASI member. The award may recognize a single event, a series of events, or a lifetime of achievement. The ISASI Awards Committee considers such traits as duration and persistence, standing among peers, manner and techniques of operating, and of course, achievements. The nomination letter for the Lederer Award should be limited to a single page, if not it will be edited down to one page. The nominees are considered for three years, if not selected, after a year they can be re-nominated. This prestigious award usually results in positive publicity for the recipient, and might be beneficial in advancing a recipient's career or standing in the community. Nominations should be mailed, or e-mailed to the ISASI office or preferably directly to the Awards Committee Chairman, Gale E. Braden, 13805 Edmond Gardens Rd, Edmond, OK 73013 USA, or to the email address, galebraden@gmail.com. More information can be found on the ISASI website under the Awards section: www.isasi.org SASI Pakistan Discusses Seminars SASI Pakistan President Sayed Naseem Ahmed held discussions with Assistant Chief of Air Staff Air Commodore Shahid Jahangiri at the College of Aviation Safety Management (CASM) regarding the possibilities of conducting seminars and courses for PAF. The Air Commodore was also briefed on the mission, role and activities of the ISASI. He expressed appreciation for SASI Pakistan's contribution to aviation safety in Pakistan. SASI Pakistan plans to hold its annual seminar in Lahore in December 2018 or January 2019. Speakers from the globe will be invited to share their views on safety with Pakistani delegates from civil society, aviation, rail, road and industrial safety organizations. NZSASI Seats New Officers The New Zealand Society of Air Safety Investigators has had a recent change of office holders. Now serving the society are: President, Graham Streatfield; Vice President, Russell Kennedy; Secretary/Treasurer, Bryan Franklin and Alister Buckingham, NZSASI Councilor. Web site posting of the regional ANZSASI seminar to be held in June and its Call for Papers is expected to be made soon. Articles in Upcoming ISASI Forum Helicopter Accident Trends in 8 ISASI Countries-Robert Matthews, former FAA Senior Safety Analyst, Office of Accident Investigation; Rex Alexander, safety consultant, and Richard "Dick" Stone, ISASI Executive Advisor review helicopter accident data to highlight safety improvements, to suggest ongoing problem areas, and to make recommendations to continue improving helicopter flight safety. Electric Air Taxis and the Adaptation of Air Safety Investigators-Nicolette R. Meyer, Kapustin Scholarship awardee from Embry-Riddle Aeronautical University offers a preview of air traffic and air safety issues in the near future that accident investigators may face. Passenger Brace Position in Aircraft Accident Investigations-Jan M Davies, Professor, University of Calgary; Martin Maurino, Technical Officer, Safety, Efficiency, and Operations, ICAO; and Jenny Yoo, Advisor to the Korea Aviation and Railway Accident Investigation Board and Cabin Safety Analysis Group Chair, Korea Transportation Safety Authority studied 34 NTSB accident reports from 1983 through 2015 finding that only five mentioned the brace position and one included brace position recommendations. Using Data to Assess Performance of Safety Management-Nektarios Karanikas, Associate Professor of Safety & Human Factors, Aviation Academy, Faculty of Technology, Amsterdam University of Applied Sciences, Amsterdam, identified positive and negative areas of safety management systems through analysis of data and discussions with organization staff. The Impact of Hollywood on Accident Investigation-Dr. Katherine A. Wilson, US National Transportation Safety Board and Darren Straker, Chief Inspector of Air Accidents with the Hong Kong Air Accident Investigation Authority (AAIA) examine how movies and other media that portray air accident investigations can delve into fiction for the sake of drama. A Trip to the Land of Merlion-Faisal Bashir Bhura, Squadron Leader, Pakistan Air Force and Directing Staff at the College of Aviation Safety Management, PAF Base, Masoor provides a personal account about attending a fellowship training program held at the Singapore Aviation Academy. Back to Top Develop your career with our Fundamentals of Accident Investigation course The Cranfield Safety and Accident Investigation Centre (CSAIC) is helping to improve safety and shape the future of the transport industry. If you're working in the air, marine or rail transport industry and are looking to further your experience in accident investigation - look no further - our Fundamentals of Accident Investigation course focuses on the core skills needed to become an accident investigator. By combining the air, marine and rail transport industries, you will gain all of the knowledge you need for a balanced view of the accident investigation process. Our next course will run 14 January -1 February 2019 Find out more and register your place Have you subscribed to our Safety and Accident Investigation Blog? Earlier this year, we launched our Safety and Accident Investigation blog which gives information, insights and thoughts from our Cranfield Safety and Accident Investigation Centre team. In our latest blog, Bill Dawson, Senior Inspector (Ports & Harbours) for the Defence Safety Authority, writes about his time at Cranfield University whilst studying our Fundamentals of Accident Investigation and Applied Marine Accident Investigation short courses. Sign up here Please take a look and subscribe, to ensure you're the first to receive our latest content. We'd love to hear your feedback too. Contact us on: E: shortcourse@cranfield.ac.uk T: +44 (0)1234 754189 Curt Lewis