[Peetwo]

Flight MH122 occurrence into Alice - ATSB to investigate.

Via the Oz:

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Malaysian airlines flight forced to land in Alice due to technical issues




Malaysia Airlines plane makes an emergency landing at Alice Springs Airport. 18 January, 2018. Picture: SUPPLIED

AAP1:03PM January 19, 2018

RHIAN DEUTROM
ReporterSydney
@Rhi_lani

UPDATE: The Australian Transport Safety Bureau has opened an investigation into an inflight engine shutdown on a Malaysia Airlines Airbus A330 after it was forced to land in Alice Springs last night.

The incident left the 224 passengers and crew on board terrified, with several describing a “loud disturbing noise” heard overhead during the flight before the plane began shaking violently.

Flight MH122, flying from Sydney to Kuala Lumpur had been in the air for several hours after taking off from Sydney International Airport about 1pm yesterday when an in-flight engine shutdown forced the aircraft to turn back and land in Alice Springs at 5.46pm.

The ATSB today announced it will be investigating the shutdown and diversion as well as crew conduct. Some passengers recalled hearing a “brace for impact” call over the loudspeakers.

“As part of its investigation, the ATSB will interview the flight crew and review available evidence,” an ATSB statement said.

“The ATSB will release a report into the occurrence once the investigation has concluded”.

“Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties”.

Despite the safe landing, passengers took to social media to criticise the airline for the distress caused to passengers and their loved ones.

“My wife is on MH122 and it was diverted to Alice Springs. My wife briefly contacted me just now and she is scared and crying. What happened to MH122?” one man said on Twitter.

“(This) has given a scare to the passengers. Pull your act together and make flying safe”.

Sanjeev Pandey was also on MH122 and said once the aircraft began shaking, the flight attendants “all seemed nervous (and) clueless”.

“For around 15 minutes, there was no announcement. 15 minutes w(as) as long as 15 hours!” Mr Pandey said.

Sanjeev Pandey@sppandey81

#malaysian airlines #mh122. Emergency landing at Alice Springs. The scariest part was that once the engine started to make a loud disturbing noise, the flight attendants all seemed nervous n clueless. For around 15 mins, there was no announcement.15 mins were as long as 15 hours!
9:19 PM - Jan 18, 2018

Another man who had booked another Malaysia Airlines flight publicly requested a refund from the company.

“Hey @MAS, can I please get a refund on my booking. Can’t gather the courage to fly with you,” he said.

MH122 diverts to Alice

The airline earlier said the plane had been forced to land at Alice Springs Airport due to technical issues. The flight was close to the West Australian coastline when it was forced to divert to Alice Springs on Thursday afternoon.

The airline said flight MH122 was forced to land in the Northern Territory for “technical reasons” in a statement.

Passenger Maryna Delport Evetts said engine problems had been blamed for the diversion.

“So just when you think this would never happen to you or it just happens in the movies, on our flight back home, four hours into the journey we had engine failure,” Ms Evetts posted to Facebook.

[/url]

Malaysia Airlines
✔@MAS
[UPDATE] Passengers of MH122 will be transferred from Alice Springs to Kuala Lumpur on MH148/ 19 January 2018. The flight is scheduled to depart Alice Springs at 5.45pm and is expected to arrive in Kuala Lumpur at 9.50pm the same day. For more info: http://bit.ly/2DL8t3r
12:02 AM - Jan 19, 2018

Madhu Alasyam@alasyam
#Malaysian #Airlines flight #MH122 scared the hell, kudos to Pilot for safe landing in #AliceSprings, after a Brace-for-impact call. @MAS I hope to get my flight home to #HYD soon. God speed on the replacement
7:45 PM - Jan 18, 2018

Brandon@b3108
‘Flight #MH122 was travelling from Sydney to Kuala Lumpur this afternoon when one of the Airbus A330-300 plane's engines is believed to have been shut down.
Passengers have been told they will have to stay overnight in Alice Springs.’ https://twitter.com/abcnews/status/953926871351099393 …
9:15 PM - Jan 18, 2018
[url=https://twitter.com/intent/tweet?in_reply_to=953933830720692224]

“We turned back and we are now sitting at the Airport in Alice Springs. Not too sure when we will be leaving but hey ho, we are on terra firma. “Not a good feeling 10,000 feet up in the air.” Malaysia Airlines said safety was its number one priority, and it would provide more information on the technical issue when it was available.

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MTF...P2

[Peetwo]

Pegasus runway overrun occurrence update -

Via Airlive.net:

ALERT Pegasus flight #PC8622: right engine gave full thrust after landing
By
 Jakob WERT
 -
January 28, 2018


[size=large]The right engine on flight #PC8622 gave full thrust after landing, which caused the aircraft to overrun the runway.

After the Boeing 737 touched down at Trabzon Airport, the thrust reverse on the right engine did not activate. Instead the engine was switched into go-around mode and gave full thrust, this caused the aircraft to turn left.

It is not yet known if this problem was caused by a technical fault or pilot error. The pilots first blamed an engine failure for the crash landing.

Technical issues with the thrust reverse on this particular aircraft were known to the airline before this accident.

MTF...P2

[Peetwo]

OS accidents - Bad start to 2018  

Hunt for clues to Russian crash
12:00am
Investigators were to examine last night numerous possible causes of one of Russia’s worst ever aviation accidents.

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Investigators scoured the scene last night after a passenger jet crashed near Moscow minutes after take-off, killing all 71 people on board, in one of Russia’s worst-ever plane crashes.

The site of the crash was enveloped in heavy snow that was waist-high in places, making it difficult to access, with emergency workers forced to reach the wreckage by foot or on snow­mobiles.

Russia’s Investigative Committee said it would consider explanations including human error, technical failure and weather conditions, as the country has experienced record snowfall in recent weeks. But it did not mention the possibility of terrorism. Some reports suggested there were questions about whether the plane had been properly de-iced. Moderate snow was falling in much of Moscow at the time of the crash.

The Antonov An-148 went down in the Ramensky district 70km southeast of Moscow at 2.48pm (11.48pm AEDT) on Sunday after taking off from Domodedovo airport in the capital.

“Sixty-five passengers and six crew members were on board, and all of them died,” Russia’s Office of Transport Investigations said.

A Swiss citizen and a citizen of Azerbaijan were among the fatalities. Three children also died, including a five-year-old girl and a 12-year-old boy, Evgeny Livanov.

The flight was operated by the domestic Saratov Airlines and was headed for Orsk, a city in the Ural mountains. The governor of Orenburg, where the plane was heading, said “more than 60 people” on board were from the region.

The Investigative Committee said that the aircraft caught fire on the ground after crashing.

“At the moment of falling, the aeroplane was intact, without a fire. An explosion took place after the plane crashed,” it said.

About one hundred investigators and criminologists were working at the scene. At least one of the plane’s two black boxes had been found.

With wreckage of the plane spread over more than 30ha around the crash site, it will take a week to inspect the whole area.

More than 900 people using equipment including drones were involved in the search, which has been reclassified as looking for bodies rather than survivors.

“We plan to carry out the main stage of the search operation in seven days because the plane debris is scattered over a very large area,” Emergency Services Minister Vladimir Puchkov said at the scene, adding that “heavy snow” hampered searchers.

“We walked about 600 to 700 metres across a field, with snow in places waist-deep,” said Alexei ­Besedin, one of the first rescuers to reach the scene.

Domodedovo airport has been the focus of security concerns in the past. Security lapses came under sharp criticism in 2004, after Chechen suicide bombers destroyed two airliners that took off from the airport on the same evening, killing a total of 90 people. A 2011 bombing in the arrivals area killed 37 people.

Transport Minister Maksim Sokolov said “genetic expertise” would be needed to help identify the victims, adding that it could “take two or three months”.

“I felt a shockwave,” said Maria, a resident of a village near the crash site. “The windows shook.”

The transport investigations office said the plane disappeared from radar screens about four minutes after take-off. The Russian-made plane was reportedly seven years old and bought by Saratov Airlines from another Russian airline a year ago.

Saratov was founded in the 1930s and flies to 35 Russian cities. Its hub is Saratov Central Airport in southern Russia.

President Vladimir Putin ­offered “his profound condolences to those who lost their relatives in the crash”. Mr Putin cancelled plans to travel to Sochi to meet Palestinian leader Mahmoud Abbas. Instead, the meeting will take place in Moscow.

Orsk Mayor Andrei Odintsov said that six psychologists and four ­ambulance crews were working with the families of the victims at the city’s airport.

Shabby equipment and poor supervision plagued Russian civil aviation for years after the 1991 collapse of the Soviet Union, with airlines often operating ageing aircraft in dangerous flying conditions, but its safety record has improved in recent years.

A light aircraft crashed in ­November in Russia’s far east, killing six people on board.

In December 2016, a military plane carrying Russia’s famed Red Army Choir crashed after taking off from the Black Sea resort of Sochi, killing all 92 people on board. The choir had been due to give a concert to Russian troops operating in Syria. Pilot error was blamed for that crash.

In March 2016, all 62 passengers died when a FlyDubai jet crashed in bad weather during an aborted landing at Rostov-on-Don airport.

AFP, AP

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Iran plane crash leaves 66 dead
8:19pm

A plane crash in southern Iran has killed all 66 people on board the Aseman Airlines ATR-72, a spokesman has told state TV.

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A plane crash in southern Iran has killed all 66 people on board, Iran’s Aseman Airlines spokesman has told state TV.

An Aseman Airlines ATR-72, a twin-engine turboprop used for short-distance regional flying, went down near its destination of the southern Iranian city of Yasuj, some 780km south of the Iranian capital, Tehran..

Aseman spokesman Mohammad Taghi Tabatabai told state TV that all on the flight were killed — 60 passengers, including one child, and six crew members. Due to foggy condition, rescue helicopters couldn’t reach the crash site in the Zagros Mountains, state TV reported.

Tabatabai said the plane crashed into Mount Dena, which is about 440m high. Aseman Airlines is a semi-private air carrier headquartered in Tehran that specialises in flights to remote airfields across the country. It also flies internationally.

The Iranian Red Crescent said it has deployed to the area. Authorities said they would be investigating.

Under decades of international sanctions, Iran’s commercial passenger aircraft fleet has aged, with air accidents occurring regularly in recent years.

AP

MTF...P2

[Peetwo]

Discombobulating auto-dependency & AIOS continues -  

AIOS - & the 21st Century??


The (other) Big "V" said.. :

My dear Gobbles:


The problem, simply put, is one of discombobulation.



In a crisis, the respones of modern systems, the changing displays, the cavalcade of warnings, and the lack of "familiar cues", completely discombobulate the crews.

The fact is, regardless of the howls of protest from the techno-nerds that design them, and those who love them "on paper" when in their arm chairs, in the "real world" the systems are actually discombobulating, ( ie, they throw the crew into a state of mental uncertainty ) and as a result, in a crisis situation, the crews quickly become completely discombobulated.

The result, is needless disaster, after needless disaster.

The "industry" will however, never admit to this truth.  

The industry has "acquired institutionalised ostrichitis syndrome" (AIOS).





So, stand by for regular repeats of AF-447 and QZ8501.


Clues:
confusion, befuddlement, bewilderment, puzzlement, perplexity, disconcertment, discomposure, daze, fog, muddle, etc ........

Love it "V" - The head in sand bit is absolutely spot on, especially here in Oz where we presently have a totally dysfunctional regulator & an irrelevant, "non-independent" AAI (Aviation Accident Investigator).  An AAI that is now so busy being 'PC' that ironically they have become a regular part of the causal chain (holes in the cheese), rather than the chief safety issue identifier to help prevent/mitigate repeat occurrences/accidents.

The classic - but not isolated - example of discombobulation/AIOS (Aussie style ) is of course the PelAir investigation, & now re-investigation: 

Example references: PelAir MK-I (& probably MK-II ) - Beyond Reason - & the pale?? + O&O thread 

Senator FAWCETT: The thing that the committee is struggling to come to is that there have been many witnesses who are pointing fingers of blame at particular incidents. Australia has been a leader in aviation safety for a number of years through its fairly robust adoption of a systems approach, and James Reason is the classic person who has driven that. So, clearly, the actions of the pilot in command and his decisions around flight planning and fuel have a role to play—so do the actions of the company in terms of their checks, training et cetera. But each slice of the Swiss cheese, as the James Reason model is often laid out, has the potential to prevent the accident. So the importance that the committee is placing on an incident such as a proactive alert to the pilot that there is now a hazardous situation is not the reason the accident occurred, but it is one of the defences that may well have prevented the accident. If Australia are to remain at the forefront of open, transparent and effective aviation safety then one of the roles of this committee is to make sure that our organisations collectively keep working towards having a very open discussion around that systems safety approach and making sure that each of those barriers is as effective as it can possibly be. That, I guess, is the intent behind a lot of the questioning this morning...

However while all this AIOS is going on ( ), the rest of the aviation safety world is struggling to get ahead of the game with the implications of the findings of repeat tragic accidents like QZ8501, Colgan etc.  

The following is an excellent (TY 4 link Tinkicker ) overview article of QZ8501, courtesy Aviation Week:

AirAsia Crash: Are Regulators Moving Too Slowly On Upset Recovery?

Findings in the Indonesia AirAsia Flight 8501 crash highlight lessons learned—but not implemented—from high-profile crashes in 2009
Dec 7, 2015 John Croft | Aviation Week & Space Technology

[/url]Indonesia is calling for the U.S., Europe and its own regulators to accelerate mandatory upset-recovery training for airline pilots in the wake of the Indonesia AirAsia Airbus A320-200 crash in December 2014. The accident has key similarities to the 2009 Air France Flight 447 and Colgan Air crashes in which pilots, for a variety of reasons, failed to properly respond to aerodynamic stalls and upsets, resulting in rapid, largely uncontrolled descents into terrain or water.

The 2009 accidents spawned a variety of countermeasures in the international community, with the International Civil Aviation Organization (ICAO) publishing new standards and recommended practices in November 2014 and the European Aviation Safety Agency (EASA) and FAA set to implement their version of training upgrades in 2018 and 2019, respectively. That is not soon enough from the perspective of the AirAsia crash investigators. Loss-of-control accidents, which are often preceded by a stall and upset scenario, are the deadliest types of airline accidents, representing only 2% of all accidents but 25% of all fatalities in 2006-13.


Flight simulators will be the tool of choice to combat loss-of-control accidents as upset-recovery training becomes routine. Credit: NASA


Along with a call for upset prevention and recovery training, the final report on the Dec. 28, 2014, crash also highlights how maintenance and pilot procedural flaws, crew resource management shortcomings, and ignorance of A320 avionics and electrical design combined in a manner that overwhelmed the two pilots.

Indonesia’s National Transportation Safety Committee (NTSC) did not assign a probable cause or blame for the accident, but issued 10 recommendations for the airline, the Directorate General of Civil Aviation (DGCA), the FAA, EASA and Airbus. AirAsia in the interim had voluntarily initiated 49 safety actions, including dedicated simulator sessions for Airbus-designed upset and stall recovery training, more hand-flying during departures and approaches, and assigning an aircraft “custodian” to monitor defective equipment.
The first officer, with 2,247 flight hours, mostly in the A320, was the pilot-flying as the aircraft reached its cruising altitude of 32,000 ft. in the midst of cumulonimbus buildups shortly after 6 a.m. on the route from Surabaya to Singapore. The captain monitoring the flight had logged more than 20,000 hr. flight time in military jet fighters and airliners.

AirAsia’s Operation Training Manual, approved by the DGCA, included ground- and simulator-based upset training, but the airline had not implemented the curriculum because it was not mandated by the DGCA nor was it called for by the Airbus-supplied Flight Crew Training Manual, according to the NTSC. “The [manual] stated that the effectiveness of fly-by-wire architecture and the existence of control laws eliminate the need for upset recovery maneuvers to be trained on [envelope-protected Airbus aircraft],” notes the NTSC. Three months after the crash, Airbus published upset training guidelines for airlines, noting that while it is “extremely unlikely” that an upset will occur in the normal envelope-protected control mode, pilots should nonetheless experience pitch-up and roll upset excursions as high as 30 deg. and 67 deg., respectively, in different configurations and potentially in degraded control modes. 

Twelve minutes after AirAsia Flight 8501 leveled off that morning, a series of amber advisories flashed on the electronic centralized aircraft-monitoring display in the cockpit, indicating the sequential failure of the two rudder travel limiter units, a safety feature that reduces rudder displacement as speed increases. In the next 11 min., as the crew turned to remain clear of cloud buildups and requested a climb to 38,000 ft., there were three additional failures. In each case, the pilots reset the two flight augmentation computers (FACS) that control the rudder limiters via two reset buttons on the overhead panel.



The captain had experienced this failure three days earlier in the same aircraft during pushback. A company engineer came into the cockpit and pulled circuit breakers for the two flight augmentation computers per the airline’s troubleshooting manual. One of the circuit breakers is in the overhead panel; the other is located on the wall behind and out of reach of the first officer’s seat. The captain had asked the engineer whether the circuit-breaker method could be used whenever the problem reappeared, to which the engineer said it could be done “whenever instructed on the ECAM [Electronic Centralized Aircraft Monitoring],” according to the NTSC. On Dec. 28, the ECAM instructed the pilots to disengage then reengage each flight augmentation computer via the push buttons. 

This particular problem had been recurring at an increasing rate, 23 times during the previous year on PK-AXC, the accident aircraft, nine of which occurred in December. The troubleshooting manual advice—either resetting the FACS via the push buttons or pulling the circuit breakers—generally cleared the fault, so the issue was not considered a “repetitive problem” in the documentation, and the pertinent electronic modules were not changed out. 

While ICAO standards call for pilots to record “all known defects” after a flight, the requirement was not specified in Indonesian regulations, and pilots often did not file reports regarding the rudder-limiter failure. Following the accident, investigators found evidence of solder cracking caused by temperature cycling in the electronics. Airbus had responded to similar reliability problems with upgraded electronic units in 1993 and 2000, both of which were installed in the accident aircraft, and again in 2015 following the accident. AirAsia in its post-crash safety actions made improvements to its maintenance processes to track repetitive issues, including assigning custodians to each aircraft.
 
One minute later, when the rudder-limiter-failure caution appeared for the fifth time, investigators surmise the captain resorted to pulling the circuit breakers. The NTSC notes that the limiter or FACS failure itself is not considered dangerous (rudder limits are maintained and the aural and textual alerts can be silenced by selecting the Emergency Cancel button). Although Airbus allows for pulling circuit breakers to reset various computers when on the ground, the airframer says “as a general rule,” resets using circuit breakers in the air must be limited to the air pack regulators and avionics ventilation system. The “general rule,” however, opens a door for other resets, providing both pilots “consider and fully understand the consequences of taking the action,” according to Airbus.
 
Based on the cockpit voice recorder (CVR), the accident pilots did not appear to discuss any consequences and were likely startled by what happened when the captain presumably pulled the breakers. Along with a series of fault messages on the ECAM, the autopilot and autothrottle disconnected, the control law transitioned to “alternate,” removing most of the fly-by-wire envelope protections, and the rudder deflected approximately 2 deg. to the left, resulting in a roll rate of 6 deg./sec. to the left. The first officer responded 9 sec. later—when the roll angle had reached 57 deg.—with a right control input initially and a nearly fully deflected rearward stick pull, rapidly increasing the pitch angle and causing an 11,000 ft./min. climb. 

[url=http://aviationweek.com/site-files/aviationweek.com/files/uploads/2015/11/DF-AIRASIA_map.jpg]

When the initial stall warning occurred, the first officer briefly responded by pushing forward on the stick, as called for in standard procedures, but soon after returned to the full-back stick, where it caused the aircraft to enter a fully developed, deep stall, a state in which it remained for the remainder of the flight. The nose-up input after a stall, which is contrary to recovery techniques issued by the airline and the international community, was a common element in the Air France Flight 447 and Colgan accidents in 2009.
 
The captain attempted to control the aircraft through his stick, but he did not press the “take over” pushbutton on the stick to transfer control from the first officer, as is allowed for in AirAsia standard procedures during an emergency. With both pilots controlling, the A320 control system averaged the two sidestick inputs—nearly full aft stick from the first officer and slightly nose down by the captain—for a nose-up command. The NTSC recommended that AirAsia “reemphasize” with its pilots the “taking-over-control procedure in various critical situations of flight.” 

At approximately 29,000 ft., the pilots were able to level the wings, but the angle of attack remained well beyond the stall, and the descent rate settled at 12,000 ft./min., with the audible stall warning and buffeting of the wings evident on the CVR. The aircraft remained in a relatively flat attitude until striking the water. “The condition of stall at [nearly] zero pitch was not a standard on pilot training as the training for stall is performed at high pitch attitude,” says the NTSC, adding that the pilot might have not recognized that the aircraft was in a deep stall despite the stall warning and the buffet.
The inability of some pilots to recognize and correctly recover from upsets and stalls has been a key safety concern in the industry for more than a decade, but it became a top priority after the 2009 crashes. 

ICAO in November 2014 called for member nations to require on-aircraft upset prevention and recovery training for multi-pilot and commercial pilot licenses, and simulator upset training for multi-crew type ratings and airline pilot initial and recurrent training programs. Last January, EASA proposed new rules similar to the ICAO standards, to be implemented in April 2018. 

The FAA’s upset training requirements for airline pilots, largely the result of Colgan, go beyond the ICAO and EASA. They mandate full-stall demonstrations in full-motion simulators by March 2019, an addition that will most likely require new expanded aerodynamic models for the devices. The agency plans next to update Part 60 rules detailing how to upgrade and gain approval for the extended simulators, although preliminary guidelines the FAA published in 2014 have already been used by FlightSafety International and Gulfstream to create an extended model for a business jet simulator. 
It is doubtful the FAA can accelerate its plan, given the training infrastructure that must be put in place, but some airlines have already taken the initiative of providing third-party upset training to their instructors in order to set up in-house training programs. South African Airways and Delta Air Lines are two of the carriers that have such programs underway. 

Somewhat promotional but I just had to include this must read post/comment from apstraining : 

First-hand Experience in Airline Upset Training


As a leading Upset Prevention and Recovery Training (UPRT) provider for pilots from airlines around the world, the reaction of this crew as described in the Indonesian Accident Report is not surprising. Regularly - on a daily basis - we see professional pilots, who have not yet had first-hand modern UPRT experience, having serious difficulty in handling time critical upsets effectively. ‘Modern UPRT’ is in compliance with 2014 ICAO and 2015 IATA UPRT guidance on its effective delivery, together addressing more than 200 training elements to enhance awareness, prevention and recovery of airplane upsets.

An airplane upset is a precursor flight condition to loss of control in-flight (LOC-I) that meets certain attitude and/or speed criteria as defined by industry. Of equal importance to modern UPRT is that the provided UPRT is of sufficient intensity, delivered by expert instructors, conducted in appropriately certified airplanes and simulators, following a comprehensive building-block curriculum.

For example; on page 107 of the report, the FDR recorded the pilot flying's (SIC) first reaction to the over-banked attitude of 57 degrees (with likely the nose dropping since the autopilot was disconnected) was to pull and then apply right aileron … three seconds later the aircraft entered a stall. In our experience, this "rolling pull" technique is very common among pilots who have not been given both academic and practical understanding of the dangers of this often-inappropriate technique in a wide diversity of upset scenarios.

"Remf" mentions that "no amount of acceleration of training/warnings will replace common sense." Based on first-hand experience, we respectfully disagree. This conclusion is not substantiated by what we see when our professional pilot customers return for recurrent upset training anywhere from one to two years after their initial UPRT and consistently prove themselves to be very disciplined and effective in a startling upset scenario. It is certainly understandable how certain "techniques" would be considered “common sense” when they are being discussed in an academic context. However, and again based on years of first hand experience delivering UPRT, when non-UPRT trained pilots are put in time-critical, life-threatening situations, "common sense" is typically replaced by ineffective and unsafe "gut-reactions" on the controls due to knowledge and skill deficiencies further degraded by the pilot/crew’s state of mind due to human factors such as startle, surprise and fear.

As alluded to above; ICAO and IATA - with EASA in the process of implementing UPRT interventions in 2016 - have recognized the benefit of integrated (on-aircraft and simulator) upset training in a pilot's skill sets. They each have proposed significant upset training changes to our current licensing and type rating system (see ICAO Doc 10011, EASA NPA 2015-13, and IATA GMBP UPRT). We certainly agree with the Indonesian Report Conclusions that integrated (on-aircraft and simulator) upset training must be implemented across the globe sooner rather than later. The FAA has yet to make this same official conclusion. However, through Advisory Circular (AC) 120-111, the FAA is requiring upset recovery in simulators for Part 121 air carriers by 2019. Improved stall training across all FAA pilot training is also already underway through AC 120-109 - soon to be superseded by AC 120-109A, which likely will include full aerodynamic stall training.

The future is looking brighter when it comes to the worldwide mitigation of LOC-I.

Meanwhile what do we get.. Beard on...beard off..mi..mi..mi..mi..mi..mi..mi..mi..Beaker-UFB!

   

I see in the Oz that BB has tapped out an article which highlights that the serious safety issues of auto-dependency are still yet to be satisfactorily risk mitigated...

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MTF...P2
Auto-pilots cut pilot experience

12:00amBYRON BAILEY

Computer-reliant planes may be making the airways safer, but emergencies expose pilot weaknesses.
 

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Pilot experience reduced by flight automation

Last month was not a good month for aviation safety statistics.

A Bangladeshi airliner crashed on approach into Kathmandu with 71 fatalities.

A day before, a private Turkish Challenger 604 crashed into the Zagros Mountains 370km south of Tehran, killing all 11 on board.

Conflicting reports put the private jet in cruise at 36,000 feet one hour 21 minutes after leaving Sharjah for destination Istanbul when it suddenly climbed to 37,700 feet before entering a pronounced descent, then crashing. The black boxes — flight data recorder and cockpit voice recorder — have been recovered and should be able to answer the question of why this popular and safe large jet crashed.

I am interested because I fly a private Challenger 604. Its avionics and electrical/hydraulic systems place it in the small air­liner class plus, as a wide-body type jet, and it is very comfortable for the rich passengers, giving the cabin a loungeroom feel. The passengers of the crashed jet were Mina Basaran, socialite daughter of a wealthy Turkish businessman, and seven of her female friends who were attending her hens party in Dubai — now playground of the rich and famous (Beirut is passe).

The crew of two pilots and one cabin attendant were all female and the captain was a former military pilot.

There are several possibilities that come to mind.

There were thunderstorms active in this area of Iran so could it have been like the Asian Airbus A320 that crashed several years ago when the pilots lost control entering thunderstorm activity.

Perhaps the captain was trying to climb over a thunderstorm and stalled because the descent was rather sudden, which may indicate loss of control.

Maybe they had picked up some ice on the wings — unlikely because the Challenger has excellent anti-ice systems but they rely on the pilots to turn them on. The B777 anti-ice systems, in contrast, are automatic.

The Challenger, which has a supercritical wing, requires careful removal of even the smallest amount of ice before takeoff in low temperatures. When first introduced into service it suffered several takeoff accidents.

Could it be a bomb on board? The descent was sudden and the crew allegedly reported a technical fault. Sharjah is more like a secondary airport that is popular with eastern European airlines, especially Russian. I cannot comment on its airport security.

Sharjah is a small emirate — one of the seven that make up the United Arab Emirates — and is overshadowed by its close, glamorous neighbour Dubai.

The reason the jet was parked at Sharjah was probably because of lack of room at Dubai International airport.

Maybe Iranian air traffic control played a part. Iran has notoriously suspect control and poor communications. I encountered a Russian IL76 military/commercial freighter reciprocal on the airway over Iran. I was in a B777-300 and, according to the EOWE (east odds/west evens) flight level rule, cruising at cleared level 32,000 feet on the way to Paris.

This bogey popped up at my level at 40 nautical miles on my traffic alert and collision avoidance system at my altitude, the wrong altitude, and Tehran ATC was not answering so I immediately deviated 5nm right to let it pass.

Then, of course, comes the human element. The biggest problem facing airlines and corporate aviation is a lack of manual flying skills because of the dumbing down of pilots. The Challenger 604, same as the Airbus and B777, is highly automated. Immediately after gear retraction on takeoff the autopilot is engaged.

Lateral navigation and speed are all programmed before engine start into the flight management system computers, which then fly the aircraft to the destination.

The approach at destination is normally flown by the autopilot after the pilots enter arrival and runway details into the computer. Late on final approach the pilot flying disconnects the autopilot and lands the aircraft.

What this means is, on a typical — for example, nine-hour — flight, the pilot is hands-on for only several minutes. This is safe as modern aircraft are so reliable that air travel is safer than driving a car. The problem occurs when something unexpectedly goes wrong and puts the pilots out of their comfort zone.

Pilots get to refresh their aircraft systems knowledge and emergency handling skills every six months in simulators. Qantas does this every three months for its pilots.

However, even in the simulator, most training is done with the autopilot engaged as it is more reliable to fly an approach, even with an engine failed, with the autopilot engaged.

What this means is if you put a pilot in a situation they have never encountered the lack of a solid basic flying skill will surface.

Take, for example, the Air France A330 that after pitot tube icing, suffered a pilot-induced stall at high altitude. The panicked pilot froze and without realising it held the aircraft in the stalled condition all the way down until it crashed into the sea.

Corporate aviation, same as airlines, is subject to the same tyranny of cost. Pilot training is expensive and the trend, especially overseas, is for crews is to be less experienced even though on paper they appear to be equally qualified.

As remarked recently by the hero of the Hudson River landing of US Airways flight 1549 in New York in 2009, Captain Chesley “Sully” Sullenberger, “There is no substitute for experience in an unexpected and difficult situation.”

The automation of modern aircraft has resulted in the dumbing down of pilots, with many lacking adequate manual flying skills. But I guess it is something that aviation has to live with.

Byron Bailey, a veteran commercial pilot with more than 45 years’ experience, is a former RAAF fighter pilot and trainer. He was a senior captain with Emirates for 15 years.

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[Peetwo]

Southwest Airlines Flight 1380 - via the Oz

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Plane hole: ‘Someone went out’

3:11pm

A mother of two died after being sucked out of a Southwest Airline plane’s blown-out window, when the engine exploded.

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Woman partially sucked from plane window after engine ‘exploded’

An airline passenger has been killed after being partially sucked out of a blown out window, when the plane engine appeared to explode.

Southwest Airlines flight 1380, en route from New York to Dallas, with 143 passengers and five crew, was forced to make an emergency landing in Philadelphia, where the mother of two, identified as Jennifer Riordan, was declared dead and seven other passengers were treated for minor injuries.

Ms Riordan, a Wells Fargo bank executive from New Mexico, had tweeted about her visit to New York before boarding the plane.

Passengers said they heard an explosion and a piece of the engine flew off, breaking the window of Row 17 on the left hand side of the plane and sending shattered glass into the plane.

Ms Riordan was partially sucked out of the window, but other passengers caught hold of her and pulled her back in.

In footage aired on TV, a female pilot told emergency services: “We’ve got injured passengers ... (the plane) isn’t on fire but part of it’s missing. There’s a hole and someone went out.”

“One passenger, a woman, was partially … was drawn out towards the out of the plane … was pulled back in by other passengers,” Todd Baur, the father of a passenger, told NBC10.

Passenger Marty Martinez said a window exploded midair and posted photo of a damaged window and emergency oxygen masks dangling down. Mr Martinez said a woman suffered a heart attack, but could not say if it was the woman who was sucked out of the window.

“Someone on the plane had a heart attack and it looks like an engine blew out then a window was blown open,” he said on Facebook. “We are still on the plane and they are trying to revive a woman on the plane.”

Passenger Amanda Bourman told the Seattle Times: “I just remember holding my husband’s hand, and we just prayed and prayed and prayed.” She said she saw medical workers using a defibrillator to help one of the passengers.

National Transportation Safety Board Chairman Robert Sumwalt said the engine will be shipped for a detailed examination.

John Goglia, a former NTSB member, told the Seattle Times: “There’s a ring around the engine that’s meant to contain the engine pieces when this happens. In this case it didn’t. That’s going to be a big focal point for the NTSB — why didn’t (the ring) do its job?”

The Federal Aviation Administration said the flight from New York to Dallas made an emergency landing after the crew reported damage to one of the engines, as well as the fuselage and at least one window.

Philadelphia’s fire chief said one person was taken to the hospital in critical condition and seven were treated for minor injuries.

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& from Byron Bailey:

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‘This is not supposed to happen’

2:49pmByron Bailey
The world’s most popular airliner has suffered an unfortunate accident, but statistically flying is still safer than driving a car.

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‘Freakish’ Southwest Airlines Boeing 737 accident wasn’t meant to happen

A Southwest Airlines Boeing 737, the world’s most popular airliner, has just suffered a freakish accident. The left engine disintegrated in flight causing a rupture of the fuselage and death and destruction.

This is not supposed to happen. The visible large front fan of the engine, which produces most of the engine thrust, is in the event of a ‘rotor burst’ supposed to be contained within a reinforced shroud. This danger area is denoted usually by a red band around the engine cowling.

The titanium fan is the largest moving part of the engine and at the high rotational revolutions per minute the fan blades are subject to very large rotational inertia (centrifugal force). It has been known for the occasional fan blade separation in past occurrences in various aircraft engines but this particular failure was very severe and large fragments penetrated the fuselage. However, it may not have been a fan failure in the initial part of the disintegration and the US National Transportation Safety Board (NTSB) will be able to quickly determine the cause.

The aircraft was cruising at 38,000 feet which my son, who flies a B737, tells me is the optimum cruising altitude for the B737 but they sometimes go to 41,000 cruise when the passenger load is light. Sea level pressure is about 15 lbs per square inch (psi).

In cruise at 38,000 feet the outside air pressure is only about one quarter the sea level value and with a cabin altitude of approximately 5,500 feet results in a pressure differential between inside and outside, of about 8.8 psi. The force therefore exerted on a 200 square inch window is nearly 1800 lbs. If the fuselage is ruptured or a window blows out, a massive outflow of cabin air would result and violently suck out any passenger or non secured cabin item.

One reason fighter pilots have to wear oxygen masks is that their fighter aircraft are not fully pressurised so as to avoid an explosive rupture if the cockpit is penetrated by a bullet or missile shrapnel. The poor unfortunate lady that was apparently violently sucked out through a window of the B737 probably would have blacked out rather quickly as the time of useful consciousness at 38,000 feet is only about 15 seconds.

The passenger emergency oxygen masks would have immediately automatically deployed when the cabin altitude raced up through a value of 13,500 feet. The British airline industry was ruined by a series of crashes of their de Havilland Comets which was the worlds first airliner. This was due to corners of the fuselage square windows suffering fatigue cracking due to the cycles of differential pressure resulting in fuselage disintegration in cruise. Aviation technology and engineering design has evolved massively since then.

Southwest Airlines, which is my airline of choice when I fly domestically in the USA, is one of the world’s largest operators of B737 and they have a very high utilisation rate. The question therefore may be how many hours of operation this particular General Electric CFM56 engine had remaining before its next major overhaul.

I have flown General Electric CFM engines in my Airbus days and they were very reliable and rugged so this engine blow-up and the resulting massive penetration of the fuselage by engine debris is very rare.

Engines do fail but sometimes not through a design fault but a minor engineering defect which can start a chain of events leading to a catastrophic engine failure. This was the case of the Qantas A380 Rolls Royce engine blow-up out of Singapore and which was magnificently handled by the very experienced and professional Qantas crew. Qantas remains the world’s safest airline.

Captain Tammie Jo Shults aged 56, a former USAF fighter pilot, has been lauded for her incredible bravery. However bravery has nothing to do with it. As a very experienced professional aviator she would have performed the emergency response checklist items for engine failure as it happened just as she would have done hundreds of times in simulator training every six months since joining Southwest Airlines in 1993.

Professionalism is reflected in her calmness under pressure which is an attribute of experience just like Captain ‘Sully’ Shultzberger — hero of the Hudson and also a former fighter pilot — who remained incredibly calm during his double engine failure and ditching.

Statistically, flying is still safer than driving a car. This was an very rare and unfortunate accident.

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&..

A rare and freakish accident
12:00amByron Bailey
Statistically, flying is still safer than driving a car.

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Death and ­destruction from a rare and freakish accident

A Southwest Airlines Boeing 737, the world’s most popular airliner, has just suffered a freakish accident. The left engine disintegrated in flight, causing a rupture of the fuselage and death and ­destruction.

This is not supposed to happen. The visible large front fan of the engine, which produces most of the engine thrust, is supposed to be contained within a reinforced shroud in the event of a “rotor burst”. This danger area is denoted usually by a red band around the engine cowling.

The titanium fan is the largest moving part of the engine and at the high rotational revolutions per minute the fan blades are subject to very large rotational inertia (centrifugal force). It has been known for the occasional fan blade separation in past occurrences in various engines but this particular failure was very severe and large fragments penetrated the fuselage. However, it may not have been a fan failure in the initial part of the disintegration and the US National Transportation Safety Board will be able to quickly determine the cause.

The aircraft was cruising at 38,000. Sea level pressure is about 15 lbs a square inch. In cruise at 38,000 feet, the outside air pressure is only about one-quarter the sea level value and with a cabin altitude of approximately 5500 feet results in a pressure differential between inside and outside, of about 8.8 psi. The force therefore exerted on a 200 square inch window is nearly 1800 lbs.

If the fuselage is ruptured or a window blows out, a massive outflow of cabin air would result and violently suck out any passenger or non-secured cabin item.

The poor lady who died yesterday would have blacked out rather quickly as the time of useful consciousness at 38,000 feet is about 15 seconds.

The British airline industry was ruined by a series of crashes of their de Havilland Comets, which was the world’s first airliner. This was due to corners of the fuselage square windows suffering fatigue cracking due to the cycles of differential pressure resulting in fuselage disintegration in cruise. Aviation technology and engineering design has evolved massively since then.

Statistically, flying is still safer than driving a car.

This was a very rare and unfortunate accident.

---

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And from the NTSB, via the Oz:

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http://www.abc.net.au/news/2018-04-18/nt...th/9670990

NTSB provides update on Pennsylvania plane death
Posted Wed at 12:14pmWed 18 Apr 2018, 12:14pm

The Chairman of the US National Transport Safety Board provides an update on an incident in which a plane's engine blew at 30,000 feet and a passenger on board died.
Source: ABC News | Duration: 3min 39sec
Topics: air-and-space, air-transport, united-states
Top Stories

[url=http://www.abc.net.au/news/2018-04-19/queensland-council-recycling-dump-to-start-nationwide-reaction/9673370][/url]

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Or the full version, via youtube:

MTF...P2

[Peetwo]

AirAsiaX FL D7207: ATSB unmask winged culprit -  

AirAsia flight turned back to Australia after suspected bird strike


July 4, 20176:10am


An AirAsia X flight from the Gold Coast was forced to divert to Brisbane on its way to Malaysia. Picture: Facebook/Calvin Boon

Staff writers News Corp Australia Network

AN AIRASIA X flight bound for Malaysia has been forced to land in Brisbane after a suspected bird strike, with terrified passengers saying they saw sparks coming from the engine.

Flight D7207 took off from the Gold Coast, bound for Kuala Lumpur, at 10.20pm last night but landed in Brisbane at 11.33pm following a mid-air emergency. The 345 passengers and 14 crew on board were not injured...

To begin - credit where credit is due - bravo to the ATSB for completing within a year (10 months) a relatively complex and serious international carrier AAI...   

Here is the blurb from the summary ATSB investigation webpage:

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What happened
On the night of 3 July 2017, AirAsia X[1] flight D7207, an Airbus 330 aircraft, registered 9M-XXT, taxied at Gold Coast Airport, Queensland for a scheduled passenger transport flight to Kuala Lumpur, Malaysia. On board the aircraft were two flight crew, 12 cabin crew and 345 passengers.

During the taxi to runway 32, all engine indications were normal.

At 2249 Eastern Standard Time, the flight crew commenced the take-off roll. Flight data recorder data shows that Engine 2 vibrations increased as the aircraft approached its take-off rotation speed. After take-off, passing approximately 2,300 ft, the electronic centralised aircraft monitor (ECAM) displayed an ENG 2 STALL alert. At the same time, loud banging noises associated with an engine stall could be heard in the aircraft. The flight crew commenced the ECAM actions for the ENG 2 STALL procedure and made a PAN PAN[2] call to air traffic control.

As the aircraft continued climb to 4,000 ft, the ECAM displayed an ENG 2 FAIL alert. About this time the flight crew received an interphone call from the cabin purser advising of a ‘starboard engine fire’, which was visible from the aircraft cabin and had been reported to the purser by a company pilot, who coincidentally was travelling as a passenger.

In response to the ECAM alert and report from the cabin purser, the flight crew carried out the ENG 2 FAIL procedure with damage actions, including discharging the fire suppression system.

The flight crew upgraded the distress phase to a MAYDAY[3] with air traffic control and requested a diversion and approach to runway 01 at Brisbane Airport for an overweight, single engine landing. The aircraft landed safely at 2310.

After the aircraft vacated the runway, the captain held the aircraft on the taxiway to allow the airport emergency services to inspect the engine before they taxied the aircraft to the arrival gate.

Information from the Gold Coast Airport operator
After the aircraft departed, the Gold Coast Airport operator performed a visual inspection of runway 32. Bird remains and engine debris were recovered on runway 32 around the intersection of taxiway D. This included one complete carcass, as well as additional debris from another bird. Other than the evidence of birds, no foreign objects were found with the potential to have resulted in the damage to the engine.

Video recordings of the runway were reviewed by the airport operator. That review identified flashes of flame emitted from the rear of engine 2 during the take-off ground roll, and the location of these flashes coincided with the area near where the bird remains and engine debris were collected. Tissue samples from the bird remains were sent to the Australian Museum, which identified the bird species as a masked lapwing (commonly known as a plover). A masked lapwing is a common medium-sized, 30–37 cm in length and weighing between 0.23–0.40 kg (see the ATSB Bird information sheet number 3 for more detail).
A post-mortem examination of the complete carcass by a veterinary specialist determined it was unlikely to have been struck by a moving object and its damage was likely the result of wake vortex. Examination of debris from the other bird identified no evidence of burning, which could be expected if the bird had been ingested into an aircraft engine.

Aerodrome bird hazard management
Part 139 of the Australian Civil Aviation Safety Regulations requires that aerodrome operators have procedures to deal with the danger to aircraft operations caused by the presence of birds on or near the aerodrome. This includes arrangements for assessing any bird or animal hazard and the removal of any such hazard. The operator of Gold Coast Airport had a comprehensive wildlife hazard management plan in place.

In 2017, the ATSB published a research report (AR-2016-063) titled Australian aviation wildlife strike statistics. The report provided information to pilots, aerodrome and airline operators, regulators, and other aviation industry participants to assist them with managing the risks associated with bird and animal strikes. For the 10-year period 2006 to 2015, this report stated that 480 birdstrikes (average of 48 per year) were reported to have occurred in the aerodrome confines at Gold Coast Airport. This equated to an average of 5.15 birdstrikes per 10,000 movements[4] at Gold Coast Airport.

Most birdstrikes involving large air transport aircraft do not result in damage (about 95 per cent). About 10 per cent of birdstrikes involving aircraft with turbofan engines result in the bird being ingested into an engine.

Across Australia, the lapwing/plover family of birds has been the third most common bird/bat struck by aircraft across the 10-year period (868 strikes). About 5 per cent of strikes involving lapwing/plover birds have resulted in some aircraft damage, and about 15 per cent involved more than one bird being struck.

The Australian Airports Association published Managing bird strike risk species information sheets focused on managing the strike risk of several bird species at Australian airports. The information sheet for the masked lapwing stated that risk assessments often ranked these birds as moderate to very high risk due to their presence on airfields, particularly in critical aircraft movement areas such as flight strips, and their highly territorial behaviour. The sheet also noted that masked lapwings often loaf at off-airport locations during daylight hours before moving to airports at night to forage. This results in increased numbers flying on and around airports during periods of decreased visibility, thereby increasing the probability of a strike.

Masked lapwings can occur in large flocks in periods just prior to their breeding season. The ATSB Australian aviation wildlife strike statistics report states that birdstrikes involving lapwing/plover birds peak between 1900 and 2100 in the evening and 0700 to 1000 in the morning.

Statistics provided by Gold Coast Airport indicated that over the previous 12 months (July 2016 to June 2017), 237 masked lapwings had been dispersed and 34 culled. The figures for previous years were generally similar, although the figures for the period July 2015 to June 2016 were much higher. It was not unusual for the birds to not require active management for several days at a time, and none had been dispersed or culled in the 4 days prior to the occurrence. Throughout the remainder of July 2017, 35 were dispersed and 45 culled.
Engineering examination of the engine

The aircraft was fitted with two Trent 700 engines, manufactured by Rolls Royce.
After the occurrence, an engineering examination at Brisbane Airport found a single fan blade-tip section, approximately 140 mm x 125 mm, had fractured from one fan blade and the fan rear seal was found broken into pieces and scattered throughout the bypass areas of the engine (Figure 1). There was also evidence of fire within the engine.

Figure 1: Damage to Rolls Royce Trent 700 engine fan blades



Source: Rolls Royce

A sample of visible organic debris was taken from engine 2 in Brisbane and sent for DNA analysis. Testing of this sample was unable to provide a result. The reasons for this could not be determined, but are usually associated with a sample being affected by heat or storage conditions.

The engine was later shipped to Hong Kong for a controlled engine strip and detailed inspection by the engine manufacturer. Some key results of the inspection related to the fan blades included:

• The front section of the engine was subjected to an ultraviolet (UV) light inspection to highlight areas of organic debris for swabbing for DNA evidence of bird ingestion. The UV light identified that organic debris was present in a number of locations around the circumference of the fan blade set and in other areas of the engine. DNA analysis identified that this debris was from masked lapwing bird(s).
  
• UV light inspection identified that blade 1 (the blade with the released tip) had organic debris in the area near the blade-tip release (Figure 2), and there was also organic debris on the blade- tip that was recovered at Brisbane Airport. DNA analysis confirmed the debris from the blade and the blade-tip was from a masked lapwing.
  
• Based on the distribution of the debris and engine speed conditions, the engine manufacturer concluded that multiple birds had impacted the fan. However, the damage on or near blade 1 was consistent with impact with a single bird.
  
• Blade 1 exhibited cupping damage consistent with soft body impact close to the point of material release. The radial height of the fracture on the blade was in a leading edge impact cup at approximately 84 per cent blade-height (Figure 1 and Figure 2).
  
• Laboratory analysis of the fracture surface of blade 1 confirmed the fracture mode as overload. There was no evidence of fatigue or pre-existing material deficiencies that could have contributed to the release of the blade-tip.
  
• There was blade damage on a blade adjacent to blade 1 (see to the right of the red square in Figure 1). This damage to the adjacent blade was consistent with impact from a hard body, and laboratory analysis did not identify that any foreign object had impacted that blade.
  

Figure 2: Ultraviolet light showing bird remains on damaged fan blade



Source: Rolls Royce

The engine manufacturer conducted a theoretical analysis to determine under what conditions an impact with a bird with a mass of 0.85 lb (0.39 kg), such as a masked lapwing, could have resulted in the discovered condition of the engine fan blade. The analysis used the engine and aircraft speed conditions at the time of the event (88 per cent N1[5] and an aircraft speed of 120–140 kt) and modelled variations of strike position (radial height) and angle of incidence (bird orientation). Only one of the modelled scenarios matched the results of the occurrence event. This was a strike from a bird with the bird’s longitudinal axis aligned with the relative velocity of the blade[6] at a radial height of 83 per cent.

The engine manufacturer concluded that the release of the blade-tip was the result of an impact from a masked plover.

In terms of other aspects of the engine examination, the engine manufacturer advised:

• The loss of material from a single blade caused the fan to run out of balance while the engine was at take-off thrust. This out of balance operation generated high levels of N1 vibration, as recorded on the aircraft’s flight data recorder.
  
• It is most likely that the outboard section of the fan rear seal released following contact between the rotating and static members, as a result of high thrust engine operation with the fan out of balance. Fragments of this seal likely entered the core of the engine leading to significant damage to the compressors. This resulted in a series of compressor stalls, which prompted the flight crew to reduce the engine thrust setting to idle in response to the ECAM ENG 2 STALL alert.
  
• At about the time of the ENG 2 STALL alert, the oil quantity on the affected engine diverged from that on engine 1. There was a loss of clamping across the front bearing chamber elastomeric oil seal, as a result of bolt unwinding. This loss of clamping allowed oil to leak from this location, and the oil ignited either by the frictional heat from the rubbing seals or the relative movement between the front bearing housing and the low pressure roller bearing housing.
  
• The resulting oil fed fire established in the cavity between the front bearing housing and the fan disc. This fire caused failure and melting of aluminium alloy components in this cavity but was not sufficient to affect the structural engine parts made from materials with higher melting points that were in the same region. It is likely that once the bolts had fully unwound, the air pressure and oil feed conditions changed sufficiently so that the fire self-extinguished.
  

Engine design requirements
The Rolls Royce Trent 700 engine met the engine certification standards for the ingestion of birds. These requirements were outlined in the European Joint Aviation Regulation JAR-E 800. For medium-sized and small birds, these requirements stated that:

It shall be established that when the front of the Engine is struck by a number of medium sized birds… or small birds… there is no unacceptable immediate or ultimate loss of Engine performance, no serious increase of Engine operating temperatures or deterioration of Engine handling characteristics, over the full range of Engine operating conditions, and no dangerous physical damage…

Medium sized birds were considered to have a weight of 0.7 kg (or 1.5 lb) and small birds up to 0.11 kg. The specified test required the impact with a number of birds to be tested over a short duration (not more than 1 second), with the number of birds dependent on the size of the engine and the size of bird.

According to the engine manufacturer, what occurred to the engine during the occurrence flight:

• …is not as experienced during the medium bird certification test when 8 birds of at least 1.5lbs [0.68 kg] were fired into the engine at >168 kts with the bird trajectory longitudinally aligned with the engine...
  
• The certification test point is intended to demonstrate a level of capability in a worst case situation of aircraft above decision speed (V1[7]) but below 1500 ft, where the aircraft is committed to flight but has minimum amount of forward speed and is therefore dependent on engine thrust to climb safely…
  
• The certification birdstrike test is a benchmark test which demonstrates a level of engine capability as required by certifying authorities. The findings of this event do not undermine the capability of the Trent 700 engine with respect to birdstrike and the engine today would be expected to replicate the behaviour demonstrated during the previous test. The Trent 700 has experienced over 430 reported in-service birdstrike events with only five events resulting in fan blade material loss, all except this event were caused by birds greater than 2.5lb [1.14 kg].
  
• It is concluded that in this event a rare combination of 0.85lb bird ingestion at adverse forward speed during the take-off roll (close to V1 but lower than VR[8]) and angle of incidence combined to cause the release of a small section of blade which [led] to the engine producing only idle thrust after approximately 2 minutes and leading to commanded shutdown approximately 4 minutes after the release of fan blade material.
  

Safety analysis
Based on the available evidence, the engine failure was concluded to be the result of a birdstrike involving a masked lapwing. As the remains of the two birds found on the runway did not show signs of being involved in an engine ingestion, the engine failure was almost certainly a result of an additional bird.

The ATSB reviewed the aircraft’s flight data recorder, cockpit voice recorder and statements from the flight crew. From these data sources the ATSB determined that the flight crew effectively managed the abnormal situation and diversion. The cabin purser relayed to the flight crew relevant information about a possible number 2 engine fire observed from within the cabin. This information assisted the decision-making of the captain.

Although aircraft engines are designed to withstand most types of birdstrikes, including those involving medium-sized birds such as a masked lapwing, this event appeared to involve a rare scenario comprising a combination of aircraft and engine speeds, the height of the fan blade at which the birdstrike occurred, and its angle of incidence. It is extremely unlikely such a scenario would occur on multiple engines simultaneously.

Findings
These findings should not be read as apportioning blame or liability to any particular organisation or individual.

• During the take-off the number 2 engine was subjected to a birdstrike, which resulted in the release of a small section of a fan blade.
  
• Following an ECAM ENG 2 FAIL alert, the flight crew shut down number 2 engine, advised air traffic control of the situation and diverted to land as soon as possible at Brisbane Airport.
  

Safety action
Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.

Rolls Royce
Following this occurrence, the engine manufacturer met with the European Aviation Safety Agency, the certifying authority for the engine, to discuss the event and the manufacturer’s investigation.

The engine manufacturer also advised that its Trent 700 project team will review the design of the fan rear seal and the low pressure roller bearing bolts to determine if there is a feasible solution to prevent the loss of a small section of fan blade leading imminently to an engine shutdown.

AirAsia X
As a result of this occurrence, AirAsia X advised the ATSB that it had conducted its own internal investigation. The occurrence information will be shared with flight crew in recurrent training programs and used to enhance simulator training exercises.

Safety message
This occurrence highlights the importance of effective crew resource management techniques, including cabin crew passing on pertinent information to flight crew, and robust emergency procedures. Additionally, regular proficiency checks in the simulator, including engine failure scenarios, allow flight crew to respond appropriately in the event of such an occurrence in flight.

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So no drone strike this time, however this occurrence does highlight the potential high risk damage that a relatively small mass (250 to 400 gram) airborne object can inflict on a high capacity RPT aircraft turbine engine...
   


MTF...P2

[Peetwo]

MH17 JIT update - The Russkies did it.


Via the SMH:

Australia accuses Russia of direct role in shooting down MH17

By Deborah Snow 25 May 2018 — 6:07pm

The federal government has charged Russia with having direct involvement in the downing of Malaysian flight MH17,  in a significant hardening of Canberra's position after the latest findings from the Joint Investigation Team which is probing the tragedy.

In a statement issued late on Friday, Prime Minister Malcolm Turnbull, Foreign Minister Julie Bishop and Attorney-General Christian Porter pointed to the "significant" finding of the Dutch-led JIT that a BUK missile system belonging to the 53rd Brigade of the Russian Army brought the plane down on July 17, 2014.

Following the findings of an international investigation, Foreign Minister Julie Bishop announces Australia formally holds Russia responsible for its role in the downing.

"Based on these findings, the only conclusion we can reasonably now draw is that Russia was directly involved," they said.

"This evening Australia and the Netherlands notified the Russian Federation that we hold it responsible for its role in the downing. We have requested negotiations to open dialogue around the circumstances leading to the tragic loss of innocent lives."

The trio said Russia must be held to account for its conduct. They said holding the Russian Federation responsible under international law was a separate, but complementary process to the efforts by Dutch prosecutors to bring individual perpetrators to justice under the Dutch national legal system.

The decision to hold Russia directly responsible was conveyed to the Putin government in Moscow, and to the Russian Ambassadors in Canberra and the Hague, government sources said.

Earlier in the day Ms Bishop told Sydney broadcaster Alan Jones that Australia, along with other JIT members Belgium, the Netherlands, Malaysia and Ukraine were considering a "range of political and legal steps" that could be taken after Thursday's findings by the JIT.



Australian Federal Police officers and their Dutch counterparts search for human remains and personal belongings from the MH17 crash site.

Photo: Kate Geraghty

The fact that the missile had been shown conclusively to have belonged to the Russian army "raises the obvious question" she told Jones.

"How is it that such a sophisticated weapon belonging to the Russian army was dispatched to Ukraine, used to shoot down a civilian aircraft and then returned to Russia?"

She said the fact that the missile was launched from a field controlled by pro-Russian fighters "gives the lie to Russia’s claims at the time that they were not involved in the fighting in Eastern Ukraine".

Despite the decision to directly point the finger at Moscow,  federal government sources ruled out any plans to boycott the FIFA World Cup, due to take place in Russia from mid-June through to July.

The government has allocated $50 million over four years to support efforts by Dutch authorities to launch a prosecution and ensure the participation of bereaved Australian family members.

Opposition Leader Bill Shorten and shadow foreign affairs minister Penny Wong on Friday praised the "professionalism and rigour" of the JIT investigation, "despite Russian intransigence".

"The finding confirms the pivotal role of Russian elements in the murder of 298 innocent people, including 28 Australians," the pair said.

New Zealand’s Foreign Minister, Winston Peters, also described the JIT’s findings as "significant".

Speculation about a possible boycott of the World Cup briefly flared in the United Kingdom earlier this year after Russia became the chief suspect in the nerve-agent poisoning of former double agent Sergei Skripol and his daughter in the British town of Salisbury.

More recently, Human Rights Watch called on world leaders to boycott the opening ceremony in protest against joint Russian-Syrian operations that have caused thousands of civilian casualties.

But a spokesman for the Football Federation of Australia said the Socceroos will be taking part in the World Cup "as planned".

Russia has described the findings of the JIT as a "regrettable version of events''.
"This is a case of unfounded accusations aimed at discrediting our country in the eyes of the international community," the Russian Foreign Ministry said.

&.. AP report on Cuban B737 charter flight disaster, via the ABC:

Cuba plane crash: Black box recovered as history of safety complaints against Mexican company emerges
Updated 20 May 2018, 11:31am
VIDEO: Cubans mourn after deadliest plane crash in nearly 30 years (ABC News)
RELATED STORY: More than 100 die in Cuba's third major aviation accident since 2010

The Mexican charter company whose plane crashed in Havana, killing 110 people, has been the subject of two serious complaints about its crews' performances over the past decade, according to authorities in Guyana and a retired pilot for Cuba's national airline.

Key points:

• The plane was barred from Guyanese airspace last year after authorities found its crew had allowed dangerous overloading of luggage
  
• The "black box" voice recorder has been recovered
  
• A former Cubana pilot says "there are many flight attendants and security personnel who refused to fly with this airline"
  

The plane was barred from Guyanese airspace last year after authorities discovered that its crew had been allowing dangerous overloading of luggage on flights to Cuba, Guyanese Civil Aviation director Captain Egbert Field told The Associated Press.

The plane and crew were being rented from Mexico City-based Damojh airlines by EasySky, a Honduras-based low-cost airline.

Cuba's national carrier, Cubana de Aviacion, was also renting the Boeing 737 and crew in a similar arrangement known as a "wet lease" before the aircraft veered on take-off to the eastern Cuban city of Holguin and crashed into a field just after noon Friday, according to Mexican aviation authorities.

A Damojh employee in Mexico City declined to comment, saying the company would be communicating only through written statements.

Mexican authorities said Damojh had permits needed to lease its aircraft and had passed a November 2017 verification of its maintenance program.

VIDEO: More than 100 feared dead after plane crash in Cuba (ABC News)

Cuban Transportation Minister Adel Yzquierdo Rodriguez told reporters Saturday afternoon (local time) that Cubana had been renting the plane for less than a month under an arrangement in which the Mexican company was entirely responsible for maintenance of the aircraft.

Armando Daniel Lopez, president of Cuba's Institute of Civil Aviation, told the AP that Cuban authorities had not received any complaints about the plane in that month. He declined to comment further.

Mr Yzquierdo said it was routine for Cuba to rent planes under a variety of arrangements because of what he described as the country's inability to purchase its own aircraft due to the US trade embargo on the island.

PHOTO: Cuban Transport Minister Adel Yzquierdo leaves after speaking to reporters on the island nation's worst aviation disaster in three decades. (AP: Desmond Boylan)

Cuba has been able to buy planes produced in other countries, including France and Ukraine, but has pulled many from service due to maintenance problems and other issues.

"It's normal for us to rent planes," he said.

"Why? Because it's convenient and because of the problem of the blockade that we have. Sometimes we can't buy the planes that we need, and we need to rent them."

PHOTO: Forensic investigators sift through the remains of the plane. (AP: Desmond Boylan)

He said that with Damojh, "the formula here is that they take care of the maintenance of the aircraft. That's their responsibility."

He said Cuba did not have pilots certified to fly the Boeing, so it had hired the Mexican crew with the expectation that they were fully trained and certified by the proper authorities.

Black box recorder recovered from crash site

Mr Yzquierdo also said the jet's "black box" voice recorder had been recovered and that Cuban officials had granted a US request for investigators from Boeing to travel to the island.

Eyewitness and private salon owner Rocio Martinez said she heard a strange noise and looked up to see the plane with a turbine on fire.

"It had an engine on fire, in flames, it was falling toward the ground," Ms Martinez said, adding that the plane veered into the field where it crashed, avoiding potential fatalities in a nearby residential area.

PHOTO: The first secretary of Communist Party in Holguin comforts relatives of the crash victims. (Reuters: ACN)

Captain Field told AP that the Boeing 737 with tail number XA-UHZ had been flying four routes a week between Georgetown, Guyana, and Havana starting in October 2016.

Cubans do not need visas to travel to Guyana, and the route was popular with Cubans working as "mules" to bring suitcases crammed with goods back home to the island, where virtually all consumer products are scarce and more expensive than in most other countries.

After Easy Sky cancelled a series of flights in spring 2017, leaving hundreds of Cubans stranded at Guyana's main airport, authorities began inspecting the plane and discovered that crews were loading excessive amounts of baggage, leading to concerns the aircraft could be dangerously overburdened and unbalanced.

In one instance, Guyanese authorities discovered suitcases stored in the plane's toilet.

"This is the same plane and tail number," Guyanese Infrastructure Minister David Patterson said.

He and other Guyanese authorities said they did not immediately know if the crew suspended last May was the same one that died in Friday's crash.

Damojh operates three Boeing 737s, two 737-300s and the 737-201 that crashed Friday, according to Mexican officials.

PHOTO: A local newspaper says three people survived. (Reuters: Alexandre Meneghini)

Ovidio Martinez Lopez, a pilot for Cubana for over 40 years until he retired six years ago, wrote in a post on Facebook that a plane rented from the Mexican company by Cubana briefly dropped off radar while over the city of Santa Clara in 2010 or 2011, triggering an immediate response by Cuban aviation security officials.

As a result, Cuban officials suspended a captain and co-pilot for "serious technical knowledge issues," and Cuba's Aviation Security authority issued a formal recommendation that Cubana stop renting planes and crews from Damojh, Mr Martinez wrote.

"There are many flight attendants and security personnel who refused to fly with this airline," Mr Martinez wrote.

"On this occasion, the recommendation was overlooked and they rented from them again."

Contacted by AP in Havana, Mr Martinez confirmed his Facebook account but declined to comment further.

Mexican officials said the Boeing 737-201 was built in 1979.

In November 2010 a Global Air flight originating in Mexico City made an emergency landing in Puerto Vallarta because its front landing gear did not deploy.

A fire was quickly extinguished, and none of the 104 people aboard were injured. That plane was a 737 first put into service in 1975.

Mexican aviation authorities said a team of experts would fly to Cuba tomorrow to take part in the investigation.
PHOTO: Relatives of passengers arrive near the airport terminal in Havana. (AP: Desmond Boylan)

MTF...P2 

[Peetwo]

Convair crash South Africa. 

Via News.com.au:

Three Australians injured, one person killed in South Africa plane crash
AN Australian pilot is fighting for his life and two more Aussies are injured after a plane crash that killed two people.
Emma Reynolds and wires
news.com.auJULY 12, 20189:24AM

• Video
  
• Image
  

The Australian pilots were due to fly the plane to the an aviation museum in the Netherlands. Picture: AFP Photo / StringerSource:AFP

AN Australian pilot is fighting for his life after he was injured along with an Aussie co-pilot and passenger in a horror plane crash in South Africa that left two people dead.

Several passengers and crew members were injured, as well as two people on the ground when the vintage aircraft due to become a theme park exhibit went down outside the country’s capital, Pretoria.

Pilots Ross Kelly and Douglas Haywood, from Sydney, were taken to Johannesburg Hospital with serious injuries, along with another Australian passenger.

South African Chris Barnard was killed at the scene and the second victim died later in hospital.

“We can confirm that a second person has unfortunately died. This was one of the people injured on the ground,” South African Civil Aviation Authority (SACAA) spokesman Kabelo Ledwaba told AFP.

The group was on a scenic flight in a Convair C-131D that was being donated by South African tour company Rovos Rail Tours to the Aviodrome aviation museum in the Netherlands.


The vintage Convair C-131D aircraft crashed into a field in South African capital Pretoria.Source:Supplied

South African paramedics and emergency services gather at the scene of a plane crash on the outskirts of Pretoria. Picture: AFP Photo / StringerSource:AFP

Brenda Vos from Rovos Rail told news.com.au that the families of the pilots were on their way to South Africa on Wednesday evening.

“It was a scenic flight for the Dutch representatives from Aviodrome,” she said. “The plane was due to leave for Holland this afternoon or tomorrow.”

A spokeswoman for Aviodrome told news.com.au that several of its representatives had been discharged from hospital with only minor injuries. The company’s general manager is on her way to South Africa to provide support.

Mr Kelly and Mr Haywood had previously flown another vintage plane belonging to Rovos Rail from South Africa to Darwin.

The pilots are both members of Australia’s Historical Aircraft Restoration Society.

Mr Kelly has been a Qantas pilot for more than 30 years and recently retired as captain on the Airbus A380.


Qantas pilot Douglas Haywood was injured in the plane crash. Picture: FacebookSource:Facebook

Co-pilot Ross Kelly, who recently retired as captain on the Airbus A380 with Qantas and is pictured with wife Lyndal, was also hurt in the crash. Picture: FacebookSource:Facebook

Mr Haywood is a former RAAF pilot, and has worked for Qantas since 1984, where he trains new pilots on the Airbus A380.

The Aircraft Owners and Pilots Association Australia said in a statement on Facebook: “Our thoughts and prayers are with the Australian pilot, co-pilot and passenger who were on-board a Convair C-131D which has crashed today in South Africa. The passenger and co-pilot are said to be in a stable condition, with the pilot critically injured.

“The Convair was being prepared for a delivery flight to the Dutch city of Leystad, where it was to go on display at the Aviodrome museum.”

The plane ploughed through a factory near an airport in the Wonderboom area and crashed in a field around five kilometres east of a small airport, according to Tshwane Emergency Services spokesman Johan Pieterse. “It was obviously chaotic,” he said.

Video of the plane’s takeoff showed smoke streaming behind it and dramatic images from the scene showed the aircraft broken in half.
The SACAA said it would produce a report on the cause of the crash within 30 days.

South African Chris Barnard was killed in the crash, which occurred during a scenic flight. Picture: AP Photo/Phil MagakoeSource:AP

And via the Oz today:

Qantas pilots ‘sticklers for safety’
ANNABEL HEPWORTH, RHIAN DEUTROM
Australia has offered to send help to investigators of a vintage plane crash which left two Qantas pilots badly injured.

---

Australian offer to help vintage plane crash investigators

The Australian Transport Safety Bureau has offered to send an experienced investigator to assist South African authorities in the wake of a vintage plane crash that has left two Qantas pilots, one former and one serving, in hospital.

As video footage circulated showing dark smoke coming from one engine after takeoff, an ATSB spokesman said they had contacted the South African Civil Aviation Authority.

Two Qantas pilots, A380 captains Douglas Haywood and Ross Kelly, who is retired, were critically injured in the crash.

Two people have died, while Mr Kelly’s wife, Lyndal, was among those who were injured.

“Given the Australians reported to be on board, last night the ATSB contacted the SACAA and offered our assistance through the deployment of an experienced transport safety investigator with a relevant background in either engineering, operations and/or human factors if the SACAA considered that this would enhance their own investigation team,” the ATSB spokesman said yesterday.

“At this stage, the ATSB has not yet received a response from SACAA.”

A close friend of Mr and Mrs Kelly and Mr Haywood told The Australian that the aviation community at home had been “devastated” by the news.

Describing the two pilots as “legends of aviation in Australia”, the friend said the pair was passionate about preserving Australian aviation history for future generations. “They are absolute enthusiasts of old world aviation and the extent of their knowledge in this field is second-to-none.”

The two men were known by their peers to be “sticklers for safety” during their work with historic aircraft. “They would never do anything remotely unsafe, they were so pedantic that if they weren’t happy with something they wouldn’t leave the ground,” they said. “That’s why we’re all so shocked by this.”

The South African air crash investigator has assigned a team to look at the accident after the crash of the 64-year old Convair CV-340 that was being prepared for transport to a Dutch museum.

The 1950s-era Convair was on short test flight from Pretoria’s Wonderboom Airport to Pilanesburg when it crashed into a nearby factory. The plane had been due to leave South Africa for a multi-leg journey to its final home at the Aviodrome aircraft museum in The Netherlands. The aircraft had been donated to the Aviodrome by Rovos Rail Tours. While it was initially unclear whether the two Qantas pilots were passengers or members of the flight crew, Aviodrome spokeswoman Lisette Kars later told The Australian: “They’ve had a long time of experience with it, that’s why they were flying the plane.”

Qantas and the South African air regulator were unable to confirm whether Mr Haywood and Mr Kelly were passengers or among the flight crew.

Organisers of one of the ­nation’s largest annual air shows, Wings Over Illawarra, released a statement of support for Mr and Mrs Kelly and Mr Haywood.

Aircraft Owners and ­Pilots Association executive director Benjamin Morgan said the aviation community is “close knit” and that “a great number of us” know the “highly accomplished” pilots.

Additional Reporting: Charlie Peel

MTF...P2 

[Peetwo]

MAL under the spotlight with latest incident YBBN?

By Robyn Ironside , via the Oz:

Near-disaster in Brisbane puts heat on Malaysia Airlines

A Malaysia Airlines flight narrowly avoided disaster in Brisbane. Picture: AFP

The Australian
12:00AM July 25, 2018
ROBYN IRONSIDE

AVIATION WRITER
Brisbane
@ironsider

Aviation experts have questioned the safety of Malaysia Airlines’ ­operations after the carrier narrowly avoided disaster in Brisbane.

The Australian Transport Safety Bureau has launched an ­investigation into flight MH134, after its airspeed indicators failed on take-off late last Wednesday night. The A330-200, with 226 people on board, was forced to return to Brisbane after dumping fuel over Moreton Bay, landing so heavily the aircraft was unable to continue to the gate.

Brisbane Airport confirmed the runway was closed for 90 ­minutes, forcing an Emirates flight from Dubai to divert to Melbourne, and delaying a Cathay ­Pacific flight from Hong Kong. The cause of the problem is thought to have been a failure to remove covers from the pitot tubes that measure airspeed and altitude, and feed that information into the on-board computer.

Australian Licensed Aircraft Engineers Association secretary Steve Purvinas said no aircraft should take off with a cover on the pitot tubes.

“In our industry it’s just little mistakes like that that can cause critical failures in flight,” Mr Purvinas said.

“There should be an engineer checking the aircraft before it ­departs and then the pilot should check it. If those checks aren’t happening, they shouldn’t be flying a plane.”

He said reports of a heavy landing were not surprising, given the pilot would not have known what altitude the aircraft was at as it ­descended.

“Before an aircraft lands, they normally flare the nose up so the landing is smooth,” said Mr Purvinas. “They would’ve found that ­really hard to judge on this flight.”

Veteran commercial pilot Byron Bailey said it was an appalling oversight not to remove the pitot tube covers as part of pre-flight checks. He said it was standard procedure for either the captain or co-pilot to conduct an external inspection of the aircraft to ensure the tyres were inflated and pitot tube covers were removed.

“The second check should have ­occurred on the runway, when the airspeed is being cross-checked. At that time if there’s a discrepancy the take-off should be aborted,” Mr Bailey said. “It’s shocking they ever actually got airborne.”

Malaysia Airlines confirmed the A330 yesterday remained in Brisbane undergoing repairs, ­almost a week after the incident.

A spokeswoman said the flight had returned to Brisbane “due to an unexpected technical issue that occurred after take-off”.

“The airline is unable to comment while investigations are still in progress but is working closely with and giving full co-operation to the authorities,” she said.

“Safety is of paramount importance to the airline at all times.”

Blocked pitot tubes were partially blamed for the crash of an Air France A330 into the Atlantic Ocean in 2009. All 228 people on board died. At Brisbane Airport, aircraft operators are required to cover pitot tubes due to the risk of mud wasps building nests over the openings following an incident involving an Etihad Airways A330 in 2013. The Civil Aviation Safety Authority issued an alert in May warning that keyhole wasps found in Brisbane could build nests in as little as 20 minutes. The alert ­advised that the consequences of blocked pitot tubes were “hazardous”. As part of its investigation into the incident, the Australian Transport Safety Bureau will examine the aircraft, collect the flight data and cockpit voice ­recorders, and interview maintenance and flight crew.

Malaysia Airlines resumed flights between Brisbane and Kuala Lumpur only in June, three years after axing the service as part of a restructure. The overhaul was the result of plunging passenger numbers in the wake of the MH370 and MH17 tragedies.

From the HVH investigation page:

Aviation safety investigations & reports

Airspeed indication failure on take-off involving Airbus A330, 9M-MTK, Brisbane Airport, Queensland, 18 July 2018
 
Investigation number: AO-2018-053
Status: Active
[img=150x0]https://www.atsb.gov.au/Assets/Progress/progress_0.png[/img]

Summary

The ATSB is investigating an airspeed indication failure on take-off involving an Airbus A330, 9M-MTK, at Brisbane Airport, Queensland on 18 July 2018.

During take-off, the airspeed indicators failed and the crew conducted a return to Brisbane.
As part of the investigation, the ATSB will examine the aircraft, collect recorders, and interview maintenance and flight crew.

A final report will be released at the end of the investigation.

Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify those affected and seek safety action to address the issue.
 
General details
Date: 18 July 2018
 
Investigation status: Active
 
Time: 13:34 UTC
 
Investigation phase: Evidence collection
 
Location   (show map):
Brisbane Airport
 
Investigation type:
Occurrence Investigation
 
State: Queensland
 
Occurrence type: Aircraft preparation
 


 
Occurrence class: Operational
 
Report status: Pending
 
Occurrence category: Incident
 
Anticipated completion: 3rd Quarter 2019
 
Highest injury level: None
 
 
Aircraft details

Aircraft manufacturer: Airbus
 
Aircraft model: A330-323XZ
 
Aircraft registration: 9M-MTK
 
Serial number: 1318
 
Operator: Malaysia Airlines
 
Type of operation: Air Transport High Capacity
 
Sector: Jet
 
Damage to aircraft: Nil
 
Departure point: Brisbane, Qld
Destination: Kuala Lumpur, Malaysia
 
 
Last update 19 July 2018

MTF...P2 

[Gobbledock]

An Aero Peru B757 crashed in 1996 due to either tape or wasps covering/blocking pitot tubes. There have been several crashes due to a failure to examine the pitot’s before departure. It’s almost an inexcusable occurrence these days. The Malaysian incident should have never occurred...

CAsA, WAKEY WAKEY.

TICK TOCK

[Gobbledock]

DASH 8 Q 400 STOLEN BY GROUND CREW AND CRASHES

Bloody hell. Another low moment in aviation. A ground crew staffer in Seattle with Horizon Airlines has had a mental breakdown, stolen a Dash 8, taken it for a joyflight and then crashed it.

One can only imagine what the reaction from Australia’s aviation security Nazi, Peter Dutton, will be?

https://www.google.com.au/amp/s/www.wash...e-seattle/

Hanging my head in disbelief......

[P7_TOM]

Convair - ZS - BRV.

Haywood and Kelly are expected ‘home’ within the next few day. Kelly remains in a coma, but no longer induced; Hayward appears to returning from beyond and back to family and the world; sad news is he may loose an eye. Safe home fellahs and get well soon.

The RSA CAA have publish their preliminary - REPORT - and make reference to the ‘go-pro’ camera which was running throughout the event and has been of some assistance to the investigators.

Notes: - Elevation 4095’  - 4%slope to the SW (08/24) Wind 270 @ 04 knots. Temperature 19c, QNH 1013. Density altitude? For a Choc Frog, anyone…

That’s about all the news I’ve been able to pick up, until next week's darts match.

[Cap'n Wannabe]

Density altitude 5535' give or take..

[Peetwo]

More on stolen Horizon Q400 - 

From Seattle Times, via the Oz:

Seattle plane thief was ‘suicidal’

Investigators are piecing together how an airline ground agent stole an empty plane from Seattle’s international airport.

---

A 29-year-old “suicidal” airport worker who commandeered an empty plane from Seattle’s main airport and took it on an hour-long flight chased by fighter jets before crashing did not commit any security violations.

Horizon Air employee Richard Russell told an air-traffic controller he was “just a broken man” minutes before dying late on Friday (Saturday Australian time) in the Bombardier Dash 8 Q400 twin-engine turboprop plane, appearing to apologise for his actions.

Authorities ruled out any link to terror. But consternation grew over the safety gaps that allowed an airport worker to gain access to a commercial airliner and fly it over a metropolitan area.

“Everybody’s stunned that something like this would happen,” said retired Horizon operations supervisor Rick Christenson. “How could it? Everybody’s been through background checks.”

Mr Russell had access legitimately to the plane at Seattle-­Tacoma International Airport, said Mike Ehl, director of aviation operations at the airport.

“No security violations were committed.”

The 76-seat plane made a big, slow loop-the-loop as US Air Force F-15 jets gave chase, then flew low over Puget Sound before crashing into sparsely populated Ketron Island, setting trees on fire.

“To our knowledge, he didn’t have a pilot’s licence,” said Horizon chief executive Gary Beck.

“Commercial aircraft are complex machines … No idea how he achieved that experience.”

Mr Russell’s role at Horizon, where he had worked since 2015, involved towing aircraft as part of a two-person team, and loading and unloading cargo and luggage and cleaning the aircraft. Horizon is a subsidiary of Alaska Airlines.

“At this time, we believe he was the only one in the aircraft but of course, we haven’t confirmed that at the crash site,” said Jay Tabb, chief of the FBI’s Seattle division.

Ruling out a terror link, Pierce County Sheriff Paul Pastor noted that “most terrorists don’t do loops over the water … This might have been a joy ride gone terribly wrong”. Ed Troyer, of the sheriff’s office, described Mr Russell as “suicidal”, saying he had acted alone.

Mr Christenson told The Seattle Times: “He was a quiet guy. It seemed like he was well liked by the other workers.

“I feel really bad for Richard and for his family. I hope they can make it through this,” he said.

The plane was stolen at about 8pm (1pm Saturday AEST) and crashed 90 minutes later, officials said.

The sheriff’s office said the F-15s arrived minutes after the plane was stolen and kept the aircraft “out of harm’s way and people on the ground safe”. The fighter jets flew at supersonic speed, triggering a boom first taken to be an explosion, as they raced to intercept the plane.

Donald Trump was briefed and the White House praised authorities’ quick response to the crisis.

John Waldron, who captured the plane’s loop-the-loop on video, told CNN he was out for an evening stroll and initially thought the aircraft were practising for an air show. He estimated the plane, at its lowest point, was no more than 30m above the water.

As Mr Russell nose-dived toward the water, “We were all screaming, ‘Oh my god, oh my god!’ and I was yelling, ‘Pull up, pull up!’,” Mr Christenson said.

In a conversation with the control tower, the pilot came across as excitable, confused and even apologetic. “Congratulations, you did it,” the control tower tells him, according to an audio feed aired on CNN. “Let’s turn around the air and land it and not hurt anybody on the ground.”

“I don’t know, man,” the pilot answers. “I don’t want to. I was kind of hoping that was going to be it, you know.”

During the conversation, the man said he had put fuel in the plane “to go check out the Olympics” (the Olympic Mountains about 160km away). But he later worried he was running low, saying the fuel had burned “quite a bit faster than I expected”.

The control tower then urged him to land at a nearby military base. “I wouldn’t want to do that. They probably have anti-aircraft,” he responds. “This is probably jail time for life, huh?” he later says, according to a recording published by The Seattle Times.

  
Next, yet another fatal accident in Indonesian province Papua ...  

Boy only survivor of plane crash

A 12-year-old boy is the sole survivor of a plane crash that killed eight people in mountainous region of Papua.

---

Boy only survivor of crash in to Papua mountainside

A 12-year-old boy is the sole survivor of a plane crash that killed eight people in mountainous region of Indonesia’s easternmost province of Papua, authorities said yesterday.

The Swiss-made Pilatus PC-6 Porter single-engine aircraft operated by private charter company Dimonin Air was reported missing on Saturday during a 45-minute flight from Tanah Merah in Boven Digul district to Oksibil, the district capital of Pegunungan Bintang, bordering Papua New Guinea.

The wreckage was found in a heavily forested area on a mountain side yesterday morning.

Local army chief Colonel Jonathan Binsar Sianipar said the boy, identified as Jumaidi, was the only passenger found alive and was evacuated to the Oksibil hospital. A statement from the army said the boy was conscious but it gave no other details.

The plane lost contact after communicating with the control tower in Oksibil just before it was due to land on Saturday afternoon, said local police chief Michael Mumbunan.

Colonel Sianipar said the cause of the crash was not clear.

The plane was carrying seven passengers and two crew.

Before the accident, villagers in nearby Okatem reported hearing a loud roar followed by an explosion. Search and rescue teams walked two hours to reach the crash site and were still recovering the bodies late yesterday morning.

Indonesia has a poor aviation safety record and Papua is a particularly difficult area to reach.

Five people died after a small plane crashed near Wamena in Papua province in July last year.

In August 2015, a commercial passenger aircraft operated by Indonesian carrier Trigana crashed in Papua due to bad weather, killing all 54 people on board.

 Finally from the Oz today on the RSA Convair prelim report:

Plane crash probe faults Aussie

ROBYN IRONSIDE


A preliminary report into a fatal plane crash in South Africa has suggested one of the two Aus­tralian pilots should not have been at the controls of the vintage ­Convair 340 aircraft.

The report by the South African Civil Aviation Authority found only one pilot was rated for the Convair, which was being flown for the first time in five months ahead of a trip to its final resting place at a museum in ­Amsterdam.

Recently retired Qantas pilot Ross Kelly and Qantas training pilot Doug Haywood were at the controls of the 64-year-old plane, having flown another Convair from Pretoria to Australia in 2016.

Both pilots were critically injured when just minutes after take-off the plane lost altitude and struck powerlines before crashing into a dairy factory, about 6km from Wonderboom Airport.

South African flight engineer Chris Barnard was killed, and one of four people struck on the ground also died.

Two more passengers were ­seriously injured, including the wife of Mr Kelly, and 14 suffered minor injuries.

GoPro footage taken inside the plane was used by investigators to piece together the moments leading to the crash, on July 10.

The footage revealed the captain was flying the plane, the first officer was manning the radio and the engineer was operating the ­engine controls.

“Although the aircraft is certified for operation by two pilots, it is not clear why the engineer was ­allowed to operate the engine controls during the operation of the aircraft,” the report says.

Shortly after take-off, a passenger went to the cockpit and told the engineer the left engine was on fire, but according to the report no corrective action was taken.

“The GoPro also shows that the pilots were not sure if they had ­retracted the landing gears as they can be heard asking each other whether the gears are out or not,” the report says. “It also shows that though the pilots and engineer were informed of the left-engine fire, they were asking each other which engine was on fire.

“At no stage did the pilots or the engineer discuss or attempt to ­extinguish the left-engine fire as the fire extinguishing system was never activated.”

The report’s 16 preliminary findings include the fact the flight plan filed was for an airport that was closed for maintenance.

It also found “crew resource management in the cockpit was lacking” and “emergency procedures were not followed”.

“The aircraft flight manual ­requires two pilots to operate the aircraft and both need to be rated on the aircraft; however, the documents and licences made available to investigators indicate only the captain was rated on the aircraft,” the report says.

Aviation sources said the report was only “preliminary” and pointed out neither Mr Kelly nor Mr Haywood had been interviewed.

Both men remain in induced comas as preparations are made to repatriate them to Australia.

MTF...P2 

[Peetwo]

More on SACAA Convair preliminary investigation report - 

Via the Oz:

Air crash report ‘full of holes’
ROBYN IRONSIDE
A report on last month’s fatal Convair crash involving two Australian pilots is full of mistakes, aviation officials say.

---

Convair crash report ‘full of holes’

A South African Civil Aviation Authority report on last month’s fatal Convair crash involving two Australian pilots has been criticised as riddled with inaccuracies and “opinions” of the engineer ­investigators.

Retired Qantas senior check captain David Harris, who travelled to Johannesburg immediately after the crash, said the assertion one of the pilots was not “type-rated” for the Convair 340 was among a series of errors.

Other inaccuracies included the geographical co-ordinates of the crash site, the time of take-off and the investigators’ interpretation of the pilots’ communication as apparent confusion rather than standard procedure.

A licensed aircraft maintenance engineer on board the 64-year-old plane was killed when it crashed into a building outside Wonderboom Airport in Pretoria on July 10.

A total of 19 people were on the joy flight, which was being undertaken ahead of a trip to the Convair’s new home at the Aviodrome Museum in The Netherlands.

The SACAA’s preliminary ­report, released on August 11, said documents and licences made available to the investigation team showed only the flight captain was rated on the aircraft.

It is understood the family of the first officer did not hand over his licence to investigators following the crash, which left both ­pilots critically injured. But Mr Harris said it would have been easy enough for the SACAA to check the licences of the two pilots with the Australian Transport Safety Bureau or the Civil Aviation Safety Authority.

Qantas training captain Douglas Haywood has since returned to Australia for ongoing hospital treatment in Sydney, while ­recently retired Qantas captain Ross Kelly remains in an induced coma in Johannesburg.

Mr Harris said Australia’s aviation community was aghast at the SACAA report.

“It’s a reaction of disbelief that the investigators could get it so wrong,” he said. “These two guys are the most senior pilots in Australia. They have done everything, from training captains on the A380 to flying Mustangs and Spitfires. Everybody knows them.”

He said it was clear that ­although the investigators understood the technical and mechanical details of flying, they had little appreciation for the pilots’ job. “They are clearly out of their depth on this investigation,” Mr Harris said.

One of the most “scathing” findings of the preliminary report was that crew resource management was lacking, he said. “Both these guys taught CRM, which is an integral part of a multi-crew situation,” he said. “The investigators may have some training in CRM but I doubt they’ve ever had first-hand ­experience.”

The Australian Transport Safety Bureau has provided an “accredited representative” to ­assist the SACAA with its ­investigation, and help obtain ­information requested by the South African investigators from involved parties in Australia. “It is not the role of ATSB to review any reports of this investigation,” an ATSB spokesman said.

And also from the Oz today:

Wrong wiring forced diversion

ROBYN IRONSIDE
The cause of a fire in an Etihad Airways’ jet that forced the passenger flight to divert to Adelaide has been revealed.

---

Incorrectly installed wiring has been blamed for a fire in the cargo compartment of an Etihad Airways’ jet that forced the passenger flight to divert to Adelaide.

The Australian Transport Safety Bureau has today released its final report on the October 14, 2017 incident involving a Boeing 777-300 en route from Abu Dhabi to Sydney.

The report said the flight crew noticed a burning smell coming from an air vent, which was followed by a message warning of a fire in the forward cargo.

In response, the pilots actioned the “non-normal checklist” closing the air vents in the forward cargo compartment, and discharging two fire extinguishers in the section.

A “mayday” message was sent to Air Traffic Control as the aircraft diverted to Adelaide as the nearest suitable airport for the 777-300.

After landing uneventfully, emergency services inspected the aircraft externally but could not find any fire or hot spots, and passengers were disembarked without incident.

A further inspection after the cargo compartment was emptied, found soot and heat damage between the cabin floor and upper cargo ceiling panel.

Further investigations revealed a wiring bundle had been incorrected routed, and as a result the wires came into contract with screws and nutplates.

Over time, the bundle chafed through the insulation coating, allowing the wire to short circuit.

Boeing reported it was the fifth such incident involving wire chafing and arcing in the cargo area of a 777, but it was the first event to trigger the cargo fire warning system in flight.

The report revealed that due to the occurrence, Boeing took a number of steps to identify similar issues and ensure the risk of wires coming into contact with screws was further minimised.

“Despite complex systems of design and manufacturing, training and quality control, errors to occur during manufacturing that may not be apparent for some time,” the ATSB report said.

“In this case, the aircraft was manufactured four years prior to the incident.”

The report acknowledged that crew actions together with regulatory design requirements, material composition and system protections minimised the severity of damage from the short circuit.

“In response to this and four other incidents, the aircraft manufacturer utilised their system of communication to alert all operators of the issue and took actions in an effort to prevent reoccurrence,” said the report.

MTF...P2  

[Peetwo]

MAL AO-2018-053 serious incident - Preliminary report released.

Via HVH's ATCB...

Preliminary report published: 30 August 2018
Sequence of events
On 18 July 2018 Malaysia Airlines Airbus A330-300, registered 9M-MTK, was scheduled to operate on a regular public transport flight from Brisbane, Queensland to Kuala Lumpur, Malaysia. The scheduled departure time was 2320 Eastern Standard Time.[1]

The aircraft had landed at Brisbane Airport at 2011, after a flight from Kuala Lumpur. The captain, first officer and certifying maintenance engineer from the previous night’s flight, who had been resting at a Brisbane hotel, arrived at the airport to commence their duties for the 18 July outbound flight.

Soon after the aircraft had landed, covers were placed on the aircraft’s three pitot probes.[2] Subsequent inspections during the turnaround did not identify the presence of the pitot probe covers and they were not removed prior to the aircraft’s departure (Figure 1).

Figure 1: Aircraft about to be pushed back with pitot covers in place (two of three visible)
[img=463x0]https://www.atsb.gov.au/media/5774872/ao2018053_picture-4.png?width=463&height=463&mode=max&sharpen=2[/img]
Source: Brisbane Airport Corporation. Image modified by ATSB.

The first officer was the pilot flying (PF) and the captain was the pilot monitoring (PM).[3] Prior to aircraft pushback, the captain and first officer calculated the aircraft’s ‘V’ (critical) speeds for the take-off.[4] For this flight, the decision speed V1 (the maximum speed at which a rejected take-off can be initiated in the event of an emergency) was 153 kt and the rotation speed VR (when rotation should be initiated) was 160 kt.

The operator’s standard operating procedures for take-off required the PM to announce when the airspeed reached 100 kt and for the PF to cross check this airspeed indication.

The wind was calm and there was no cloud. At 2324, the flight crew commenced taxi for a take-off on runway 01. Subsequent events included:

• 2331:05: The flight crew commenced the take-off roll.
  
  
• 2331:38: The cockpit voice recorder (CVR) recorded that the captain called ‘100 knots’. The the aircraft’s recorded groundspeed at this time was 100 kt.
  
  
• 2331:47: The first officer initiated rotation. The recorded groundspeed at this time was 165 kt.
  

The flight crew recalled that they detected an airspeed anomaly during the take-off roll, including red speed (SPD) flags on both primary flight displays (PFD).

The standard operating procedures stated that the captain held responsibility for the decision to reject the take-off or continue. It stated that rejecting a take-off between 100 kt and V1 was a serious matter, that a captain should be ‘go-minded’, and that very few situations should lead to the decision to reject the take-off. There was no indication on the CVR recording that the captain or the first officer discussed rejecting the take-off.

After take-off the flight crew carried out actions for unreliable airspeed indications and made a PAN call[5] to air traffic control (ATC), advising they had unreliable airspeed indications.

The flight crew continued to climb above 10,000 ft and manoeuvred the aircraft to the north-east of Brisbane Airport where they carried out several checklists, troubleshooting and preparation for an approach and landing on runway 01 (Figure 2).

Figure 2: Flight path of 9M-MTK during turn-back
[img=463x0]https://www.atsb.gov.au/media/5774873/ao2018053_picture-5.png?width=463&height=463&mode=max&sharpen=2[/img]
Source: Google Earth / ATSB.

In accordance with published procedures, the flight crew turned off the three air data reference systems (ADRs) at 1343. This activated the aircraft’s backup speed scale (BUSS) (Figure 3), which provided a colour-coded speed scale derived from angle of attack and other information, and altitude derived from GPS data.[6] The flight crew also obtained groundspeed information from ATC, and used the aircraft’s radar altimeter.

Figure 3: Example of the backup speed scale (BUSS), showing the colour-coded scale (left) that indicates derived speed, and a GPS altitude scale (right)

Source: Airbus

Normal landing gear extension could not be accomplished with all three ADRs off.[7] The flight crew performed a landing gear gravity extension before conducting an overweight[8] landing on runway 01 at 0033.

After landing the flight crew stopped the aircraft on the runway as nose wheel steering was unavailable following a landing gear gravity extension. The main landing gear doors, which remain open following a gravity extension, had minor damage where they contacted the runway surface. The aircraft was towed to the gate where the passengers and crew disembarked. There were no reported injuries during the flight.

A subsequent inspection identified that the pitot probe covers were still fitted to the aircraft’s three pitot probes after it landed.

Recorded data

The ATSB recovered and downloaded data from the aircraft’s CVR and flight data recorder (FDR), and obtained data from the aircraft’s digital ACMS[9]recorder (DAR), used for routine monitoring by the operator.

The data from the CVR and FDR contained all of the occurrence flight, while the DAR included all data up to 2348 and intermittent data after that time.[10] At the time of publication, the ATSB had not fully validated the data and analysis is ongoing.

The aircraft had three sources of airspeed:

• ADR1, processing data for the captain’s pitot probe on the left side of the airframe, and usually presented on the captain’s PFD.
  
  
• ADR2, processing data from the first officer’s pitot probe on the right side of the airframe, and usually presented on the first officer’s PFD.
  
  
• ADR3, processing data from the standby pitot probe on the left side of the airframe, and usually presented on the integrated standby instrument system to the right of the captain’s instruments.
  

Airspeed was not recorded or displayed to the flight crew when it had a calculated value below 30 kt.

The FDR recorded airspeed from ADR3 once per second, and additionally from any one of the three ADRs twice per second depending on flight crew selection and data validity. Data from the FDR showed that ADR1 first sensed airspeed above 30 kt at 2331:39. At rotation, the FDR recorded 38 kt airspeed from ADR1 and the airspeed from ADR3 had not yet reached 30 kt. ADR3 first sensed airspeed above 30 kt at 2331:54.

The DAR sampled airspeed once per second and preliminary analysis shows broadly similar values as the FDR.

The maximum recorded airspeeds after take-off were 66 kt on the FDR and 57 kt on the DAR, prior to the ADRs being selected off when the data became invalid. These recorded airspeeds were consistent with the pitot probes being covered.

Preliminary analysis of the available groundspeed and angle of attack data indicated that the aircraft was flown within operational limits.

Further investigation is required to determine the airspeed indications and related warnings and cautions being displayed to the flight crew during the take-off roll.

Previous occurrences at Brisbane Airport

There have been multiple reports of insect activity disrupting aircraft systems at Brisbane Airport. These included blocked pitot probes, mainly from nests built by mud-dauber and other wasps, resulting in airspeed discrepancies and other effects.

A preliminary review of the ATSB database indicated that, from 2008 to 2018, there were at least 15 incidents involving high-capacity regular public transport aircraft departing from Brisbane Airport where one of the pitot probes had a partial or total blockage, at least four of which were identified as insect nests.

These resulted in three rejected take-offs, four aircraft returning to Brisbane Airport after continuing the take-off and one aircraft that continued to its destination.

The ATSB investigated two rejected take-offs that involved A330 aircraft where one of the pitot probes had been blocked with wasp nests, one in 2006 and one in 2013.[11]

After the 2006 occurrence, the Brisbane Airport Corporation (BAC) commenced a monthly wasp eradication program, which was made weekly after the 2013 occurrence. BAC also undertook research to understand wasp behaviour and identify the pitot probe types at highest risk of contamination.

In May 2015, the Civil Aviation Safety Authority (CASA) issued Airworthiness Bulletin 02-052 ‘Wasp Nest Infestation – Alert’[12] to ‘urgently advise operators, maintainers and pilots of the dangers associated with undetected wasp infestation in aircraft, and the circumstances under which they can occur.’ It stated that wasps could build nests in aircraft that are stationary for more than 20 minutes with uncovered pitot probes.

From November 2015 onwards, the Airservices Australia produced publication En Route Supplement Australia (ERSA) entry for Brisbane Airport included a note that stated:

Significant mud wasp ACT WI AD VCY [activity within aerodrome vicinity] affecting pitot tubes [probes]. Pitot tube covers recommended.

Similarly, the Jeppesen aeronautical information publication Australia Airport Directory, used primarily by international pilots operating into Australia, also had the following in the Brisbane airport information section:

Significant mud wasp activity within apt [airport] vicinity affecting pilot tubes. Pitot tube covers recommended.

Some operators using Brisbane Airport use pitot probe covers for routine turnarounds.

Operator’s arrangements for ground handling at Brisbane Airport

Having previously ceased Brisbane operations in 2015, the aircraft operator recommenced flights to Brisbane on 6 June 2018. At the time of the occurrence arrangements had been made for the provision of services by a local ground handing provider and a local engineering support provider. On the day of the occurrence, aircraft turnaround duties were shared between:

• a maintenance engineer from the operator who was rostered to return to Kuala Lumpur as a passenger on the departing aircraft
  
  
• two non-certifying engineers from the engineering support provider
  
  
• four ground handlers from the ground handling service provider.
  

The operator’s personnel and the ground handlers were both responsible for conducting pre-departure checks.

Use of pitot probe covers

The pitot probe covers were fitted on the aircraft’s three pitot probes by one of the engineering support personnel, as it was his understanding this was normal practice. He later reported that he advised the operator’s maintenance engineer that pitot probe covers were fitted during a brief exchange discussing turnaround tasks, but that the maintenance engineer did not directly respond.

The maintenance engineer later reported that he did not recall hearing the advice, and he did not make an entry in the aircraft’s technical log to record that the covers had been fitted.

The presence of the pitot covers was not detected by the operator’s maintenance engineer or captain during separate external aircraft inspections.

The operator’s maintenance engineer boarded the aircraft during turnaround, and the engineering support personnel left the bay to attend to other aircraft. The pitot covers were not detected by ground handlers during pushback.

The flight crew and operator’s maintenance engineer later reported that they would not routinely use pitot probe covers on a turnaround. They advised that the operator did not normally fly to airports where the use of pitot probe covers was standard. Security video recordings of the operator’s three previous turnarounds at Brisbane Airport showed that pitot probe covers were not used.

The pitot covers fitted to the aircraft were provided by the engineering support provider and were manufactured to fit Airbus aircraft types including the A330.

They consisted of a tightly woven Kevlar sheath about 12 cm long, with a 30 cm streamer.

Examination of the three covers fitted to the aircraft following the occurrence found that they were partially burned by the heated pitot probes. They each had a hole burned through where the cover folded around the probe in the airstream. The streamers were damaged by contact with the aircraft skin during the flight (Figure 4 and Figure 5).

Figure 4: Pitot probe covers removed from 9M-MTK after the incident flight
[img=463x0]https://www.atsb.gov.au/media/5774867/ao2018053_figure-4.jpg?width=463&height=463&mode=max&sharpen=2[/img]
Source: ATSB

Figure 5: Reconstruction of pitot probe covers on 9M-MTK, showing pitot cover damage and rub marks on aircraft skin from the streamer
[img=463x0]https://www.atsb.gov.au/media/5774875/ao2018053_picture-7.png?width=463&height=463&mode=max&sharpen=2[/img]
Source: ATSB

Ongoing investigation

The ATSB has interviewed the flight and ground crews, and examined data from the aircraft’s FDR, CVR and DAR, as well as airport security video footage from before and after the flight.

The investigation will examine the:

• procedures, arrangements and interactions between the operator’s maintenance engineers, flight crews, engineering support provider and ground handling service provider
  
  
• procedures relating to ground and flight crew pre-flight checks, including walk-around procedures
  
  
• training records for flight crew, engineers and ground handling personnel
  
  
• warnings, cautions and other information displayed to the flight crew during the occurrence flight
  
  
• ATC recordings
  
  
• closed-circuit video recordings
  
  
• FDR, CVR and DAR recordings.
  

The investigation will also interview the air traffic controllers who communicated with the flight crew during the flight.

Safety actions

Proactive safety action

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.

• The aircraft operator provided a notice to all of its engineers and flight crew, which highlighted the need for pitot covers to be fitted to aircraft at Brisbane Airport during turnarounds or when parked, as well as the required procedures for their fitment and removal.
  
  
• The aircraft operator and engineering support provider clarified and formalised more detailed service level arrangements.
  
  
• The engineering support provider improved its procedures for conducting turnarounds, including improved inspection, documentation, and tool control.
  
  
• The ground handling service provider provided all employees with a ‘read and sign’ bulletin emphasising its arrival and departure inspection procedures.
  

Safety advisory notice to all international operators using Brisbane Airport
Action number: AO-2018-053-SAN-003

The Australian Transport Safety Bureau advises all operators that conduct flights to Brisbane Airport to consider the use of pitot probe covers and, if covers are used, ensure there are rigorous procedures for confirming that covers are removed before flight.

---

& from AA online...

ATSB ISSUES SAFETY NOTICE ON PITOT PROBES AFTER MAS A330 INCIDENT
by australianaviation.com.au August 30, 2018

The Australian Transport Safety Bureau has issued a safety notice after a Malaysia Airlines A330-300 took off from Brisbane with its three pitot probe covers still on.

Finally from Ironsider, via the Oz on twitter:

 Robyn Ironside@ironsider
ATSB investigation confirms serious safety oversight..

 The Australian @australian



Forgotten probe covers designed to keep out wasps and marked ‘remove before flight’ forced Malaysia Airlines’ Brisbane landing emergency
https://t.co/ofrE14oXcc


1:44 PM - 30 Aug 2018

---

Malaysia Airlines safety breach ‘endangered all’

A serious safety oversight that has stunned many in the aviation industry has been blamed for an incident involving Malaysia Airlines at Brisbane Airport last month.

Flight MH134 was forced to return to Brisbane soon after takeoff on July 18 when the Airbus A330-300’s airspeed indication failed.

The aircraft made an “overweight” landing and had to be towed from the main runway to the gate due to the loss of nose wheel steering and minor damage to the main landing gear doors.

A preliminary report by the Australian Transport Safety Bureau found the reason for the loss of airspeed indication was that the pitot probes were not uncovered before takeoff.

Pitot probes provide air data computers and flight instruments with airspeed information and are ineffective if covered or blocked.

The report noted that external checks of the aircraft by the captain and maintenance engineer failed to detect the probe covers, which are red and have a long tag carrying the words “remove before flight”. Ground handlers also failed to notice the covers, which were fitted by one of the engineering support personnel as advised by Brisbane Airport.

An airport wasp problem has led to pitot probes being covered while aircraft are on the ground, even during routine turnarounds, to prevent nests being built.

Some airlines such as Qantas require the flight crew to be presented with or shown the covers once they are removed from the pitot probes shortly before takeoff.

Australian and International Pilots Association technical and safety manager Shane Loney said plenty of questions remained about the MH134 incident.

“The key things are, how they came to leave with the pitot covers still on, and what was seen (in the cockpit) at the 100-knot call,” Mr Loney said. “I would not have expected the airspeed indications to be accurate at that point but the report suggests the 100-knot-speed call was made. I wonder what the crew were looking at?”

Former airline captain Byron Bailey said it was unclear from the report whether the co-pilot called “check” in response to the captain’s call of 100 knots. “It is unbelievable that a professional airline crew could sit on the takeoff roll for 42 seconds and not notice they had no airspeed,” Mr Bailey said.

“These calls are mandatory checks. The incompetence of this crew endangered the lives of all on board because flying around with no airspeed indication is haz­ardous in the extreme,” he said.

The report said the flight crew and engineer were not in the habit of using pitot covers on turnarounds and did not normally fly to airports where the use of covers was standard. Security video showed pitot covers were not used on three previous turnarounds by Malaysia Airlines’ flights at Brisbane Airport despite airworthiness bulletins and airfield information about the wasps.

The ATSB issued a safety advisory in response to the incident, urging airlines to ensure “there were rigorous procedures for confirming pitot covers were removed before flight”.

ATSB chief commissioner Greg Hood said it was a serious incident and the investigation was continuing. “We will be focusing specifically on the procedures for flight crew and ground crew in relation to the pre-flight checks for the aircraft, and also the cockpit warning systems received by the flight crew as they accelerated down Runway 01,” Mr Hood said.

---

Simon Lee‏ @salee75 

Replying to @ironsider

Would love to hear the tapes from the cockpit as their headed down the runway? Speed cross-check anyone?

---

Robyn Ironside‏ @ironsider 


Yes that part of report seemed a bit lacking in detail but it was only the preliminary report.

MTF...P2 

[Peetwo]

MAL AO-2018-053 serious incident - Preliminary report released.

Use of pitot probe covers

The pitot probe covers were fitted on the aircraft’s three pitot probes by one of the engineering support personnel, as it was his understanding this was normal practice. He later reported that he advised the operator’s maintenance engineer that pitot probe covers were fitted during a brief exchange discussing turnaround tasks, but that the maintenance engineer did not directly respond.

The maintenance engineer later reported that he did not recall hearing the advice, and he did not make an entry in the aircraft’s technical log to record that the covers had been fitted.

The presence of the pitot covers was not detected by the operator’s maintenance engineer or captain during separate external aircraft inspections.

The operator’s maintenance engineer boarded the aircraft during turnaround, and the engineering support personnel left the bay to attend to other aircraft. The pitot covers were not detected by ground handlers during pushback.

The flight crew and operator’s maintenance engineer later reported that they would not routinely use pitot probe covers on a turnaround. They advised that the operator did not normally fly to airports where the use of pitot probe covers was standard. Security video recordings of the operator’s three previous turnarounds at Brisbane Airport showed that pitot probe covers were not used.

The pitot covers fitted to the aircraft were provided by the engineering support provider and were manufactured to fit Airbus aircraft types including the A330.

They consisted of a tightly woven Kevlar sheath about 12 cm long, with a 30 cm streamer.

Examination of the three covers fitted to the aircraft following the occurrence found that they were partially burned by the heated pitot probes. They each had a hole burned through where the cover folded around the probe in the airstream. The streamers were damaged by contact with the aircraft skin during the flight (Figure 4 and Figure 5).

Figure 4: Pitot probe covers removed from 9M-MTK after the incident flight
[img=463x0]https://www.atsb.gov.au/media/5774867/ao2018053_figure-4.jpg?width=463&height=463&mode=max&sharpen=2[/img]
Source: ATSB

Figure 5: Reconstruction of pitot probe covers on 9M-MTK, showing pitot cover damage and rub marks on aircraft skin from the streamer
[img=463x0]https://www.atsb.gov.au/media/5774875/ao2018053_picture-7.png?width=463&height=463&mode=max&sharpen=2[/img]
Source: ATSB

Ongoing investigation

The ATSB has interviewed the flight and ground crews, and examined data from the aircraft’s FDR, CVR and DAR, as well as airport security video footage from before and after the flight.

The investigation will examine the:

• procedures, arrangements and interactions between the operator’s maintenance engineers, flight crews, engineering support provider and ground handling service provider
  
  
• procedures relating to ground and flight crew pre-flight checks, including walk-around procedures
  
  
• training records for flight crew, engineers and ground handling personnel
  
  
• warnings, cautions and other information displayed to the flight crew during the occurrence flight
  
  
• ATC recordings
  
  
• closed-circuit video recordings
  
  
• FDR, CVR and DAR recordings.
  

The investigation will also interview the air traffic controllers who communicated with the flight crew during the flight.

Safety actions

Proactive safety action

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.

• The aircraft operator provided a notice to all of its engineers and flight crew, which highlighted the need for pitot covers to be fitted to aircraft at Brisbane Airport during turnarounds or when parked, as well as the required procedures for their fitment and removal.
  
  
• The aircraft operator and engineering support provider clarified and formalised more detailed service level arrangements.
  
  
• The engineering support provider improved its procedures for conducting turnarounds, including improved inspection, documentation, and tool control.
  
  
• The ground handling service provider provided all employees with a ‘read and sign’ bulletin emphasising its arrival and departure inspection procedures.
  

Safety advisory notice to all international operators using Brisbane Airport
Action number: AO-2018-053-SAN-003

The Australian Transport Safety Bureau advises all operators that conduct flights to Brisbane Airport to consider the use of pitot probe covers and, if covers are used, ensure there are rigorous procedures for confirming that covers are removed before flight.

---

Finally from Ironsider, via the Oz on twitter:

 Robyn Ironside@ironsider
ATSB investigation confirms serious safety oversight..

 The Australian @australian



Forgotten probe covers designed to keep out wasps and marked ‘remove before flight’ forced Malaysia Airlines’ Brisbane landing emergency
https://t.co/ofrE14oXcc


1:44 PM - 30 Aug 2018

---

Malaysia Airlines safety breach ‘endangered all’

A serious safety oversight that has stunned many in the aviation industry has been blamed for an incident involving Malaysia Airlines at Brisbane Airport last month.

Flight MH134 was forced to return to Brisbane soon after takeoff on July 18 when the Airbus A330-300’s airspeed indication failed.

The aircraft made an “overweight” landing and had to be towed from the main runway to the gate due to the loss of nose wheel steering and minor damage to the main landing gear doors.

A preliminary report by the Australian Transport Safety Bureau found the reason for the loss of airspeed indication was that the pitot probes were not uncovered before takeoff.

Pitot probes provide air data computers and flight instruments with airspeed information and are ineffective if covered or blocked.

The report noted that external checks of the aircraft by the captain and maintenance engineer failed to detect the probe covers, which are red and have a long tag carrying the words “remove before flight”. Ground handlers also failed to notice the covers, which were fitted by one of the engineering support personnel as advised by Brisbane Airport.

An airport wasp problem has led to pitot probes being covered while aircraft are on the ground, even during routine turnarounds, to prevent nests being built.

Some airlines such as Qantas require the flight crew to be presented with or shown the covers once they are removed from the pitot probes shortly before takeoff.

Australian and International Pilots Association technical and safety manager Shane Loney said plenty of questions remained about the MH134 incident.

“The key things are, how they came to leave with the pitot covers still on, and what was seen (in the cockpit) at the 100-knot call,” Mr Loney said. “I would not have expected the airspeed indications to be accurate at that point but the report suggests the 100-knot-speed call was made. I wonder what the crew were looking at?”

Former airline captain Byron Bailey said it was unclear from the report whether the co-pilot called “check” in response to the captain’s call of 100 knots. “It is unbelievable that a professional airline crew could sit on the takeoff roll for 42 seconds and not notice they had no airspeed,” Mr Bailey said.

“These calls are mandatory checks. The incompetence of this crew endangered the lives of all on board because flying around with no airspeed indication is haz­ardous in the extreme,” he said.

The report said the flight crew and engineer were not in the habit of using pitot covers on turnarounds and did not normally fly to airports where the use of covers was standard. Security video showed pitot covers were not used on three previous turnarounds by Malaysia Airlines’ flights at Brisbane Airport despite airworthiness bulletins and airfield information about the wasps.

The ATSB issued a safety advisory in response to the incident, urging airlines to ensure “there were rigorous procedures for confirming pitot covers were removed before flight”.

ATSB chief commissioner Greg Hood said it was a serious incident and the investigation was continuing. “We will be focusing specifically on the procedures for flight crew and ground crew in relation to the pre-flight checks for the aircraft, and also the cockpit warning systems received by the flight crew as they accelerated down Runway 01,” Mr Hood said.

---

Safety risk mitigation of nesting wasps and pitot tube safety issue goes global -   

Via the Oz today:

Wasp study sparks global buzz

ROBYN IRONSIDE
A study by Brisbane Airport Corporation into mud wasps could ­determine the future design of aircraft pitot probes.

---

Brisbane Airport leads way in studies of mud wasp activity

A landmark study by Brisbane Airport Corporation into the ­behaviour of mud wasps could ­determine the future design of aircraft pitot probes.

With the problem of wasps building their nests in pitot probes affecting several subtropical airports, the study is attracting international attention.

As well as a half-dozen airports in the US and the South Pacific, Airbus is seeking to use information gleaned from the Brisbane study to inform the future design of pitot probes, which provide air data computers and other instruments with airspeed information.

Overseen by BAC wildlife co-ordinator Jackson Ring, the study examines the risk mud wasps pose to aircraft and the best way to ­reduce those risks.

Mr Ring said the study made use of 100 3D-printed pitot probes replicating the exact specifications of various aircraft designs ­including the A330, B737-400 and 737-800, Dash 8, B747 and E190.

The probes were mounted on sheets of aircraft life material and set up in 24 locations at parking positions around the ­airfield.

“Each set location is inspected regularly for evidence of mud wasp activity, and if a blocked pitot probe is located the contents are hatched and examined by an ecologist,” Mr Ring said.

“From this study, the BAC is gaining some insight into what species are present at Brisbane Airport, the prey used in provisioning nests, the pitot probe size/type preference, any seasonal trends and possible environmental factors that may affect nesting.”

In addition, BAC encouraged airline staff to report mud wasp ­activity along with relevant information on the time of day, weather conditions and food source.

Mr Ring said all information was passed to aircraft manufacturers and shared with airline operators and the broader industry.

“The research is ongoing, and the data collected will inform our pest mitigation program ­moving forward and provide ­invaluable learnings for the industry,” he said.

Although the study began in 2014, the serious implications of the wasp issue were given far greater impetus recently ­when a Malaysia Airlines’ aircraft took off from Brisbane Airport with its pitot probes covered.

Similar to other airports with a wasp problem, Brisbane requires aircraft to cover their pitot probes after ­landing to avoid them being blocked by mud wasp nests, which can be built in as little as 20 minutes.

The red covers, carrying the words ­“remove before flight”, were somehow missed by ground crew, engineers and the pilot on the night of July 18, leading to the ­Malaysia Airlines’ A330 taking off without airspeed indication.

Fortunately, the pilots were able to use a back-up system to get enough information to land safely, without injury to any passengers or crew.

A preliminary report by the Australian Transport Safety ­Bureau found the Malaysia Airlines’ crew was not aware of the requirement to cover the pitot probes in Brisbane and had not done so on three previous turnarounds.

There have been more than a dozen incidents since 2008 ­involving blocked pitot probes at Brisbane Airport because of wasp activity. In the case of a 2013 ­rejected takeoff incident, it was determined that the captain’s pitot probe was almost com­pletely obstructed by a wasp nest despite the A330 being on the ground for only two hours.

Mr Ring said the airport had achieved a significant reduction in wasp activity through a comprehensive pest control program but it recognised that wasps would never be completely eradicated from the site.

Therefore, he said, pitot tube coverings were the most effective mitigation measure available, as recommended by BAC, the Civil Aviation Safety Authority and the ATSB.

All airlines were expected to follow safety bulletins on pitot covers issued by BAC and CASA but some had instituted their own procedures to leave no doubt the probes were ­uncovered before take off. These included presenting the captain with the covers or waving the covers in front of the cockpit before push back.

MTF...P2 

[Peetwo]

Air Canada Flight 759: Seconds from disaster.

I was reflecting on the disturbing evidence that the Australian aviation safety bureaucracy, that is supposedly fully compliant and operating under a ICAO Annex 19 SSP, has been obfuscating it's safety promotion and oversight responsibilities for identified safety issues such as fatigue - see FRMS & the timeline of regulatory embuggerance - for the better part of two decades...

It was therefore heartening to be provided another perfect 'other hemisphere' point of comparison with the NTSB final investigation report into the Air Canada FL759 taxiway overflight at San Francisco Airport on July 7 2017: see abstract here - 
https://ntsb.gov/news/events/Documents/D...stract.pdf

Note the way the NTSB in their recommendations do not pull any punches...  
 

Recommendations

As a result of this investigation, the NTSB makes safety recommendations to the FAA and Transport Canada:

To the Federal Aviation Administration:

1. Work with air carriers conducting operations under Title 14 Code of Federal Regulations Part 121 to (1) assess all charted visual approaches with a required backup frequency to determine the flight management system autotuning capability within an air carrier’s fleet, (2) identify those approaches that require an unusual or abnormal 
manual frequency input, and (3) either develop an autotune solution or ensure that the manual tune entry has sufficient salience on approach charts.
2. Establish a group of human factors experts to review existing methods for presenting flight operations information to pilots, including flight releases and general aviation flight planning services (preflight) and aircraft communication addressing and reporting system messages and other in-flight information; create and publish guidance on best practices to organize, prioritize, and present this information in a manner that optimizes pilot review and retention of relevant information; and work with air carriers and service providers to implement solutions that are aligned with the guidance.
3. Establish a requirement for airplanes landing at primary airports within class B and class C airspace to be equipped with a system that alerts pilots when an airplane is not aligned with a runway surface.
4. Collaborate with aircraft and avionics manufacturers and software developers to develop the technology for a cockpit system that provides an alert to pilots when an airplane is not aligned with the intended runway surface and, once such technology is available, establish a requirement for the technology to be installed on airplanes landing at primary airports within class B and class C airspace.
5. Modify airport surface detection equipment (ASDE) systems (ASDE-3, ASDE-X, and airport surface surveillance capability) at those locations where the system could detect potential taxiway landings and provide alerts to air traffic controllers about potential collision risks.
6. Conduct human factors research to determine how to make a closed runway more conspicuous to pilots when at least one parallel runway remains in use, and implement a method to more effectively signal a runway closure to pilots during ground and flight operations at night.

To Transport Canada:
7. Revise current regulations to address the potential for fatigue for pilots on reserve duty who are called to operate evening flights that would extend into the pilots’ window of circadian low.

And from Christine Negroni: http://christinenegroni.com/fatigue-and-...francisco/

Fatigue and Confusion Factors in Air Canada Near Disaster in San Francisco

September 25, 2018 /

[img=565x0]http://christinenegroni.com/wp-content/uploads/2018/05/Air-Canada-near-accident-SFO.jpg[/img]

The pilots whose 2017 flight very nearly landed atop four loaded airliners waiting in line on a taxiway to take off from San Francisco International Airport, failed to manually tune the airplane’s navigation system for the landing. Had they done so, it may have helped them realize they were off the lateral track for the runway, according to investigators looking into the near disaster.

Tuning the instrument landing system frequency was not a typical procedure for the Air Canada crews. This lapse was one but not the only factor that led the pilots of Flight 759 to get “dangerously close to other airplanes” so that at one point it was at the level of the 66-foot high tails of the two United Boeing 787s waiting in the line. A third United airliner, a Boeing 737 and a Philippine Airlines Airbus A340 widebody were also on the taxiway that pilots mistakenly believed to be Runway 28R.

How the experienced Air Canada pilots confused the dimly lit and fully occupied taxiway with the brightly illuminated runway was the subject of the investigation by the National Transportation Safety Board. At its hearing Tuesday, the board indicated that flight preparation, pilot judgment, perception and fatigue were some of many factors that nearly caused a multi-airplane pileup of record-breaking scale.

“This was a very close call,” Robert Sumwalt, the NTSB’s chairman told those gathered for the public hearing at the board’s headquarters in Washington, DC.

Air Canada Flight 759 was finishing a five-and-a-half-hour flight from Toronto to San Francisco on July 7, 2017. By their body clocks, it was 3:00am for the crew. Runway 28 left had been closed an hour earlier – a fact which had been noted on the crew’s 27-page list of NOTAMS, and transmitted via ACARS during the flight. The Airbus A320 was cleared to land on the parallel Runway which is 28R.

The night was clear and the pilots were making a visual approach over San Francisco Bay. But as the two pilots got closer to the airport, the captain asked the first officer to confirm with air traffic control that the runway was clear. The controller said that it was. There were two controllers working that night, but one was out of the tower at the time and the other was occupied with other business.

[size=undefined]The flight continued and as it approached the airport seawall, the pilot of United Flight 1, the first in the line of airliners, saw the plane descending towards him and said over the radio, “Where’s this guy going?”

“The crew sensed something was not right, and they initiated a go-around over the taxiway, avoiding aircraft by very narrow margins,” Sumwalt said. But the near-disaster, which was highly-publicized, prompted the board to take the unusual step of conducting an investigation even though no one was injured and no aircraft was damaged.

Airport surface detection equipment, known as ASDE-X has the capacity to trigger alerts when planes are not lined up over the runway, an enhancement that is being tested at Seattle airport, according to the NTSB investigation.

The NTSB issued seven recommendations including that Canada’s safety authorities review its flight and duty time regulations. The captain of flight 759 would not have been allowed to fly the night of the incident under U.S. rules, the NTSB noted. Transport Canada told investigators it has been trying to update its 22-year old regulations for several years.

The board also issued a general plea to the Federal Aviation Administration to research ways to “more effectively signal a runway closure to pilots during ground and flight operations at night. ”

The safety board did not address the fact that after the plane landed, Air Canada failed to preserve the cockpit voice recorder. The plane was dispatched on further flights so that the information was taped over. It did, however, confirm that the loss of the CVR was detrimental to its investigation. “CVR information, if it had been available, could have provided direct evidence about the events leading to the overflight and the go-around,” the NTSB said.[/size]

And for the Oz take:

Runway mix-ups cause concern

ROBYN IRONSIDE
Aviation authorities are watching the US response to a series of incidents in which aircraft have mixed taxiways for runways.

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Aviation authorities keep eye on runway mix-ups

Australian aviation authorities are closely watching the US response to a series of incidents in which aircraft have mistakenly lined up for landing on an airport taxiway rather than a runway.

The National Transportation Safety Board released its report this week on an incident in San Francisco last year in which an Air Canada jet came within a couple of metres of landing on four aircraft lined up for departure on a taxiway. With each aircraft filled with passengers and tonnes of fuel, the incident could have been a disaster of monumental proportions. The NTSB report found pilot fatigue was a factor, along with ineffective review of airport information.

But after a series of similar close calls in the past three years, the NTSB is considering whether further measures are needed, such as enhanced cockpit warning systems and new technology in air traffic control towers.

In November last year, a Delta 737 approaching Atlanta in cloudy weather came within 20m of landing on a taxiway, and a month later a turboprop operated by Horizon Air mistakenly landed on a taxiway at Pullman, Washington.

Research has found such ­errors tend to occur at night, when taxiway lights are mistaken for runway lights, and when one of two parallel runways is closed to traffic. Any extra measures to guard against these mistakes have previously been resisted by regulators due to airline opposition and cost concerns.

In Australia, there has been only one confirmed incident of an aircraft landing on a taxiway.

According to the Australian Transport Safety Bureau, a Cessna 206 landed on the taxiway at Archerfield Airport in Brisbane on July 20, 2011. There was no ­effect on any other aircraft as a result of the incident.

The ATSB has also recorded seven other incidents since 2015 relating to aircraft inadvertently approaching a taxiway rather than a runway. “None of these incident involved regular public transport or passenger carrying aircraft,” an ATSB spokeswoman said. “In each instance, air traffic control intervened and advised of the error and the issue was ­resolved.”

Airservices Australia provides air traffic control and does not have any specific concerns in relation to taxiways being mistaken for runways at Australian airports. But a spokeswoman said occurrences such as the Air Canada incident and the subsequent NTSB report were used by Airservices to check and learn.

“We will take this information as a lessons learned activity across our operation,” she said.

“The report does not trigger any need for changes here in ­Australia.”

Pilots believe the more pressing issue is that of fatigue, with the Civil Aviation Safety Authority recently deferring the implementation of new fatigue risk ­management guidelines from October to next September.

Australian Air Line Pilots Association acting president Murray Butt said CASA’s response was hugely disappointing.

Reference: Frank and Ernest.

"..What a bloody shambles. What a disgrace. What a horrendous cost – but most of all; what an unashamed arrogance it is to ignore the worlds best practice set by the USA..."

Indeed 'what a bloody shambles ' the state of aviation safety is in the 'lucky land' Downunda - TICK TOCK miniscule McDo'Naught...  
  

MTF...P2 

[Peetwo]

TC response to NTSB recommendation - 

To Transport Canada:

7. Revise current regulations to address the potential for fatigue for pilots on reserve duty who are called to operate evening flights that would extend into the pilots’ window of circadian low.

Via the Canuck's National Post:

Near-collision of Air Canada jet should be wake-up call on pilot fatigue, union says

The U.S. National Transportation Safety Board concluded that pilot error and fatigue were contributing factors to the July 2017 incident

TORONTO — A near-collision of an Air Canada jet at San Francisco’s airport should be a wake-up call for the federal government to adequately address pilot fatigue for overnight flights, the union representing the airline’s pilots said Wednesday.

“I don’t know what else it would take to wake them up that this is a significant concern,” said Capt. Matt Hogan, chairman of the Air Canada Pilots Association master elected council.

The pilots’ group was responding to the U.S. National Transportation Safety Board, which concluded that pilot error and fatigue were contributing factors to the July 2017 incident.

The NTSB issued 19 findings, including that current Canadian regulations don’t, in some circumstances, allow for sufficient rest for reserve pilots. The flight’s captain had been awake for more than 19 hours while the first officer on the flight from Toronto had been awake 12 hours.

“I would suggest that’s a very strong message that they should probably take action sooner than later and do it properly,” Hogan said in an interview.

The pilots were apparently confused because one of two parallel runways was closed and dark before the late-night incident. The crew was seconds from landing their Airbus A320 jet on a taxiway where other planes loaded with passengers were waiting to take off.

Transport Minister Marc Garneau says the government agrees that pilot fatigue rules need updating and that he has been working on the issue since coming into office in 2015.

“I take the safety or air travellers and the public very seriously, and believe a well-rested pilot is central to this,” he said in a statement.

But Hogan says Ottawa hasn’t gone far enough. He said the flight duty limit for evening and overnight flights should be changed to 8.5 hours, in line with NASA recommendations. The Federal Aviation Administration limits crews to 8 hours at night on flights that aren’t ultra long haul.

I take the safety or air travellers and the public very seriously

Draft proposals by the government are suggesting the threshold drop from almost 14 hours to a maximum of nine hours for night-time flights and up to 13 hours for daytime flights.

But the union argues that duty time for flights taking off between 5 p.m. and 9:59 p.m. is still too high under the proposal at 10.5 hours.

Flights during overnight hours when crews would normally be asleep can be especially challenging because it coincides with the start of the human circadian low period when alertness and performance are degraded.

Although various proposals have been studied since 2010, the minister proposed regulations more than a year ago and has consulted with pilots, industry and passengers.

Transport Canada said it is working to have the final regulations that “will be aligned with those of the U.S. and Europe” to be published in the Canada Gazette this year.

Air Canada submitted a joint proposal to the government in September 2017 that addressed duty time and fatigue rules, including maximum flight duty periods, reserve crews, rest periods, time zone differences and unforeseen operations.

“It should be noted that Air Canada flight time rules are significantly enhanced and more robust than those contained in the Canadian Aviation Regulations (CARS),” the airline Wednesday said in an email. “Air Canada’s Fatigue Risk Management System is the most advanced in the country.”

During the NTSB hearing on Tuesday, board staff called Air Canada’s safety culture “robust.”

Air Canada said the two pilots remain out of service.

Some Canadian aviation groups have complained that imposing strict limit on flying hours would make it more expensive to operate because additional pilots would be required.

A U.S. airline lobby group claimed that these regulations would bankrupt the industry after the government took action following a February 2009 crash in Buffalo, N.Y., that killed 49.

“There has been no sort of audit of these regulations and in fact the American airline industry has prospered with record profits since that time,” said Hogan.

Reference 'Shame or Fame for McCormack': http://www.auntypru.com/forum/thread-177...ml#pid9236

The industry has "acquired institutionalised ostrichitis syndrome" (AIOS).

Meanwhile, in the AIOS inflicted land Downunda, yet another major pilot union voices it's concerns for the lack of affirmative safety risk mitigation by CASA and the lack of oversight by the Govt, on the 20+ year identified safety issue of fatigue...  

Via the Mirage News: https://www.miragenews.com/pilots-concer...gue-rules/

Pilots concerned about CASA response to Report on Australia’s Fatigue Rules
 
In reply to the release of the Civil Aviation Safety Authority’s (CASA) response to the Independent Report on Australia’s Fatigue Rules, the Australian Air Line Pilots Association (AusALPA), the technical body representing more than 7,000 of Australia’s professional pilots has expressed disappointment in CASA’s to conduct itself as an independent regulator.
 
Acting President Captain Murray Butt said the language in the report focused on commercial considerations over the required safety arguments, and consequently, pilots in Australia have little confidence that the safety of the travelling public is the number one priority of CASA as stated in its Charter.
 
“CASA has apparently decided that Australian airlines are capable of self-regulating when it comes to fatigue,” Captain Butt said.
 
“Australia’s experience with self-regulation has never ended well, particularly in a complicated industry such as aviation, where history shows that commercial interests must be balanced with safety considerations,” he said.
 
Captain Butt said the International Civil Aviation Organisation (ICAO) approach to fatigue management has been a co-operative one between regulator, airline operator and pilot representatives to achieve fatigue mitigating solutions. This contrasts with the CASA proposal which is a hands-off regulator once a fatigue system is approved, with no requirement for airlines to ensure pilot representatives are independently selected by pilots.
 
“We have seen this in the past where WH&S representatives were hand-picked by commercial interests. This eventually led to the requirement that representatives be elected to ensure their independence. CASA has resisted any such system for fatigue management throughout this rule-making process.”
 
“AusALPA regards this fatigue management rule-making as being symptomatic of the wider CASA approach in appointing unbalanced decision-making bodies with representatives of vested commercial interests, without the balancing views of pilot representative organisations.”
 
“Pilots are losing faith in this process and the Government which is overseeing it,” Captain Butt said

MTF...P2 

[Peetwo]

Around the traps - 

First with:

YMML ATC  - "Where are you going?"

(pause)

Malindo Air Pilot: "Err...Indonesia??"    

Malaysian plane takes wrong turn

ROBYN IRONSIDE

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Concerns have been raised about another Malaysia-based carrier following an incident at Melbourne airport last week.

Two months after a safety failure involving a Malaysia Airlines’ flight from Brisbane, a Malindo Air flight bound for Denpasar surprised Melbourne air traffic controllers by turning left as the plane took off from runway 34.

When air traffic control ­inquired where the plane was going, there was a long silence ­followed by the pilot’s reply: ­“Indonesia.”

A further inquiry about why the Boeing 737 had turned left ­instead of going straight ahead resulted in a response indicating that the pilots thought they were on a different runway.

Australian pilots yesterday ­expressed their concern that the incident could have easily resulted in a mid-air collision had there been incoming traffic at the time.

Civil Air Australia president and full-time air traffic controller Tom McRobert said the incident certainly had the potential to be “extraordinarily unsafe”.

“Essentially, the aircrew had the correct flight route but the wrong runway keyed into their flight data computer,” he said.

“It meant as they left the runway they veered hard left, which came as a surprise to air traffic control.

“It was just completely unexpected.’’

The runway the crew thought they were on (27) was closed because of strong northerly winds.

Mr McRobert said it was ­expected the crew of the Malindo Air flight would be interviewed to gain a better understanding of what went wrong, but Airservices Australia yesterday said the incident had not been reported.

The Australian Transport Safety Bureau was unable to comment due to a public holiday.

Retired airline captain Robert Cassidy said the issue of fatigue should be investigated in relation to such an incident.

It is the second Malaysian carrier to trigger concerns in recent months following a Malaysia Airlines’ incident at Brisbane Airport in July.

The ATSB is investigating why pilots on flight MH138 took off with the pitot tubes covered, leaving the aircraft with no reliable airspeed indication.

Malindo Air, which was set up by Indonesia’s Lion Air, is considered a safe airline despite several incidents over the past five years.

In a previous incident in April, a Malindo Air 737 skidded off the runway at Kathmandu in Nepal and became stuck in the mud, forcing the airport to close for 12 hours.

Malindo Air had not commented by the time of publication last night.

Update to Air Niugini undershoot ditching accident in Chuuk, Micronesia:

Survivors of Chuuk plane crash demand answers
7:41 pm today 
 
Jamie Tahana, RNZ Pacific Journalist
@JamieTahana jamie.tahana@radionz.co.nz

The Air Niugini plane after it crashed into the sea short of the runway at Chuuk, in Federated States of Micronesia. Photo: Supplied / US Navy

For Bill Jaynes, it seemed like a normal landing. Air Niugini flight PX073 to Chuuk was descending smoothly, the weather was clear, there were no weird noises, there was no warning.

But at the last minute, something wasn't quite right.

"My thought as I was watching the vapour trails off the wing as we descended was: usually when we're this low, we're on the runway.

"And then we were in the water," he said.

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Listen to Dateline Pacific interview with Bill Jaynes duration5′ :45″
from Dateline Pacific 
Download - https://podcast.radionz.co.nz/pacn/datel...rs-128.mp3

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The Boeing 737 had crash-landed into the ocean about 200 metres short of the runway at Chuuk, one of the main islands in Federated States of Micronesia.

Mr Jaynes, who is the editor of Micronesia's Kaselehlie Press newspaper and a regular visitor to Chuuk, said he was thrown forward by the impact, which caused a head wound.

He then turned around to see water pouring through a gash in the side of the plane.

"It's not what you want in your plane," he chuckled.

Within minutes, passengers poured out of the emergency exits and gathered on the wings, which were the only things floating as the fuselage rapidly took on water.

Chuuk locals, who saw the crash, rushed out in about a dozen small boats to meet the passengers, and a US Navy construction team who happened to be nearby also raced to join them.

"If it had been full we would not have made it off," Mr Jaynes said.
Air Niugini claimed that everyone on board had been saved.

Four of the passengers were transferred from Chuuk to Guam on Sunday for further medical treatment, as the Papua New Guinea-based airline then announced that, in fact, one person was unaccounted for.

On Monday, Air Niugini said a man's body had been recovered by divers from the wreckage, which by now has sunk to the sea floor, about 90 feet below.

RNZ Pacific understands there were problems with the plane's manifesto, and one crew member was not marked properly, which led to the mix-up.

But as Navy divers scour the scene for clues and to recover the plane's black boxes, which PNG authorities say will be sent there, those who were on board are demanding answers.

Mr Jaynes said the pilot had claimed that there was no visibility as he came in to land, which is something he and several other passengers disputed.

"It wasn't raining, as the pilot claimed," he said, citing the fact that as the plane was descending, he could clearly see the Chuuk docks, which sit more than a mile-and-a-half from the airport.

"There was no wind shear that a passenger felt. There was no downward push. It was just a normal landing, except that it was ridiculously low," said Mr Jaynes.

"I simply thought that we had landed awfully, awfully hard for a landing in Chuuk, until I looked over and saw a hole in the plane behind me and water was coming in."

"In my personal opinion and the opinions of many of the passengers I talked to is that it was pilot error, he was too low, and that at the last moment he made the best of the bad situation that he had perhaps created" by landing on the water.

Several investigations into the crash are now underway. Papua New Guinea authorities say they are investigating, and the Federated States of Micronesia has asked the United States to investigate on its behalf.

The Air Niugini plane in the lagoon off Weno airport in Chuuk. Photo: AFP or licensors

Mr Jaynes said US Navy divers were at the scene when he left Chuuk, and investigators from both the FBI and the National Transportation Safety Board had arrived. The US is responsible for airports and aviation in Federated States of Micronesia, which is an associated state of the US.

On Tuesday, Mr Jaynes had returned to his home in Pohnpei, one of the other states that make up FSM. He had lost all his camera gear, and apart from what he was wearing - denim shorts and an aloha shirt - his entire wardrobe had gone down with the plane.

"I'm thankful to be alive," he said.

"There were dozens of local boats that came out and approached this dangerous wreck, kind of at risk of their own life and brought us back to the main dock in Chuuk."

"I'll never forget the local Chuukese who pulled off the rescue, they weren't officials they were private citizens."

 
MTF...P2