The Passengers Who ‘Caused’ a 737 Tail Strike: Ground Handling Lessons
The Passengers Who ‘Caused’ a 737 Tail Strike On 12 January 2003 a serious incident occurred involving Transavia Boeing 737-800 PH-HZB at Rotterdam. The Dutch Safety Board (DSB) report says the aircraft: …pitched nose-up just after take -off thrust had been selected. The pitch up movement stopped when the aft fuselage and the tailskid assembly contacted the runway. The crew rejected the take -off, after which the aircraft’s nose came down again to the ground. The aircraft sustained damage to the lower fuselage area in front of the tailskid, to the tailskid and to the nose gear. There were no injuries to persons. The Investigation So what did the passengers have to do with this? Well, nothing in relation to any action they took but everything to do with it in relation to the body weight of the 113 passengers and where they had been allocated seats! The aircraft was scheduled for flight from Rotterdam, via Maastricht-Aachen to Arrecive, Lanzarote. The DSB found that: …nearly all passengers at Rotterdam Airport were checked in at the rear of the cabin and seated themselves there. To facilitate boarding at the next airport (Maastricht-Aachen Airport) the ground handling company Aviapartner had assigned these rear seats to the passengers at Rotterdam Airport. After all, this allowed passengers at MaastrichtAachen Airport to seat themselves in front of the cabin. Because of the uneven passenger distribution, the aircraft’s centre of gravity was situated far behind the applicable aft limit. As a result the nose of the aircraft pitched up and its tail touched the ground. The DSB used Tripod-Beta as an accident analysis tool. Tripod-Beta is derived from classic bow-tie theory. The DSB identified four main groups of contributing factors: The flight crew’s centre of gravity awareness (and so failed to “respond adequately” when the cabin crew reported the uneven passenger distribution) The loading procedures (a “process of producing the load and trim sheets is separated in time and place from the process of actual loading”) The airline’s supervision of its ground handling company, who had come on contract the previous year, and the airline’s quality system (both inconsistent reporting and “an internal audit, identified several deficiencies…[but] the subsequent corrective actions…were insufficient” say the DSB, and while crew had reported loading problems in the past, various methods had been used, limiting the ability to detect a trend) The effectiveness of the ground handling company’s quality system (as the DSB say the company “did not instruct and train its staff sufficiently”) The DSB also state: Search in databases of other Safety Boards and international organizations revealed that similar occurrences of uncommanded pitch up movements on the ground had occurred. In three cases the aft limit of the CG for take-off was exceeded. The cause was that the distribution of the passengers in the cabin deviated from the load and trim sheet used by the cockpit crew. In another case a significant error in the CG calculation itself was made. Safety Recommendations Consequently recommendations were raised. To the airline: Enhance its pilot’s awareness about the effect of passenger distribution on the centre of gravity of Boeing 737-800 aircraft, and Evaluate its quality system, in particular regarding the: supervision on contracted ground handling companies; results of audits, and the effectiveness of associated corrective actions; procedures about reporting safety-related occurrences. To the ground handler: Improve its quality system as such that shortcomings regarding the dispatch of passengers become visible. To Minister of...
read moreAerossurance Marks RAeS 150th Anniversary by Sponsoring Rotorcraft Automation Conference
Aerossurance Marks RAeS 150th Anniversary by Sponsoring Rotorcraft Automation Conference The Royal Aeronautical Society (RAeS) was founded on 12 January 1866, so is today celebrating its 150th anniversary (or sesquicentennial). To mark this significant milestone Aerossurance is pleased to be sponsoring the Society’s 2016 Rotorcraft Conference. This conference, to be held 6-7 July 2016 at the Society HQ at 4 Hamilton Place, London, will be the second in the series of ‘Automation & Offshore Operations’ conferences held by the RAeS Rotorcraft Group. Aerossurance was delighted to attend and report on the 2014 conference: Technology Friend or Foe – Automation in Offshore Helicopter Operations. The 2014 Technology Friend or Foe conference was triggered by: A CFIT accident on approach to Sumburgh airport in August 2013 (AS332L2 G-WNSB), for which the UK Air Accidents Investigation Branch (AAIB) final report is expected soon (UPDATE 15 March 2016: AAIB Report on 2013 Sumburgh Helicopter Accident), The issue, a few weeks later in 2013, of a Transportation Safety Board of Canada (TSB) report into a serious incident where S-92A C-GQCH where the helicopter descended to within 38ft of the sea, and The realisation that automation issues were not addressed in detail in the UK Civil Aviation Authority (CAA) North Sea Review, which resulted in the CAP1145 report (the ‘Safety review of offshore public transport helicopter operations in support of the exploitation of oil and gas’) issued 20 February 2014. The RAeS will publish further details of the 2016 Rotorcraft Conference in due course. Confirmed Speakers include: Dr Hazel Courteney, Head of Research Management, Civil Aviation Authority Capt Ian Scott FRAeS, Head of Aircraft Services UPX, Shell International Simon Sparkes, Head of Rotary Wing, Nova Systems Rick Newman, Flight Operations Manager – Helicopter, Civil Aviation Authority UK Alex Stobo, Director of Operations, Babcock Mission Critical Services Onshore Lt Steve Baldie, Training Officer 846 Naval Air Squadron, Royal Navy Adam Poole, WW Customer Support & Service, AgustaWestland / Leonardo Helicopters UPDATE: HeliOffshore Conference Summary RAeS Conference Report: what good might look like The Royal Aeronautical Society Originally formed as the Aeronautical Society of Great Britain, the Society gained its Royal Charter in 1918. The Society now has over 20,000 members and is an international, multidisciplinary professional institution dedicated to the global aerospace community. Extra Helicopter Automation Resources: The European Helicopter Safety Team (EHEST) has published: Safety Leaflet HE9 Automation and Flight Path Management At the EHEST Safety Worksop at Helitech in London in October 2015: The UK CAA gave this presentation: Training – Overview of Automation Issues Airbus Helicopters presented: Training – For Automation UPDATE 18 September 2016: AAIB: Human Factors and the Identification of Flight Control Malfunctions UPDATE 9 January 2017: HeliOffshore have released a HeliOffshore Automation Guidance document and six videos to demonstrate the offshore helicopter industry’s recommended practice for the use of automation. UPDATE 13 August 2018: Isn’t it ironic, don’t you think Thirty-five years ago a paper was presented entitled Ironies of Automation, by Lisanne Bainbridge. It included many insightful ideas: The designer’s view…may be that the operator is unreliable and inefficient… so should be eliminated from the system. There are two ironies of this attitude. One is that designer errors can be a major source of operating problems… The second irony is that the designer who tries to eliminate the operator still leaves the operator to do the tasks which the designer cannot think how to automate…it means that the...
read moreHelicopter HUMS Maintenance Credit: New Initiatives
Helicopter HUMS Maintenance Credit: New Initiatives Health and Usage Monitoring Systems (HUMS) were first introduced 25 years ago as a safety enhancement for offshore helicopters in the UK and Norway. Even in the early days of HUMS the prize of ‘maintenance credits’ was envisaged: i.e. using the HUMS data to reduce invasive physical inspections and disassembly (with the inherent risks of maintenance error) and to tailor maintenance around the actual usage of an individual helicopter. Such maintenance credits were the topic of several presentations at the 9th Rotorcraft Symposium of the European Aviation Safety Agency (EASA) held in Cologne in December 2015. The Prize The potential was demonstrated by Emmanuel Laillet and Sophie Hasbroucq of Airbus Helicopters. In two presentations they discussed a significant HUMS usage credit example, namely customised service life limits. HUMS data would be used to recognise flight regimes and record the actual usage in different conditions. Lailett noted that: The typical offshore spectrum is much less severe than our certification reference spectrum. Data presented from initial Airbus Helicopters studies suggested that some component life limits set by this single reference spectrum are being set at half or even a third of the true service life limit of a component flown to a realistic spectrum for the missions flown. This is consistent with data from a 1990s study that Aerossurance has access too. It is also possible that flying particularly demanding mission profiles will reduce individual life limits (a sort of ‘maintenance debit’) but thus improve safety for some extreme missions. A better understanding by operators of what manoeuvres create fatigue damage could also drive refined operational procedures to avoid unnecessary damage or at least equalise it across a fleet. An interesting question is how much of such usage monitoring will be via a traditional HUMS approach and how much via a Helicopter Flight Data Monitoring (HFDM) approach. It is often forgotten that the wildly successful UK Civil Aviation Authority (CAA) Helicopter Operational Monitoring Programme (HOMP) HFDM development, launched with with Bristow Helicopters in 1999, followed an earlier research project to analyse usage spectrum via FDR downloads. Regulations and Making It Happen One brake on the use of HUMS this purpose has been the perception that certification of such credits would be highly problematic due to onerous interpretations of AC 29-2 Miscellaneous Guidance (MG) 15 in relation to ground station software in particular. In April 2015 Aerossurance attended a very encouraging presentation by EASA and a subsequent regulatory round-table discussion at the SAE/RAeS/Cranfield University Integrated Vehicle Health Management (IVHM) Workshop at Cranfield. At this year’s Rotorcraft Symposium, EASA’s Alastair Healey discussed maintenance credits further. He highlighted even the term ‘credit’ is rather unique and of its time (when HUMS were being introduced at the operator’s behest in the early 1990s as a safety improvement). It is in fact derived from an avionics certification caveat that the HUMS installation were initially approved as not hazarding the aircraft but that the system functionality was not (‘no hazard no credit’). His presentation can be downloaded as part of a large zip file from the EASA website or here. Last year we reported that the Federal Aviation Administration (FAA) planned to review MG 15. At this year’s EASA symposium the FAA’s Jorge Castillo discussed past FAA HUMS research and the plan for MG15. That presentation can be downloaded here. Encouragingly the FAA will incorporate, by reference EASA AMC 29.1465 for VHM systems...
read moreG-III Attempted Takeoff Using Runway Edge Lights as Centerline
Gulfstream III Attempted Takeoff Using Runway Edge Lights as Centerline The UK Air Accidents Investigation Branch (AAIB) has recently reported on an attempted Gulfstream G-III business jet take off at Biggin Hill Airport where: The aircraft lined up for takeoff in conditions of reduced visibility [at 20:28 local time]. The crew believed that the lights they could see ahead were runway centreline lights when they were actually runway edge lights [though this runway had no centreline lights]. The aircraft began its takeoff run but ran off the paved surface and onto grass. The commander closed the thrust levers to reject the takeoff. The incident involved US registered G-III (G-1159A) N103CD on 24 November 2014, departing on a private flight to Gander, Canada. The crew of 2 and the 5 passengers were unharmed. The aircraft was assessed as being beyond economic repair. The nose landing gear broke off and tore a 6.5 m long hole on the fuselage skin. A number of frames were damaged and the upper fuselage skin creased and ruptured. Investigation Visibility was not in practice as good as the crew thought: This was a private flight which could not depart in conditions of less than 400 m [Runway Visual Range] RVR. RVR cannot be measured at the threshold end of Runway 03 but the prevailing visibility was reported as being more than 10 km. The crew reported that there was moisture on the windscreen from the mist and they could see a “glow” around lights which were visible to them. They were also aware while taxiing that there was some patchy ground fog on the airfield. The ATC controller transmitted that visibility had not been measured in the fog patches but there seemed to be ‘very low, very thin fog from the zero three threshold to approximately half way down the runway’. With hindsight, this piece of information is significant but, at the time, the crew did not consider the fog to be widespread or thick; operating under FAR Part 91 in the United States, they were used to making their own judgments as to whether the visibility was suitable for a takeoff. However, after the aircraft came to a halt following its abortive takeoff attempt, the controller could only see the top of the fuselage and tail above the layer of fog. It is likely, therefore, that the visibility was worse than the crew appreciated at the time N103CD taxied from Holding Point J1. Biggin Hill was originally a Royal Air Force (RAF) station. At the beginning of Runway 03 there is a former RAF Operational Readiness Platform (ORP). The aerodrome chart used by the crew was contained in an iPad app which was updated through a subscription service with the product supplier. [That] and the source of information in the UK [Aeronautical Information Publication] AIP, suggested that the aircraft would be required to taxi in a straight line from J1 to the runway and then make a right turn onto the runway heading. In fact, in order to taxi from J1 onto the runway, an aircraft must: taxi in a straight line; follow a curve to the right onto runway heading but still displaced to the right of the runway itself; turn left towards the runway; and then turn right again onto runway heading. The UK AIP states that there is no centreline lighting on Runway 03, and that the pavement width at the...
read moreProcedural Drift at Saab 340 Operator Leads to Taxiway Excursion
Procedural Drift at Saab 340 Operator Leads to Taxiway Excursion Saab 340A LV-BMD, operated by SOL Líneas Aéreas was damaged beyond economic repair in a taxiway excursion accident at Mendoza-El Plumerillo Airport, Argentina on 2 January 2013. There were no injuries among the 31 passengers and crew. Argentina’s air accident investigation agency, the Junta de Investigación de Accidentes de Aviación Civil (JIAAC), issued their final report (in Spanish only) on 23 December 2015. The crew initially attempted to start the right-hand engine. This failed, but they were able to start the left-hand engine and then successfully start the right-hand engine after that. Upon taxying, the Captain encountered difficulties in maintaining directional control of the aircraft and in particular when trying to turn right found the aircraft was in fact turning left. The checklist was not consulted. Asymmetric braking and asymmetric engine power were both attempted but proved ineffectual. The aircraft left the paved surface of the taxiway and came to a halt 58 meters from the edge of the taxiway with both propellers contacting obstacles. The Saab 340 uses hydraulic power for landing gear retraction, braking, nose wheel steering and flaps. The investigation identified that the electric pump that powered the hydraulic system was not operating. Consequently, the HYD warning on the central panel warning (CWP) was illuminated (although it does not appear to have been noticed) The pump is controlled using a panel with three settings: OVRD / AUTO / OFF The switch would normally be in the AUTO position (and the loss of directional control checklist, if followed, would have first checked this switch was in AUTO). However, during post-accident interviews it emerged that an undocumented, but orally communicated and unnecessary practice had developed within the operator of setting the switch to OFF during engine starts. This was allegedly done with the intention of protecting the electronic system flight instrument system (EFIS) from electrical spikes. While the JIAAC don’t comment, its possible that the initial right-hand engine failure to start may have distracted the crew from reselecting AUTO. Procedural Drift / Practical Drift The accident investigators comment of the phenomena of procedural drift / practical drift. This is something we discussed in our article: ‘Procedural Drift’: Lynx CFIT in Afghanistan One major study of an accident that featured drift was by Scott Snook, then of the US Army. His book, Friendly Fire, examined the accident shoot down of two US Army Black Hawk helicopters on a peacekeeping mission in Iraq in 1994 by the US Air Force, and what he called ‘practical drift’. Such drift occurs when group norms and practices start to deviate from formal procedures. In some cases this may be because procedures no longer match operational circumstances, however practicality can be a factor too. These do not appear to have been factors here. Instead the practice seems simply to have been a misguided ‘improvement’. In The Field Guide to Understanding Human Error Prof Sidney Dekker lists several potential reasons for procedural drift: Rules or procedures are over-designed and do not match up with the way work is really done. There are conflicting priorities which make it confusing about which procedure is most important. Past success (in deviating from the norm) is taken as a guarantee for safety. It becomes self-reinforcing. Departures from the routine become routine. Violations become compliant behaviour with local norms. Safety Management System The JIACC note that the operator’s Safety Management System (SMS) did not detect this drift. The JIACC question the effectiveness of the SMS but provide...
read moreOur Top 20 Articles of 2015
Aerossurance: Our Top 20 Articles of 2015 As we start the new year we look back on the 20 articles that proved most popular with our readers in 2015. In reverse order: Number 20: Building St Helena Airport – An Industrial Scale ‘Grand Design’ This started with the building of the first airport on the volcanic British Overseas Territory of St Helena and has been updated through the year as the first calibration flights occurred. The new airport is expected to be licensed early in 2016. We will keep following the story into 2016! Number 19: Crashworthiness and a Fiery Frisco US HEMS Accident We are proud that this article, originally focused on an accident to a medical helicopter in Colorado and commercially available Crash Resistant Fuel System (CRFS) upgrades, came: DAYS BEFORE the NTSB recommended (A15-012) a change in regulations MONTHS BEFORE an association of US medical helicopter operators agreed to retrofit CRFS Again we have repeatedly updated this article with the latest developments. Below are a sequence of screen shots from security CCTV video (first shown by 9News): Number 18: DuPont Reputational Explosion Two process safety articles feature in the top 20. Chemical company DuPont has been feted for its safety performance for many years, and even formed its own safety consultancy to market its ‘secrets’. But David Michaels, who heads the US Occupational Safety and Health Administration (OSHA), said in one interview in May 2015: Based on what we saw in our inspection, if I were an employer, I would think twice before hiring DuPont to give me advice on safety. Between 1995 and 2007 DuPont suffered one fatality but from 2007 to date they had 8. We looked in particular at an accident in November 2014. Four workers were asphyxiated at a DuPont facility in La Porte, Texas when 20 tonnes of a flammable and highly toxic gas were released into a building. The US Chemical Safety Board, in an interim statement, identified serious process safety shortcomings at the plant. Number 17: USAF RC-135V Rivet Joint Oxygen Fire A US Air Force (USAF) accident investigation paradoxically determined that a $62.4mn fire was due to a maintenance error but that no human factors were involved. We look further at this accident, one of three top 20 articles that featured B-Nuts. Number 16: NTSB Report on 2013 S-76 Tail Rotor Blade Loss The US National Transportation Safety Board (NTSB) reported on a fatal Sikorsky S-76A++ accident. During a post-maintenance check flight (one of three in the top 20) 2 tail rotor blades separated and the TGB began to disintegrate. All 3 POB died. Number 15: Southwest Unstabilised Approach Accident An unstabilised approach and a late change of control were critical in an accident that resulted in a nose gear collapse of a Southwest Airlines (SWA) Boeing 737-700 at La Guardia say NTSB. Number 14: S-92A Emergency Landing: MGB Oil Checklist Recommendation The Norwegian Accident Investigation Board (AIBN) raises concerns over the S-92A emergency checklist after a Main Gear Box related incident that resulted in a helicopter making an emergency landing on the obstructed helideck of a disused offshore platform. We also look at sources of guidance for checklist design. Number 13: AW101 VVIP For the Very Very Important Person who wants a slight feeling of agoraphobia aboard their personal helicopter (or a shower!) we discussed the AW101. In the VVIP role the large AW101 cabin has the flexibility to be fitted out in a wide range of configurations. We also look at how 3-D printing can help visualise cabin layouts. The first flight took place...
read moreDangers of Aircraft Tyre Inflation
Dangers of Aircraft Tyre (US: Tire) Inflation The Royal Canadian Air Force are investigating two recent tyre inflation burst accidents. Both involve visiting aircraft using borrowed equipment: 25 August 2015 CT-114 Tutor CT114058 A Snowbird aircraft was diverted from the rest of the deployed team due to an in-flight emergency. The aircraft was repaired, including a successful maintenance flight test, and was refuelled for a later departure to re-join the Snowbird team. The aircraft tire was due for its 7-day inspection/refill and nitrogen tanks were borrowed from a local facility to service the aircraft. While topping up the right hand main tire with nitrogen, the tire was over pressurized and exploded. The force of the explosion seriously damaged the right hand main landing gear leg, the wing rear spar and the split rim was propelled into and crushed the right hand diesel tank. The aircraft sustained “Category B” damage, primarily due to the damage in the wing spar. There were no injuries resulting from this occurrence. The investigation determined that the technician misinterpreted the gauges on this unfamiliar equipment, and attempted to fill the tire to 150 Bars instead of 150 pounds per square inches (PSI). The wheel/tire assembly failed around 120 Bars (over 1700 PSI). The investigation is focussing on the human factors aspects surrounding this occurrence. UPDATE 25 November 2016: The RCAF say that during the maintenance “the pilot was showing it to students from the local Flight College”: The investigation concluded that all reasons why technicians elect to deviate from the Approved Maintenance Program by not using the inflator assembly kit, either because of lack of availability or familiarity with the kit, are avoidable. Preventive measures are recommended to alleviate those circumstances. Further it is recommended: …the inflating procedure manual be clarified to alleviate any potential confusion. And: The investigation also put forth safety recommendations with respect to showcasing aircraft that are being maintained. 13 October 2015 CH-124 Sea King CH12419 While at RAF Odiham, the main landing gear tires were found to be low. A dual-pressure inflation kit was used, the low side reported to be set for 60 psi. The high pressure side was reported to be around 500 psi. Normal tire pressure is 105 psi. During inflation, the left hand inboard tire ruptured. Rim fragments caused damage to the left hand and right hand landing gear as well as the fuselage. The investigation is focussing on human factors procedures for the use of unfamiliar equipment. Note the N2 GSE bottle trolley next to the aircraft. UPDATE 25 November 2016: This investigation is ongoing. UPDATE 2 November 2017: This incident and 4 others were discussed by the UK Military Aviation Authority (MAA) at an RAeS conference. A common thread was the use of GSE available on the line rather than tyre inflation kits from stores (due to stores being shut, kits unserviceable or a separate regulator needed with the kit not being available or issued). Other Cases In 2008 the UK Air Accidents Investigation Branch (AAIB) investigated a horrific accident that cost a visiting engineer at Manchester airport two limbs. The AAIB report: Whilst a technician was rectifying an under-inflated tyre, a pressure of approximately six times the normal tyre pressure was developed. The tie bolts on the wheel failed, the assembly exploded and the technician was seriously injured. It is not...
read moreUK BOSIET/FOET Cat-A CA-EBS HUET Update
UK BOSIET/FOET Cat-A CA-EBS HUET Update Category A Compressed Air Emergency Breathing Systems (CA-EBS) were introduced for helicopter passengers flying offshore over the UK Continental Shelf in September 2014. This followed the UK Civil Aviation Authority (CAA) North Sea Review, which resulted in the CAP1145 report. Oil and Gas UK, Step Change in Safety, OPITO, the International Association of Drilling Contractors (IADC) and the Trade Unions have recently agreed a joint statement on the current status of the Helicopter Underwater Escape Training (HUET): After extensive engagement with industry, regulators, training providers and workforce representatives, agreement has been reached on the new Basic Offshore Safety Induction and Emergency Training (BOSIET) and Further Offshore Emergency Training (FOET) standard to be applied across the UK sector. This new standard, which will be introduced early in 2016, will meet the manufacturer minimum training requirements specified by the CAA. The standard will involve ‘dry’ Cat A EBS training with in-water HUET breath hold exercises using the Survitec Mk50 [Sentinel] life jacket. This will remove the Lapp jacket and re-breather from the existing BOSIET/FOET standard for personnel travelling offshore in the UKCS. In the longer term, all industry stakeholders wish to work towards providing in-water training exercises using the Survitec Mk50 life jacket and Compressed Air Cat A EBS equipment. This will finally eliminate the anomaly of negative training using the former life jacket (the LAP (aka LAPP) jacket, a hybrid ‘Cat B’ EBS), 17+ months since the Mk50 was introduced (the first with an EBS to be approved by UK CAA in accordance with the Category A specification in CAP1034). UPDATE 25 January 2016: OPITO has issued an update that the ‘interim’ standard will be introduced across the UK on 15 February 2016. They have provided two sets of FAQs: Oil and gas workforce – BOSIET FAQs Training Providers – BOSIET FAQs The current Health and Safety Executive (HSE) restrictions (due to the applicability of Diving at Work Regulations when breathing pressurised gas) on in-water ‘wet’ CA-EBS training mean that the new interim training standard will feature fewer underwater escapes during HUET. With the LAP jacket for every scenario with breath hold another was also done using the Cat B air pocket within the LAP. This regulatory challenge was predicted by Survivex in their evidence to the UK CAA in Appendix 5 to Annex D of CAP1145 in October 2013. It has been eased by some time-limited concessions by the HSE in Q3 2015 (although they still require more than a basic offshore medical will involve). UPDATE 20 September 2016: The UK CAA today briefed the Oil and Gas UK Aviation Seminar the following: Mk51 Sentinel Aircrew Life Preserver Survitec have also designed an aircrew jacket with CA-EBS. Extra Resources If you found this article of interest you may also enjoy: Rapid Progress with a Category A EBS in the UK following CAP1145 OPITO Compressed Air Emergency Breathing System (CA-EBS) Initial Deployment Training Standard Helicopter Ditching – EASA Rule Making Team RMT.0120 Update on a new rule making initiative in Europe that will shortly proceed to a Notice of Propose Rulemaking Dramatic Malaysian S-76C 2013 Ditching Video probably the only video shot from within a helicopter during a real underwater escape The Hon Robert Wells QC’s Offshore Helicopter Safety Inquiry (OSHSI) following an S-92A accident offshore Canada in 2009, in which 17 people died and one passenger, Robert Decker, survived. The Dangers of Cold Water Immersion New Helicopter Survival Suits in Canada for oil and gas flights off the Atlantic coast...
read moreB1900C PSM+ICR Accident in Pakistan 2010
B1900C PSM+ICR Accident in Pakistan 2010 The Pakistan Civil Aviation Authority (CAA) has recently published the report into the loss of a Beechcraft B1900C in 2010. The aircraft, AP-BJD, was being operated by JS Air (as subsidiary of the JS Group) when it crashed on 5 November 2010, killing 21 people. The accident featured what a 1998 AIA/AECMA study termed a Propulsion System Malfunction + Inappropriate Crew Response (PSM+ICR). The 17 passengers worked for Italian oil and gas company ENI, who had chartered the aircraft. They were en route to work at the Bhit Shah gas field. The Accident Flight Shortly after take-off from Jinnah International Airport (JIAP), Karachi, the aircraft experienced a No 2 Engine anomaly. The crew decided to land back at Karachi. The aircraft could not sustain flight. It impacted the ground in a stalled state with a 45° right hand bank about 1 nm from the airport. The Captain (53, ex-Pakistan Air Force, ATPL, 8,114 hours total, 1,820 hours on type) was the Pilot Flying (PF) and the First Officer (FO: 33, ATPL, 1,746 hours total, 1,338 hours on type) was Pilot Monitoring (PM). Following analysis of the Cockpit Voice Recorder (CVR), the investigators comment that just before take-off: At 02:03:55.1 UTC [07:03:55.1 local time] FO told Captain “autofeather” and Captain acknowledged by saying “autofeather off”. It is important to note that autofeather switch should be in “Arm” position instead of “OFF” as per the OEM instructions and laid down procedures in [Flight Crew Operaing Manual] FCOM and QRH [to avoid the need for manual feathering]… At 02:04:02.8 UTC Captain told FO “all set, we are cleared for takeoff”. It is important to note that cockpit crew were supposed to carry out “run up checks” prior to entering the runway as per QRH however, those were not carried out. At 02:04:05 UTC, the engine torque and propeller RPM parameters began to increase and there was an increase in longitudinal acceleration indicating start of takeoff roll. At 02:04:14.2 UTC FO told Captain “power set autofeather light is ON”. At 02:04:18.7 UTC Captain said “off”. As the cockpit crew before takeoff intentionally selected the autofeather switch to “OFF” position, therefore the light was “ON” and the autofeather “OFF” position is confirmed by the Captain. The aircraft continued to accelerate and at 02:04:31 UTC it rotated. However, two seconds later the engine noise reduced. At 02:04:36.5 UTC the FO told Captain that the “right engine prop has gone”. At 02:04:41.1 UTC the FO said “it is feathering…should I select it to feather position?”. The Captain said “yes, put it to feather position” at 02:04:43.1 UTC. The investigators comment that: …probably [the] FO may have observed partial feathering due to which he wanted to feather the propeller of engine No 2 which was approved by Captain contrary to the documented procedures of no remedial action below 400 ft above ground level. The crew then decided to return to Karachi. The crew never raised the landing gear as per the FCOM/QRH, restricting aircraft performance. The investigators highlight that the Captain called Air Traffic and erroneously identified a No 1 engine problem. At 02:05:17.7 UTC Captain told FO “wait for a minute, wait for a minute”. As per the recorded data, at this particular moment the airspeed of aircraft was 98 knots with altitude recorded as 268 ft Above Mean Sea Level… [At] this stage, [the] Captain had not been able to achieve the minimum safe recommended flying parameters and the airspeed of aircraft was continuously decreasing with increasing pitch attitude as...
read moreSeason’s Greetings from Aerossurance
Aerossurance sends its Season’s Greetings to all its customers, partners, suppliers, colleagues and friends. We also wish you all a safe and prosperous New Year! Aerossurance has proven aviation safety, operations, airworthiness, regulation and accident analysis expertise. For aviation advice you can trust, contact us at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...
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