Asiana B777 Accident at SFO 6 July 2013
Asiana Accident at San Francisco 6 July 2013 (Asiana Flight 214, Boeing 777 HL7742) There are a host of human factors, automation, crashworthiness, survivability and emergency response lessons from this 2013 accident. The National Transportation Safety Board (NTSB) held a Board Meeting in Washington on 24 June 2014 to finalise their conclusions on this landing accident to Asiana Flight 214, Boeing 777 HL7742 at San Francisco International Airport. Acting Chairman’s Opening Statement IIC Opening Presentation – Bill English, Investigator-in-Charge Operational Factors Presentation – Roger Cox, Operations Group Chairman Human Performance Presentation – Dr. William Bramble, Senior Human Performance Investigator Survival Factors Presentation – Jason Fedok, Survival Factors Group Chairman Acting Chairman’s Closing Statement A summary can be found here. The full report is here. NTSB Probable Cause: ….the flight crew’s mismanagement of the airplane’s descent during the visual approach, the PF’s unintended deactivation of automatic airspeed control, the flight crew’s inadequate monitoring of airspeed, and the flight crew’s delayed execution of a go-around after they became aware that the airplane was below acceptable glidepath and airspeed tolerances. Contributing to the accident were (1) the complexities of the autothrottle and autopilot flight director systems that were inadequately described in Boeing’s documentation and Asiana’s pilot training, which increased the likelihood of mode error; (2) the flight crew’s nonstandard communication and coordination regarding the use of the autothrottle and autopilot flight director systems; (3) the PF’s inadequate training on the planning and execution of visual approaches; (4) the PM/instructor pilot’s inadequate supervision of the PF; and (5) flight crew fatigue, which likely degraded their performance. Aviation Week & Space Technology highlighted one significant recommendation, the call for a special certification review, a rare measure for an in-service aircraft. Immediately after the accident there was speculation on the influence of national culture: Could Malcolm Gladwell’s Theory of Cockpit Culture Apply to Asiana Crash?. This was based on the discussion in Malcolm Gladwell‘s book Outliers on the 1997 Korean Air B747 accident in Guam. This logic was rapidly debunked: Culturalism, Gladwell, and Airplane Crashes. There is also a view on the traps investigators fall into: A careful listener will note the presenter falls into his own first trap at 2:16! Other Safety Resources Investigation into Jet Airways B777 VT-JEK Serious Incident at Heathrow Singapore Airlines B777 41t Fuel Discrepancy Incident B777 in Autoland Mode Left Runway When Another Aircraft Interfered With the Localiser Signal Forgotten Fasteners – Serious Incidents UPDATE 6 February 2020: Emirates B777 Runway Impact During Attempted Go-Around, 3 August 2016, Dubai: Accident Report UPDATE 3 July 2020: Fatigue Featured in Anchorage Alaska Air Ambulance Accident UPDATE 3 July 2020: New surveillance, eyewitness footage of Asiana Flight 214 crash released The clips, obtained by The Desk…include a previously-unknown eyewitness video shot by a crane operator moments after the jet crashed on runway 28L. In the video, the operator could be heard describing the incident as it unfolded to a nearby worker. Aerossurance has extensive air safety, flight operations, airworthiness, human factors, survivability, aviation regulation and safety analysis experience. For practical aviation advice you can trust, contact us at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...
read moreMisjudgement during abrupt helicopter maneuvering
Misjudgement during abrupt helicopter manoeuvring (AS350B3 LN-OVO) The Accident Investigation Board Norway (the Statens Havarikommisjon for Transport) has issued its report into an accident that occurred to Airbus Helicopters AS350B3, LN-OVO, operated by Fonnafly AS, on 27 April 2013. Their report is in Norwegian only. The helicopter was being used to transport personnel participating in the Røldal Freeride 2013 alpine skiing event. The flight started at the Hordatun Hotel, with five persons on board. AIBN report: As the helicopter ascended along the ski slope, a steep 360 degree turn was executed. Near the completion of the turn the helicopter came too low and hit the ground. No one on board were seriously injured. The helicopter was destroyed. Based on this investigation, the SHT is of the opinion that the accident with LN-OVO is a consequence of misjudgement during abrupt manoeuvring at low altitude. AIBN go on to say: Breathalyzer tests carried out by the police indicates that the commander may have been under the influence of alcohol, which, if that was the case, would have influenced negatively on his decisions and performance. Aerossurance understands this turn of phrase was adopted because, for reasons that are unclear, analysis of a blood sample was not subsequently completed. Aerossurance has extensive air safety, operations, SAR, airworthiness, human factors, aviation regulation and safety analysis experience. For practical aviation advice you can trust, contact us at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest updates. TRANSLATE with x English Arabic Hebrew Polish Bulgarian Hindi Portuguese Catalan Hmong Daw Romanian Chinese Simplified Hungarian Russian Chinese Traditional Indonesian Slovak Czech Italian Slovenian Danish Japanese Spanish Dutch Klingon Swedish English Korean Thai Estonian Latvian Turkish Finnish Lithuanian Ukrainian French Malay Urdu German Maltese Vietnamese Greek Norwegian Welsh Haitian Creole Persian TRANSLATE with COPY THE URL BELOW Back EMBED THE SNIPPET BELOW IN YOUR SITE Enable collaborative features and customize widget: Bing Webmaster Portal...
read more737 Descent Below Instrument Approach Minima – HF Lessons
737 Descent below Instrument Approach Minima – HF Lessons Human factors are discussed in the report into an incident in New Zealand. Using the autopilot, the aircraft descended on the glideslope but at decision height (200 feet Above Ground Level) the aircraft was still in cloud and the runway or approach lights were not visible. The captain however did not initiate a go-around, but just as first officer and check captain were about to intervene, the approach lights became visible at about 100 feet AGL and the captain continued for a safe landing. On 26 June 2014, the New Zealand Transport Accident Investigation Commission (TAIC) issued their report into this incident with an Air New Zealand Boeing 737-300, registration ZK-NGH in Christchurch on 29 October 2011. Crew: Captain (Pilot Flying): 68, ATPL, 23,875 hours total, 7,210 hours on type FO: (Pilot Monitoring): 43, ATPL, 8,420 hours total, 2,320 hours on type Check Captain: 49, ATPL, 17,200 hours total, 9,200 hours on type The weather forecast for Christchurch indicated broken cloud ceiling at 1200 feet, rain, visibility of 1500 meters reducing to 200 meters in rain. As the aircraft approached the airport was reporting overcast cloud at 300 feet, runway wet, winds from 020 degrees at 6 knots, visibility of 6000 meters reducing to 2000 meters TAIC state: A pilot not initiating a missed approach when they do not have the required visual reference at decision height is a safety issue. Before reaching the decision height, the captain had failed to respond to two other procedural check calls, and these two failures went unchallenged by the first officer, which is another safety issue. …the captain did not comply fully with the procedures and perform the mandatory missed approach because he was under stress brought on by a combination of factors comprising: the Canterbury earthquakes and their aftershocks, personal health issues and anxiety associated with the route check flight. The captain’s communication style could have been described as minimalistic – not wishing to promote interactive communication. He had a reported reputation within the company for saying little on the flight deck, and the first officer was aware of that reputation. The captain’s communication style and his reputation could well have contributed to the observed breakdown in the communication loop during the approach to Christchurch. It could also explain why the first officer was unwilling to challenge the lack of response to the 1000-feet call.. In this case the first officer should have challenged the captain on two occasions for not making the correct response to the automatic calls generated by the aeroplane systems. The first officer was aware that the captain was being assessed, but he said that this was not an issue as far as he was concerned. However, the psychologist was of the opinion that any first officer faced with the captain’s uncommunicative style, in a similar situation could have found themselves having to determine the boundaries of their involvement. Stepping in too early to take corrective action or waiting too long for the captain to respond to a call may have been resented by the captain or seen by the check captain as interfering with the check process. In other words, because the two pilots were meant to act as a team, the first officer’s performance could be perceived as...
read moreThat Others May Live – Inadvertent IMC & The Value of Flight Data Monitoring
That Others May Live – Inadvertent IMC & The Value of Flight Data Monitoring Airbus Helicopters have produced a remarkable 15 minute video that describes the lessons from an Inadvertent Instrument Metrological Condition (IIMC) incident during a Helicopter Emergency Medical Service (HEMS) flight in the US, which includes a frank interview with the pilot. That Others May Live Video Inadvertant IMC Such operation in a Degraded Visual Environment (DVE) was the subject of a UK Civil Aviation Authority (CAA) research report in 2003. Analysis by the European Helicopter Safety Analysis Team (EHSAT) shows that the resulting spatial disorientation in IIMC/DVE is a major cause of accidents. Consequently, the French Institut pour l’Amélioration de la Sécurité Aérienne (IASA) developed a video to highlight the threat. Vision 1000 This event, which could so easily have been a fatal accident, would have passed by with no learning if it wasn’t for the data from a small on-board Appareo Vision 1000 unit. Vision 1000 was developed by Appareo with Airbus Helicopters (formerly Eurocopter), and enhances the low cost, lightweight flight data recorder capability of Appareo’s earlier ALERTS system (developed in partnership with Bristow Group), by adding a cockpit camera. Vision 1000 was first introduced in 2009. The unit weighs around 300g, can be retrofitted for less than US$10,000, requires simply a 28V power supply and can record up to two hours of sound and visual images and now in the order of 200 hours of flight data. It has been standard on US produced AS350s for a number of years and Airbus Helicopters have announced it will be standard on all their new production helicopters. Airbus Helicopters Vision 1000 Video: Appareo FDM Brochure Examples: EC135, EC145 UPDATE 5 November 2014: NTSB held a board meeting on a loss of control accident in 2013 to an Alaskan State Trooper AS350B engaged in a search and rescue mission. NTSB made a number of findings and recommendations and again emphasise the value of recorders such as, in this case, the Appareo Vision 1000. UPDATE 10 June 2018: Italian HEMS AW139 Inadvertent IMC Accident We look at the ANSV report on a HEMS helicopter Inadvertent IMC event that ended with an AW139 colliding with a mountain in poor visibility. UPDATE 31 March 2021: Aerossurance has first-hand experience with the development of FDM technology and the implementation & management of FDM programmes. For aviation advice you can trust, contact: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest updates. TRANSLATE with x English Arabic Hebrew Polish Bulgarian Hindi Portuguese Catalan Hmong Daw Romanian Chinese Simplified Hungarian Russian Chinese Traditional Indonesian Slovak Czech Italian Slovenian Danish Japanese Spanish Dutch Klingon Swedish English Korean Thai Estonian Latvian Turkish Finnish Lithuanian Ukrainian French Malay Urdu German Maltese Vietnamese Greek Norwegian Welsh Haitian Creole Persian TRANSLATE with COPY THE URL BELOW Back EMBED THE SNIPPET BELOW IN YOUR SITE Enable collaborative features and customize widget: Bing Webmaster Portal...
read moreFocus on Gust Locks After US GIV accident
Focus on Gust Locks After US G-IV accident On 12 May 2014, 7 people died when Gulfstream G-IV business aircraft N121JM was destroyed at Hanscom Field, Bedford, Massachusetts, after a rejected takeoff and runway excursion. Among the dead was Lewis Katz, co-owner of the US’s third-oldest daily newspaper. the Philadelphia Inquirer, who had been attending a charity event with his fellow travellers. Katz died just days after he and business partner Jerry Lenfest succeeded in agreeing a $88 million deal to be sole owners of the newspaper’s parent company. NTSB report that: A witness observed the airplane on the takeoff roll at a “high speed” with “little to no altitude gained.” The airplane subsequently rolled off the end of the runway, on to a runway safety area, and then on to grass. The airplane continued on the grass, where it struck approach lighting and a localizer antenna assembly, before coming to rest in a gully, on about runway heading, about 1,850 feet from the end of the runway. A postcrash fire consumed a majority of the airplane aft of the cockpit… Tire marks consistent with braking were observed to begin about 1,300 feet from the end of runway 11. The tire marks continued for about another 1,000 feet through the paved runway safety area. The CVR captured callouts of 80 knots, V1, and rotate. After the rotate callout, the CVR captured comments concerning aircraft control. FDR data indicated the airplane reached a maximum speed of 165 knots during the takeoff roll and did not lift off the runway. FDR data further indicated thrust reversers were deployed and wheel brake pressures increased as the airplane decelerated. The FDR data ended about 7 seconds after thrust reverser deployment, with the airplane at about 100 knots. The FDR data did not reveal evidence of any catastrophic engine failures and revealed thrust lever angles consistent with observed engine performance. NTSB attention has focused on the aircraft’s gust locks: The airplane was equipped with a mechanical gust lock system, which could be utilized to lock the ailerons and rudder in the neutral position, and the elevator in the down position to protect the control surfaces from wind gusts while parked. A mechanical interlock was incorporated in the gust lock handle mechanism to restrict the movement of the throttle levers to a minimal amount (6-percent) when the gust lock handle was engaged. The FDR data revealed the elevator position was consistent the gust lock being engaged and there were no indications of a flight control check before take off. However the gust lock handle was found in the forward (OFF) position and the elevator gust lock latch was found not engaged. While the investigation is ongoing, on 13 June 2014, Gulfstream issued a precautionary maintenance and operations letter to GIV operators stating that: Flight crews are reminded to perform the following as set forth in the applicable AFM procedures for each model aircraft: ensure the gust lock is OFF prior to starting engines (not applicable for G650); check flight controls for freedom and correct movement prior to taxi/takeoff; [and] confirm the elevators are free during the takeoff roll. The NTSB preliminary is here. Further details can be found on Aviation Safety Network here. UPDATE 21 August 2014: Gulfstream: Flight Controls Best Check for Lock Release UPDATE 8 April 2015: The NTSB released data into the public...
read moreAirbus Report: Commercial Aviation Accidents 1958-2013 – A Statistical Analysis
Airbus Report: Commercial Aviation Accidents 1958-2013 – A Statistical Analysis Airbus have published an analysis report on accidents to western-built commercial air transport jets since 1958. Airbus identify 4 generations of aircraft. Over time the usage of these generations has changed. Of particular interest is Airbus’ claim that the 4th generation has halved the fatal accident rate of the previous generation. While fatal Controlled Flight Into Terrain accidents have dropped dramatically and Loss of Control – Inflight accidents have dropped, Runway Excursions have continued more or less unabated. Airbus says that new technology aimed at preventing over runs has not achieved enough uptake to affect the statistics at this stage. Boeing ‘s own analysis for 1959-2012 is here. Aerossurance has extensive experience in safety data analysis and accident investigation. To discuss the issues raised here, and how they affect your business contact: enquiries@aerossurance.com Follow us on LinkedIn for our latest...
read moreFixed Wing Accident & Incident Digest
Fixed Wing Accident & Incident Digest There have been a number of interesting air accident reports or updates recently on a range of fixed wing accidents and incidents, each with unique lessons. 1) Loss of propeller control during descent causes fatal DHC-8 forced landing in Papua New Guinea On 15 June 2014 the Papua New Guinea Accident Investigation Commission (AIC) released their final report into a fatal accident to Bombardier DHC-8-100 (aka Dash 8-100) P2-MCJ of Airlines PNG near Madang on 13 October 2011. The AIC concluded that both propellers oversped during descent after having been put incorrectly into beta range. A forced landing occurred on sparsely timbered terrain. Twenty eight passengers died but the Australian and New Zealand pilots, a cabin crew member and one passenger survived the accident. The pilot-in-command (PIC) conducted a low power, steep descent with the propellers set at 900 revolutions per minute (RPM) in an attempt to get below cloud. Neither pilot noticed that the airspeed increase to the aircraft’s maximum operating speed (VMO). At that point a warning sounded in the cockpit and the PIC pulled the power levers backwards, through the flight idle gate and into the ground beta range. Moments later, at 10,090 feet, both propellers oversped simultaneously, back-driving the engines, causing damage to both engines, so a forced landing without power became inevitable. The landing gear and flaps were not lowered, if they had been the impact could have been less severe. The AIC stated: …the aircraft’s degraded controllability and the high rate of descent/short time to impact were at least partly attributable to the fact that the flight crew did not use the standard emergency procedures early on. While it is not possible to determine exactly what would have happened if the flight crew had had more time to deal with the situation, it is reasonable to suppose it may have positively affected their ability to assess and manage the situation in a systematic manner. The AIC identified the following contributing safety factors: The Pilot-in-Command moved the power levers rearwards below the flight idle gate shortly after the VMO overspeed warning sounded. This means that the release triggers were lifted during the throttle movement. The power levers were moved further behind the flight idle gate leading to ground beta operation in flight, loss of propeller speed control, double propeller overspeed, and loss of usable forward thrust, necessitating an off-field landing. A significant number of DHC-8-100, -200, and -300 series aircraft worldwide did not have a means of preventing movement of the power levers below the flight idle gate in flight, or a means to prevent such movement resulting in a loss of propeller speed control. If a beta lockout mechanism had been installed on the aircraft, the double propeller overspeed would not have occurred when the power levers were moved below the flight idle range and into the ground beta range during flight. The Civil Aviation Safety Authority of Papua New Guinea issued their own Airworthiness Directive shortly after the accident. Installation of the beta lockout mechanism became a mandatory requirement of the State of Design following the issue of a Transport Canada Airworthiness Directive (Bombardier is a Canadian manufacturer) in 2013. They had however been required on DHC-8s in the US since 2000 following National Transportation Safety Board recommendations after an 1994 SF340 accident. However, if you charter DHC-8-100, -200, and -300 series aircraft you should however be...
read moreUnfit for Flight or Unfit for Publication?
Unfit for Flight or Unfit for Publication? This week US newspaper USA Today has featured a 3 part ‘exposé’ on general aviation and its safety record by Tom Frank that claimed ‘Lies and coverups mask roots of small-aircraft crashes’: Unfit for Flight: Hidden defects linked to small-aircraft crashes over five decades Unchecked carnage: NTSB probes don’t dive deep after small-aircraft crashes How much is a human life worth? This series caused outrage in the aviation community: The Aircraft Owners and Pilots Association (AOPA) called the report ‘extremely flawed’, ‘one-sided’ and ‘inaccurate’ in their press release: The article leads one to believe that general aviation is an unsafe form of transportation, but in truth, general aviation has demonstrated significant progress in safety. According to the National Transportation Safety Board, the number of fatalities has declined by over 40 percent since the early 1990s. Of course mentioning that sort of fact would have undermined reporter Tom Frank’s narrative; you won’t find those statistics in his piece. It is clear that Mr. Frank could make no space in his lengthy article for evidence of progress—evidence laid out in an hour-long discussion AOPA had with him last week. Including this information would have undermined his misplaced notion that general aviation is unsafe. The General Aviation Manufacturers Association (GAMA) called the story ‘sensationalistic’ and stated in their press release: The reality is that the number of fatal accidents in general aviation aircraft has declined substantially in recent years. In fact, the goal of 1 fatal accident per 100,000 hours flown by 2018 now appears increasingly likely. The General Aviation Manufacturers Association (GAMA), along with other members of the General Aviation Joint Steering Committee (GAJSC)—a group of government, industry, and user groups dedicated to improving aviation safety—has pressed the FAA to streamline requirements governing the use of Angle of Attack (AoA) indicators in general aviation aircraft. AoA indicators can help pilots avoid losing control of the aircraft in flight, the primary cause of accidents. Thanks to these efforts, the FAA recently made it easier and more cost-effective for pilots to install AoAs. This initiative has the potential to have a significant impact toward combatting loss-of-control accidents. The GAJSC continues to develop other concrete improvements to improve overall safety. As Mr. Frank notes, the average general aviation aircraft is now 41 years old. That’s why the FAA and industry partnered in 2011 to form the Part 23 Aviation Rulemaking Committee (ARC), a group of 150 government and industry experts who spent 18 months studying how to more efficiently and effectively introduce new safety technology into new and existing small general aviation airplanes. GAMA’s Greg Bowles co-chaired this effort. Congress and industry are now actively working to ensure the FAA implements the ARC’s recommendations. Independently, Jeff Schweitzer, a former White House Assistant Director for International Affairs in the Office of Science and Technology Policy during the Clinton Administration, published a damning piece entitled ‘Unfit for Publication: How USA Today Got Everything Wrong’ in the Huffington Post: Nearly every inference about aviation in the article is wrong. The real story here is media bias and editorial malpractice, not the dangers of aviation or manufacturing defects. The article insinuates that huge numbers of people are dying in small airplanes, and that the cause is largely manufacturing defects. Both conclusions are untrue. Deaths in...
read moreFAA Identify Widespread Use of Unapproved Parts
FAA Identify Widespread Use of Unapproved Parts On 16 November 2013, a Piper PA-28-140 N57DB lost engine power shortly after takeoff in San Antonio, TX and crashed. The aircraft was destroyed and the pilot seriously injured. US Federal Aviation Administration (FAA) has revealed that the carburettor air inlet duct in the aircraft “did not meet the specifications of the air duct authorized and provided by Piper” and this thinner duct had collapsed cutting off air flow to the engine. The FAA state (emphasis added) that: We believe that “off the shelf” ducts may be being used as a normal replacement part instead of the authorized Piper carburettor air inlet duct. We say this because there have been no approved carburettor air inlets ducts ordered from Piper since 1999 even though the FAA registry indicates there are over 5000 registered PA-28-140 aircraft. This suggests widespread use of unapproved parts and deviation from published instructions for continued airworthiness in the US fleet. The FAA Safety Team (FAAST) is a safety initiative of the FAA. Read the FAASTeam Notice on this accident here. UPDATE: 6 weeks after we published this article, the FAA issued Special Airworthiness Information Bulletin (SAIB) CE-14-23 on the subject, covering the PA-28, PA-32, PA-34, PA-44, and PA-46 series aircraft, including a non-mandatory, recommended inspection within 25 flying hours. Curiously, there is no requirement to inform the FAA if a replacement is made, although orders of genuine parts will help indicate the true scale of the problem. UPDATE: In December 2014, NTSB published this Probable Cause: A partial loss of engine power after departure due to the collapse of the carburettor air inlet duct, which restricted the airflow to the engine. Contributing to the accident was the overdue annual inspection and the installation of the improper air inlet duct. Aerossurance is pleased to sponsor this Royal Aeronautical Society (RAeS) Human Factors Group: Engineering conference on 12 May 2015 at Cranfield University: Human Factors in Engineering – the Next Generation For specialist aviation advice you can trust on continuing airworthiness and safety investigations, contact Aerossurance at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest updates. TRANSLATE with x English Arabic Hebrew Polish Bulgarian Hindi Portuguese Catalan Hmong Daw Romanian Chinese Simplified Hungarian Russian Chinese Traditional Indonesian Slovak Czech Italian Slovenian Danish Japanese Spanish Dutch Klingon Swedish English Korean Thai Estonian Latvian Turkish Finnish Lithuanian Ukrainian French Malay Urdu German Maltese Vietnamese Greek Norwegian Welsh Haitian Creole Persian TRANSLATE with COPY THE URL BELOW Back EMBED THE SNIPPET BELOW IN YOUR SITE Enable collaborative features and customize widget: Bing Webmaster Portal...
read moreEDA Announce 2014 Military Airworthiness Conference
The European Defence Agency (EDA) has announced that the annual Military Airworthiness Authorities (MAWA) Military Airworthiness Conference will be held 24-25 September 2014 in Rome. The MAWA Forum oversees the development of European Military Airworthiness Requirements (EMARs) and promotes ways of achieving the harmonisation of military airworthiness regulation and certification processes across Europe. See http://www.eda.europa.eu/info-hub/news/2014/06/19/coming-soon-military-airworthiness-conference-2014 Aerossurance has intimate knowledge of the EMARs and their implementation. For advice on EMARs contact us at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...
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