Focus 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...
read more‘Heir Force One’ – Second Helicopter for the Royal Family
‘Heir Force One’ – Second Helicopter for the Royal Family The British tabloids have finally caught up with regular users of the UK Civil Aviation Authority (CAA) G-INFO Database and spotted that the Royal Family is leasing a second helicopter (AgustaWestland A109S G-XXEC). The aircraft, to be based at RAF Odiham, joins Sikorsky S-76C++ G-XXEB, itself chartered in 2009 to replace G-XXEA, which replaced RAF Westland Wessex in 2001. According to reports, the Queen has leased the helicopter because it is thought to be safer to operate another aircraft on long-term lease rather than several on ad hoc charters. The press are speculating that the aircraft will be regularly used by the Prince William, Duke of Cambridge, himself a former RAF Search and Rescue pilot, leading to snappy headlines about Heir Force One. For more background see: https://www.royal.gov.uk/TheRoyalHousehold/Transport/Royalairtravel.aspx UPDATE October 2019: G-XXEC has been sold back to Leonardo. You don’t need to be a Head of State to face decisions on purchasing, dry leasing or chartering aircraft. Aerossurance can help you determine the safety, security and economic benefits of each option. For 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 morePlanning for Mass Evacuations
Planning for Mass Evacuations A wave of mass evacuations of foreign workers from Iraq is a timely reminder of the importance of having pre-arranged evacuation arrangements in place for companies operating in the less stable of overseas locations. Similar evacuations have occurred in a range of other countries in recent years, particularly in the Middle East and North Africa, after political instability, civil unrest, terrorist attacks and armed conflict. Similar evacuations may also be necessary after major natural disasters. It is essential these preparations involve the right security, safety and logistics expertise in order to consider all the potential obstacles and risks. UPDATE 12 December 2016: The Security Committee of the International Oil and Gas Producers Association (IOGP) has published ‘Country Evacuation Planning Guidelines’ (IOGP report, No. 472). They say: The trigger for evacuation could be due to a gradual deterioration in conditions. This allows for companies to conduct a gradual departure. A sudden deterioration, however, might mean that people might have to remain where they are while the situation is assessed and then respond accordingly. The report includes sections on “operation concepts, threat levels, crisis command centres, communications, training and briefing, reception arrangements and post-crisis reviews”. Aerossurance can bring essential aviation expertise to your emergency response and crisis planning. To get independent advice you can trust, contact: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest updates....
read moreEmergency AD – Honeywell TFE731 Engines
The U.S. Federal Aviation Administration (FAA) issued Emergency Airworthiness Directive (EAD) 2014-12-52 on 10 June 2014 in response to a production defect on the Honeywell TFE731 engine type. This was prompted by reports of 2nd stage Low Pressure Turbine (LPT2) blade separations due to casting anomalies at or near the root of the LPT2 blade. The EAD requires review of maintenance records before next flight to determine if any engine has LPT2 blades with less than 250 operating hours and not flying an aircraft with more than one engine so affected. This action is to manage the risk of a double engine shutdown due to the same failure mode. Affected are the TFE731-4, -4R, -5AR, -5BR, -5R, -20R, -20AR, -20BR, -40, -40AR, -40R, -40BR, -50R, and -60 engines, which are fitted to a wide variety of corporate jets and some military trainers. This is not the first significant production quality defect that Honeywell has suffered with TFE731 critical parts. In 2008 the FAA issued Airworthiness Directive (AD) 2008-02-19 following production defects in TFE731 engine discs. In that case Honeywell became aware from a manufacturing audit in June 2006 that some High Pressure Turbine (HPT) discs had received “improperly machined radii in the root of the forward and aft curvic teeth”. This increased the risk of an uncontained engine failure. Honeywell quickly issued a Service Bulletin on in July 2006 but the FAA did not propose making that mandatory until September 2007 when they issued a Notice of Proposed Rule Making (NPRM). The AD was finally issued in February 2008, 20 months later. This shows the importance of operator’s Continuing Airworthiness Management Organisation (CAMO) correctly classifying important Service Bulletins and promptly acting in advance of a regulator. For more details on the earlier problem see: http://www.flightglobal.com/news/articles/faa-proposes-recall-on-hundreds-of-tfe731-bizjet-engines-216631/ To discuss the issues raised here, and how they affect your business contact: enquiries@aerossurance.com Follow us on LinkedIn for our latest...
read moreAerossurance joins ADS
In addition to being an already active member of Oil & Gas UK, the trade association that speaks for the whole UK offshore sector, Aerossurance has been accepted as a member of ADS, the trade body advancing UK Aerospace, Defence, Security & Space Industries, globally. Follow us on LinkedIn for our latest...
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