NTSB

NTSB Sunshine Meeting Continental Airlines Flight 1404

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Aug 032010

Courtesy: NTSB National Transportation Safety Board

Washington, DC – The National Transportation Safety Board today determined that the probable cause of the 2008 Continental Airlines flight 1404 runway excursion accident was the captain’s cessation of rudder input, which was needed to maintain directional control of the airplane, about 4 seconds before the aircraft departed the runway, when the airplane encountered a strong and gusty crosswind that exceeded the captain’s training and experience.

Contributing to the accident was the air traffic control system that did not require or facilitate the dissemination of key available wind information to air traffic controllers and pilots, and inadequate cross wind training in the airline industry due to deficient simulator wind gust modeling.

On December 20, 2008, Continental Airlines flight 1404 veered off the left side of runway 34R during a takeoff from Denver International Airport. As a result, the captain initiated a rejected takeoff and the airplane came to rest between runways 34R and 34L. There was a post-crash fire. All 110 passengers and 5 crewmembers evacuated the airplane immediately after it came to rest. The captain and five passengers were seriously injured.

At the time of the accident, mountain wave and downsloping wind conditions existed in the Denver area and the strong localized winds associated with these conditions resulted in pulses of strong wind gusts at the surface that posed a threat to operations at Denver International Airport.

“This aircraft happened to be in the direct path of a perfect storm of circumstances that resulted in an unexpected excursion in an airport with one of the most sophisticated wind sensing systems in the country,” said NTSB Chairman Deborah A.P. Hersman. “It is critical that pilots receive training to operate aircraft when high wind conditions and significant gusts are present, and that sufficient airport-specific wind information be provided to ATC controllers and pilots as well.”

As a result of this accident the NTSB issued 14 recommendations to the Federal Aviation Administration regarding mountain waves, wind dissemination to flightcrews, runway selection, pilot training for crosswind takeoffs, and crashworthiness.

A synopsis of the Board’s report, including the probable cause, conclusions, and recommendations, is available on the NTSB’s website, at http://ntsb.gov/Publictn/2010/AAR1004.htm

The Board’s full report will be available on the website in several weeks.

Posted by Airboyd at 18:59 Tagged with: , , ,

Turkish Airlines Flight 1951 Accident Animation Dutch Safety Board

Aviation, NTSB, YouTube 1 Response »
May 172010

Courtesy: Dutch Safety Board

Turkish Airlines, Crashed during approach, Boeing 737-800, Amsterdam Schiphol Airport [pdf]

A Boeing 737-800 (flight TK1951) operated by Turkish Airlines was flying from Istanbul Atatürk Airport in Turkey to Amsterdam Schiphol Airport, on 25 February 2009. As this was a Line Flight Under Supervision, there were three crew members in the cockpit, namely the captain, who was also acting as instructor, the first officer who had to gain experience on the route of the flight and who was accordingly flying under supervision, and a safety pilot who was observing the flight. There were also four cabin crew members and 128 passengers on board. During the approach to runway 18 Right (18R) at Schiphol airport, the aircraft crashed into a field at a distance of about 1.5 kilometres from the threshold of the runway. This accident cost the lives of four crew members, including the three pilots, and five passengers, with a further three crew members and 117 passen- gers sustaining injuries.
Shortly after the accident, the initial investigation results indicated that the left radio altimeter sys- tem had passed on an erroneous altitude reading of -8 feet to the automatic throttle control system (the autothrottle). In response to this, the Board had a warning sent to Boeing on 4 March 2009. This asked for extra attention to be paid to the Dispatch Deviation Guide for the Boeing 737-
800, which is a manual of additional procedures and warnings for maintenance crews and pilots to consult before the aircraft is flown. This warning, which was added in 2004, states that with radio altimeter(s) inoperative, the associated autopilot or autothrottle must not be used for the approach and landing. The Board asked Boeing to investigate whether this procedure should also apply during the flight itself. With regard to the content of the Dispatch Deviation Guide, Boeing has answered that a provision such as this did not lend itself for inclusion in a defects checklist in the Quick Reference Handbook – the handbook containing the checklists for normal and abnormal procedures during the flight. On the one hand because a non-normal checklist must be based on a readily identifiable failure that is identified by an alert or a fault-warning, which was not the case with this radio altimeter failure. On the other hand because of the complexity of the fault, it is not practical to develop a non-normal checklist that would address all possible situations. Furthermore incorporating the procedure in the Quick Reference Handbook would unnecessarily remove airplane system functionality. This means that as an aircraft has two identical systems, one system is also
a back-up for the other system. When one of these systems does not work prior to dispatch no back-up system is available and the flight should not be dispatched or the systems should not be used. If however during the flight one of the systems should fail the other system, the back-up, will take over and that is what it is meant for. Not using a system anymore at that moment should be too big a restriction for the operations. On the same date, 4 March 2009, following consultation with the Dutch Safety Board, Boeing did sent a notice to all companies flying with the Boeing 737 regarding the facts of the accident flight, as they were known at that point.

Posted by Airboyd at 04:58 Tagged with: , , , , , , , , , ,

US Airways 1549 Final Report NTSB: Credits Crew Actions And Safety Equipment

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May 052010

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Courtesy: NTSB – Aircraft Accident Report – Loss of Thrust in Both Engines After Encountering a Flock of Birds and Subsequent Ditching on the Hudson River, US Airways Flight 1549, Airbus A320-214, N106US, Weehawken, New Jersey, January 15, 2009.

A synopsis of the Board’s report, including the probable cause, conclusions, and recommendations, is available on the NTSB’s website, at http://www.ntsb.gov/Publictn/2010/AAR1003.htm.

CREW ACTIONS AND SAFETY EQUIPMENT CREDITED WITH SAVING LIVES IN US AIRWAYS 1549 HUDSON RIVER DITCHING, NTSB SAYS

Washington, DC – In addition to the decisions and actions of the flight crewmembers, overwater safety equipment likely saved lives that might have otherwise been lost to drowning, the NTSB said.

Today the Safety Board met to conclude its 15-month investigation into the January 15, 2009, accident in which a US Airways A320 jetliner bound for Charlotte was ditched into the Hudson River after striking a flock of Canada geese shortly after departing New Yorks LaGuardia Airport. All of the 150 passengers and five crewmembers survived.

Investigators said that had the airplane not been equipped with forward slide/rafts, many of the 64 occupants of those rafts would likely have been submerged in the 41-degree Hudson River, potentially causing a phenomenon called cold shock, which can lead to drowning in as little as five minutes.

The accident flight had the additional safety equipment available only because the particular aircraft operated that day happened to be certified for extended overwater (EOW) operations even though current FAA regulations did not require the flight from New York to Charlotte to be so equipped.

Good visibility, calm waters, and proximity of passenger ferries, which rescued everyone on flight 1549 within 20 minutes, were other post-accident factors the Safety Board credited with the survival of all aboard the aircraft.

Once the birds and the airplane collided and the accident became inevitable, so many things went right, said NTSB Chairman Deborah A.P. Hersman. This is a great example of the professionalism of the crewmembers, air traffic controllers and emergency responders who all played a role in preserving the safety of everyone aboard.

The Safety Board said that the probable cause of the accident was the ingestion of large birds into each engine, resulting in an almost total loss of engine power. Contributing to the severity of the fuselage damage and resulting unavailability of the aft slide/rafts, the Board cited the FAAs inadequate ditching certification standards, lack of industry training on ditching techniques, and the captains resulting difficulty maintaining his intended airspeed on final approach due to task saturation resulting from the emergency situation.

The report adopted by the Safety Board today validated the Captains decision to ditch into the Hudson River saying that it provided the highest probability that the accident would be survivable. Contributing to the survivability of the accident was the crew resource management between the captain and first officer, which allowed them to maintain control of the airplane, increasing the survivability of the impact with the water.

In addressing the hazards that birds pose to aircraft of all sizes, the report noted that most bird strike events occur within 500 feet of the ground while flight 1549 struck geese at 2700 feet. Investigators said that this difference demonstrates that bird strike hazards to commercial aircraft are not limited to any predictable scenario.

Concluding that engine screens or changes to design would not be a viable solution to protect against bird ingestion events on commercial jetliners, the Board made it clear that the potential for significant damage from encounters with birds remains a challenge to the aviation community.

Posted by Airboyd at 09:44 Tagged with: , , , , , , , , , ,

Runway Overrun During Rejected Takeoff - Learjet 60 Columbia South Carolina September 19 2008

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Apr 132010

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Courtesy: NTSB

These hearings are provided as a safety and training resource for the professional pilots who watch this channel. Casual viewers may find the information to be of little interest.

POOR MAINTENANCE STARTED ACCIDENT CHAIN THAT RESULTED IN HIGH-SPEED RUNWAY EXCURSION THAT KILLED FOUR IN 2008, NTSB DETERMINES

Washington, DC – A chartered business jet crashed at a South Carolina airport 18 months ago because of the operators inadequate maintenance of the airplanes tires and the decision by the captain to attempt a high-speed rejected takeoff, which went against standard operating procedures and training, the NTSB determined today.

On September 19, 2008, at 11:53 p.m. EDT, a Bombardier Learjet Model 60 (N999LJ) operated by Global Exec Aviation and destined for Van Nuys, California, overran runway 11 during a rejected takeoff at Columbia Metropolitan Airport. After the airplane left the departure end of runway 11, it struck airport lights, crashed through a perimeter fence, crossed a roadway and came to rest on a berm. The captain, the first officer, and two passengers were killed; two other passengers were seriously injured.

The investigation revealed that prior to the accident the aircraft was operated while the main landing gear tires were severely underinflated because of Global Exec Aviations inadequate maintenance. The underinflation compromised the integrity of the tires, which led to the failure of all four of the airplanes main landing gear tires during the takeoff roll.

Shortly after the first tire failed, which occurred about 1.5 seconds after the airplane passed the maximum speed at which the takeoff attempt could be safely aborted, the first officer indicated that the takeoff should be continued but the captain decided to reject the takeoff and deployed the airplanes thrust reversers. Pilots are trained to avoid attempting to reject a takeoff at high-speed unless the pilot concludes that the airplane is unable to fly; the investigation found no evidence that the accident airplane was uncontrollable or unable to become airborne.

The tire failure during the takeoff roll damaged a sensor, which caused the airplanes thrust reversers to return to the stowed position. While the captain was trying to stop the airplane by commanding reverse thrust, forward thrust was being provided at near-takeoff power because the thrust reversers were stowed. The Safety Board determined that the inadvertent forward thrust contributed to the severity of the accident.

The Safety Board also found that neither the Federal Aviation Administration nor Learjet adequately reviewed the Airplanes design after a similar uncommanded forward thrust accident that occurred during landing in Alabama in 2001. While the modifications put into place after the Alabama accident provided additional protection against uncommanded forward thrust upon landing, no such protection was provided for a rejected takeoff.

This accident chain started with something as basic as inadequate tire inflation and ended in tragedy, said NTSB Chairman Deborah A.P. Hersman. This entirely avoidable crash should reinforce to everyone in the aviation community that there are no small maintenance items because every time a plane takes off, lives are on the line.

The safety recommendations that the NTSB made to the Federal Aviation Administration as a result of this investigation are: provide pilots and maintenance personnel with information on the hazards associated with tire underinflation, including the required intervals for tire pressure checks, and allow pilots to perform pressure checks in air taxi operations to ensure that tires remain safely inflated at all times; require tire pressure monitoring systems for all transport category airplanes; identify and correct deficiencies in both Learjets thrust reverser system safety analysis and the FAAs design certification process to ensure that hazards encountered in all phases of flight are mitigated; require that simulator training for pilots who conduct turbojet operations include opportunities to practice responding to events other than engine failures near takeoff speeds; require that pilots who fly air taxi turbojet operations have a minimum level of pilot operating experience in an airplane type before acting as pilot-in- command in that type; and require that airplane tire testing criteria reflect the loads that may be imposed on tires both during normal operating conditions and after the loss of one tire.

A synopsis of the Board’s report, including the probable cause, conclusions, and recommendations, is available on the NTSB’s website, at http://www.ntsb.gov/Publictn/2010/AAR1002.htm. The Board’s full report will be available on the website in several weeks.

Posted by Airboyd at 14:39 Tagged with: , , , , , ,

Reduce Accidents and Incidents Caused by Human Fatigue in the Aviation Industry - NTSB Most Wanted

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Feb 192010

Courtesy NTSB The National Transportation Safety Board today issued its 2010 Federal Most Wanted List of Transportation Safety Improvements, adding rail, aviation and marine issues, and updating the status of other issues on the list. At the same time, the Board removed the issue areas dealing with improved protection for school bus passengers and fatigue in the pipeline industry. “Every one of the hundreds of currently open safety recommendations address concerns that the Safety Board has uncovered in its accident investigations,” NTSB Chairman Deborah AP Hersman said. “But the recommendations on the Most Wanted list represent those improvements that can have the widest benefit.” Besides removing two issue areas on the list, the Board reviewed the remaining 13 issue areas on the list and added two new ones. Each issue area is color coded by the NTSB to designate its action/timeliness: Red for Unacceptable Response; Yellow for Acceptable Response, Progressing Slowly; and Green for Acceptable Response, Progressing in a Timely Manner. Reduce Accidents and Incidents Caused by Human Fatigue in the Aviation Industry • Set working hour limits for flight crews, aviation mechanics, and air traffic controllers based on fatigue research, circadian rhythms, and sleep and rest requirements. • Develop a fatigue awareness and countermeasures training program for controllers and those who schedule them for duty. • Develop guidance for operators to establish fatigue management systems, including a methodology that will continually assess the effectiveness of these systems. www.ntsb.gov


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