One year later: The crash of Flight 3296

A commuter airplane has crashed near the airport in a small Alaska community on the Bering Sea, Thursday, Oct. 17, 2019, in Unalaska, Alaska. Freelance photographer Jim Paulin says the crash at the Unalaska airport occurred Thursday after 5 p.m. Paulin says the Peninsula Airways flight from Anchorage to Dutch Harbor landed about 500 feet (152 meters) beyond the airport near the water. (Jim Paulin via AP)
A commuter airplane has crashed near the airport in a small Alaska community on the Bering Sea, Thursday, Oct. 17, 2019, in Unalaska, Alaska. Freelance photographer Jim Paulin says the crash at the Unalaska airport occurred Thursday after 5 p.m. Paulin says the Peninsula Airways flight from Anchorage to Dutch Harbor landed about 500 feet (152 meters) beyond the airport near the water. (Jim Paulin via AP)

Twelve months ago, on Oct. 17, 2019, PenAir Flight 3296 overran the runway while landing at the Dutch Harbor airport, resulting in one passenger killed and four others injured. Since then, Ravn Alaska, which owned PenAir along with sister companies Corvus Airlines and Hageland Aviation, declared bankruptcy and auctioned off or sold the bulk of its assets.

Company executives blamed Ravn’s failure on the coronavirus, but on the Flight 3296 anniversary, it is worth considering just what happened to PenAir in the single year it was owned by Ravn, and what we have learned since the accident that exposes problems within the company in the months leading up to the tragedy.

Soon after the accident, the National Transportation Safety Board released an investigative update detailing the flight crew’s minimal experience in the aircraft. Ravn stopped all flights of the Saab 2000 into Unalaska and Alaska Airlines dropped the lucrative Capacity Passenger Agreement (CPA) it had with Ravn. The loss of the CPA, which paid Ravn for the Unalaska flights at “predetermined rates plus a negotiated margin, regardless of the number of passengers on board or the revenue collected,” had serious financial ramifications for the company. Questions raised by the NTSB’s preliminary investigation, however, left Alaska Airlines with little choice.

According to the NTSB’s initial report, and heavily covered in the media, the pilot in command (PIC) for Flight 3296 had an estimated 20,000 hours total flight time, but only 101 hours in the Saab 2000 (the co-pilot, with 1,446 hours total time, had 147 hours in the aircraft). Under PenAir’s previous ownership by the Seybert family, PICs were required to have 300 hours minimum in the Saab 2000 before operating into Dutch Harbor. (Similar requirements have existed for other companies operating at the challenging airfield.)

Based on the PenAir Operations Manual, flight-time minimums could be waived if approved by the company Chief Pilot. While the existence of such a waiver has not been addressed publicly, one month after the accident, the Federal Aviation Administration confirmed that Chief Pilot Crystal Branchaud had been replaced and no longer held a position of operational control with PenAir. The extent to which she or any other management personnel played a role in assigning the PIC to Flight 3296 will likely receive serious attention in the accident’s final report.

Another area of significant interest for investigators will be the flight crew’s decision to land in turbulent weather conditions. In the report, the NTSB stated that when Flight 3296 first attempted to land on Runway 13, the winds were at 10 knots from 270 degrees. After initiating a go-around, the winds were reported at 16 knots, gusting to 30, from 290 degrees. While on final approach the second time, the winds were 24 knots from 300 degrees, providing almost a direct tailwind. The aircraft was configured for approach with 20 degrees of flaps both times.

Aircraft landing performance standards are based on multiple factors including weight and balance, wind and runway conditions. While Flight 3296′s weight and balance has not been released, it is possible to determine a conservative estimate of its total weight from available data. According to the manufacturer, the aircraft has a basic empty weight of about 30,500 pounds (this includes the three-member crew). Adding fuel for required reserves and Cold Bay as an alternate destination (about 2,000 pounds) and weight for 39 passengers at the FAA standard for summer adults (195 lbs x 39 = 7,605 pounds), a total weight of 40,105 pounds can be calculated. This excludes any baggage that may have been onboard.

For Runway 13 at Dutch Harbor, PenAir’s company performance standards permitted a landing weight, with 20 degrees of flaps, of 40,628 pounds with zero wind, 35,402 pounds for 5 knots of tailwind and 29,955 pounds for 10 knots of tailwind. It recommended a reduction of 1,031 pounds for each additional knot of tailwind. There is thus no discernible calculation that would recommend landing on Runway 13 with the reported winds at the time of the crash at the aircraft’s approximate weight.

According to the NTSB, the flight crew reported touching down about 1,000 feet down the runway, with skid marks first appearing at about 1,840 feet. From there, the marks continued 200 feet before the aircraft crossed a grassy area, impacted the airport’s perimeter fence, crossed a ditch, hit a large rock and then crossed Ballyhoo Road. It was on the opposite shoulder of the road, over the rock seawall and nearly into the waters of Dutch Harbor, that Flight 3296 finally came to rest.

After the aircraft stopped and a desperate but ultimately unsuccessful effort was underway to save the life of passenger David Oltman, the flight crew waited with forward passengers for assistance in exiting. It was at that point, according to passenger Steve Ranney, that a brief verbal exchange occurred. “A passenger asked the captain why he landed,” explained Ranney in an email, “and he calmly said the computer showed he was within the safety margin.” According to Ranney, who was interviewed by NTSB investigators, neither the captain nor co-pilot spoke another word.

There is no onboard computer that calculates landing performance for the Saab 2000; the PIC could only have been referring to an app likely used on his company-issued iPad. “Electronic flight bags” are commonly utilized by pilots, but the use of any software for the purposes of formal flight planning in commercial operation would have to be approved by the FAA. When asked if PenAir had authorization to utilize performance calculation software, the FAA referred the question, as part of an ongoing investigation, to the NTSB. The NTSB would state only that “crew performance standards equipment procedures and a host of other factors” would be part of the investigation.

Decision-making is always an area of particular inquiry following a commercial crash, both on the part of the flight crew and company management. As investigators moved from the aircraft to the cockpit and back to the offices of PenAir, Ravn Air Group and even the FAA, there are other events in 2019 that may have garnered interest and point to further issues within the newly acquired company.
In February last year, PenAir Flight 3298 suffered an engine loss about an hour after departing King Salmon. In a statement to ADN at the time, FAA spokesman Allen Kenitzer said the aircraft “experienced engine trouble, so pilots shut it down.” The flight crew then returned to the village. In a subsequent Service Difficulty Report (SDR), the company reported a “right engine auto shutdown in flight, did not attempt restart. Troubleshooting in progress.” It is unknown what the final remedy was for that engine.

In July, PenAir Flight 2051 was en route from Anchorage to Dillingham when it suffered the loss of the right engine near its destination. As later detailed in a passenger complaint submitted to the FAA, the flight crew chose to turn around and fly all the way back to Anchorage on only one engine.

PenAir subsequently reported in an SDR that there was a “RT engine overtemp in cruise with auto shutdown” and that the engine was to be removed and replaced. Additionally, in a separate SDR the same day, the company reported a problem with the aircraft’s left engine, which went to “0 PU’s 5SEC.” The remedy was for that engine also to be replaced.
No mention of the problems with the left engine nor the necessary replacement of both engines was passed on to the passenger who filed the complaint. Neither was an explanation provided for the flight crew’s decision to forgo immediate landing at the nearest suitable airport (as required by federal regulation 121.565).

FAA Safety Inspector David Friend wrote to the passenger, a licensed pilot from the Bristol Bay region, that “it has been determined that the flight crew acted within the scope of all applicable Federal Aviation Regulations and associated PenAir Operations Specifications.” In a subsequent Freedom of Information Act request I submitted for a deviation of 121.565 report, the FAA responded that nothing pertaining to my request existed.

Months later, in the days after the crash of Flight 3296, Ravn announced a shift to using Dash-8 aircraft on the route and company management initiated a concerted effort to deflect blame to the Saab 2000. In an October 25 town hall meeting, CEO Dave Pflieger said Ravn would “need to go through a multifaceted process to ensure it is safe to land Saabs in Unalaska before they can return to service there.” This negative sentiment was echoed by Ravn’s new management, which acquired the PenAir and Corvus Airlines certificates along with several Dash-8 aircraft in a private sale last summer. In a July interview with KUCB, that company’s CEO, Rob McKinney, responded to questions about safe operations in rural Alaska by commenting on the crash of Flight 3296. “The Saab 2000 has a narrower margin of safety,” he asserted, “so that… potentially was a contributory cause of that unfortunate accident last year.”

Both Pfleiger and McKinney’s assessments ran sharply counter to the more than two years of accident-free flying with the aircraft under the Seyberts’ ownership, including thousands of flights into Unalaska. Further, from the time the Saab 2000s were acquired by the Seyberts and long before they were put into service, there was extensive flight testing, upgrades, modifications and certifications required for their transition to Part 121. All of this was heavily supervised by the FAA. By the time PenAir was purchased by Ravn in October 2018, there was nothing left for the Saab 2000 to prove; the aircraft simply needed the company to assign pilots who were trained how to fly it.

For now, Alaska Airlines flies scheduled service into Cold Bay, with continuing service to Unalaska provided by Grant Aviation. Alaska Central Express offers both regular cargo flights and passenger charter service and other operators, including Dena’ina Airtaxi, Alaska Air Transit, Resolve Aviation and Security Aviation also fly passenger charters. The Saab 2000s, which were leased by PenAir, have been parked at Anchorage International by their Florida-based owner since Ravn’s collapse. They will likely be relocated to the Lower 48 for maintenance and storage in the near future.

The NTSB’s final report on Flight 3296 should be released early next year. What it will reveal about problematic risk management assessments at all levels of the company is of great interest to anyone following aviation safety in Alaska. And while the detrimental fallout from the subsequent pandemic can not be ignored, it must be noted that Ravn was the only Alaska aviation company of significant size to file for bankruptcy after the virus. Further, although Ravn destroyed numerous financial, professional and customer relationships, many other companies shouldered the pieces it left behind while still continuing to navigate the current uncertain economic landscape.

The easiest thing in the world would be to dismiss PenAir’s summer engine problems and the decisions leading up to the Unalaska crash, disregard how long Ravn’s $90 million worth of unpaid bills were accruing, pay no attention to the likely sky-high fleet insurance the company was paying and simply blame everything that happened to it on the coronavirus. But just like the transparent attempt to shift responsibility of the Flight 3296 tragedy onto the aircraft, this would also require a determination to blindly ignore so many events leading up to Ravn’s demise, including its 16 accidents and incidents over the previous ten years. It is worth noting the most recent of those was not Flight 3296, but rather a gear-up landing by Hageland Aviation in Fairbanks, four months before Ravn shut down. It was easy to miss that one when the company was so loudly insisting everything was COVID-19′s fault.

Link: https://www.adn.com/opinions/2020/10/21/one-year-later-the-crash-of-flight-3296/

UN body advises Pakistan to stop issuing pilots’ licenses: Report

United Nations logo

Advice comes after Pakistan opened a probe into allegations that many airline pilots have been issued fake credentials.

The International Civil Aviation Organization (ICAO) has advised Pakistan to undertake “immediate corrective actions” and suspend the issuance of any new pilot licenses in the wake of a scandal over falsified licenses, according to an official and a document seen by the Reuters news agency.

The recommendations from ICAO, a specialised agency of the United Nations that works to ensure safety in international air transport, come days after Pakistan opened a criminal probe into 50 pilots and five civil aviation officials who allegedly helped them falsify credentials to secure pilot licences.

“Pakistan should improve and strengthen its licensing system to ensure that it takes into account all necessary processes and procedures and prevents inconsistencies and malpractices before new licenses are issued and privileges of suspended licenses are re-established,” the ICAO said in a previously unreported letter to the Pakistan Civil Aviation Authority (PCAA) last week.

A Pakistan International Airlines Airbus A320 crashed into a residential area of Karachi, Pakistan, on May 24, killing 98 people [File: Shahzaib Akber/EPA]
A Pakistan International Airlines Airbus A320 crashed into a residential area of Karachi, Pakistan, on May 24, killing 98 people [File: Shahzaib Akber/EPA]

A Pakistani aviation ministry official told Reuters that the country has not issued any new licenses since July, in the wake of the scandal.

A spokesperson for Pakistan’s aviation ministry, who is also a spokesperson for the PCAA, was not immediately available for comment on the ICAO advisory when contacted by Al Jazeera.

Al Jazeera reported in July claims by Pakistani pilots that fraud and improper flight certification practices at the country’s civil aviation regulator were rampant, and that air safety has routinely been compromised by airlines through faulty safety management systems, incomplete reporting and the use of regulatory waivers.

Pakistan International Airlines (PIA), the country’s largest airline and only major international carrier, was at the centre of most of the air safety complaints, and has denied all of the allegations.

The country’s aviation minister has said that almost a third of all licensed Pakistani pilots had obtained their certifications fraudulently.

A troubled record
His comments came weeks after a PIA passenger jet crashed in May in the southern city of Karachi, killing 98 people.

Pakistan has had a troubled aircraft safety record, with five significant commercial or charter airliner crashes in the last 10 years alone, killing 445 people.

In the same period, there have been numerous other non-fatal safety incidents, including engines shutting down in mid-flight or on takeoff, landing gear failures, runway overruns and on-the-ground collisions, according to official reports and pilot testimony.

In 2019, Pakistan’s aviation industry registered 14.88 accidents per million departures, according to the ICAO, far above the global average of 3.02.

The Montreal-based agency’s recommendations come ahead of an ICAO audit to assess the country’s aviation safety management systems.

The ICAO audit, originally scheduled for November this year, has been moved to June, effectively giving the PCAA more time to work on reforms, the official said.

An ICAO representative declined to comment to Reuters on specific details of the advice to Pakistan, but said in an email that ICAO is “helping Pakistan to recognise concerns, and if they do not take swift action on them we will actively notify other countries about them.”

The pilot scandal has tainted Pakistan’s aviation industry and hurt PIA, which has been barred from flying into Europe and the United States.

In addition to revoking the licenses of 50 pilots, Pakistan has also suspended another 32 pilots for a year.

Link: https://www.aljazeera.com/economy/2020/9/25/un-body-advises-pakistan-to-stop-issuing-pilots-licenses-reporthttps://www.aljazeera.com/economy/2020/9/25/un-body-advises-pakistan-to-stop-issuing-pilots-licenses-report

House Report Condemns Boeing and F.A.A. in 737 Max Disasters

Here I share Final Committee Report – The Design, Development and Certification of the Boeing B737 Max from MAJORITY STAFF OF THE COMMITTEE ON TRANSPORTATION AND INFRASTRUCTURE (The House Committee on Transportation and Infrastucture), USA Congress

A committee’s Democrats say two fatal crashes were a “horrific culmination” of engineering flaws, mismanagement and oversight lapses.

A congressional report released on Wednesday followed an 18-month investigation of two Boeing 737 Max crashes that killed 346 people.
A congressional report released on Wednesday followed an 18-month investigation of two Boeing 737 Max crashes that killed 346 people.Credit…Lindsey Wasson for The New York Times

The two crashes that killed 346 people aboard Boeing’s 737 Max and led to the worldwide grounding of the plane were the “horrific culmination” of engineering flaws, mismanagement and a severe lack of federal oversight, the Democratic majority on the House Transportation and Infrastructure Committee said in a report on Wednesday.

The report, which condemns both Boeing and the Federal Aviation Administration for safety failures, concludes an 18-month investigation based on interviews with two dozen Boeing and agency employees and an estimated 600,000 pages of records. The report argues that Boeing emphasized profits over safety and that the agency granted the company too much sway over its own oversight.

“This is a tragedy that never should have happened,” said Representative Peter A. DeFazio of Oregon, the committee chairman. “It could have been prevented, and we’re going to take steps in our legislation to see that it never happens again.”

Republicans on the committee, without issuing their own report, also called for safety improvements. But Representative Sam Graves of Missouri, the committee’s top Republican, said that while change was needed, congressional action should be based on expert recommendations, “not a partisan investigative report.”

The report was issued as the F.A.A. appeared close to lifting its March 2019 grounding order for the Max after evaluating data from test flights this summer and proposing changes to the jet. F.A.A. clearance could lead aviation authorities elsewhere to follow suit and allow the plane to fly again as soon as this winter.

Even as it strives to get the Max back into service, Boeing is contending with other challenges, including the deep downturn in air travel because of the coronavirus pandemic, and quality concerns about its 787 Dreamliner.

The congressional report on the Max identified five broad problems with the plane’s design, construction and certification. First, the race to compete with the European rival Airbus and its new A320neo led Boeing to make production goals and cost-cutting a higher priority than safety, the Democrats argued. Second, the company made deadly assumptions about software known as MCAS, which was blamed for sending the planes into nose dives. Third, Boeing withheld critical information from the F.A.A. Fourth, the agency’s practice of delegating oversight authority to Boeing employees left it in the dark. And finally, the Democrats accused F.A.A. management of siding with Boeing and dismissing its own experts.

“These issues must be addressed by both Boeing and the F.A.A. in order to correct poor certification practices that have emerged, reassess key assumptions that affect safety and enhance transparency to enable more effective oversight,” the Democrats said in the report.

A 737 Max crashed in Ethiopia last year. Investigators blamed faulty sensors for activating software that pushed the plane’s nose down.
A 737 Max crashed in Ethiopia last year. Investigators blamed faulty sensors for activating software that pushed the plane’s nose down.Credit…Mulugeta Ayene/Associated Press

The findings are largely in line with an abundance of information uncovered by federal investigators, news reporters and the committee’s preliminary work after the crashes in Indonesia in October 2018 and Ethiopia in March 2019.

Those crashes were caused in part by the MCAS system. Because the engines are larger and placed higher than those on the plane’s predecessor, they can cause the jet’s nose to push upward. MCAS was designed to push the nose back down. In both crashes, the software was activated by faulty sensors, sending the planes toward the ground as the pilots struggled to pull them back up.

The deaths could have been avoided if not for a series of safety lapses at Boeing and “grossly insufficient” oversight at the F.A.A., the Democrats argued. Internal communications at Boeing showed that several employees raised concerns about MCAS over the years, but their concerns were either dismissed or inadequately addressed, the House report said. It also accused Boeing of intentionally misleading the F.A.A., echoing a July report from the Transportation Department’s inspector general.

That report found that Boeing had failed to share critical information with regulators about important changes to MCAS and had been slow to share a formal safety risk assessment with the agency. The inspector general also said that Boeing had chosen to portray the MCAS software as a modification to an existing system rather than a new one, in part to ease the certification process, a decision that an authorized F.A.A. representative at the company agreed with, according to the congressional report.

Debris from the crash in Indonesia in 2018. Regulators could clear the 737 Max to fly again by this winter.
Debris from the crash in Indonesia in 2018. Regulators could clear the 737 Max to fly again by this winter.Credit…Beawiharta Beawiharta/Reuters

Under federal law, the agency is allowed to delegate some oversight to manufacturers, but that practice backfired at Boeing, the congressional report found.

In 2012, for example, a Boeing test pilot took more than 10 seconds to reverse an MCAS activation, a response time that he later described as “catastrophic.” Boeing cited that finding several times over the years in internal documents, but the House report found no evidence that any of the four F.A.A. representatives at the company who knew of the finding ever passed it on to the agency. Sharing the information was not required, but the failure to do so was “inconceivable and inexcusable,” the report said.

F.A.A. management came in for severe criticism over its response to the crashes. In December, the report said, Ali Bahrami, the F.A.A.’s associate administrator for aviation safety, told committee staff members that he was unaware of an internal assessment produced after the first crash that had predicted 15 more over the lifetime of the Max fleet if MCAS was not fixed.

The report also said the agency was “inexplicably slow” in turning over records.

“The F.A.A. was actually more frustrating” than Boeing, Mr. DeFazio said on a call with reporters. “I’m not sure that we ever got all of the email chains we wanted. They claimed to have a very primitive old computer system.”

The report faulted Boeing for a lack of transparency, driven in part by a desire to play down the need for simulator training for pilots. Under a 2011 contract with Southwest Airlines, for example, Boeing had promised to discount each of the 200 planes in the airline’s order by $1 million if the F.A.A. required such simulator training for pilots moving from an earlier version of the aircraft, the 737NG, to the Max. That, the committee argued, created an incentive for Boeing to withhold critical safety information from the agency.

“This report lays bare the lie that Boeing cares about safety or the hundreds of lives they have ruined,” said Yalena Lopez-Lewis, whose husband, Army Capt. Antoine Lewis, died in the Ethiopian Airlines crash. “Boeing cut corners, lied to regulators, and simply considers this the cost of doing business.”

Democrats declined to provide details of prospective legislation, but said they were working on bipartisan reforms that could be passed before the end of the year.

“We are working closely with Republicans in the hope of coming to an agreement on a reform proposal in the very near future,” Representative Rick Larsen of Washington, the chairman of the aviation subcommittee, told reporters.

In a statement, Boeing said it had learned lessons from the crashes and had started to act on the recommendations of experts and government authorities.

“Boeing cooperated fully and extensively with the committee’s inquiry since it began in early 2019,” the company said. “We have been hard at work strengthening our safety culture and rebuilding trust with our customers, regulators and the flying public.”

The revised Max design has received extensive review, the company said, arguing that once the plane is ready to fly again, “it will be one of the most thoroughly scrutinized aircraft in history.”

The F.A.A. said in a statement that it would work with the committee to carry out any recommended changes and was already making some of its own.

“These initiatives are focused on advancing overall aviation safety by improving our organization, processes and culture,” it said.

Last month, the agency announced plans to require a number of design changes to the Max before it can fly again, including updating MCAS and rerouting some internal wiring. The proposed rule is open for public comment until next week. Barring major obstacles, the agency could lift its grounding order on the plane in the weeks or months to come, allowing Boeing to prepare the planes to fly as soon as this winter.

While hundreds of orders for the jet have been canceled, several thousand remain. In some cases, customers cannot break contracts or are otherwise deeply entwined with Boeing. Many also still want to add the Max to their fleet. A new plane can last a generation and typically requires little maintenance in the first few years of use. The Max promises substantial fuel savings, too, which can add up over several decades.

Still, Boeing warned in January that the grounding would cost more than $18 billion. And that was before the severe downturn in travel caused by the pandemic. Last month, Boeing said it would expand the 10 percent cut to its work force announced in April. And the company said last week that deliveries of its 787 Dreamliner, a large twin-aisle jet used for long-distance flights, had been slowed by new quality concerns.

Link: https://www.nytimes.com/2020/09/16/business/boeing-737-max-house-report.html

Report: ATR 72-600 crew in Taiwan excursion incident did not see centreline on touchdown

Silhouette image of generic AT76 model; specific model in this crash may look slightly different
Date:20-APR-2019
Time:21:19 LT
Type:
ATR 72-600 (72-212A)
Owner/operator:Far Eastern Air Transport
Registration:B-28082
C/n / msn:1464
Fatalities:Fatalities: 0 / Occupants: 76
Other fatalities:0
Aircraft damage:None
Category:Serious incident
Location:Taichung-Ching Chuan Kang Airport (RMQ/RCMQ) –    Taiwan
Phase:Landing
Nature:Passenger – Scheduled
Departure airport:Magong Airport (MZG/RCQC)
Destination airport:Taichung-Ching Chuan Kang Airport (RMQ)
Investigating agency: TTSB

Narrative:
Far Eastern Air Transport scheduled passenger flight FE3060, an ATR 72-600 aircraft, registration B-28082, took off at
20:52 local time from Penghu Airport to Taichung International Airport, with the captain, the first officer, 2 cabin crews and 72 passengers on board.
The crew completed the approach briefing and descent preparations at about 21:03 hours and started to descend. They executed the runway 36 ILS approach at Taichung Airport. After the plane passed through Changhua, the flight crew found thunderstorms with lighting in front of the route and the destination airport. After discussion, they judged that this situation would not change shortly, while could contact the ground, the flight crew believed that the visibility would be acceptable.

At 21:18 hours, the aircraft landed on runway 36 at Taichung Airport and deviated from the runway during the landing roll. The aircraft and runway facilities were not damaged and the persons on board were safe.

Findings Related to Probable Causes
1. The flight crew did not fully correct the aircraft’s left deviation before landing. They did not see the centerline and touched down on the left side of the runway. The appropriate wet runway landing techniques was not applied, and the flight crew did not properly correct the aircraft’s left deviation tendency after landing.

Weather about the time of the incident (1319Z):
RCMQ 201221Z 31007KT 0800 R36/1600D -RA VCTS BR SCT004 BKN008 FEW016CB OVC020 23/23 Q1009 NOSIG RMK A2981 TS SW MOV VRBL
RCMQ 201300Z 34008KT 0600 R36/1400N RA VCTS FG SCT004 BKN008 FEW016CB OVC020 23/23 Q1010 BECMG 0300 RA VCTS FG RMK A2983 RA AMT 4.0MM TS S STNRY
RCMQ 201404Z 05003KT 0600 R36/1400U TSRA SCT004 BKN008 FEW016CB OVC020 23/22 Q1010 NOSIG RMK A2985 TS SW MOV E
Sources:
Accident investigation:

Investigating agency:  TTSB
Status: Investigation completed
Duration: 1 year and 3 months
Download report:  Final report

Link: https://aviation-safety.net/wikibase/224218

NTSB Illuminates Pilot Performance in AW139 Fatal

Leonardo AW139 medevac
The NTSB has reported on a July 4, 2019 fatal accident involving a private medical evacuation flight from the Bahamas to Fort Lauderdale in Florida.

The NTSB’s recently released accident docket of the July 4, 2019, Leonardo AW139 crash in the Bahamas points to pilot performance and lack of situational awareness. However, the NTSB has yet to issue a final report or conclude a probable cause of the accident.  

According to the NTSB, the AW139 crashed shortly after lifting off from a private helipad in the Bahamas shortly before 2 a.m. on a private medical evacuation flight to Fort Lauderdale, killing the pilots and five passengers. The NTSB’s performance study indicates that one minute and two seconds into the flight, the helicopter hit the water at a speed of 141 knots.

The study concludes: “While longitudinal input was not initially different from the prior 10 flights, the combination of high collective input and increasingly forward longitudinal cyclic inputs lead to significant nose-down attitudes during the flight that led to losses of altitude. A calculation of apparent pitch showed that it was possible for the pilots to have misinterpreted the helicopter’s nose-down attitude to be nose up for the entirety of the flight.” 

Other documents contained in the docket, including the transcript from the cockpit voice recorder (CVR) and human factors report, fashion a mosaic of two pilots with marginal training performance, still unfamiliar with key systems of their aircraft, and a lack of crew resource management. The accident PIC was faulted for a basic lack of skills and knowledge during initial and recurrent training in 2017 and 2018. During 2018 recurrent training, “progressive training/checking was halted and changed to traditional 61.58 training due to the applicant not reaching the required proficiency and failed more items than required.”

Meanwhile, during the SIC’s initial training, instructors noted that he struggled with the FMS and had crew resource management “issues;” could be “overwhelmed” with weather, ATC, and flying; and did not always use a checklist, which led to “momentary loss of situational awareness during the flight.” Similar to the PIC’s 2018 recurrent training, the SIC’s training reverted to 61.58 due to failures. He also scored below average for Category A takeoffs and use of the flight director. His instructor noted, “The SIC was not trained or he received substandard initial training for all the maneuvers he failed.” Additional training led to a proficiency check pass. 

Before the accident, the PIC and the SIC had flown together 14 times between November 2017 and February 2019. Ten of those flights were daylight, the other four could not be determined. On all flights, the PIC was always the pilot flying. 

Twenty-three seconds before impact, the PIC appears to recognize and momentarily recover from pitch down attitude, acknowledging, “Yeah, we were diving,” before reinitiating it. Fifteen seconds before impact, against the background of multiple electronic voice terrain warning alerts, the SIC remarked, “There was a fatal accident in the UK and this is exactly what happened there.”

Link: https://www.ainonline.com/aviation-news/general-aviation/2020-08-25/ntsb-illuminates-pilot-performance-aw139-fatal

Iran details factors involved in the shootdown of Ukraine International Airlines flight PS752

Type: Boeing 737-8KV (WL) Photographer: © Gilles Brion Registration:UR-PSR Date:23 April 2017 Operator:Ukraine International Airlines Taken at: Genève-Cointrin Airport (GVA/LSGG)
Status:Preliminary – official
Date:Wednesday 8 January 2020
Time:06:18
Type:
Boeing 737-8KV (WL)
Operator:Ukraine International Airlines
Registration:UR-PSR
C/n / msn:38124/5977
First flight:2016-06-21 (3 years 7 months)
Engines:CFMI CFM56-7B24E
Crew:Fatalities: 9 / Occupants: 9
Passengers:Fatalities: 167 / Occupants: 167
Total:Fatalities: 176 / Occupants: 176
Aircraft damage:Destroyed
Aircraft fate:Written off (damaged beyond repair)
Location:near Sabashahr (   Iran)
Phase:En route (ENR)
Nature:International Scheduled Passenger
Departure airport:Tehran-Imam Khomeini International Airport (IKA/OIIE), Iran
Destination airport:Kiev-Borispol Airport (KBP/UKBB), Ukraine
Flightnumber:PS752

Narrative:
Ukraine International Airlines flight 752, a Boeing 737-800, crashed near Sabashahr, 7 minutes after takeoff from Tehran Imam Khomeini International Airport, Iran. Al 167 passengers and nine crew members on board were killed.
The Boeing 737-800, registration UR-PSR, had landed on schedule at 00:57 hours local time at Tehran. The return leg back to Kiev was due to depart at 05:15 local time (01:45 UTC).

In the meantime, around 02:15 hours local time in Iran, numerous ballistic missiles were fired from Iran towards U.S. bases in Iraq in response to the killing of Major General Qasem Soleimani by a United States drone strike.
As a result this military operation changed the alertness level of Iran’s air defense. At approximately 04:00 the military sector informed the civil sector of the country’s Airspace Control that only the flights already detected and cleared for flight operations by the defense network could be permitted to start up. This would ensure the correct identification of civil flights by the defense network and avoiding targeting them by mistake.

At 05:49 the doors were closed and the aircraft was ready to depart. Two minuts later the flight requested the to start up the engines.

After contacting the Area Control Center, the ATC unit requested clearance for the Ukrainian flight at 05:52. The Area Control Center forwarded the request for flight PS752 to the Air Defense Coordination Center, which subsequently issued the clearance accordingly.

The aircraft then taxied to runway 29R and commenced the takeoff roll at 06:11. After takeoff the flight contacted Mehrabad Radar and was cleared to climb to FL260 and turn right after reaching 6000 feet, heading direct to the PAROT reporting point.
As the aircraft was climbing after departure, it appeared on the air defense system. However, a wrong initialisation procedure of the system’s north alignment had induced a 107-degree error in the system. Thus, the direction of objects and targets detected by this system was being observed with an increase of 107 degrees by the operator.
At 06:13:56, the air defense unit operator detected a target at his 250-degree azimuth, flying on a 52-degree course. At the same time, PS752 had been flying towards the defense system from a 143-degree azimuth. The aircraft was flying a 309-degree course.

At 06:14:21, the operator notified the specifications of the detected target to the Coordination Center over the communication network. The notification was not communicated successfully.

Meanwhile the system operator began analyzing the observable information and categorized the detected target as a threat. At 06:14:41, without receiving any response from the Coordination Center, the air defense unit operator fired a missile at the threatening target he had detected.

Under the applicable procedures, if the defense system operator cannot establish communication with the Coordination Center and does not receive the fire command, they are not authorized to fire.

The missile radio fuse was activated at 06:14:59. At that point flight PS752 was at 8100 feet at a position about 20 km west-northwest of the airport.

After the first missile radio fuse was activated, the air defense unit radar still locked on the target, and the defense system kept detecting and tracking it. By observing the continuity of trajectory of detected target, the second missile was fired at the aircraft by the operator of defense system at 06:15:11.

At 06:45:24, the last communication between the missile and the defense system was recorded in a place close to the aircraft route. After that, the defense system showed a message indicating the strike had failed, with the aircraft clearing from the radar lock-on after some time.

The aircraft turned to the right and about 06:16:11, a fire broke out on the aircraft, which was intensifying. Altitude was lost and at 06:18:23, the aircraft crashed into a playground in Khalajabad near Shahedshahr area, 15 km north of the airport. It disintegrated completely and wreckage was strewn along a 300 m long path.

Accident investigation:

Investigating agency: AAIB Iran 
Status: Investigation ongoing
Accident number: Factual report
Download report: Preliminary report
Classification: Shot down from the ground
Loss of control

METAR Weather report:02:44 UTC / local time:
OIIE 080200Z 28006KT CAVOK M01 / M04 Q1021

Photos of Ukraine International Airlines Boeing 737-8KV (WL) UR-PSR:

Type: Boeing 737-8KV (WL) Photographer: © Arno Janssen; Jetfotos.de Registration: UR-PSR Date: 25 March 2018 Operator: Ukraine International Airlines Taken at: Düsseldorf International Airport (DUS/EDDL)

Link: https://aviation-safety.net/database/record.php?id=20200108-0

Hong Kong Express investigates ground collision of two aircraft at Hong Kong International Airport

Luckily both aircraft were empty at the time. Photo credit: Getty Images
  • Luckily both aircraft were empty at the time.

Many of us know how expensive a nose-to-tail can be in a car, but imagine the cost when two multi-million dollar aircraft collide.

That’s the case for airline Hong Kong Express, which has had two of its Airbus A321 aircraft collide on the tarmac at Hong Kong International Airport.

The crew of the aircraft registered as ‘B-LEF’ probably couldn’t believe what had happened when its tug drove the A321 into the back of ‘B-LEG’, which was parked at a gate at the time.

“While a Hong Kong Express aircraft without passengers onboard was being towed on the taxiway by ground handling staff of China Aircraft Services Limited, it collided with a parked aircraft, also of the same airline,” the airline spokesperson said.
“The airline is currently communicating with its service provider and undertaking a detailed investigation of the incident.

“Both aircraft were damaged.”

Local police confirmed they were called to Chek Lap Kok following the incident which took place before 10am on Wednesday (local time) and would be submitting a report to the Civil Aviation Department.

“There was a minor collision between two aircraft and no casualties were reported,” a police spokesperson told the South China Morning Post.

The handling of the aircraft by the contracted third party was forming part of the airline’s investigation.

Hong Kong Express is a low-cost airline and operates single-class economy aircraft, the total capacity of the Airbus A321s is around 230 passengers.

Link: https://www.newshub.co.nz/home/travel/2020/08/hong-kong-express-investigates-ground-collision-of-two-aircraft-at-hong-kong-international-airport.html

European Air Safety Agency maintains ban on PIA flights

The European Air Safety Agency (EASA) has rejected the appeal of Pakistan International Airlines (PIA) for resumption of flights, instead deciding to extend the ban on PIA flights till December 31, 2020. However, the extension in the ban is conditional on the measures taken by Pakistan’s civil aviation, Business Recorder reported on Thursday.

The European Air Safety Agency (EASA) had issued a six-month ban on all PIA flights to Europe on July 1. The United Kingdom and the USA also followed suit banning all PIA flights. These bans came after the inquiry report regarding the crash of PIA flight 8303, operated by Airbus A320 came out.

Earlier, in June, Aviation Minister Ghulam Sarwar also said that 260 of 860 Pakistani pilots, including 141 PIA pilots, never sat for the exams and that their licenses were fake, which also culminated to PIA’s woes.

Link: https://profit.pakistantoday.com.pk/2020/08/13/european-air-safety-agency-maintains-ban-on-pia-flights/

Report: Boeing 747-400 nearly hit the ground after descending below MDA at Tokyo-Haneda Airport

Silhouette image of generic B744 model; specific model in this crash may look slightly different
Aircraft Photo of HS-TGX | Boeing 747-4D7 | Thai Airways International | AirHistory.net #261293
Date:11-APR-2018
Time:23:50 LT
Type:
Boeing 747-4D7
Owner/operator:Thai Airways International
Registration:HS-TGX
C/n / msn:27725/1134
Fatalities:Fatalities: 0 / Occupants: 384
Other fatalities:0
Aircraft damage:None
Category:Serious incident
Location:8km northeast of Tokyo International Airport/Haneda (HND/RJTT) –    Japan
Phase:Approach
Nature:Passenger – Scheduled
Departure airport:Bangkok Suvarnabhumi Airport (BKK/VTBS), Thailand
Destination airport:Tokyo International Airport/Haneda (HND/RJTT), Japan
Investigating agency: JTSB

Narrative:
A Boeing 747-400 of Thai Airways International, operating flight THA/TG660 from Bangkok/Suvarnabhumi, Thailand to Tokyo/Haneda, Japan, experienced “Too Low” EGPWS warning during a night time approach to runway 16L of Haneda.

The flight was cleared for a VOR A approach for runway 16L after DARKS arrival. The aircraft arrived from the east and after passing over DARKS, aircraft have to cross SAZAN at or above an altitude of 1,100 ft while descending at a bearing of 274 ° toward Haneda VOR/DME (HME), and enter a circling approach (down-wind leg of runway 16L) after visually recognizing runway 16L and with turning to the right. Normally, pilots visually select a route in circling approach and approach landing runway. However, noise abatement procedures require aircraft to fly along or inside a specified course for landing on runway 16L.

In circling, MDA is established as a minimum altitude applied until commencing visual descending for landing. MDA in this approach procedure is 760 ft.

TG660 howefer, immediately began turning on the down-wind leg of runway 16L directly after crossing SAZAN, which was outside the specified approach procedure.
Both the PIC and the FO then visually recognized lights that appeared to be the approach guidance lights ahead in the left. The PIC commenced the base turn by turning left in an attempt to enter inside the designated course using the landmark beacon as a reference because the PIC realized that the aircraft was off the designated course.
The FO performed altiude an call-out passing over 500 ft. The PIC continued the approach saying, “Check, continue” in response to the call-out of the FO because runway was always visible.

Tokyo Tower then radioed : “Your altitude is too low, confirm, do you have runway 16L insight?”. Flight 660 responded saying, “Negative”.

Due to the low altitude, the PIC could not visually the recognize approach light beacon of runway 16L which was blocked by the container piers ahead on the left and lost sight of runway 16L.

Two seconds later the EGPWS caution “TOO LOW TERRAIN” was enunciated at an altitude of 304 ft (93 m).
The flight reported to Tokyo Tower “Now going around”. The lowest altitude the aircraft recorded was 282 ft (86 m).
The Boeing executed a go-around, and made a safe landing on runway 22 about 15 minutes later at 00:04 LT of 12 April.

Similar incident has happened on 22 December 2016, i.e. an A320-214 of Peach Aviation aligned wrong runway 23 of Haneda during a VOR A approach for runway 16L after DARKS arrival.

PROBABLE CAUSES
In this serious incident, it is probable that the Aircraft maneuvered an emergency operation to avoid crash into the ground because it came close to the ground surface in approach to Runway 16L at Tokyo International Airport.

It is probable that coming close to the ground was caused by the PIC’s concentration on modifying the lateral flight path continuing descent without paying an appropriate attention to the descent path, and by the FO’s unawareness of the too low descent path due to his concentration on monitoring the lateral path course.

Weather about the time of the serious incident (23:50 LT/14:50Z)
RJTT 111400Z 17014KT 9999 FEW015 SCT035 BKN050 18/15 Q1009 TEMPO 20018G28KT
RJTT 111500Z 19013KT 9999 FEW015 SCT025 BKN060 19/15 Q1009 NOSIG

Sources:
http://jtsb.mlit.go.jp/jtsb/aircraft/detail2.php?id=2211
https://www.flightradar24.com/data/flights/tg660#1100c236

Accident investigation:

Investigating agency: JTSB
Status:Investigation completed
Duration:2 years and 3 months
Download report:  Final report

Link: https://aviation-safety.net/wikibase/209441

Korean Air flight flew to Japan with mechanical damage: BAI

(Yonhap)
(Yonhap)

Korean Air flew a damaged plane in 2018 without being aware of it until landing in Japan, and then falsely reported that the damage happened after the flight, an audit report said Friday.

According to the report issued by the Board of Audit and Inspection, the South Korean flag carrier filed a false report to the Transport Ministry after discovering that its plane leaving from Incheon to Kansai, Japan, in April of 2018 had been damaged near the cover of the its engine inlet before take-off.

The airline had changed the location and the time of when the damage occurred in its report, the BAI said.

The audit found that Kansai Airport had discovered the damage and reported it to the Incheon International Airport Corporation. IIAC then passed the information on to Korean Air but was found to have not reported the case directly to the Transport Ministry as of November last year.

In response to the BAI report, Korean Air denied having falsely reported the case, explaining it filed the incident with the Transport Ministry within 72 hours, and that they had specified Kansai airport as the point of discovering the damage, as the details of the incident were not clarified at the time.

The airline later received 400 million won in compensation from IIAC as the damage was deemed to have been caused by the airport crew.

Meanwhile, the BAI said between 2017 and 2018, nine cases of accidents and negligence, were not reported to the ministry, including entering taxiways without due notice and a collision between a plane and a boarding bridge.

Link: http://www.koreaherald.com/view.php?ud=20200731000700