BEA releases final report on Air France Airbus A380 fan failure accident over Greenland

Status:Final
Date:Saturday 30 September 2017
Time:ca 09:45
Type:
Airbus A380-861
Operator:Air France
Registration:F-HPJE
C/n / msn:052
First flight:2010-08-10 (7 years 2 months)
Total airframe hrs:27184
Engines:Engine Alliance GP7270
Crew:Fatalities: 0 / Occupants: 24
Passengers:Fatalities: 0 / Occupants: 497
Total:Fatalities: 0 / Occupants: 521
Aircraft damage:Substantial
Aircraft fate:Repaired
Location:over southern Greenland (   Greenland)
Phase:En route (ENR)
Nature:International Scheduled Passenger
Departure airport:Paris-Charles de Gaulle Airport (CDG/LFPG), France
Destination airport:Los Angeles International Airport, CA (LAX/KLAX), United States of America
Flightnumber:AF066

Narrative:
An Air France Airbus A380, operating flight 66 from Paris-Charles de Gaulle Airport, France, to Los Angeles International Airport, California, USA, diverted to Goose Bay, Canada after suffering an uncontained GP7270 engine failure over Greenland.
The aeroplane took off at 09:50 UTC with the three pilots (the captain and two first officers, FO/1 and FO/2) in the cockpit. The cruise altitude (FL 330) was reached around 25 minutes later. The crew agreed on the division of the rest time. FO/2 took the first duty period around 30 minutes after take-off. The aeroplane changed levels several times during the cruise and then stabilized at FL370 at 11:14.
At 13:48, the crew asked Gander Oceanic to climb to FL380. The controller accepted and asked them to report when reaching FL380. The low pressure compressor and turbine rotation speed (N1) of the four engines increased from 98% to 107%.
At 13:49, the titanium fan hub of the right outer engine (No 4) separated into at least three parts. This failure was the result of the progression of a crack originating in the part’s subsurface. The central fragment of the hub stayed attached to the coupling shaft between the low pressure compressor and the low pressure turbine. The two other hub fragments were ejected, one upwards and the other downwards. The interaction between the liberated fan rotor fragments and the fixed parts of the engine caused the destruction of the engine casing and the separation of the air inlet which fell to the ground. Debris struck the wing and airframe without affecting the continuation of the flight.

After the failure, the aeroplane’s heading increased by three degrees to the right in three seconds, and there were vibrations in the airframe for around four seconds.
The crew perceived these variations and associated them with engine surging by analogy with the sensations reproduced in simulator sessions. An “ENG 4 STALL” ECAM message came up. The captain requested the “ECAM actions”. He engaged Autopilot 1 and indicated that he was taking the controls and would thus be Pilot Flying. He reduced engine No 4 thrust by positioning the associated lever to IDLE. The engine performed an automatic shutdown and the FO/2 confirmed the sequence by depressing the Engine 4 Master and Engine 4 fire pushbuttons, a few seconds later.

The damaged engine could not be seen from the cockpit or in the image from the camera located on the fin of the A380. A member of the cabin crew brought to the cockpit, a photo of the engine taken by a passenger with his smartphone.
FO/1 who had returned to the cockpit to help the flight crew on duty, went to the upper deck to assess the damage and take other photos. He observed damage on the leading edge slats and small vibrations in the flaps.

From the time of the failure and for around 1 min 30 s, the CAS had decreased from 277 kt to 258 kt and level flight at FL370 was maintained. The captain noticed this reduction in speed and decided to descend to the drift-down level calculated by the FMS (EO MAX FL 346) to maintain a constant speed in level flight. Observing that it was not possible to hold this level and this speed, he continued descending level by level. He selected FL 360, FL 350 then FL 330 and lastly FL 310. The level by level descent obliged the crew to stop their ECAM actions each time a descent was initiated. During level flight at FL310, the N1 rotation speeds of the three remaining engines decreased to 103%. The captain stabilized the descent to FL290 with a constant speed (CAS was 290 kt) by keeping the three engines in maximum continuous thrust (MCT). He decided to continue the descent and stabilize at FL270 in order to spare the engines to destination. The speed stabilized at 279 kt. Around five minutes after the A380 had started its descent, the controller in the Gander Oceanic control centre with which the crew were in datalink contact (CPDLC), detected the deviation from the vertical profile of the path and sent a message: “ATC NOW SHOWS YOU FL330. IS THERE A PROBLEM”.

At the same time, the control centre received an audio Mayday message from AF066, relayed by another aeroplane. One minute later, the PM replied to the CPDLC question with a MAYDAY. Direct audio communication between the flight and ATC resumed a few minutes later.

The crew decided, in agreement with Air France’s Operational Control Centre , to divert to Goose Bay airport and asked the controller for a direct route. After studying the available approaches and taking into consideration the captain’s experience and the airport’s immediate environment, the crew confirmed the selection of Goose Bay airport as the alternate airfield even though it was at a greater distance than Kangerlussuaq airport in Greenland.
The crew started the descent to Goose Bay and were cleared to carry out the RNAV GNSS RWY 26 approach. They were then cleared to land on runway 26. They configured the aeroplane for landing. On approaching the altitude of 1,000 ft, the captain disconnected Autopilot 1 and the flight director (FD) and continued the landing in manual flight. The aeroplane landed at 15:42. The taxiing phase to the stand took some time due to having to stop several times so that the airport services could collect the debris which had fallen onto the runway during the landing. At 16:22, all the engines were shut down.

Probable Cause:
Contributing factors
The following factors may have contributed to the failure of the fan hub on engine No 4:
– engine designer’s/manufacturer’s lack of knowledge of the cold dwell fatigue phenomenon in the titanium alloy, Ti-6-4;
– absence of instructions from the certification bodies about taking into accout macro-zones and the cold dwell fatigue phenomenon in the critical parts of an engine, when demonstrating conformity;
– absence of non-destructive means to detect the presence of unusual macro-zone in titanium alloy parts;
– an increase in the risk of having large macro-zones with increased intensity in th Ti-6-4 due to bigger engines, and in particular, bigger fans.
Accident investigation:

Investigating agency: BEA Status:Investigation completedDuration: 3 yearsAccident number:BEA2017-0568Download report:Final report:  https://www.bea.aero/uploads/tx_elydbrapports/BEA2017-0568.en.pdf

Link: https://aviation-safety.net/database/record.php?id=20170930-1

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

B763, Halifax NS Canada, 2019, Loss of Control During Roll Out

Contents

Description

On 4 March 2019, the crew of a Boeing 767-300 (C-FTCA) being operated by Air Canada on a scheduled domestic passenger flight from Toronto International to Halifax International as AC614 were unable to maintain directional control of their aircraft as it slowed after a night touchdown in normal ground visibility and were unable to stop it performing a slow 180° rotation during which the nose gear departed the runway paved surface before the aircraft came to a stop facing the runway landing threshold with all the landing gear on the runway. There were no injuries and inspection of the aircraft showed it was undamaged.

Investigation

An Investigation was carried out by the Transportation Safety Board of Canada (TSB) focusing primarily on the procedures associated with ensuring that active runways at Halifax were fit for use during adverse weather conditions and that the communications in that respect with aircraft landing there were also adequate. The performance of the flight crew of the aircraft involved was not examined.

What Happened

On reaching the destination vicinity, the weather was below the applicable approach minima for the runway in use so the aircraft entered a holding pattern to await the forecast improvement. After a little over half an hour, the expected improvement had occurred and radar vectors for an approach to runway 32 were given. Following a frequency change from Moncton Centre to the Halifax Terminal, the crew were advised of a just-issued SPECI which gave the prevailing visibility as (equivalent to) 1600 metres in light freezing drizzle and mist with the vertical visibility 200 feet agl and temperature and dew point both -1 °C. The controller also gave the current surface wind velocity as 350° at 20 gusting 30 knots and offered the option of a landing on Runway 23 which had just become available after snow clearance and was longer (2682 metres) than runway 32 (2347 metres) and for which a Cat 2 ILS approach was available. Despite given surface wind representing a crosswind component of between 17 and 26 knots and a tailwind component of 10-15 knots, the crew decided to take this option and the controller then passed them the most recent Runway Surface Condition (RSC) report for the runway to both the 767 crew and the crew of an Embraer aircraft (type not specified) that was number 1 for a 23 approach. This gave almost the full 61 metres width as 20% compacted snow, 80% bare and wet and the edges as 70% wet snow to a maximum height of 25mm and 30% bare and wet. It was noted that “based on this RSC, a Canadian Runway Friction Index was not provided, nor was one required”.

The Embraer aircraft landed four minutes later and its crew then advised the Halifax TWR controller that “we had the field at 300 feet, braking action was very poor, actually” and subsequently after being transferred to GND advised that the runway was “very, very icy, it’s basically a skating rink“. The TWR controller relayed the comments received from the Embraer crew after landing on runway 32 to a DHC-8 which was on approach to Runway 32 as “lights in sight at 300 feet and braking action poor on Runway 23” and then called the Halifax Terminal controller and said that the pilot of the Embraer aircraft had said that “the runway is a skating rink” and that “he barely got stopped by the end of the runway”. The Terminal controller then called the 767 crew and passed on the information provided by the Embraer crew as runway in sight at 300 feet but “the 23 rollout had been very slippery, he barely got stopped towards the end of it”.

Shortly after this, the 767 was transferred to TWR and after they had checked in, the controller asked the crew of the DHC-8 which had just landed on runway 32 for comments and the response included that “braking was good for them but they could see how it was slippery”.

The 767 was then cleared to land on Runway 23 and given a spot wind of 350° at 24 – 31 knots, with instructions to exit the runway at its end. The aircraft subsequently touched down “within the first third of the runway at an airspeed of about 140 knots” and the crew initially used full reverse and auto-braking having understood from ATC “that it was the end portion of the runway that was slippery”. However, as the speed decreased and reverse thrust was reduced, braking action became nil and as it reached about 15 knots, the aircraft began to slide. As it began to ‘weathervane’ due to the effect of the crosswind component, the Captain reported that in the absence of any steering authority, he had attempted to use asymmetric reverse thrust to correct this but the crosswind had “pushed the aircraft sideways, causing the nose wheel to roll into the snow off the right edge of the runway”. This led to the remaining forward motion of the aircraft to be translated into a slow clockwise rotation as the man gear lost traction on the icy runway and it eventually came to a stop facing in the opposite direction to landing with all the landing gear still on the runway paved surface. The aircraft was subsequently found to be undamaged and there were no occupant injuries. The passengers were disembarked to buses and taken to the terminal.

An aerial view showing the landing direction and (inset) the position of the stopped aircraft. [Reproduced from the Official Report]

Meanwhile, three minutes after the 767 event had led to the closure of runway 23, an Airbus 320 successfully completed a landing on Runway 32, but was unable to taxi off it until sand and chemicals had been applied because of ice covering the surfaces of both the runway and the exit taxiway. Runway 32 was subsequently reopened almost two hours later. After release by the TSB (at an unspecified time), the 767 aircraft was subsequently towed off the runway and runway 23 was also reopened.

The aircraft after coming to a stop. [Reproduced from the Official Report]

The Prevailing Weather and Runway Surface Conditions

Four aspects of the prevailing conditions and the airport’s response to them were reviewed:

  • Forecast and Actual Weather Conditions

It was noted that the TAF for Halifax current at the time of the investigated event was valid for 24 hours from 4½ hours prior to the event. For the period around the occurrence time, it gave the surface wind as 360°/15 knots, visibility (equivalent to) 2400 metres in light drizzle and mist and cloud overcast at 400 feet with a TEMPO (temporary) of visibility (equivalent to) 4,800 metres in light rain and mist with cloud overcast at 800 feet.

However, the actual weather was not as good as had been forecast. The METAR issued half an hour prior to the event gave the wind as 320°/19 knots, visibility (equivalent to ) 400 metres and a RVR for runway 23 (equivalent to) 1067 metres in light drizzle and fog with a vertical visibility of just 100 feet. The SPECI issued nine minutes later then gave the wind as 320° 24-29 knots, the visibility (equivalent to) 2,000 metres and a runway 23 RVR in the range (equivalent to) 900 -1,800 metres in light freezing drizzle and mist with the cloud overcast at 200 feet. Just before the 767 touched down, another SPECI gave the wind as 330° 24-31knots, visibility 3,200 metres with the overcast now at 400 feet agl. This second SPECI also recorded a drop in the surface temperature and dew point from the earlier -1°C to -2°C and a third SPECI five minutes later recorded a further drop of both to -3°C.

  • ATC Relays of Pilot Reports of Braking Action

The standard phraseology for the communication of runway braking action was noted as being ‘good’, ‘medium’ or ‘poor’ whereas after their landing on runway 32, the Embraer crew advised ATC of “very poor” braking action and further stressed this in plain language. It was noted that although NAV Canada permits its controllers to use plain language to relay information, the sense of the message must not be altered and in this case, subsequent relays to the 767 crew had not mentioned that “very” poor braking action had been reported or included any reference to the “skating rink” analogy used by the reporting crew.

  • The Airport Response to Runway Contamination by Frozen Deposits

It was noted that the responsibilities of the airfield maintenance crew on shift at Halifax included the removal of frozen deposits from runways as required and these crews are managed by an Airfield Maintenance Supervisor (AMS). Shift change time was scheduled for the same time as the 767 landed. It was found that “approaching the end of each shift, there is a period of time when the departing crew is preparing the equipment for use by the next crew (during which) the airfield may be unattended for up to 30 minutes”.

On the day of the investigated event, snow in the morning had changed to freezing rain and then rain in the afternoon and since the temperature was expected to drop below freezing in the evening, a second airfield maintenance crew was called in to assist. By early afternoon, the two crews had cleared most of the width of runway 32 to “70% bare and damp” and had begun removing snow from Runway 23 in anticipation that the forecast weather for later in the day would favour it for landing. An hour prior to the 767 landing, the duty AMS issued an RSC report which included that there were windrows of snow on either edge of runway 23 and was told by the Airport Duty Manager (ADM) that these would have to be removed before the runway could be reopened to aircraft. This was achieved after a further half hour and was communicated in another RSC report at 1808, removing the windrows comment and increasing the available width of the 61 metre-wide runway by 6 metres to 48 metres and it was then re-opened. At about this time, airfield maintenance crew day shift “was returning to the maintenance building to prepare the vehicles for the night shift”.

  • The Halifax Runway Weather Information System

The Runway Weather Information System in use at the time of the investigated event consisted of 6 sensors, 3 embedded in the centreline of each runway which detected atmospheric conditions and relayed them in real time to computer screens in the offices of the AMS and the ADM and made them accessible on the AMS’s PED as long as it was refreshed manually to ensure that the most current conditions were shown.

A little under half an hour before the time of the airfield maintenance crew shift change (and the 767 landing), the runway weather information system’s status changed from ‘wet’, which indicates the presence of a continuous film of moisture on the surface of the sensor with temperature above 0°, to ‘ice warning’ which indicates that there is a continuous film of ice and water mixture at or below 0°C with insufficient chemical present to keep the mixture from freezing.

During this time, it was found that “the ADM had not been available to monitor the conditions” and that “the AMS was returning from the airfield, issuing his revised RSC and preparing for shift change”. As a result, this important change in system status “went unnoticed”.

Three Safety Messages were formally documented upon completion of the Investigation as follows:

  • To ensure the accuracy of Runway Safety Condition (RSC) reports, it is important that a comprehensive runway inspection be performed before a report is issued, especially in times of changing weather.
  • Monitoring the airfield at all times is important, particularly during rapidly changing weather, when runway surface conditions can deteriorate quickly.
  • The use of standard phraseology between pilots and air traffic controllers may help reduce the likelihood of misunderstanding the degree to which a runway may be contaminated.

Safety Action taken as a result of the occurrence by the Halifax International Airport Authority was noted as having included the following:

  • Implementation, effective for the next winter season, of a mandatory briefing checklist to ensure that the off-going Airfield Maintenance Supervisor properly briefs their incoming replacement during shift changeovers in inclement weather.
  • Selection of a single weather forecast and observation website for use by Airfield Maintenance Supervisors to be accessed via cellular-enabled tablets mounted in their vehicles to ensure they are all using the same weather information provider.
  • Installation of an improved runway weather information system which doubles the number of sensors on the airfield and is designed to automatically refresh on the portable electronic devices used by Airfield Maintenance Supervisors.

The Final Report of the Investigation was authorised for release on 2 October 2019 and it was officially released on 9 October 2019. No Safety Recommendations were made.

Link: https://www.skybrary.aero/index.php/B763,_Halifax_NS_Canada,_2019?utm_source=SKYbrary&utm_campaign=227751b05b-%23684+Are+Safety+Management+Systems+failing+to&utm_medium=email&utm_term=0_e405169b04-227751b05b-276643500

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

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

Texas pilot warned not to fly plane before fatal 2018 Detroit crash, report says

NTSB agents work at the site of the fatal plane crash in Detroit in June 2018.
NTSB agents work at the site of the fatal plane crash in Detroit in June 2018. (Photo: Daniel Mears, The Detroit News)

A Texas pilot was warned three times not to fly his airplane before it crashed in a Detroit neighborhood in 2018, killing him and his wife and severely injuring his son, according to a federal accident investigation.

The factual report by the National Transportation Safety Board also says the pilot reported running out of fuel while struggling to get his landing gear down as the single-engine Cessna P210N approached Coleman A. Young Municipal Airport on June 24.

Pilot Greg Boaz, a restaurateur, and his wife, Julie, both of League City, Texas, died in the crash. Boaz’s 17-year-old son Peyton rolled out of the burning wreckage and was critically injured.

The family was on its way to watch daughter Krysta play in a volleyball tournament in Detroit.

The NTSB report and documents, filed June 24, detail the final moments before the crash, including the air traffic control recordings of dialogue between the plane and control tower. A final report, which will include a probable cause of the crash, is expected to be filed within a week.

Three weeks before the crash, mechanic Randy Wahlberg at the Pearland Regional Airport told Boaz that it appeared that pieces of the missing oil dipstick had gotten into the engine and “his engine needed to be overhauled since the dipstick was stainless steel and it made it through the oil pump into the filter,” according to an inspector statement in the report.

“The pilot told the mechanic that he had just purchased the airplane and that he could not afford to overhaul the engine,” the report states. “The mechanic then placed a red ‘Do Not Fly’ placard on the pilot-side yoke.”

According to the report, a couple of weeks later, Boaz came back with another oil filter for the mechanic to inspect and told him he had looked up on the internet “how to remove metal from an engine by flushing it with diesel fuel.”

While there was no metal in the filter, “the mechanic again told the pilot that he should not fly the airplane until the engine had been overhauled.”

Another airplane mechanic, Robert Mutina, told investigators that he was a personal friend of Boaz since high school. Although he had not seen the plane, he had discussed it and advised Boaz not to fly it.

According to the report, a post-crash inspection of the engine found three “small metal pieces that were consistent with remnants of the fractured oil gauge rod” as well as “numerous scratches” in the crankcase.

However, the report concluded, “The post-accident engine examination did not reveal any mechanical malfunctions or failures that would have precluded normal operation during the flight.”

The NTSB did find other reasons for concern about the fatal flight, which originated in Baytown, Texas, with a fuel stopover in West Memphis, Arkansas. According to the agency’s report, data recovered from the plane’s engine monitor showed that while cruising during six previous cross-country flights, Boas “would lean rich-of-peak” – meaning the plane consumed more fuel than expected.

The average fuel use while cruising during those flights was about 21 gallons per hour – the same level recorded during the fatal flight, according to the report. The Cessna, with a fuel capacity of 90 gallons, had used 71.6 gallons “when the recorded fuel flow suddenly dropped to zero” seconds before the crash in Detroit, the report states.

According to the Aircraft Owners and Pilots Association, a Cessna P210 normally burns about 17 gallons of gas per hour. Robert McSpadden, senior vice president of the organization’s Air Safety Institute, said the fatal flight’s cruising rate of 21 gallons per hour was unusual.

“That number seems incredibly high to me,” McSpadden said. “The pilot was flying rich-of-peak, meaning he would burn more fuel; it keeps the engine cooler. That’s typical practice. But 21 just seems really high.”

The fuel selector valve was set to draw fuel from the right-wing tank, the report added, instead of drawing fuel from both tanks simultaneously.

“This may not have been a situation of fuel exhaustion, but of fuel starvation,” McSpadden said.

Upon approaching the airport in Detroit at 7:48 p.m., the pilot told the control tower that his land gear had not locked into place, according to the report. The pilot then requested to land on the infield next to the runway.

“It’s not unusual for a plane to land without landing gear engaged on an airstrip,” McFadden said. “All the gear would just have to be retracted.”

Harro Ranter, CEO of Aviation Safety Network, said it “remains to be seen” how the aircraft ran out of fuel. Ranter speculated that either the pilot misread the fuel gauge or was so fixated on the landing gear issue that he neglected to watch it.

A faster burn rate of fuel would mean that a pilot would use more fuel than expected to reach his destination. Pilots are required to have enough fuel on board to reach their destination plus 30 minutes of additional flying during day flights, according to FAA regulations.

McSpadden added: “Seventy-five percent of aviation accidents are pilot errors. There are a lot of clues that show that there was something else wrong with this flight.”

Boaz, 54, was owner of two Texas venues, Lone Star Grill in Bacliff, Texas and Palapa Bar, a nightclub, in Kemah. Julie Boaz was 48. The couple was recently married and were survived by children Tyler, Krysta and Peyton and Daniel Costano Jr. and Cecilia Costano, according to an obituary with Carnes Funeral Home.

Link: https://www.detroitnews.com/story/news/local/detroit-city/2020/08/01/houston-area-pilot-warned-not-fly-plane-before-fatal-detroit-crash/5521343002/