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/

FAA chief will pilot Boeing’s 737 MAX in Seattle Wednesday as ungrounding nears

Federal Aviation Administration (FAA) chief Steve Dickson on Wednesday will fulfill a promise he made just months after taking command of the regulatory agency in the midst of Boeing’s 737 MAX crisis.

“I am not going to sign off on this aircraft until I fly it myself and am satisfied I would put my own family on it without a second thought,” Dickson told FAA employees last November.

On Wednesday he’ll take off from Boeing Field in a high-profile test flight intended as Dickson’s personal assurance to the public that the MAX is safe following 19 months of intense scrutiny by his agency.

It’s the clearest signal yet that the FAA is poised to unground the jet in late October or early November.

The MAX was grounded worldwide in early March 2019 after the second of two fatal accidents that together killed 346 people aboard almost-new aircraft. A series of investigations established that the pilots on the Lion Air and Ethiopian Airlines jets struggled against a flawed flight control system on the MAX that overcame their commands.

Since then, the FAA and international regulators have been minutely examining the fixes proposed by Boeing.

As the company girds against the new existential threat posed by the historic pandemic-driven aviation downturn, Dickson’s flight is a high-stakes moment.

For the MAX crisis that has consumed Boeing, shattering its plans for accelerated production and causing the loss of significant market share to rival Airbus, it could perhaps at last be a turning point.

Dickson tests Boeing’s fixes
Dickson’s MAX test plane is scheduled to depart from Boeing Field at about 9 a.m. and is expected to fly for about two hours. Dickson will brief reporters after landing, at a news conference around 11:30 a.m. that will be broadcast live on the FAA’s website and social-media platforms.

On Tuesday in Seattle, Dickson and FAA Deputy Administrator Dan Elwell completed the recommended new pilot training for the MAX as part of the preparation for the flight.

Dickson is a former Air Force F-15 jet fighter pilot, and as a captain with Delta Air Lines he flew the previous models of the 737 as well as other Boeing and Airbus jets. At Delta, he rose to senior vice president of flight operations, responsible for the safety and operational performance of the airline’s global fleet.

He took charge of the FAA in July 2019.

Testifying in December before the U.S. House Transportation Committee, Dickson reiterated the FAA position that “when the 737 MAX is returned to service, it will be because the safety issues have been addressed and pilots have received all the
training they need to safely operate the aircraft.”

Last December, Dickson starkly rebuked Boeing’s then-CEO Dennis Muilenburg for seeming to push for clearance to fly the MAX by the end of that month.

In August, the FAA laid out the proposed design changes on the MAX that it believes will make it safe. The proposals drew more than 200 comments from the public and aviation experts.

As the ungrounding approaches, foreign aviation regulators are lining up their own requirements and Congress is beginning to consider legislation to reform the process through which the FAA certifies airliners.

Last week, the executive director of the European Union Aviation Safety Agency (EASA), Patrick Ky, said publicly that his agency expects to sign off on ungrounding the 737 MAX in November.

EASA will stipulate further changes beyond those in the FAA proposal, but Ky said those can be retrofitted after the jet’s return to service and so won’t delay the MAX’s ungrounding.

And on Monday, the House Committee on Transportation announced a bipartisan legislative proposal designed to strengthen the FAA certification process.

However, at this point ahead of the election, it’s unlikely new legislation can be passed before next year.

An FAA report detailing the required pilot training must be published, with a period for public comment.

And a multi-agency Technical Advisory Board must review the final design documentation and issue its report.

Federal Aviation Administration administrator Steve Dickson speaks to journalists at the Dubai Airshow in November 2019. Dickson will fly Boeing’s updated 737 MAX  Wednesday to assure the public the jet is now safe. (Jon Gambrell / The Associated Press)
Federal Aviation Administration administrator Steve Dickson speaks to journalists at the Dubai Airshow in November 2019. Dickson will fly Boeing’s updated 737 MAX Wednesday to assure the public the jet is now safe. (Jon Gambrell / The Associated Press) 

Link: https://www.seattletimes.com/business/boeing-aerospace/faa-chief-will-pilot-boeings-737-max-in-seattle-wednesday-as-ungrounding-nears/

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

Helikopter Milik PT NUH Hilang Kontak dalam Penerbangan dari Nabire Papua

DSCF0056
Foto helikopter jenis Bell 212 dengan registrasi PK-USS dari weblog
https://donibrahimovic.wordpress.com/2016/08/07/catatan-perjalanan-carstensz-pyramid/

Jayapura – 

Satu unit helikopter milik PT National Utility Helicopters (NUH) dilaporkan hilang kontak ketika terbang dari Bandara Nabire, Papua. Kepala Bandara Nabire, M Nafiq menjelaskan, helikopter yang membawa tiga orang itu hilang kontak sejak pukul 10.16 WIB atau 12.06 WIT.

“Kita masih cek di lokasi, sudah ada sinyal emergency yang keluar. Tapi sinyal emergency itu bisa sengaja dihidupkan atau karena tabrakan, itu yang kita belum tahu,” ujar Nafiq saat dihubungi, Kamis (17/9/2020).

Nafiq belum bisa memastikan dimana titik sinyal darurat yang dikeluarkan oleh helikopter PT NUH itu. Titik koordinatnya juga belum diketahui.

“Tadi kita sudah berangkatkan satu pesawat untuk mengecek lokasi itu, hanya cuaca mendung jadi kita tidak tahu apa bisa terlihat atau tidak. Kalau belum bisa, kita tunggu besok pagi atau siang kalau cuacanya bagus karena sekarang mendung, awannya rendah sekali. Kalau dipaksakan malah membahayakan yang nyari karena itu daerah pegunungan,” sambung Nafiq.

Menurut dia, helikopter tersebut bisa saja melakukan pendaratan darurat karena kondisi cuaca atau ada gangguan pada mesin pesawat. Nafiq mengatakan hal itu biasa dilakukan apabila helikopter membutuhkan lahan terbuka untuk mendarat.

“Heli itu biasanya kalau ada tempat terbuka saat cuaca buruk dia mendarat sementara, karena mungkin dia tidak sempat kasih tahu dia nyalakan sinyal daruratnya supaya stationnya tahu dia ada di posisi itu, semoga itu yang terjadi,” tutur Nafiq.

Hely bell 212 milik PT NUH, menurut Nafiq tengah mengangkut kargo berupa bahan makanan. Rute penerbangan heli tersebut ada di sekitar Nabire hingga Paniai.

“Di dalam heli ada tiga orang dan infonya mereka bawa kargo bahan makanan. Heli itu terbang di satu area pegunungan, jadi dia mampir-mampir, satu hari itu dia terbang di area itu,” kata Nafiq.

Dari informasi yang didapat, heli milik PT NUH terbang dari Nabire menuju kawasan Baya Biru, Kabupaten Paniai.

Link : https://news.detik.com/berita/d-5177045/helikopter-milik-pt-nuh-hilang-kontak-dalam-penerbangan-dari-nabire-papua

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

NTSB EXTENDS TERM FOR GA SAFETY EXPERT LANDSBERG

NTSB Vice Chairman Bruce Landsberg, an aviation safety expert who is a familiar face to general aviation pilots, will serve in his NTSB leadership role for three additional years, the board announced August 26.

The former AOPA Air Safety Institute executive director was appointed to a five-year NTSB board position in August 2018 when he was also designated the NTSB’s vice chairman for a two-year term.

Landsberg is a respected aviation safety advocate and a 7,000-hour pilot who holds an airline transport pilot certificate as well as single-engine, multiengine, and instrument flight instructor certificates.

He has been an AOPA member for more than 40 years and is often seen piloting his pristine Beechcraft Bonanza A36.

“Bruce brings a wealth of experience to the NTSB with his extensive general aviation safety background,” said NTSB Chairman Robert Sumwalt. “While serving as vice chairman during the past two years, Bruce has provided great assistance to me in my role as chairman. I’m delighted that President Trump has allowed him to continue in that capacity for another three years.”

Landsberg is advocating for several GA safety recommendations during his term. He would like to see a more user-friendly notam system, as well as improved weather forecasts and the reduction of weather-related aviation crashes through more extensive in-flight weather reporting by pilots.

He also supports a reduction in driving distractions and speed-related highway crashes, reliable automation in vehicles, and automated enforcement on highways.

Bruce Landsberg. Photo by Christopher Rose.
Bruce Landsberg. Photo by Christopher Rose.

Link: https://www.aopa.org/news-and-media/all-news/2020/august/27/ntsb-extends-term-for-ga-safety-expert-landsberg

UN’s ICAO to conduct another audit of India’s air safety readiness

airlines, flights, aviation, plane, runway, airport
“We changed the system and now DGCA has almost completed licensing all 2,500 ATCO officials,” the official said.

The UN’s aviation watchdog International Civil Aviation Organization (ICAO) has decided to conduct another safety audit of India’s air safety readiness.

The audit, which was pre-planned, assumes significance as it comes in the aftermath of the Air India Express crash in which 20 people were killed, including the pilot and the co-pilot, and several others were injured when the flight from Dubai with 190 people onboard overshot the runway at Calicut airport and fell into a valley.

“An ICAO team was supposed to come for an audit in November, but due to the Covid-19 pandemic and border closures, the audit has been postponed to January. ICAO team will check safety aspects of airlines, airports, ground handling firms, regulatory bodies to ascertain that they are upto the international standards,” said an official aware of the development.

ICAO had carried out the Universal Safety Oversight Audit Programme for India in November 2017, followed by a second audit in February 2018. The audit result showed that the country’s score declined to 57.44 per cent from 65.82 per cent earlier, placing India below Pakistan, Nepal and many other nations.

However, subsequently, the civil aviation ministry and aviation regulator DGCA took steps, following which the score improved to 74.

ALSO READ: Covid-19-hit aviation industry requires $5 bn to stay afloat: CAPA

During its audit, ICAO looks at eight areas. These include primary aviation legislation and civil aviation regulations, civil aviation organisation, personnel licensing and training, aircraft operations and airworthiness of aircraft.

The outcome of the audit score is crucial for Indian airlines as it could impact their international expansion plans.

During its audit in 2012, ICAO had placed India in its list of 13 worst-performing nations. This triggered an audit by US aviation regulator, Federal Aviation Administration (FAA) in 2014, which downgraded the country’s ranking, citing a lack of adequate regulatory oversight.

Indian airlines were not allowed to add new routes to the US or sign commercial agreements with US airlines during this period. The rating were restored one year later.

“Naturally when there has been an accident where lives were lost, an ICAO audit is significant, but we are well prepared. The accident investigation is also taking its own course and by the time ICAO is here, it will be completed. We are also keeping ICAO updated about the progress in investigation,” the official said.

The primary issue pointed out during the 2017 and 2018 audit by ICAO was to make DGCA licensing authority for ATC officers. Earlier, Airports Authority of India (AAI), which is also ATC service provider, had been licensing ATCOs. ICAO considered it a conflict of interest for the service provider to be its regulator as well. In fact, India was the only big aviation market where the safety regulator did not have authority to license ATC officers

“We changed the system and now DGCA has almost completed licensing all 2,500 ATCO officials,” the official said.

Link: https://www.business-standard.com/article/companies/icao-to-conduct-another-safety-audit-of-india-s-air-safety-readiness-120082501484_1.html

NTSB: Lawmaker in plane crash flew despite vision problems

An Alaska state lawmaker who was involved in a July midair collision that killed seven people was piloting his plane even though his medical flight certification was denied eight years ago because of vision problems, a federal agency reported Tuesday.

Alaska State Troopers identified the pilot as state Rep. Gary Knopp, 67, of Kenai, who was flying a Piper PA-12 when it collided with a de Havilland DHC2 shortly after both planes had taken off in the area of Soldotna, Alaska, on the evening of July 31.

Both airplanes crashed, killing Knopp, the other pilot and five passengers who were being flown to a remote lake for a fishing trip. The de Havilland was flown by a local pilot and carried a guide from Kansas and four people from South Carolina.

The National Transportation Safety Board, in a preliminary report on the crash issued Tuesday, wrote that a witness to the crash told investigators the northbound Piper hit the westbound de Havilland on the left side of the fuselage toward the back of the aircraft.

The unidentified male witness said he saw what he believed was the de Havilland’s left wing separate from the aircraft, and the airplane went into an uncontrolled spin toward the ground, the report said. Investigators found dark green paint from the Piper on the rear fuselage of the de Havilland, according to the report.

The crash occurred around 8:30 a.m. at about 1,175 feet with clear skies up to 8,500 feet, the report stated. The de Havilland, which was equipped with floats to land on water, took off from a nearby lake about the same time as Knopp’s plane left the Soldotna Airport.

The NTSB wrote that information on file with the Federal Aviation Administration’s Civil Aeromedical Institute showed that Knopp was denied medical certification in June of 2012 by the Alaska Regional Flight Surgeon because of vision problems. The denial was appealed and upheld a month later.

Knopp’s plane also had an invalid registration number, the NTSB said. The plane had a valid number that was registered to Knopp, but a different number was on the plane’s exterior. That number had been reserved by Knopp but was not valid, the report said.

Troopers said six of the seven people were pronounced deceased at the scene of the accident. The seventh person died while being transported to a hospital.

Besides Knopp, troopers identified the other six people killed as pilot Gregory Bell, 57, of Soldotna; guide David Rogers, 40, of Kansas; and Caleb Hulsey, 26; Heather Hulsey, 25; Mackay Hulsey, 24, and Kirstin Wright, 23, all of South Carolina.

Bell was one of the owners of High Adventure Air Charter in Soldotna, which offers bear viewing adventures, fishing and hunting trips and glacier tours, according to its website.

The two planes collided about 2 miles northeast of the Soldotna Airport, the FAA statement said after crash.

The FAA sent two investigators to the crash site, which is about 150 miles (241 kilometres) southwest of Anchorage.

Knopp, a Republican, left the House GOP caucus and served in a coalition of Democrats, independents and GOP lawmakers that comprised the House Majority. That left the remaining House Republicans in the minority.

Knopp was first elected to the state House in 2016. He served for years before that on the Kenai Peninsula Borough Assembly.

He was born in Whitefish, Montana, and moved to Alaska in 1979. He eventually settled in Kenai and worked as a general contractor.

His hobbies included flying, diving, hunting, golfing “and enjoying life in general at home on the Peninsula,” according to his legislative biography.

Link: https://finance.yahoo.com/news/ntsb-lawmaker-plane-crash-flew-204624896.html

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