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Multi-Agency Effort to Glean Facts on Asiana 777

Today at 2:30 EST, Debbie Hersman, Chairperson of the NTSB conducted an update of the Asiana 777 flight crash at San Francisco International Airport (SFO). The crash of the Boeing 777 resulted in two deaths 181 injured people. Forty-nine patients are at area hospitals after surviving the crash. Some of the important points that she made:

• The investigating parties along with the NTSB will be the FAA, Boeing, Pratt & Whitney, the Korean Aviation & Rail Association, and Asiana Airlines. Their focus will be on the operations of the aircraft, as well as human performance. The FBI has already provided GPS-based documentation and aerial photos to assist.

• All four pilots on board will be questioned; the Captain that was flying (training to receive his 777 rating), the Training Captain, and the relief Captain and First Officer (standard procedure for long international flights)

• There is no evidence of distress calls or problem reports prior to impact. The flight was vectored in to a 17 mile approach, cleared for both visual approach and landing.

• The Cockpit Voice Recorder (CVR) is a mixture of both English and Korean. It’s important to note that, despite the reports from some news agencies, there was no call for permission for a go-around – it was mentioned on the CVR only.

• The crash site has lower portions of the aircraft in the sea wall, with a significant portion of the tail in the water, and debris is visible at low tide. Seawall debris has been found several yards up the runway as well.

• Despite initial reports of one the fatalities being caused by an emergency vehicle, the coroner has not rendered an official cause of death.

• The airspeed required for landing is 137 kts, and Flight Data Recorder shows that the aircraft had already dropped to 118 kts by 200 ft (about 16 seconds from impact). At 125 ft (8 seconds to impact), the throttles were moving forward. At 3 seconds to impact, the engines were back up to 50% power, with an airspeed of 103 kts. At impact, the airspeed has only climbed to 106 kts.

NTSB To Assist Afghan Authorities With Investigation Into Bagram Cargo Plane Crash

WASHINGTON - The National Transportation Safety Board will lead a team to assist the Afghanistan Ministry of Transportation and Commercial Aviation in the investigation of a cargo plane crash at Bagram Air Base in Afghanistan.

NTSB Senior Air Safety Investigator Tim LeBaron will be the U.S. accredited representative. He will lead a team of three additional investigators from the NTSB as well as representatives from the Federal Aviation Administration and The Boeing Company.

The private cargo plane, a Boeing 747-400 operated by National Air Cargo, crashed just after takeoff from the U.S.-operated air base at 11:20 a.m. local time Monday. All seven crewmembers onboard were killed and the airplane destroyed. The seven crew members were all American citizens. The accident site is within the perimeter of Bagram Air Base.

The international cargo flight was destined for Dubai World Central - Al Maktoum International Airport, Dubai, United Arab Emirates.

The Afghanistan Ministry of Transportation and Commercial Aviation is leading the investigation and will be the sole source of information regarding the investigation. According to the International Civil Aviation Organization, they can be reached at (873) 68 2341450 / 49 or by fax at (873) 68 1280784.

Contact Information
Office of Public Affairs
490 L'Enfant Plaza, SW
Washington, DC 20594

Eric M. Weiss
(202) 314-6100
eric.weiss@ntsb.gov

NTSB: Pilot Action, Icing Led To NJ Plane Crash

Article By: David Porter
FMI: bigstory.ap.org

NEWARK, N.J. (AP) — A pilot's inability or reluctance to fly quickly enough out of icing conditions led to a fiery plane crash on a New Jersey highway median that killed all five people aboard, a federal report published Thursday concluded.

The December 2011 crash claimed the lives of pilot Jeffrey Buckalew, an investment banker; his wife and two children, and Rakesh Chawla, a colleague at New York's Greenhill & Co. Buckalew was the registered owner of the single-engine Socata TBM 700 and had more than 1,400 hours of flight time, according to the report.

The plane had just departed Teterboro Airport en route to Georgia when it began spiraling out of control at about 17,000 feet and crashed on a wooded median on Interstate 287 near Morristown. No one on the ground was injured. Wreckage was scattered over a half-mile area, forcing the closure of the busy roadway for several hours.

The National Transportation Safety Board report concluded that while Buckalew had asked air traffic controllers to fly higher and out of the icing conditions, he may have been reluctant to exercise his own authority to do so, or may have been unaware of the severity of the conditions.

The NTSB attributed the cause of the accident to "the airplane's encounter with unforecasted severe icing conditions that were characterized by high ice accretion rates and the pilot's failure to use his command authority to depart the icing conditions in an expeditious manner, which resulted in a loss of airplane control."

According to the report, an air traffic controller advised Buckalew of moderate icing from 15,000 to 17,000 feet, at which point Buckalew responded, "we'll let you know what happens when we get in there and if we could go straight through, it's no problem for us." The controller then directed him to climb to 17,000 feet.

When the plane reached 16,800 feet Buckalew reported light icing and said "a higher altitude would be great." Seventeen seconds later, he said the plane was experiencing "a little rattle" and asked to be cleared to go to a higher altitude "as soon as possible please."

The controller coordinated with a controller in an adjacent sector and, 25 seconds later, directed Buckalew to climb higher. Within about a minute the plane had reached 17,800 feet and then began an uncontrolled descent.

Ice can form on airplanes when temperatures are near freezing and there is visible moisture, such as clouds or rain. The ice adds weight to an aircraft, and rough accumulations known as rime interrupt the flow of air over wings.

Numerous pilots had reported icing conditions in the area around the time of the accident, including at least three flight crews that characterized the icing as severe, according to the report. One pilot told NTSB investigators his wing anti-icing system "couldn't keep up" with ice accumulation of as much as 4 inches that had developed over a span of five minutes.

Pilots are required to fly under the direction of air traffic controllers but federal regulations allow for some deviation in emergency situations. The NTSB report quotes a part of the Federal Aviation Regulations that reads, "in an in-flight emergency requiring immediate action, the pilot in command may deviate from any rule of this part to the extent required to meet that emergency."

NTSB Determines Fatal Missouri Helicopter Accident Was Caused By Fuel Exhaustion, Poor Decision Making And Inability To Perform Critical Flight Maneuver

WASHINGTON -- A pilot’s decision to depart on a mission despite a critically low fuel level as well as his inability to perform a crucial flight maneuver following the engine flameout from fuel exhaustion was the probable cause of an emergency medical services helicopter accident that killed four in Missouri, the National Transportation Safety Board said today.

“This accident, like so many others we’ve investigated, comes down to one of the most crucial and time-honored aspects of safe flight: good decision making,” said NTSB Chairman Deborah A.P. Hersman.

On August 26, 2011, at about 6:41 pm CDT, a Eurocopter AS350 B2 helicopter operated by Air Methods on an EMS mission crashed following a loss of engine power as a result of fuel exhaustion a mile from an airport in Mosby, Missouri. The pilot, flight nurse, flight paramedic and patient were killed, and the helicopter was substantially damaged.

At about 5:20 pm, the EMS operator, located in St. Joseph, Mo., accepted a mission to transport a patient from a hospital in Bethany, Mo., to a hospital 62 miles away in Liberty, Mo. The helicopter departed its base less than 10 minutes later to pick up the patient at the first hospital. Shortly after departing, the pilot reported back to the company that he had two hours’ worth of fuel onboard.

After reaching the first hospital, the pilot called the company’s communication center and indicated that he actually had only about half the amount of fuel (Jet-A) that he had reported earlier, and that he would need to obtain fuel in order to complete the next flight leg to the destination hospital.

Even though the helicopter had only about 30 minutes of fuel remaining and the closest fueling station along the route of flight was at an airport about 30 minutes away, the pilot elected to continue the mission. He departed the first hospital with crew members and a patient in an attempt to reach the airport to refuel.

The helicopter ran out of fuel and the engine lost power within sight of the airport. The helicopter crashed after the pilot failed to make the flight control inputs necessary to enter an autorotation, an emergency flight maneuver that must be performed within about two seconds of the loss of engine power in order to execute a safe emergency landing. The investigation found that the autorotation training the pilot received was not representative of an actual engine failure at cruise speed, which likely contributed to his failure to successfully execute the maneuver.

Further, a review of helicopter training resources suggested that the accident pilot may not have been aware of the specific control inputs needed to successfully enter an autorotation at cruise speed. The NTSB concluded that because of a lack of specific guidance in Federal Aviation Administration training materials, many other helicopter pilots may also be unaware of the specific actions required within seconds of losing engine power and recommended that FAA revise its training materials to convey this information.

An examination of cell phone records showed that the pilot had made and received multiple personal calls and text messages throughout the afternoon while the helicopter was being inspected and prepared for flight, during the flight to the first hospital, while he was on the helipad at the hospital making mission-critical decisions about continuing or delaying the flight due to the fuel situation, and during the accident flight.

While there was no evidence that the pilot was using his cell phone when the flameout occurred, the NTSB said that the texting and calls, including those that occurred before and between flights, were a source of distraction that likely contributed to errors and poor decision-making.

“This investigation highlighted what is a growing concern across transportation – distraction and the myth of multi-tasking,” said Hersman. “When operating heavy machinery, whether it’s a personal vehicle or an emergency medical services helicopter, the focus must be on the task at hand: safe transportation.”

The NTSB cited four factors as contributing to the accident: distracted attention due to texting, fatigue, the operator’s lack of policy requiring that a flight operations specialist be notified of abnormal fuel situations, and the lack of realistic training for entering an autorotation at cruise airspeed.

The NTSB made a nine safety recommendations to the FAA and Air Methods Corporation and reiterated three previously issued recommendations to the FAA.

A synopsis of the NTSB report, including the probable cause, findings and a complete list of the safety recommendations, is available at http://go.usa.gov/TxYT. The full report will be available on the website in several weeks.

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Contact Information:
Office of Public Affairs
490 L'Enfant Plaza, SW
Washington, DC 20594

(202) 314-6100
Peter Knudson
peter.knudson@ntsb.gov

When Aircraft Touch On The Ramp

It's a beautiful day. You are sitting in a chair outside your favorite FBO at the local, uncontrolled airport watching the traffic. An aircraft is taxiing onto the ramp towards an aircraft that is poorly parked too close to the taxiway line. From your perspective, it looks like it will be close, but you can't tell for sure whether the taxiing aircraft has enough room to pass the parked aircraft. The next thing you hear is the unmistakable sound of metal scraping against metal. Not good.

Fortunately, this situation doesn't occur too often. However, it does happen. A recent enforcement case involved this very scenario. In Administrator v. Smith, an airman was taxiing his Cessna 210D aircraft equipped with Flint Aero tip tanks following the taxiway lines. At the time, the tail cone of a Citation XL extended approximately four feet over the line delineating the perimeter of the taxiway. The Cessna 210 collided with the Citation's tailcone resulting in a scratched area on the Cessna's wing tip/tip tank.

Shortly after the collision, the airman allegedly inspected the Cessna and observed that the wing tip/tip tank merely had a paint scratch. Believing that the Cessna was in an airworthy condition despite the collision, the airman then flew the aircraft to his home airport. At some point thereafter, the FAA became involved.

After investigating, the FAA issued an order seeking to suspend the airman's private pilot certificate for 60 days based upon alleged violations of 14 C.F.R. §§ 91.7(a) (operating an aircraft in an unairworthy condition), and 91.13(a) (careless and reckless). The airman appealed the order and a hearing was held before a National Transportation Safety Board administrative law judge ("ALJ").

At the hearing, the FAA argued that after the collision the Cessna was not airworthy because it did not conform with its type certificate until someone inspected it and compared it to the Cessna manual to confirm that it did, in fact, conform to the type certificate. Ironically, both of the FAA inspectors who testified at the hearing admitted they did not review the Cessna's type certificate or the supplemental type certificate ("STC") applicable to the Flint Aero tip tanks to determine whether the Cessna complied with its type certificate.

The airman argued that the STC was a modification to the Cessna's original type certificate and, as a result, it was necessary to actually review the aircraft’s type certificate, as modified by the tip tank STC in order to determine whether the aircraft was unairworthy under § 91.7(a). However, the ALJ disagreed and held the airman should have had the aircraft inspected after the collision before flying it.  As a result, he concluded that the airman was aware of the potentially unsafe condition when he operated the aircraft after the collision in a violation of § 91.7(a). The airman then appealed to the full Board arguing, among other things, that the FAA did not meet its burden of proving the § 91.7(a) violation.

The Board initially observed that the FAA may prove a § 91.7(a) violation by either showing that (1) an aircraft did not comply with its type certificate or (2) the aircraft was not in a condition for safe operation. With respect to the first prong of the test, the Board noted the absence of the Cessna's type certificate, type certificate data sheet, applicable airworthiness directives, or STCs in the record and the lack of testimony that the FAA inspectors reviewed those documents to determine whether the Cessna complied with its type certificate or STCs.

Regarding the second prong, the Board cited its precedent which allows the FAA to simply prove whether the airman "knew or should have known" the aircraft was not in a condition for safe operation, rather than proving the airman had "actual knowledge" that the aircraft was not in a condition for safe operation. It also noted that "a collision resulting in visible damage further requires an aircraft to undergo an inspection to ensure its continued airworthiness."

The Board then concluded that the damage to the Cessna constituted both actual and implied knowledge on the airman's part that an inspection was necessary. However, that wasn't the end of the story. The Board then determined that the absence of the type certificate or substantive testimony on either of the two requisite prongs of the airworthiness test meant the FAA had only shown the aircraft "might not have been" in a condition for safe operation.

The Board stated "[a]t this juncture, it is not clear to us that the Administrator fulfilled his burden in this regard by proving either the aircraft did not comply with its type certificate or was not in a condition for safe operation." As a result, the Board remanded the case to the ALJ asking him to provide specific factual findings to support his conclusions of law that the aircraft was not in a condition for safe operation.

What can we learn from this? Well, if you are ever involved in a situation that results in visible damage to your aircraft, even if it appears to be only scratched paint, the safe/conservative approach is to have an A&P inspect the aircraft and sign off on its airworthiness. Yes, this may cost a little money. However, it will be a lot less money than you would otherwise have to spend defending yourself in an enforcement action. And, if the FAA comes knocking alleging that you knew or should have known of a potentially unsafe condition with your aircraft and you operated it anyway, and you know the FAA will, you will have proof to the contrary.