NTSB: Preventing aircraft accidents involving controlled flight into terrain

The U.S. National Transportation Safety Board (NTSB) has issued a new Safety Alert that addresses accidents involving controlled flight into terrain (CFIT) during visual night conditions. The Safety Alert arose from information collected during the NTSB's investigations of six general aviation accidents over a three-year period in which "aircraft collided with terrain while either climbing shortly after takeoff or descending to prepare to land."

A press release announcing the Safety Alert says that the pilots and air traffic controllers involved in the six accidents "all appeared to have been unaware that the aircraft were in danger by approaching terrain." The NTSB concluded that all six of these accidents could have been prevented by increased altitude and position awareness, and better preflight planning.

NTSB Safety Alert SA-013 suggests these ways for pilots to CFIT accidents during visual night conditions:

• CFIT accidents are best avoided through proper preflight planning.
• Terrain familiarization is critical to safe visual operations at night. Use sectional charts or other topographic references to ensure that your altitude will safely clear terrain and obstructions all along your route.
• In remote areas, especially in overcast or moonless conditions, be aware that darkness may render visual avoidance of high terrain nearly impossible and that the absence of ground lights may result in loss of horizon reference.
• When planning a nighttime VFR flight, follow IFR practices such as climbing on a known safe course until well above surrounding terrain. Choose a cruising altitude that provides terrain separation similar to IFR flights (2,000 feet above ground level in mountainous areas and 1,000 feet above the ground in other areas.)
• When receiving radar services, do not depend on air traffic controllers to warn you of terrain hazards. Although controllers will try to warn pilots if they notice a hazardous situation, they may not always be able to recognize that a particular VFR aircraft is dangerously close to terrain.
• When issued a heading along with an instruction to “maintain VFR,” be aware that the heading may not provide adequate terrain clearance. If you have any doubt about your ability to visually avoid terrain and obstacles, advise ATC immediately and take action to reach a safe altitude if necessary.
• ATC radar software can provide limited prediction and warning of terrain hazards, but the warning system is configured to protect IFR flights and is normally suppressed for VFR aircraft. Controllers can activate the warning system for VFR flights upon pilot request, but it may produce numerous false alarms for aircraft operating below the minimum instrument altitude—especially in en route center airspace.
• For improved night vision, the FAA recommends the use of supplemental oxygen for flights above 5,000 feet.
• If you fly at night, especially in remote or unlit areas, consider whether a global positioning system-based terrain awareness unit would improve your safety of flight.

The NTSB alert includes links to the Air Accident Briefs for the six accident investigations that led to the current Safety Alert. Commenting on the results of those investigations, NTSB Chairman Mark V. Rosenker said, "Some of the pilots involved in these accidents had many hours of experience and were instrument rated, yet for some lapses in basic airmanship they failed to maintain proper altitude."

AAIB Update on the British Airways accident at Heathrow

The United Kingdom's Air Accidents Investigation Branch (AAIB) has issued an update to its initial report on the British Airways B-777 accident that occurred last week at London's Heathrow International Airport (LHR). In that accident, a British Airways Boeing 777-236ER, operating as Flight BA 038, landed several hundred meters short of runway 27L at LHR. Both of the aircraft's engines reportedly failed to respond to throttle inputs during final approach to the airfield, after a flight from Beijing.

Here is an excerpt from the AAIB update, issued on January 23, 2008:

The AAIB, sensitive to the needs of the industry including Boeing, Rolls Royce, British Airways and other Boeing 777 operators and crews, is issuing this update to provide such further factual information as is now available.

As previously reported, whilst the aircraft was stabilised on an ILS approach with the autopilot engaged, the autothrust system commanded an increase in thrust from both engines. The engines both initially responded but after about 3 seconds the thrust of the right engine reduced. Some eight seconds later the thrust reduced on the left engine to a similar level. The engines did not shut down and both engines continued to produce thrust at an engine speed above flight idle, but less than the commanded thrust.

Recorded data indicates that an adequate fuel quantity was on board the aircraft and that the autothrottle and engine control commands were performing as expected prior to, and after, the reduction in thrust.

All possible scenarios that could explain the thrust reduction and continued lack of response of the engines to throttle lever inputs are being examined, in close cooperation with Boeing, Rolls Royce and British Airways. This work includes a detailed analysis and examination of the complete fuel flow path from the aircraft tanks to the engine fuel nozzles.

Further factual information will be released as and when available.

The AAIB update also noted that the wreckage of the accident aircraft "was moved from the threshold of Runway 27L to an airport apron on Sunday evening, allowing the airport to return to normal operations."

Related:  Click here to view all posts on Aircrew Buzz about British Airways Flt 038.

ALPA to represent pilots at Canada's Wasaya Airways

The Air Line Pilots Association (ALPA) has been certified by the Canada Industrial Relations Board as the official collective bargaining unit for the pilots at Canadian carrier Wasaya Airways.

According to a news release issued by ALPA, the pilots at Wasaya Airways first contacted an officer of the ALPA Canada Board last year. ALPA put together an organizing team, and in November 2007, the team visited the Wasaya pilots during a tour of their bases. ALPA said, "Pilot turnout at the meetings was extremely high, and the tour led to a successful card drive in which Wasaya pilots overwhelmingly chose ALPA to represent them."

Wasaya Airways provides passenger, cargo, and charter operations in northern Ontario. The airline has a fleet of 24 aircraft and employs 70 pilots. Aircraft types include the Pilatus PC12-45, the Hawker Siddeley 748, the Beech 1900D, and the Caravan C208B. Headquartered in Thunder Bay, Ontario, Wasaya Airways also has bases in Sioux Lookout, Red Lake, Pickle Lake, and Timmins.

Capt. Jeff Braun, is serving as the interim leader of the Wasaya pilot group.

NTSB reports on Alpine Air crash in Hawaii

The U.S. National Transportation Safety Board (NTSB) has issued a preliminary report on the loss of a Beech 1900C and its pilot earlier this month in Hawaii. The aircraft is believed to have crashed into the Pacific Ocean near the island of Kauai. The body of the pilot has not been recovered. The aircraft (registration number N410UB) was operated by Alpine Aviation Inc., doing business as Alpine Air, as an on-demand cargo flight under 14 CFR Part 135 rules at the time of the accident.

According to the NTSB report, the aircraft departed Honolulu International Airport at 04:43 AM local time on January 14, 2008 carrying 4,200 pounds of mail en route to Lihue, on the island of Kauai. The report notes that "night visual meteorological conditions prevailed, and an instrument flight rules flight plan had been filed." The aircraft was lost from radar over the ocean about 7 miles south of the Lihue, at 05:08 AM. It had been scheduled to arrive in Lihue at 05:15 AM.

Here is an excerpt from the NTSB report:

The Coast Guard indicated that debris from the airplane was initially identified floating on the ocean surface at 0848, approximately 11 miles south-southwest of the airport. The water depths in the search area were up to 800 fathoms (4,800 feet). Additional debris was identified and collected and then transported to the Coast Guard station at Lihue. The Coast Guard discontinued the search on the afternoon of January 15.

An Airport Duty Operations Controller was conducting an airport inspection while the accident airplane was approaching the airport. He recalled that he heard a pilot who identified himself as Alpine Air state that he was, "...landing 35 and 7 miles out." Airport personnel reported that the runway lights, medium intensity approach lighting system with runway alignment indicator lights (MALSR), and precision approach path indicator (PAPI) lights for runway 35, were recorded as functional at the time of the accident.

The following weather conditions were reported at Lihue Airport at 0453: wind from 030 at 23 knots with gusts to 27 knots, 10 miles visibility, cloud layers scattered at 4,100 feet and overcast at 5,500 feet, temperature 20 degrees Celsius, dew point 13 degrees Celsius, and the altimeter setting was 30.13 inches of Mercury. [NTSB ID: SEA08FA062]

The pilot, identified in news reports as Paul Akita of Honolulu, was making his first flight following a two day scheduled rest period, and had been scheduled to return to Honolulu later on the same day as the accident. The Honolulu Advertiser reported:

Akita was one of 10 pilots employed by Alpine Air in Hawai'i. He graduated from Everglades University with a bachelor's degree in aviation and joined Alpine Air in July 2004 after flying for Big Kahuna Aviation.

The NTSB expects to issue its final report on the accident within eight months to one year.

BALPA statement on the British Airways accident at Heathrow

The British Air Line Pilots Association (BALPA) issued an official statement in support of the flight deck crew of BA Flight 038, the British Airways Boeing 777 that crash landed at London's Heathrow International Airport on January 17.

In the statement, Jim McAuslan, BALPA's General Secretary, said:

‘Captain Peter Burkill and his First Officer John Coward are ordinary people who did an extraordinary thing. Air transport remains the safest form of transport, by a long way, but accidents do happen and the text book way in which this was handled by the pilots and the cabin crew is a testament to the professionalism of all involved.

‘The BALPA web forum has been inundated overnight with compliments from their fellow professionals. The vast majority of pilots will go through their whole career without experiencing the events of BA038, but all of them are trained to cope with the possibility. This training includes frequent simulator checks in which pilots rehearse how to calmly deal with the completely unexpected.

‘The pilots and BALPA will be co-operating fully with the Air Accident Investigation Branch (AAIB) enquiries. Until we have their interim report it is inappropriate to comment on the cause of the accident; and history teaches us that their conclusions rarely reflect the immediate speculation.

‘After the long flight culminating in the accident, the pilots were then interviewed extensively yesterday by AAIB. The pilots were supported throughout by experienced BALPA representatives. The pilots do not wish to be in the public spotlight and went out for a quiet curry last night. They do not wish or seek “hero status”, and are ‘’embarrassed that their aircraft is all over the front page.’’

‘The events of yesterday did not stop with the crew of BA038. Other pilots in other aircraft lined up behind on the approach would have needed to calmly gone about re-routing. All are ordinary people who do an extraordinary thing.’

BALPA is the union that represents the pilots of British Airways.

Related:  Click here to view all posts on Aircrew Buzz about British Airways Flt 038.

British Airways Flight 038: The day after

The senior crew members from BA Flight 038, the British Airways Boeing 777 that crash landed at London's Heathrow International Airport (LHR) on January 17, were introduced at a press conference earlier today. Pictured here, left to right, are senior First Officer John Coward, who was the pilot flying at the time the emergency arose; Captain Peter Burkill, pilot in command; and Cabin Service Director Sharron Eaton-Mercer, the senior cabin crew member on the flight.

Another flight deck crew member, First Officer Conor Magenis, is not pictured. Other cabin crew members were not identified by name.

The crew members were praised for their actions during the emergency -- the pilots for managing to land the disabled aircraft without causing any loss of life to those on board or on the ground; and the cabin crew for quickly initiating and efficiently carrying out the evacuation of the aircraft once it had come to a rest. Those who lauded the crew included UK Prime Minister Gordon Brown, and British Airways CEO Willie Walsh, as well as passengers who had been on board BA Flight 038.

The United Kingdom's Air Accidents Investigation Branch (AAIB) has issued a preliminary report about the accident. The date and time of the accident were listed officially as 17 January 2008 at 1243 hrs in the report.

The one-page AAIB report presented a brief summary of the events leading to the aircraft landing short of runway 27L at LHR. The preliminary report, based on interviews with the crew, and initial examination of the aircraft's Flight Data Recorder, indicated that, "At approximately 600 ft and 2 miles from touch down, the Autothrottle demanded an increase in thrust from the two engines but the engines did not respond. Following further demands for increased thrust from the Autothrottle, and subsequently the flight crew moving the throttle levers, the engines similarly failed to respond."

The aircraft struck the ground inside the airfield's perimeter fence, about 1000 ft. short of the paved surface of runway 27L, according to the AAIB report. The report went on to say that during the short ground roll, "the right main landing gear separated from the wing and the left main landing gear was pushed up through the wing root." The report also noted that a "substantial amount" of fuel spilled from the aircraft at the accident site, but there was no fire.

All 136 passengers and 16 crew members evacuated the aircraft using emergency slides. According to the AAIB preliminary report, four crew members and eight passengers sustained minor injuries, while one other passenger's injuries were described as "serious." At least one news report mentioned that one passenger had suffered a concussion and had remained in hospital overnight, but this has not been officially confirmed.

The AAIB report lists damage to the aircraft as "substantial." The accident aircraft was described by the AAIB as a Boeing 777-236, registration number G-YMMM, manufactured in 2001. The aircraft was powered by two Rolls-Royce RB211 Trent 895-17 turbofan engines.

The accident investigation is ongoing, under the direction of the AAIB, with assistance from other interested parties, as follows:

In accordance with the established international arrangements the National Transportation Safety Board (NTSB) of the USA, representing the State of Design and Manufacture of the aircraft, was informed of the event. The NTSB appointed an Accredited Representative to lead a team from the USA made up of investigators from the NTSB, the FAA and Boeing. A Boeing investigator already in the UK joined the investigation on the evening of the event, the remainder of the team arrived in the UK on Friday 18th January. Rolls-Royce, the engine manufacturer is also supporting the investigation, an investigator having joined the AAIB team.

The AAIB also reported that the Flight Data Recorder (FDR), Cockpit Voice Recorder (CVR) and Quick Access Recorder (QAR) were retrieved from the accident aircraft.

The CVR and FDR have been successfully downloaded at the AAIB laboratories at Farnborough and both records cover the critical final stages of the flight. The QAR was downloaded with the assistance of British Airways and the equipment manufacturer. All of the downloaded information is now the subject of detailed analysis.

The AAIB report states that the focus of the continuing investigation will be "on more detailed analysis of the Flight Recorder information, collecting further recorded information from various system modules and examining the range of aircraft systems that could influence engine operation."

[Photo Source]

Related:  Click here to view all posts on Aircrew Buzz about British Airways Flt 038.

UK's AAIB: Initial report on British Airways accident at Heathrow

The United Kingdom's Air Accidents Investigation Branch (AAIB) issued its initial report regarding yesterday's crash landing of a British Airways Boeing  777 at London's Heathrow International Airport (LHR). The B777-236ER aircraft (registration number G-YMMM), operating as British Airways Flight BA 038 from Beijing to London, landed short on runway 27L at LHR. All 136 passengers and 16 crew on board survived. The aircraft was substantially damaged.

The AAIB investigation is ongoing, however today's report describes the event, and reports the agency's preliminary findings based on the initial examination of the Flight Data Recorder, and interviews with the crew and others at the accident scene.

Here are some excerpts from the report, which describe the event (re-paragraphed for easier reading):

Following an uneventful flight from Beijing, China, the aircraft was established on an ILS approach to Runway 27L at London Heathrow.

Initially the approach progressed normally, with the Autopilot and Autothrottle engaged, until the aircraft was at a height of approximately 600 ft and 2 miles from touch down. The aircraft then descended rapidly and struck the ground, some 1,000 ft short of the paved runway surface, just inside the airfield boundary fence. The aircraft stopped on the very beginning of the paved surface of Runway 27L.

During the short ground roll the right main landing gear separated from the wing and the left main landing gear was pushed up through the wing root. A significant amount of fuel leaked from the aircraft but there was no fire.

An emergency evacuation via the slides was supervised by the cabin crew and all occupants left the aircraft, some receiving minor injuries.

...

The flight crew were interviewed on the evening of the event by an AAIB Operations Inspector and the Flight Data Recorder (FDR), Cockpit Voice Recorder (CVR) and Quick Access Recorder (QAR) were removed for replay.

The CVR and FDR have been successfully downloaded at the AAIB laboratories at Farnborough and both records cover the critical final stages of the flight. The QAR was downloaded with the assistance of British Airways and the equipment manufacturer. All of the downloaded information is now the subject of detailed analysis.

Examination of the aircraft systems and engines is ongoing.

Initial indications from the interviews and Flight Recorder analyses show the flight and approach to have progressed normally until the aircraft was established on late finals for Runway 27L.

At approximately 600 ft and 2 miles from touch down, the Autothrottle demanded an increase in thrust from the two engines but the engines did not respond. Following further demands for increased thrust from the Autothrottle, and subsequently the flight crew moving the throttle levers, the engines similarly failed to respond.

The aircraft speed reduced and the aircraft descended onto the grass short of the paved runway surface. [AAIB Ref: EW/C2008/01/01]

The AAIB states that the accident investigation will continue, focusing on "more detailed analysis of the Flight Recorder information, collecting further recorded information from various system modules and examining the range of aircraft systems that could influence engine operation."

UPDATE January 24, 2008: The UK's AAIB has issued an update to its preliminary report on the British Airways accident. Excerpt:

Recorded data indicates that an adequate fuel quantity was on board the aircraft and that the autothrottle and engine control commands were performing as expected prior to, and after, the reduction in thrust.

All possible scenarios that could explain the thrust reduction and continued lack of response of the engines to throttle lever inputs are being examined, in close cooperation with Boeing, Rolls Royce and British Airways. This work includes a detailed analysis and examination of the complete fuel flow path from the aircraft tanks to the engine fuel nozzles.

Click here to read the update on the AAIB website.

NOTE:  Click here to view all posts on Aircrew Buzz about British Airways Flt 038.

British Airways Boeing 777 down at Heathrow

A British Airways B777-236ER landed several hundred meters short of a runway at London's Heathrow Airport (LHR) earlier today, January 17, 2008. BA Flight 038, arriving at LHR on a scheduled flight from Beijing, had 132 passengers and 16 crew on board, all of whom were evacuated safely using emergency slides. Early news reports said a few people sustained "minor injuries." The aircraft (registration number G-YMMM) was severely damaged. There was no fire.

The aircraft reportedly touched down at 12:42 GMT, several hundred meters short of runway 27L, and plowed through the grass, coming to a rest on its belly just at the threshold of the runway. Several eyewitnesses at the airport said that the aircraft appeared to lose power on short final, and that the landing gear collapsed shortly after the aircraft touched down.

BBC News reported that all BA short-haul flights scheduled to leave from Heathrow were immediately cancelled or delayed. A number of incoming flights were diverted to Stansted and Luton.

A press advisory issued by the U.S. National Transportation Safety Board (NTSB) said that a team had been dispatched to assist the government of the United Kingdom in its investigation of today's accident. The NTSB designated investigator Bill English as the U.S. Accredited Representative. An aviation systems technical specialist and a powerplants technical specialist will accompany him. The Federal Aviation Administration and the Boeing Aircraft Company are also sending investigators as part of the team, according to the NTSB. The UK Air Accident Investigation Branch (AAIB) is leading the investigation.

Kudos to the flight crew for landing the apparently disabled aircraft without loss of life or serious injury to anyone on board or on the ground, and to the cabin crew for quickly evacuating everyone from the aircraft without further incident.

Click here for the BBC's photo collection of the aircraft and the accident site at Heathrow.

Follow-up details regarding the this accident will be posted here on Aircrew Buzz as factual information becomes available.

[Photo Source]

UPDATE January 17, 2008: Willie Walsh, CEO of British Airways released a statement publicly commending the crew of BA Flight 38, identifying the PIC by name:

" I would like to pay tribute to the 16 crew of the BA038 led by Captain Peter Burkill. The flight crew showed great courage and professionalism in landing the aircraft safely. All of the crew did a fantastic job evacuating the 136 passengers. They are all heroes and everyone at British Airways is very proud of them." [Source: British Airways Press Statement, January 17, 2008]

In a separate statement, Mr. Walsh also praised the fire, ambulance and police services for their response at the scene of the accident.

UPDATE January 18, 2008: The UK's Air Accident Investigations Branch (AAIB) has issued a preliminary report on the British Airways accident.

UPDATE January 24, 2008: The UK's AAIB has issued an update to its preliminary report on the British Airways accident.

UPDATE February 9, 2010: The AAIB has issued its Final report on 2008 British Airways Boeing 777 accident at Heathrow.

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