EASA publishes Annual Safety Review 2020

EASA publishes Annual Safety Review 2020

As an overview of the safety situation in aviation in Europe, EASA published the 2020 edition of its Annual Safety Review (ASR).

The ASR identifies the most important safety challenges faced in European aviation today and supports the decision making for the next edition of the European Plan for Aviation Safety (EPAS) to further improve aviation safety and environmental protection throughout Europe.

 

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Pilot decision-making in poor weather contributed to fatal CFIT accident in Canada

Pilot decision-making in poor weather contributed to fatal CFIT accident in Canada

TSB Canada found that pilot decision-making was a factor in a fatal controlled flight into terrain accident involving a Cessna 208B in 2019 near Mayo, Yukon.

On 6 August 2019, a Cessna 208B Supervan 900 operated by Alkan Air was on a visual flight rules (VFR) flight from Rau Airstrip to Mayo Airport, Canada, with one pilot and one passenger on board. While enroute, the aircraft entered an area of low visibility and low cloud ceilings. The aircraft departed from the intended route, turned into a box canyon and struck rising terrain, fatally injuring the pilot and passenger. The aircraft was destroyed and there was a brief post-impact fire.

The investigation found that the pilot’s decision to continue a low altitude flight into poor weather conditions in mountainous terrain was influenced by several factors. The pilot had recently completed a flight along the same route, in similar weather conditions. The pilot’s decision-making would have been affected by his familiarity with the route and, consequently, he likely did not consider an alternate route to avoid the poor weather conditions.

The high speed at low altitude and low visibility reduced the opportunities for the pilot to take alternative action to avoid terrain. Within the box canyon, the canyon floor elevation increased abruptly within less than one nautical mile and the low visibility prevented the pilot from detecting this and taking sufficient actions to prevent a collision. Additionally, the aircraft’s terrain awareness and warning system aural alerts were ineffective in warning the pilot of the rising terrain because he had already heard multiple similar alerts in the preceding minutes of flight, or had silenced these alerts.

Following the occurrence, Alkan Air made changes to its Caravan operations, including requiring a second flight crew member for Cessna 208B Grand Caravan captains with less than 2000 hours. Before becoming a captain on the Caravan, candidates must perform as a second crew member on the Caravan for 1 season. The company has also made modifications to its emergency response plan.

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Departure procedures misunderstanding contributed to serious loss of separation incident at Sydney Airport

Departure procedures misunderstanding contributed to serious loss of separation incident at Sydney Airport

Likely flight crew confusion with Sydney-centric departure procedures contributed to a Boeing 777 turning right instead of left on departure from Sydney Airport, resulting in a serious airprox incident with an ATR 72 which had taken off from the parallel runway, an ATSB investigation notes.

The United Airlines Boeing 777-300ER had departed from Sydney Airport’s runway 34L bound for San Francisco and was cleared to follow a standard instrument departure (SID) requiring the aircraft to maintain runway heading until reaching 1,500 feet, at which point the aircraft was required to turn left and track towards Richmond, northwest of Sydney. However, the 777 instead climbed straight ahead through 1,500 feet to about 2,100 feet and then turned to the right, resulting in a loss of separation with the Virgin Australia ATR aircraft, which had departed from the parallel runway (runway 34R).

The ATSB’s investigation found that in entering the cleared ‘RIC5’ standard instrument departure in the 777’s flight management computer (FMC), the aircraft captain, who was the pilot flying, closed (removed) a deliberate ‘discontinuity’ – or gap – in the waypoint sequence. This discontinuity was pre-programmed to represent where air traffic control was to provide radar vectors to transition from the SID to join the planned oceanic track to San Francisco.

In removing the discontinuity, likely due to the captain’s limited exposure to the assignment of varying Sydney-centric departure procedures, the aircraft was in effect programmed to track direct to a navigation waypoint (DIPSO), about 45 nautical miles to the east of Sydney, after reaching the initial waypoint at 1,500 feet. This resulted in the right turn and the subsequent loss of separation with the ATR 72.

Removing the discontinuity would have been appropriate for many procedural transitions, which are commonplace in the United States, the ATSB noted. The ATSB’s investigation also notes that the pilot flying probably did not effectively communicate the changes made to the FMC coding to the other members of the flight crew, after reprogramming the FMC from the anticipated simpler ‘SYD1’ standard instrument departure, which had been entered based on previous experience.

More information: ATSB report

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Report: Insufficient fuel for flight resulted in forced landing of Beech 200 near Gillam, Canada

Report: Insufficient fuel for flight resulted in forced landing of Beech 200 near Gillam, Canada

TSB Canada concluded that an unnoticed fuel shortage resulted in fuel exhaustion and a subsequent forced landing of a Beechcraft B200 medevac aircraft in April 2019.

On 24 April 2019, the Beechcraft B200, was on a positioning flight from Winnipeg/James Armstrong Richardson International Airport, Canada to station the aircraft at Rankin Inlet Airport, with a stop planned in Churchill. The captain was receiving line indoctrination training from the training pilot, who assumed the role of first officer during the flight. Two flight nurses were also on board.

While in cruise flight, the crew declared an emergency due to a fuel issue. The flight crew diverted to Gillam Airport and initiated an emergency descent. During the descent, the fuel supply was exhausted and both engines eventually lost power. The crew attempted a forced landing on runway 23, but instead touched down on the frozen surface of Stephens Lake, 750 feet short of the runway threshold. There were no injuries, although the aircraft sustained substantial damage.

The investigation found that the flight crew had multiple opportunities to identify the shortage of fuel on board the aircraft. Before takeoff, when the captain asked if the aircraft was ready for flight, the first officer replied that it was, not recalling that the aircraft required fuel. Then, while performing the Fuel Quantity item on the After Start checklist, the captain responded to the first officer’s prompt with an automatic response that the fuel was sufficient without looking at the fuel gauges. As a result, the aircraft departed Winnipeg with insufficient fuel on board to complete the planned flight.

During the flight, the crew did not include the fuel gauges in their periodic cockpit scans nor did they confirm their progressive fuel calculations against the fuel gauges. As a result, their attention was not drawn to the low-fuel state at a point that would have allowed for a safe landing.

When the left fuel pressure warning light illuminated and the flight crew realized they had insufficient fuel, they became startled. After declaring a fuel emergency with air traffic control, and initiating an emergency descent, the left engine lost power due to fuel exhaustion. Still feeling the effect of the startle response, the captain quickly became task saturated, which led to an uncoordinated response by the flight crew, delaying the turn towards Gillam and extending the approach. The right engine lost power due to fuel exhaustion when the aircraft was one nautical mile from runway 23. From that position, a successful forced landing on the intended runway was no longer possible.

More information: TSB Report.

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Cessna 208B Grand Caravan suffers runway excursion, hits building after landing on Mexican airstrip

Cessna 208B Grand Caravan suffers runway excursion, hits building after landing on Mexican airstrip

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FAA requires additional post-storage B737 engine inspections after several in-flight shutdown incidents

FAA requires additional post-storage B737 engine inspections after several in-flight shutdown incidents

The U.S. FAA is requiring operators of Boeing 737 aircraft to inspect engine bleed air valves of aircraft that have been stored after several incidents of in-flight engine shutdowns.

Many airlines are restarting flights following groundings related to the COVID-19 pandemic. The FAA received four recent reports of single-engine shutdowns due to engine bleed air 5th stage check valves being stuck open. Corrosion of the engine bleed air 5th stage check valve internal parts during airplane storage may cause the valve to stick in the open position. If this valve opens normally at takeoff power, it may become stuck in the open position during flight and fail to close when power is reduced at top of descent, resulting in an unrecoverable compressor stall and the inability to restart the engine. Corrosion of these valves on both engines could result in a dual-engine power loss without the ability to restart.

This led the FAA to issue an Emergency Airworthiness Directive AD 2020-51, requiring inspections of the engine bleed air 5th stage check valve on each engine and replacement of the engine bleed air 5th stage check valve if any inspection is not passed. The EAD applies to all Boeing 737-300, -400, -500, -600, -700, -700C, -800, and -900 models in storage on or after the date of receipt of this AD, and any airplane that, as of the date of receipt of the AD, has been operated for 10 or fewer flight cycles since returning to service from the most recent period of storage.

 

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Maintenance omission resulted in forced landing of a DHC-8 with a partially extended nose landing gear

Maintenance omission resulted in forced landing of a DHC-8 with a partially extended nose landing gear

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NTSB: Flight crew actions led to fatal Atlas Air Boeing 767 loss of control accident, Trinity Bay, Texas

NTSB: Flight crew actions led to fatal Atlas Air Boeing 767 loss of control accident, Trinity Bay, Texas

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FAA downgrades international safety rating for Pakistan

FAA downgrades international safety rating for Pakistan

The U.S. Federal Aviation Administration (FAA) announced that Pakistan has been assigned a Category 2 rating because it does not comply with ICAO safety standards.

Under the International Aviation Safety Assessment (IASA) program, the FAA assesses the civil aviation authorities of all countries with air carriers that have applied to fly to the United States, currently conduct operations to the United States, or participate in code-sharing arrangements with U.S. partner airlines. The Pakistan Civil Aviation Authority provides aviation safety oversight for Pakistan.

IASA assessments determine whether foreign civil aviation authorities comply with ICAO safety standards. Air carriers from countries with Category 2 ratings are not allowed to initiate new service to the United States, are restricted to current levels of existing service to the United States, and are not permitted to carry the code of U.S. carriers on any flights. Currently, no airlines operate regularly scheduled flights between Pakistan and the United States.

ICAO also audits it’s member states under the Universal Safety Oversight Audit Programme (USOAP). The last audit in Pakistan was conducted in 2011, resulting in an average level of Effective Implementation score of 85%.

The FAA did not elaborate on the reason for their decision, but the news comes three weeks after the Pakistani aviation minister revealed that more than 30% of civilian pilots in Pakistan had fake licenses and were not qualified to fly. These pilots did not take exams themselves but paid someone else to sit it on their behalf.

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RR Trent engine fan blade failure on A330-300 leads to enhanced inspection processes

RR Trent engine fan blade failure on A330-300 leads to enhanced inspection processes

A fan blade failure in an Airbus A330’s Rolls-Royce Trent 700 engine due to a fatigue crack has led to enhanced inspection processes and technical solutions that reduce the likelihood of future similar occurrences, a new ATSB investigation report details.

In June 2017, an AirAsia X Airbus A330-300 sustained an engine failure while operating a scheduled passenger flight from Perth to Kuala Lumpur. About one hour into the flight, during a step change in altitude, the flight crew heard a metallic bang, significant vibrations could be felt through the airframe, and an ‘ENG 1 STALL’ warning was triggered. The flight crew executed the relevant engine malfunction procedure and commenced a single-engine return to Perth. While the airframe vibrations continued during the return to Perth, the aircraft landed there without further incident.

On the ground an inspection found about three quarters of one fan blade was missing from the failed left engine.
Subsequent detailed structural analysis determined that the failure of the fan blade was due to a fatigue crack which had initiated from within the blade’s internal structure where an internal reinforcing membrane joins to the blade’s convex skin panel. Detailed structural analysis determined that the failure of the fan blade was due to a fatigue crack.

The report notes the blade manufacturing process produced a variation in the internal membrane-to-panel acute corner geometry that, in combination with the inherent high level of blade panel stress, could lead to increased localised stresses in those corner areas and the initiation and propagation of fatigue cracking.
The investigation also determined that the scheduled inspections recommended by Rolls-Royce to detect cracking in Trent 700 fan blades were insufficient to detect early onset fatigue cracks in the membrane to panel bond before those cracks could progress to failure.

Rolls-Royce have taken a number of proactive safety actions to mitigate future blade failures. These include reviewing the design and manufacturing of the Trent 700 fan blade and releasing service bulletins covering engine inspections (one of which was supported by a European Aviation Safety Agency (EASA) issued Airworthiness Directive).
The engine manufacturer also introduced new a control system modification, designed to shut the engine down quickly when fan blade failure event occurs to reduce damage to the fan shaft.

During the complex manufacturing process of Trent 700 fan blades, a latent issue developed that was not realised for a number of years, the investigation notes. This demonstrates the importance for manufacturers of critical components, and regulators monitoring the manufacturers, to have systems in place to quickly identify core issues and put in place measures to mitigate risk.

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