Tag Archives: NTSB

NTSB Video: Air Canada taxiway overflight at San Francisco

San Francisco International Airport Terminal 2 security camera video of the July 7, 2017, Air Canada taxiway overflight.

NTSB Opens Docket for San Francisco International Airport Incident

The National Transportation Safety Board opened the public docket Wednesday as part of its ongoing investigation of the July 7, 2017, Air Canada overflight of a taxiway at San Francisco International Airport.

Air Canada flight 759, an Airbus A-320, was cleared to land on runway 28R at San Francisco International Airport, but the aircraft lined up on parallel taxiway C, which had four airplanes on it awaiting takeoff clearance. Air Canada flight 759 descended below 100 feet above the ground and initiated a go-around after overflying the first airplane on taxiway C.

(The top portion of this not-to-scale NTSB graphic, created from Harris Symphony OpsVue radar track data analysis, depicts the positions of aircraft on an overhead view of the runways and taxiways at San Francisco International Airport. The text is from a transmission to air traffic control from a United Airlines airplane on the taxiway.  The bottom photo, taken from San Francisco International Airport video, shows Air Canada Flight 759 passing over the first United Airlines airplane.)

The docket includes factual reports for operations, human performance, air traffic control, aircraft performance, and the flight data recorder.  The docket also contains a video that shows the overflight, as well as interview summaries, photographs and other investigative material.

The docket contains only factual information collected by NTSB investigators. No conclusions about how or why the overflight occurred should be drawn from the information in the docket, as the investigation is ongoing. Analysis, findings, recommendations, and probable cause determinations related to the incident will be issued by the NTSB at a later date.

The docket material is available online at https://go.usa.gov/xQ8Mp

Additional material may be added to the docket as it becomes available.

NTSB Issues its latest update on the accident of Delta flight 1086 at LaGuardia Airport

NTSB logo

The National Transportation Safety Board (NTSB) (Washington) has issued this update report on Delta Air Lines flight DL 1086 at LaGuardia Airport in New York on March 5, 2015:

As part of its ongoing investigation into last week’s accident at LaGuardia Airport where Delta Air Lines flight 1086 veered off the runway shortly after touching down, the NTSB on March 9 released its second investigative update.

On Thursday, March 5, 2015 at approximately 11:18 A.M., Delta flight 1086, a Boeing (McDonnell Douglas) MD-88 flying from Atlanta, GA to LaGuardia, NY exited the runway and came to rest with its nose on an embankment. There were 127 passengers (including 2 lap children) and 5 crewmembers on board the flight. Twenty three passengers received minor injuries, and others were transported to the hospital for evaluation. All passengers have been released from the hospital. Since arriving on scene, the NTSB, with assistance from the FBI, has documented the runway markings and the airplane. Investigators have determined:

1. The airplane departed the left side of runway 13 about 3,000 feet from the approach end of the runway. The tracks were on a heading of about 10 degrees from the runway heading.
About 4,100 feet from the approach end of the runway, the airplanes left wing initially struck the airport’s perimeter fence, which is located on top of the berm, and the airplane tracks turn back parallel with runway 13.

2. About 5,000 feet from the approach end of the runway, the airplane came to rest with its nose over the berm,. The left wing of the airplane destroyed about 940 feet of the perimeter fence.

3. Significant damage to the airplane was noted, including:

A. Damage on the left wing’s leading edge slats, trailing edge flaps, and flight spoilers.

B. The breach of the left wing fuel tank was noted in the area of the outboard end of the outboard trailing edge flap.

C. Damage to the front radome, weather radar and to the underside of the fuselage from the front of the airplane all the way back to the area of the left front passenger door.

D. Damage was also noted in the nose landing gear well and main electronics bay.

4. The tailcone handle in the main cabin was actuated.

5. The autobrake selector switch in the cockpit was found in the “max” position.

As part of the investigative process, the following investigative groups have been formed: Operations and Human Performance, Airworthiness, Airports, Flight Data Recorder, Cockpit Voice Recorder, and Maintenance Records. Below is a summary of some their work, to date.

1. The Maintenance Records group began reviewing the maintenance records on Saturday and that work is ongoing.

A. Delta Air Lines is the original owner of the accident airplane and took delivery of it on December 30, 1987.

B. The aircraft had 71,195.54 flight hours and 54,865 flight cycles at the time of the accident.

C. The last major maintenance visit took place on September 22, 2014 in Jacksonville, Fla. This visit was part of the airplane’s regularly scheduled maintenance program, and included tests of the auto brake, antiskid and auto spoiler systems.

D. The last overnight service check was completed March 2, 2015 in Tampa, Fla.

2. Investigators with the Airworthiness group will continue to examine and test the antiskid, autobrake and thrust reverser systems today.

3. The Operations and Human Performance groups interviewed the flight crew on Saturday in Atlanta, Ga. The crew stated:

A. They based their decision to land on braking action reports of “good,” which they received from air traffic control.

B. That the runway appeared all white when they broke out of the overcast, moments before landing.

C. That the automatic spoilers did not deploy but that the first officer quickly deployed them manually.

D. That the auto brakes were set to ‘max’ but that they did not sense any wheel brake deceleration.

E. The captain reported that he was unable to prevent the airplane from drifting left.

4. An NTSB air traffic control specialist has gather the following information: another Delta Air Lines MD-88 airplane landed on runway 13 about 3 minutes prior to flight 1086 (the FDR has been sent to the NTSB recorder lab and investigators will interview this flight crew in the coming days) and confirmed that air traffic controllers relayed the braking action reports to the flight crew of 1086,which were based on pilot reports from two other flights that landed several minutes prior to flight 1086. Both earlier flights reported the breaking action on the runway as “good”.

5. A preliminary readout of the Flight Data Recorder found:

A. That the autopilot was engaged until the airplane was about 230 feet above the ground.

B. That the airspeed during the final approach was about 140 knots and touchdown occurred at about 133 knots.

C. That the airplane’s heading deviated to the left and it departed the runway shortly after touchdown.

D. That there are degradations in recorded signal quality around the time the airplane departed the runway and extraction and verification of the data is continuing.

6. The quick access data recorder on flight 1086 was also recovered and that recorder is being readout at NTSB headquarters on March 9.

7. An NTSB meteorologist is examining the weather conditions at the time of the accident.

8. The Cockpit Voice Recorder group plans on convening at NTSB headquarters Tuesday, to begin developing the CVR transcript.

The investigation is ongoing and any future updates will be issued as events warrant.

The NTSB blames the crew for the crash of UPS flight 1354 at Birmingham, Alabama

UPS A300-600F N155UP Crash Birmingham (NTSB)(LRW)

The National Transportation Safety Board determined that UPS flight 1354 crashed because the crew continued an unstabilized approach into Birmingham-Shuttlesworth International Airport in Birmingham, Alabama. In addition, the crew failed to monitor the altitude and inadvertently descended below the minimum descent altitude when the runway was not yet in sight.

The board also found that the flight crew’s failure to properly configure the on-board flight management computer, the first officer’s failure to make required call-outs, the captain’s decision to change the approach strategy without communicating his change to the first officer, and flight crew fatigue all contributed to the accident.

The airplane, an Airbus A300-600, crashed in a field short of runway 18 in Birmingham on August 14, 2013, at 4:47 a.m. The captain and first officer, the only people aboard, both lost their lives, and the airplane was destroyed by the impact and a post-crash fire. The flight originated from UPS’s hub in Louisville, Kentucky.

“An unstabilized approach is a less safe approach,” said NTSB Acting Chairman Christopher A. Hart. “When an approach is unstable, there is no shame in playing it safe by going around and trying again.”

The NTSB determined that because the first officer did not properly program the flight management computer, the autopilot was not able to capture and fly the desired flight path onto runway 18. When the flight path was not captured, the captain, without informing the first officer, changed the autopilot mode and descended at a rate that violated UPS’s stabilized approach criteria once the airplane descended below 1,000 feet above the airport elevation.

As a result of this accident investigation, the NTSB made recommendations to the FAA, UPS, the Independent Pilots Association and Airbus. The recommendations address safety issues identified in the investigation, including ensuring that operations and training materials include clear language requiring abandoning an unstable approach; the need for recurrent dispatcher training that includes both dispatchers and flight crews; the need for all relevant weather information to be provided to pilots in dispatch and enroute reports; opportunities for improvement in fatigue awareness and management among pilots and operators; the need for increased awareness among pilots and operators of the limitations of terrain awareness and warning systems — and for procedures to assure safety given these limitations.

A synopsis of the NTSB report is available at: http://www.ntsb.gov/investigations/2013/birmingham_al/birmingham_al.html

Top Copyright Photo: NTSB.

UPS Aircraft Slide Show: AG Slide Show

Bottom Copyright Photo: Ken Petersen/AirlinersGallery.com. N155UP is pictured on the cargo ramp at New York’s John F. Kennedy International Airport before the tragic accident. Airbus A300F4-622R N155UP (msn 841) crashed on August 14, 2013 while on approach from the north to Birmingham-Shuttlesworth International Airport, Birmingham, Alabama. The crew was operating cargo flight 5X 1354 from the Louisville hub to Birmingham. The two crew members were tragically killed in the crash.

NTSB: “Asiana flight 214 crashed when the airplane descended below the visual glidepath due to the flight crew’s mismanagement of the approach and inadequate monitoring of airspeed.”

The National Transportation Safety Board (NTSB) (Washington) yesterday (June 24) issued its probable cause and report on the July 6, 2013 crash of Asiana Airlines (Seoul) flight 214 with the pictured Boeing 777-28E ER HL7742 (msn 29171) at San Francisco. Here is the full statement and link:

In a Board meeting held on June 24, 2014, the National Transportation Safety Board determined that Asiana flight 214 crashed when the airplane descended below the visual glidepath due to the flight crew’s mismanagement of the approach and inadequate monitoring of airspeed. The Board also found that the complexities of the auto throttle and autopilot flight director systems, and the crew’s misunderstanding of those systems, contributed to the accident.

On July 6, 2013, about 11:28 a.m. (PDT), the Boeing 777 was on approach to runway 28L at San Francisco International Airport in San Francisco, California when it struck the seawall at the end of the runway. Three of the 291 passengers died; 40 passengers, eight of the 12 flight attendants, and one of the four flight crewmembers received serious injuries. The other 248 passengers, four flight attendants, and three flight crewmembers received minor injuries or were not injured. The impact forces and a postcrash fire destroyed the airplane.

The NTSB determined that the flight crew mismanaged the initial approach and that the airplane was well above the desired glidepath as it neared the runway. In response to the excessive altitude, the captain selected an inappropriate autopilot mode and took other actions that, unbeknownst to him, resulted in the autothrottle no longer controlling airspeed.

As the airplane descended below the desired glidepath, the crew did not notice the decreasing airspeed nor did they respond to the unstable approach. The flight crew began a go-around maneuver when the airplane was below 100 feet, but it was too late and the airplane struck the seawall.

“In this accident, the flight crew over-relied on automated systems without fully understanding how they interacted,” said NTSB Acting Chairman Christopher A. Hart. “Automation has made aviation safer. But even in highly automated aircraft, the human must be the boss.”

As a result of this accident investigation, the NTSB made recommendations to the Federal Aviation Administration, Asiana Airlines, The Boeing Company, the Aircraft Rescue and Firefighting Working Group, and the City of San Francisco.

These recommendations address the safety issues identified in the investigation, including the need for reinforced adherence to Asiana flight crew standard operating procedures, more opportunities for manual flying for Asiana pilots, a context-dependent low energy alerting system, and both certification design review and enhanced training on the Boeing 777 autoflight system.

The recommendations also address the need for improved emergency communications, and staffing requirements and training for aircraft rescue and firefighting personnel.

“Today, good piloting includes being on the lookout for surprises in how the automation works, and taking control when needed,” Hart said. “Good design means not only maximizing reliability, but also minimizing surprises and uncertainties.”

A synopsis of the NTSB report, including the probable cause, findings, and a complete list of the 27 safety recommendations, is available at http://www.ntsb.gov/news/events/2014/asiana214/abstract.html. The full report will be available on the website in several weeks.

Copyright Photo: Michael B. Ing/AirlinersGallery.com. Boeing 777-28E ER HL7742 is pictured on approach at Los Angeles International Airport before the accident at SFO.

Asiana Airlines: AG Slide Show

NTSB issues recommendations to the FAA for the evaluation and certification of lithium-ion batteries on Boeing 787s

NTSB Safety Recommendation logo

The National Transportation Safety Board (NTSB) (Washington) has issued a series of recommendations related to the evaluation and certification of lithium-ion batteries for use in aircraft systems, as well as the certification of new technology.

The five safety recommendations, all addressed to the Federal Aviation Administration (FAA) (Washington), are derived from the NTSB’s ongoing investigation of the January 7, 2013, fire event that occurred in a lithium-ion battery on a Boeing 787 that was parked at Boston Logan Airport.

Investigators found that the battery involved in the Boston 787 fire event showed evidence not just of an internal thermal runaway but that “unintended electrical interactions occurred among the cells, the battery case, and the electrical interfaces between the battery and the airplane.”

The 12-page safety recommendation letter said that the processes used in 2006 to support the certification of the lithium-ion battery designed for the 787 were inadequate, in part, because there is no standardized thermal runaway test that’s conducted in the environment and conditions that would most accurately reflect how the battery would perform when installed and operated on an in-service airplane.

Further, the NTSB said that because there is no such standardized thermal runaway test, lithium-ion battery designs on airplanes currently in service might not have adequately accounted for the hazards associated with internal short circuiting.

In its examination of the challenges associated with introducing newer technologies into already complex aircraft systems, the NTSB said that including subject matter experts outside of the aviation industry “could further strengthen the aircraft certification process” by ensuring that both the FAA and the aircraft manufacturer have access to the most current research and information related to the developing technology.

To address all of these issues, the NTSB asked the FAA to do the following:

1. Develop an aircraft-level thermal runaway test to demonstrate safety performance in the presence of an internal short circuit failure
2. Require the above test as part of certification of future aircraft designs
3. Re-evaluate internal short circuit risk for lithium-ion batteries now in-service
4. Develop guidance for thermal runaway test methods
5. Include a panel of independent expert consultants early in the certification process for new technologies installed on aircraft

“The history of commercial aviation is one in which emerging technologies have played a key role in enhancing flight safety,” said NTSB Acting Chairman Christopher A. Hart. “This is why it’s crucial that the process by which these technologies are evaluated and certified is as robust and thorough as possible. These recommendations will take us further in that direction.”

The final report on the January 2013 Boston 787 battery fire investigation is estimated to be completed in the fall.

Read the full report: CLICK HERE

Read about the original Boston JAL Boeing 787 incident: CLICK HERE

 

NTSB Chairperson Hersman briefs the media on hearing into crash of a UPS Airbus A300 in Birmingham, Alabama

UPS A300-600F N155UP Crash Birmingham (NTSB)

NTSB Chairperson Hersman briefs the media after investigative hearing into Alabama UPS cargo airplane crash last August.

NTSB is also investigating Monday’s turbulence accident involving United Airlines flight 1676.

Read the full story of the United incident: CLICK HERE

Video:

NTSB Chairman Hersman’s briefing on the Asiana Airlines Boeing 777 crash at San Francisco

National Transportation Safety Board’s Chairperson Hersman briefs the media at yesterday’s hearing in Washington on the Asiana Airlines Boeing 777 crash. The main theme of the investigation is centered around the overuse of automation.

Read the analysis by Reuters: CLICK HERE

Spirit Airlines Airbus A319 suffers a serious uncontained engine failure

Spirit A319-100 N516NK (04-blk)(Apr) FLL (BD)(46)

Spirit Airlines‘ (Fort Lauderdale/Hollywood) flight NK 165 from Dallas/Fort Worth to Atlanta on Tuesday (October 15) operated with Airbus A319-132 N516NK (msn 2704) with 145 passengers and five crew members, was climbing out of DFW when the left V2500 engine exploded with a large bang. Smoke filled the passenger cabin and the cockpit prompting the flight crew to don their oxygen masks and shut the engine down. The airliner returned to DFW and made a safe emergency landing.

The V2500 engines are built by International Aero Engines, a consortium led by Pratt and Whitney.

The NTSB and the FAA are investigating. According to this report by the Seattle Times, the event was uncontained engine failure, quoting an unnamed NTSB official.

Read the full report: CLICK HERE

Copyright Photo: Bruce Drum/AirlinersGallery.com. Airbus A319-132 N516NK is still painted in the old 2004 black and silver scheme.

Spirit Airlines: AG Slide Show

Video:

Southwest fires the pilot who landed on the nose gear at La Guardia Airport on July 22

Southwest logo

Southwest Airlines (Dallas) has fired the captain who crash landed the Boeing 737-700 with the nose gear first at New York’s La Guardia Airport on July 22. According to the NTSB, the captain took control of the aircraft at 400 feet before the mishap. The first officer will receive additional training according to the report by Reuters.

Read the full report by Reuters: CLICK HERE

Read about the NTSB report: CLICK HERE

Read the full report about the accident: CLICK HERE

Southwest Airlines: AG Slide Show