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Four recent uncontained engine failure events prompt NTSB to issue urgent safety

Aviation Safety Network News - Thu, 05/27/2010 - 03:00

27 MAY 2010

The National Transportation Safety Board issued two urgent safety recommendations to the Federal Aviation Administration (FAA) following four recent events in which the aircraft experienced an uncontained engine failure of its GE CF6-45/50 series engine.

The first recommendation asks that the FAA require operators of aircraft equipped with a particular model engine to immediately perform blade borescope inspections (BSI) of the high pressure turbine rotor at specific intervals until the current turbine disk can be redesigned and replaced with one that can withstand the unbalance vibration forces from the high pressure rotor. The second recommendation asks the FAA to require the engine manufacturer to immediately redesign the disk. The NTSB issued an additional recommendation for a requirement that operators perform a second type of inspection and another recommendation related to the engine manufacturer regarding the installation of the replacement disk.

All four recommendations apply to the low pressure turbine (LPT) stage 3 (S3) rotor disk in the General Electric (GE) CF6-45/50 series turbofan engines that can fail unexpectedly when excited by high-pressure (HP) rotor unbalance.
An uncontained engine event occurs when an engine failure results in fragments of rotating engine parts penetrating and exiting through the engine case. Uncontained turbine engine disk failures within an aircraft engine present a direct hazard to an airplane and its passengers because high-energy disk fragments can penetrate the cabin or fuel tanks, damage flight control surfaces, or sever flammable fluid or hydraulic lines. Engine cases are not designed to contain failed turbine disks. Instead, the risk of uncontained disk failure is mitigated by designating disks as safety-critical parts, defined as the parts of an engine whose failure is likely to present a direct hazard to the aircraft.
In its safety recommendations to the FAA, the NTSB cited four foreign accidents, which the NTSB is either investigating or participating in an investigation led by another nation, in which the aircraft experienced an uncontained engine failure of its GE CF6-45/50 series engine.

The date, location, and circumstances of these four events (none had injuries or fatalities) are as follows:

On July 4, 2008, a Saudi Arabian Airlines (Saudia) Boeing 747-300 experienced an engine failure during initial climb after takeoff from Jeddah, Kingdom of Saudi Arabia. This investigation has been delegated to the NTSB.

On March 26, 2009, an Arrow Cargo McDonnell Douglas DC-10F, about 30 minutes after takeoff from Manaus, Brazil, experienced loss of oil pressure in one engine. The pilots shut down the engine and diverted to Medellin, Columbia. This investigation has been delegated to the NTSB.

On December 17, 2009, a Jett8 Cargo Boeing 747-200F airplane was passing through 7,000 feet above ground level (agl) when the flight crewmembers heard a muffled explosion and immediately applied left rudder. With one engine losing oil pressure, the airplane returned to land at Changi, Singapore. The NTSB is participating in the investigation that is being led by the Air Accident Investigation Bureau of Singapore.

On April 10, 2010, an ACT Cargo Airbus A300B4 experienced an engine failure while accelerating for takeoff at Manama, Bahrain. The crew declared an emergency, rejected the takeoff, activated the fire suppression system, and evacuated the airplane. The NTSB is participating in the investigation that is being led by the Bahrain Ministry of Transportation – Civil Aviation.
The four recommendations to the FAA are as follows:
1. Immediately require operators of CF6-45/50-powered airplanes to perform high pressure turbine rotor blade borescope inspections every 15 flight cycles until the low pressure turbine stage 3 disk is replaced with a redesigned disk that can withstand the unbalance vibration forces from the high pressure rotor. (Urgent)

2. Require operators of CF6-45/50-powered airplanes to perform fluorescent penetrant inspections of CF6-45- 50- low pressure turbine stage 3 disks at every engine shop visit until the low pressure turbine stage 3 disk is replaced with a redesigned disk that can withstand the unbalance vibration forces from the high pressure rotor.

3. Immediately require General Electric Company to redesign the CF6-45/50 low pressure turbine stage 3 disk so that it will not fail when exposed to high pressure rotor unbalance forces. (Urgent)

4. Once General Electric Company has redesigned the CF6- 45/50 low pressure turbine (LPT) stage 3 disk in accordance with Safety Recommendation [3], require all operators of CF6-45/50-powered airplanes to install the newly designed LPT S3 at the next maintenance opportunity.

India to establish Civil Aviation Safety Advisory Council

Aviation Safety Network News - Thu, 05/27/2010 - 03:00

27 MAY 2010

In the wake of the serious accident involving an Air India Express Boeing 737 at Mangalore, the Civil Aviation Minister decided to establish the Civil Aviation Safety Advisory Council (CASAC).

The Council will work directly with the Directorate General of Civil Aviation (DGCA) and recommend steps for improving air safety.

The proposed Council will constitute of pilots, air traffic controllers, airport operators, the air force and medical specialists. Also representatives from manufactures like Boeing, Airbus and Bombardier will be special invitees to the Council.

NTSB issues update on its investigation of Boeing 757 windshield fire

Aviation Safety Network News - Fri, 05/21/2010 - 03:00

21 MAY 2010

In its continuing investigation of a fire aboard a Boeing 757 that diverted to Dulles Airport (IAD) enroute to the Los Angeles International airport (LAX) from New York’s John F. Kennedy International airport (JFK), the National Transportation Safety Board (NTSB) has developed the following factual information.

On Sunday, May 16, 2010, about 21:17 the pilots on United Airlines flight 27, a Boeing 757-222, N510UA, noted a strong acrid smell and observed smoke from the Captain’s lower front windshield.  The incident occurred about 30 minutes into the flight while the aircraft was level at 36,000 feet MSL.   On board the aircraft were 7 crew members and 105 passengers.

The Captain and First Officer reported that they donned their oxygen masks and smoke goggles immediately after observing the smoke and fire. The Captain then gave control of the airplane to the First Officer and discharged a halon fire extinguisher. The smoke and fire dissipated but then re-ignited. The Captain obtained a second bottle from the Purser.  The fire remained extinguished after this second bottle was discharged. At approximately 500 feet MSL on final approach to Runway19L at IAD, the Captain’s windshield cracked. The landing was uneventful. The airplane cleared the runway, after which ARFF (Aircraft Rescue Firefighting) entered the aircraft to check for residual heat and fire. None was found and the airplane was towed to the gate for deplaning. There were no evacuation and no injuries to the flight crew or passengers.

Preliminary examination of the cockpit area revealed that the inner pane of the Captain’s windshield had cracked. One of the five terminal blocks attached to the inside of the lower left windshield was consumed by fire and the portion of the wire harness associated with this terminal block was significantly damaged by fire. There was significant sooting and paint peeling to the left hand side of the windshield air frame support.

The Captain’s windshield was moved and will be examined by Board investigators at the manufacturer.

Two previous windshield fire events on B757-200 aircraft prompted the NTSB to issue Safety Recommendation A-07-50 http://www.ntsb.gov/recs/letters/2007/A07_49_50.pdf.  The Safety Board investigators will look closely at the recovered hardware to determine if this latest event is related.

Report: Fatal EMB-120 loss of control accident during a simulated engine failure

Aviation Safety Network News - Thu, 05/20/2010 - 03:00

20 MAY 2010

Aerial view of the accident site at Darwin Airport. Photo: ATSB

A preliminary report released today by the Australian Transport Safety Bureau (ATSB) indicates that the fatal crash of an EMB-120 Brasilia at Darwin occurred during a simulated engine failure.

On 22 March 2010 an Embraer 120ER Brasilia turboprop plane, registered VH-ANB, was destroyed in a takeoff accident at Darwin Airport, NT (DRW), Australia. Both pilots were killed.
The ATSB report states that flight was a training flight to revalidate the captain’s command instrument rating. The supervisory pilot/training captain advised the aerodrome controller that the departure would incorporate asymmetric flight (a simulated engine failure), and was approved by the controller to perform the manoeuvre.
Witnesses reported that the takeoff appeared ‘normal’ until a few moments after becoming airborne, when the aircraft rolled and diverged left from its take-off path. They watched as the aircraft continued rolling left, and entered a steep nose-down attitude. The airplane impacted the ground in a right wing-low, nose-down attitude of about 65 degrees. A high intensity, fuel-fed fire that followed the collision with the ground destroyed most of the fuselage and cabin and right wing.

FAA proposes $1.55 Million civil penalty against Federal Express

Aviation Safety Network News - Thu, 05/20/2010 - 03:00

20 MAY 2010

The U.S. Federal Aviation Administration (FAA) has proposed a $1.55 million civil penalty against Federal Express for allegedly failing to revise its Continuous Airworthiness Maintenance Program in accordance with FAA regulations.

Federal Express allegedly failed to ensure that the air carrier used approved standards, inspections, and time limitations for 14 cargo Unit Load Devices (ULDs) used on the company’s airplanes beginning in early 2008. The civil penalty addresses 124 flights from March 20 to April 17, 2008. Aircraft ULDs are sophisticated containers with integral pallets that are used to load freight.

During a routine surveillance from March 14-20, 2008, FAA inspectors determined that Federal Express had failed to incorporate Technical Standard Orders (TSOs) into its Continued Airworthiness Maintenance Program for 14 cargo ULDs. The TSOs contain specific maintenance instructions for the ULD smoke detector, power distribution feed, and batteries. Federal Express could not ensure that it used approved maintenance standards for the 14 newly installed ULDs because the company failed to make the necessary revisions to its program for overhauling and inspecting the devices.

On March 20, 2008, Federal Express was notified of the problem by the FAA but did not make the necessary revisions to its Continuous Airworthiness Maintenance Program until April 17, 2008.

Federal Express has 30 days from the receipt of the FAA’s civil penalty letter to respond to the agency.

Report: Ilyushin 96 suffers control problems near London-Gatwick

Aviation Safety Network News - Wed, 05/19/2010 - 03:00

19 MAY 2010

According to a report released today by the Russian Interstate Aviation Committee (IAC) an Ilyushin 96 passenger plane was involved in a serious incident on 28 April 2010. It suffered control problems after takeoff from London-Gatwick.

The Ilyushin 96-300 passenger jet, registered CU-T1250, suffered control problems on departure from London-Gatwick Airport (LGW/EGKK), UK. The airplane operated on scheduled service CU401 to Holguín Airport (HOG/MUHG) and Havana-José Martí International Airport (HAV/MUHA).
Shortly after takeoff the airplane banked right. The pilots switched off the autopilot and attempted to control the plane manually. Considerable physical effort was necessary to control the plane. Fuel was dumped and the pilot made a safe emergency landing back at London-Gatwick.
The occurrence was classified as a serious incident and is under investigation by the U.K. AAIB. The airplane was ferried to Moscow-Domodedovo in May 7 for further inspection.

Airport safety recommendations after Indonesian B737 runway excursion accident

Aviation Safety Network News - Tue, 05/18/2010 - 03:00

18 MAY 2010

Wreckage of the Boeing 737 after it came to rest in an area of shallow muddy water surrounded by mangrove vegetation. Photo: NTSC

The Indonesian National Transportation Safety Committee (NTSC) issued their preliminary report regarding the runway excursion accident involving a Boeing 737. Seven safety recommendations were issued addressing various aspects of airport safety.

On April 13, 2010 a Boeing 737-322 passenger plane, registered PK-MDE, sustained substantial damage in a runway excursion accident at Manokwari-Rendani Airport (MKW/WASR), Indonesia. All 103 passengers and seven crew members survived but ten sustained serious injuries.
Merpati Flight MNA836 operated on a scheduled flight from Sorong-Dominique Edward Osok Airport (SOQ/WAXX). Departure was delayed for almost three hours due to heavy rain over Manokwari.
On approach Rendani Radio informed the crew that the weather was continuous slight rain, visibility 3 kilometers, cloud overcast with cumulus-stratocumulus at 1,400 feet, temperature 24 degrees Celsius, QNH 1012 hectopascals.
At 10:54 the crew reported that they were on final for runway 35. The controller informed them that the wind was calm, runway condition was wet and clear.
The crew read back the wind condition and that the runway was clear, but did not mention the wet runway condition.
The aircraft was observed to make a normal touchdown on the runway, about 120 meters from the approach end of runway 35. Witnesses on the ground and on board reported that engine reverser sound was not heard during landing roll.
During the landing roll, the aircraft veered to the left about 140 meters from the end of runway 35, then overran the departure end of runway 35. It came to a stop 205 meters beyond the end of the runway in a narrow river; the Rendani River.
The airport rescue and fire fighting unit was immediately deployed to assist the post-crash evacuation. Due to the steep terrain 155 meters from the end of runway 35, the rescuers had to turn back and use the airport’s main road to reach the aircraft. The accident site was in an area of shallow muddy water surrounded by mangrove vegetation.

Seven safety recommendations were issued:

1) The Directorate General Civil of Aviation (DGCA) should ensure that Merpati Nusantara Airlines Operational Specifications and other technical and operational safety requirements are met.

2) DGCA should urgently review the Rendani Airport, Manokwari runway complex, to ensure that the runway end safety areas (RESA) meet the dimension Standards prescribed in ICAO Annex 14.

3) DGCA should urgently review all airports involving Part 121 and 135 operations, to ensure that the runway end safety areas (RESA) meet the dimension Standards prescribed in ICAO Annex 14.

4) DGCA should urgently ensure that Indonesian airports equipped with visual approach slope guidance systems, maintain the equipment to a serviceable standard.

5) DGCA should review the procedures and equipment used by airport Rescue and Fire Fighting Services to ensure that they a) meet the minimum requirements, including timeliness, specified in ICAO Annex 14; and b) meet the requirements to cover the area up to 5 NM (8 Km) from the airport perimeter.

6) Merpati should review its technical and operational safety requirements to ensure they are implemented.

7) Merpati should review equipment used by airport Rescue and Fire Fighting Services at airports in its network, to ensure that they meet the minimum requirements for Boeing 737 aircraft.