Aviation Human Factors Industry News
July 20, 2006
Vol. II, Issue 25.
TSB Final Report A03P0332—Maintenance Error—In-flight
Fuel Leak
On November 6, 2003, an Airbus A330-300 departed Vancouver International
Airport, B.C., at 14:23 Pacific Standard Time (PST) on a scheduled flight to
Calgary, Alta., with 6 crew members and 92 passengers on board. Shortly after
takeoff, the Vancouver tower informed the pilots that a substantial amount of
smoke or vapor was coming from the No. 2 engine. Although the pilots did not
receive any abnormal engine indications or cockpit warnings, they declared an
emergency and advised that they were returning to Vancouver. After an uneventful
landing, the pilots shut down the No. 2 engine. Aircraft rescue and firefighting
(ARFF) services, following the aircraft, advised the pilots that fuel was
leaking from the engine but there was no sign of fire. Eventually, the aircraft
was towed back to the terminal where the passengers were deplaned. There were no
injuries or damage to the aircraft.
Visible fuel leak from the
Airbus A330
Findings as to causes and contributing factors
1. Because of an
incorrect entry on the maintenance
office duty board, and because technicians
did not follow the
troubleshooting manual (TSM), they
unnecessarily removed the low-pressure (LP) fuel line from the fuel/oil
heat exchanger.
2. Because the technicians were
unfamiliar with the coupling, because
the retainer was
hidden from view, and because they
did not refer
to the aircraft maintenance manual (AMM), the technicians
did not properly reconnect
the LP fuel line.
3. Upon the application of take-off power, the fuel pressure, the
fuel flow rate, and engine vibration caused the fuel/oil heat exchanger
LP fuel line to detach, causing a substantial fuel leak from the No. 2
engine.
Findings as to risk
1. A high-power engine run was not performed by the operator ( nor
was one required by the engine manufacturer),
which would have produced conditions similar to those that caused the LP
fuel line to detach from the fuel/oil heat exchanger on takeoff. A
high-powered engine run could decrease the risk that a leak or
mis-installed component would go undetected.
2. Correct inspection of the
fuel/oil heat exchanger would require the use of an elevated platform
both prior to and after the actual engine run-up. A proper inspection of
the LP fuel line connection was
not accomplished after the
engine run-up, increasing the risk that a leak or mis-installed
component would go undetected.
3. The operator had
not implemented Airbus
Service Bulletin (SB) A330-28-3080.
Implementing this SB would reduce the risk that a fuel leak could go
undetected, leading to fuel exhaustion, engine failure, or fire.
Other finding
1. The removal and re-installation of the fuel/oil heat exchanger LP
fuel line was not
documented, as required by the
operator's maintenance policy manual and Transport Canada regulation.
Poor Maintenance Endemic to Air Cargo Operations
Ten months after the death of a cargo pilot in a crash in which he was the
only one aboard, the FAA revoked the carrier’s license. A number of FAA reports
indicated inadequate flight personnel,
and shortcomings in training and
maintenance at Las Vegas-based American
Aviation. Although a 2001 FAA inspection report warned, "This operator needs to
be watched closely," the company continued to fly despite
documented deficiencies,
including the failure to give pilots the required uninterrupted rest. The death
of Perry Grant flying a Piper PA-34 was the catalyst that provoked the FAA to
finally revoke the carrier’s license. The case is one of a number discussed in
the final part, appearing July 11, of a three-part series in The Miami Herald
concerning the safety of air cargo operations. The article maintains that a
culture of risk prevails in the air cargo
industry, with older planes, less-experienced pilots, longer hours, overnight
flying and dangerous weather. The article does not point out the lack of FAA
oversight of cargo flight operations and
maintenance,
which some experts say is another risk factor that should be factored into a
dismal safety record where about one cargo plane falls from the sky each month.
The newspaper’s series on air cargo operations, titled "Deadly Express,"
appeared just before National Transportation Safety Board (NTSB) hearings into
the safety of air cargo operations. The NTSB hearings are slated for July 12 &
13.
Man dies after walking into helicopter rotor
A Waverley man died yesterday when he walked into the spinning tail rotor of
a helicopter on a farm.
Ronald Derek Heal, 61, died at the scene following the 10.50am accident on
Waipipi road, the Taranaki Daily News reported today.
Wanganui Sergeant Kevin Smith said it appeared Mr Heal had walked over to the
machine, while it was being loaded with fertilizer, and got too close to the
spinning rotor.
Electrical Arcing Caused Fuel Tank Explosion
The National Transportation Safety Board (NTSB) is assisting the Indian
Directorate of Civil Aviation in the investigation of the explosion on a
Transmile Airlines B727 at Bangalore. Investigators found evidence that
dangerous electrical arcing caused the explosion that destroyed the structural
integrity of the left wing. On May 4, 2006, the left wing fuel tank exploded as
the Malaysian-registered freighter was waiting to be towed. Investigators found
evidence of damaged wiring
and electrical arcing in an aluminum conduit
running inside the tank. The conduit carried 115 volt AC electrical power to the
fuel pump. Wire arcing within the conduit was previously recognized as a
potential ignition source, and
the accident airplane had been
modified in accordance with an FAA airworthiness directive (AD).
The AD required removal of the wires from the
conduit, inspection, and re-installation of the wires, or replacement wires,
into the conduit after insertion of a protective plastic sleeve. The AD actions
proved insufficient to prevent the Bangalore accident. Had the explosion
occurred in flight, catastrophic failure of the wing would have resulted in the
airplane crashing
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Evidence of electrical arcing of the wiring inside the
exploded fuel tank is shown by the circles in these photographs. |
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Accident airplane. |
View inside fuel tank. |
UK AAIB urges action to improve wiring safety
Agency awaits full response
The AAIB’s progress report says the European Aviation Safety Agency (EASA)
has replied to the circuit breaker proposal, saying: "EASA continues to be an
active participant in the ageing systems rulemaking process. Industry continues
to develop arc fault circuit breaker technology. A regulatory impact assessment
will need to be performed before action may be taken."
The AAIB classified EASA’s response as "partially accepted, open"
while the US Federal Aviation Administration’s is "reply awaited, open". The
same classification is accorded to another recommendation to the FAA: "It is
recommended that the [FAA] accelerate the publication and adoption of the
guidance material produced by the Ageing Transport Systems Rulemaking Advisory
Committee on developing an
electrical systems standard wiring practices manual, developing an effective
wiring systems training programmed and on changes to existing maintenance
practices and analysis methods, which could be applied to both in-service
aircraft and new designs, to ensure adequate consideration is given to potential
in-service deterioration of electrical wiring systems."
Aviation safety agencies on both sides of the Atlantic
are moving too slowly on improving
electrical wiring safety in older aircraft,
says the UK Air Accidents Investigation Branch (AAIB). In its first progress
report to the European Aviation Safety Agency on the status of follow-up
actions recommended in accident/incident reports, it calls on both the European
Aviation Safety Agency (EASA) and the US Federal Aviation Administration to
"expedite a requirement for the replacement of existing thermal/mechanical type
circuit breakers [CBs] by arc fault circuit breakers".
The AAIB says it is aware that plans are in progress through both agencies to
reduce the likelihood of damage to old wiring looms, but since this will never
be completely effective the introduction of more sensitive "intelligent" circuit
breakers that recognize momentary arcing is the most critical part of the
solution, it insists.
Checking progress on its recommendations from reports on four serious
incidents in 2002 and 2003 – three of them to Boeing 737s and one to a Concorde
– the AAIB says: "However strenuous the efforts to avoid design and
maintenance quality lapses, their essentially
random natures make them very difficult to eliminate. There are many reports of
wiring loom damage where sustained arcing within/between looms occurred, or
probably occurred, where [thermal/mechanical] CBs have failed to operate, or to
operate in sufficient time to prevent serious wiring damage and, in some cases,
loss of the aircraft. The four incidents reported here present such examples of
sustained arcing."
The lost aircraft were a Trans World Airlines Boeing 747-100 in July 1996 and
the September 1998 Swissair Boeing MD-11.
China sets up aviation safety academy
BEIJING, (Xinhua) -- China's aviation sector, the fastest growing in the
world, established the China Civil Aviation Safety Academy here on Wednesday.
Yang Yuanyuan, director of China's General Administration of Civil Aviation
said safety is an important criteria in judging a country's aviation
development.
With a growing air transportation, it is crucial for China's aviation sector
to improve its safety so as to move into a higher level of development, Yang
said.
The academy will offer the staff in China's air transportation sector eight
courses from theoretical studies to practical operations.
Wang Changshun, president of the academy, said although its accident rate is
lower than the international average level, China's aviation industry still has
a long way to go to catch up with countries with advanced aviation
transportation systems.
Wang said that the academy will endeavor to set up a complete series of
courses on aviation safety
in five years and aim to provide 6,000 and
8,000 training opportunities for aviation staff every year.
Statistics show that China's total air transportation grew by 18.2 percent,
passenger traffic by 16.5 percent and cargo transportation jumped 15.6 percent
annually from 1978 to 2004, nearly double worldwide growth.
Pilots May Have Mishandled Airbus Brakes in Siberia Crash
Investigators are looking into whether the crew of an Airbus jet that went
off a runway in Siberia on July 9
may have improperly used a braking
system that was partly disabled before
takeoff, people with knowledge of the inquiry say.
The model involved in the crash, the Airbus A310, has a thrust reverser on
each of its two engines, and normal procedure, as with other large jets, is that
after touchdown the crew deploys the reversers, which direct jet blast toward
the front of the plane, to assist the wheel brakes in slowing the plane down.
After the thrust reversers are deployed, the crew applies the throttles on the
engines.
But the plane in the accident, flown by a Russian airline called S7, began
its overnight flight from Moscow with one of its thrust reversers disabled.
While the reason is not clear, there are a number of causes, including
mechanical failure, that could disable a thrust reverser.
Planes can land safely without thrust reversers, but if only one is deployed
and power is applied to both engines, the forces are applied in opposite
directions, tending to spin the airplane. Normal procedure is to alert the crew
to important items that are not working, including thrust reversers.
Planes are permitted to fly disabled thrust reversers for a limited time
before they are repaired.
In Irkutsk, the plane ran off the runway and ripped through a six-foot
concrete barrier, slammed into several small buildings, and burst into flames,
killing 124 of the 203 passengers and crew aboard.
Survivors were quoted as saying that the plane’s engines appeared to be
accelerating, then shut down. That would be normal in any landing in which both
thrust reversers were used.
Investigators said that in some circumstances, a pilot could use a single
thrust reverser, providing that power was applied only to that engine.
Several witnesses were reported to have seen the plane actually accelerate
after landing before leaving the runway and slamming into the concrete wall at
about 100 miles an hour, then hitting several unoccupied storage buildings and
stopping in flames.
Investigators examining the flight data recorder have not reached any
definitive conclusions about the cause of the crash. It appeared, according to
one investigator, that while both engines gained power after touchdown, the one
without the thrust reverser gained power more slowly.
The authoritative journal, Flight International, reported Tuesday that the
aircraft had landed at the proper point on the runway, then continued down the
runway for some distance before yawing off to the right.
"This has led to speculation among Russian pilots that there might have been
asymmetric thrust reverser deployment or braking, but no official sources will
confirm or deny it at this stage," the publication said.
The two pilots, Sergei Shibanov, 45, and Vladimir Chernykh, 48, had no
previous accidents, the airline said, and were highly experienced pilots
qualified to fly international flights.
The benefits of breakfast
A healthy breakfast that includes high-fiber cereal can not only help keep
diabetes, heart disease, and stroke at bay, it can also help you achieve and
maintain a healthy weight.
Research suggests that breakfast eaters are leaner than those who skip the
morning meal, with one study reporting that missing breakfast was associated
with a fourfold increase in the risk of obesity. High-fiber cereals are central
to breakfast's health benefits and can help you reduce the risk of heart
disease, stroke, diabetes, and even intestinal polyps and colon cancer. Look for
breakfast cereals that provide at least 6 grams of fiber per serving, but make
sure your choice is low in sugar (less than 10 grams per serving). Add nonfat
milk and bananas, berries, or apple slices to create a tasty meal.
You needn't limit your morning menu to high-fiber cereals, but wise choices
are important. Stick to whole-grain or pumpernickel breads for toast; opt for
trans-fat-free soft margarines or cholesterol-lowering spreads that contain
plant stanols. Eggs needn't be banned from the breakfast table, but are better
reserved for the occasional brunch, particularly for people with diabetes. In
one study, men with diabetes who ate more than one egg a day were twice as
likely to develop cardiovascular problems. To date, there is no solid evidence
that organic eggs or brands high in omega-3 fats offer any particular health
benefits—and they still count as eggs. Many typical breakfast foods (hash
browns, bacon, croissants) have too much fat or salt—and fast-food breakfasts
have too much of everything, except the fiber that adds the real punch to
breakfast's health benefits.
A little experimentation—a whole grain cereal one day, pumpernickel toast
with peanut butter the next—can help you find the combination of foods that make
breakfast a welcome start to your day.
END with appreciation to jetBlue
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