Six month safety review for 2014

This review of plane crashes and other significant events from the first six months of 2014 discusses three airline events, two of which involved at least one confirmed passengers fatality, and the third, which involved suspected passenger fatalities on Malaysia Airlines flight MH370.

Since AirSafe.com began tracking such events in 1996, there have been three or fewer fatal events in the first six months of a calendar year on five other occasions. There were also three fatal events in the first six months of 2001, 2005, and 2010. There was a single fatal event in the first six months of 2006 and 2013.

This review includes all fatal events, specifically events involving passenger fatalities in aircraft which have the capacity to seat at least 10 passengers where those models are used in regular airline service in North America, western Europe, Australia, or Japan. Also included are plane crashes and other significant events that did not qualify as a fatal event, but that either had high media interest or that had noteworthy aviation safety or security implications.

All of the events in the first half of 2014 were fatal events, and there were no significant events. From 1996 to 2014, there have been a total of 81 fatal events and 35 significant events in the first half of the year, for an average of 4.26 fatal events and 1.94 significant events each year.

The AirSafe.com definitions page has additional details on how an event is assigned to a category. The Malaysia Airlines flight MH370 event led to a change in the definitions, expanding the fatal event category to include situations where an airliner has been missing for at least 30 days, and where there is also substantial indirect evidence that one or more passengers were killed.

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Events Killing Airline Passengers

1. 16 February 2014; Nepal Airlines DHC-6 Twin Otter 300; 9N-ABB; flight 183; en route between Pokhara and Jumla, Nepal: The aircraft was on a scheduled domestic flight from Pokhara to Jumla, Nepal. Radio contact was lost about 30 minutes after takeoff. The crashed aircraft was found the next day, and all three crew members and 15 passengers had been killed.

2. 8 March 2014; Malaysia Airlines 777-200; 9M-MRO; flight MH370; unknown location: The aircraft was on a scheduled international flight between Kuala Lumpur, Malaysia and Beijing, China and went missing while en route. The current location and status of the aircraft, along with that of the 227 passengers and 12 crew members who were on board, is unknown.

   This is a numbered event as defined by AirSafe.com because there is substantial indirect evidence that one or more passengers were killed.

   Visit the Malaysia Airlines flight MH370 page for additional information, including links to articles and interviews of Dr. Todd Curtis of AirSafe.com

3. 24 June 2014; Pakistan International Airlines (PIA); A310-300; AP-BGN; flight PK756; Peshawar, Pakistan The aircraft was on a scheduled international flight from Riyadh, Saudi Arabia to Peshawar, Pakistan, when it was struck by several bullets shortly before landing. Two cabin crew members and one passenger were hit, and the passenger died of her injuries. There were no other injuries among the 10 other crew members or 177 other passengers.
   Fatal PIA Events

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Other Significant Events

None

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Other Years
1996, 1997, 1998, 1999, 2000,
2001, 2002, 2003, 2004, 2005
2006, 2007, 2008, 2009, 2010
2011, 2012, 2013

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AirSafe.com Bonuses
All subscribers to the AirSafe.com mailing list at subscribe.airsafe.com will be able to download free copies of all of the recent AirSafe.com books, including the AirSafe.com Family Air Travel Guide.

Also available is the AirSafe.com Fear of Flying Resource Guide, with an overview of the symptoms of fear of flying, as well as recommended resources for managing or eliminating these fears.

Passenger killed by shots fired at airliner

24 June 2014; Pakistan International Airlines (PIA); A310-300; AP-BGN; flight PK756; Peshawar, Pakistan - The aircraft was on a scheduled international flight from Riyadh, Saudi Arabia to Peshawar, Pakistan, when it was struck by several bullets shortly before landing. Two cabin crew members and one passenger were hit, and the passenger died of her injuries. There were no other injuries among the 10 other crew members or 177 other passengers.

According to one Pakistani newspaper, an airline official stated that the plane was 5.6 kilometers (3.5 miles) away from the runway when it was hit by gunfire from the ground.

This was the eighth event involving a passenger fatality on an A310, and the first since a June 2009 crash that killed all but one person on board the aircraft.

This was the ninth event involving a passenger fatality on a PIA flight, and the first since a July 2007 crash that killed all 41 passengers and four crew members on board the aircraft.

Related information
Crashes and other fatal passenger events on the A310
Fatal passenger events involving PIA

New search area for Malaysia Airlines flight MH370

26 June 2014, Canberra, Australia - Australian Deputy Prime Minister Warren Truss announced a new search area for Malaysia Airlines flight MH370. Based on a revised analysis of information from the aircraft and from the Inmarsat satellite, this new search area is several hundred miles away from the areas that were extensively searched from late April to late May of this year.

The highlights of today's announcement included the following:

• The new primary search area is about 60,000 square kilometers, which is about the size of the state of West Virginia, or the nation of Norway.

• The area to be searched is previously uncharted, and a three-month charting effort involving two ships is currently underway.

• The underwater search effort will commence in August, and is expected to last 12 months.

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Primary search area in orange lies southwest of earlier search areas in red, yellow, and green

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Updated analyses refocused search area
To date, no physical or photographic evidence from the aircraft has been recovered from the surface or the bottom of the ocean, and Australian officials, who are in charge of the search effort, have concluded that acoustic signals that were the focus of the earlier underwater search during April and May of this year are unlikely to have been associated with the missing aircraft.

A new and more extensive analysis of data from the Inmarsat satellite, and analysis of the performance of the aircraft, led to the identification of the new search area.

The analysis team, which included satellite and aircraft specialists from Boeing, the NTSB, Inmarsat, and several other organizations, uses the limited data that was transmitted between the aircraft and the ground, radar and other flight data from the early part of the flight, and combined that information with the known behavior of the aircraft's systems, to determine the new search areas. The search areas were identified using the aggregate result of five independent analyses.

Satellite communications with the aircraft
The recently released report stated that after normal communications between the aircraft and the ground ceased, and after the last recorded radar contact with the aircraft, that there were nine satellite communications attempts either to or from the aircraft. Two were unanswered ground to air telephone calls, and seven were 'handshake' signals between the aircraft and Inmarsat. These signals consistent of short messages with no significant data about the aircraft speed, position, or status.

An analysis of the seven handshake signals allowed the authorities to estimate the distance the aircraft traveled. The timing of last transmitted handshake signal was consistent with a shutdown of the engine electrical generators due engine flameouts due to fuel starvation.

Additional insights into the investigation
Earlier in the week, on June 23rd, Todd Curtis of AirSafe.com was interviewed on CJOB radio in Winnipeg, Canada on the progress of the investigation. Part of the interview concerned recent statements by the Malaysian authorities that if the plane was lost by deliberate action, then the captain would be the main suspect.

Resources
26 June 2014 report from the Australian Transport Safety Bureau
29 May 2014 update from the Australian JACC
ATSB determination of search area
Ocean mapping effort
Satellite communications logs
Additional information from the Ministry of Transport
AirSafe.com MH370 page

Graphics: Australian Transport Safety Bureau

NTSB report on July 2013 crash of an Asiana Airlines 777 in San Francisco

On 24 June 2014, NTSB Board members met to determine the probable cause of the July 2013 crash of Asiana Airlines flight 214 in San Francisco, CA, which resulted in the deaths of there passengers. The Board concluded that there were a number of probable and contributory causes for the accident, with many of them revolving around the crew's understanding of the aircraft's automated systems.

Synopsis
On July 6, 2013, about 11:28 am local time, a Asiana Airlines flight 214, a Boeing 777-200ER (HL7742), struck a seawall while attempting to land on runway 28L at San Francisco International Airport (SFO). Three of the 291 passengers were killed, and 40 passengers were serious injured. All 16 crew members survived, but nine were seriously injured.

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Aprroach sequence
Although air traffic control (ATC) allowed the aircraft to attempt a landing under visual flight rules, the flight crew used both the autopilot and autothrottle system during the landing. The sequence of events shortly before the crash featured a number of changes in the flight control system, and according to the NTSB the flight crew's understanding of how the aircraft performed in various autopilot and autothrottle modes led to the crash.

The following is a synopsis of the portion of the NTSB report on the crash of flight 214 that focused on the landing approach:

• The flight was vectored for a visual approach to runway 28L, and intercepted the final approach course about 14 nautical miles from the threshold at an altitude that put the aircraft slightly above the desired three degree glide path.

• The flight crew accepted an ATC instruction to maintain 180 knots until five nautical miles from the runway, but mismanaged the airplane’s descent, which resulted in the airplane still being above the desired three degree glide path when it reached the five nautical mile point.

• In an attempt to increase the airplane’s descent rate and capture the desired glide path, the pilot flying (PF) selected an autopilot mode that resulted in the autoflight system initiating a climb. The chosen autopilot mode, 'flight level change,' attempted to bring the aircraft to the selected altitude, which was above the aircraft's altitude at that point of the approach.

• The PF disconnected the autopilot, moved the thrust levers to idle, and then pitched the aircraft down, which increased the decent rate.

• When the PF disconnected the autopilot, that action caused the autothrottle to change to the 'hold' mode, which is a mode where the autothrottle does not control airspeed. Neither the PF or the other two pilots in the cockpit noted this change in the autothrottle mode.

• Asiana’s procedures dictated that the approach must be stabilized by the time the aircraft descends to 500 feet above the airport elevation. The approach was not stabilized, and the crew should have initiated a go-around, but instead continued the approach.

• As the approach continued, it became increasingly unstabilized as the airplane descended below the desired glidepath.

• Airspeed continued to decrease, and at about 200 feet, the flight crew became aware of both a low airspeed and low glide path condition, but still did not initiate a go-around.

• The crew finally initiated a go-around when the airplane was at less then 100 feet of altitude. However, at that point the airplane did not have the performance capability to accomplish a go-around.

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NTSB animation of the final approach

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Crash sequence
The following information was in the NTSB report synopsis released on 24 June 2014, and from two NTSB media briefings given shortly after the accident.

• The main landing gear hit the sea wall first, followed by the tail section.

• The main landing gear sheared away from the aircraft as designed, and the wing fuel tanks were not punctured by the gear separation or during the rest of the crash sequence.

• The tail section broke off after the aircraft contacted the sea wall. Cabin flooring and galley components were found on the chevrons in the runway overrun area between the sea wall and the runway threshold.

• Two passengers and four flight attendants were ejected from the aircraft. All four flight attendants were seriously injured, and both passengers were killed.

• Neither of the ejected passengers were wearing seat belts at the time of the crash, and one of these passengers was later run over by two of the responding firefighting vehicles. The NTSB noted that had the passengers been wearing their seat belts, they would have likely remained in the aircraft and survived.

• One of the flight attendants initiated an evacuation after became aware of a post-crash fire. All but five of the passengers were able to evacuate on their own. Firefighters rescued five passengers, one of whom later died.

NTSB probable and contributing causes
The NTSB determined that the probable causes of this accident was due to a combination of flight crew actions:

• Mismanagment of the airplane’s descent during the visual approach,

• Unintended deactivation of the automatic airspeed control system,

• Inadequate monitoring of airspeed, and

• Delayed execution of a go-around after they became aware that the airplane was below acceptable glide path and airspeed tolerances.

The NTSB found that there were also several contributing causes:

• Complex autothrottle and autopilot flight director systems that were inadequately described in Boeing’s documentation and Asiana’s pilot training,

• The flight crew’s nonstandard communication and coordination regarding the use of the autothrottle and autopilot systems,

• Inadequate training on the planning and executing of visual approaches;

• Inadequate supervision of the pilot flying by the instructor pilot; and

• Flight crew fatigue.

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Key NTSB Asiana investigation resources
Abstract of NTSB accident report
Asiana flight 214 investigation main page
Asiana flight 214 accident docket
Asiana flight 214 investigative hearing transcript (11 December 2013 hearing archived by AirSafeNews.com)

Related AirSafeNews.com articles

• AirSafeNews.com Review of the 11 December 2013 NTSB hearing on the Asiana flight 214 investigation

• AirSafeNews.com 13 July 2013 article summarizing final two NTSB briefings at SFO

• AirSafeNews.com 10 July 2013 article on the role of the autothrottle

• AirSafeNews.com 8 July 2013 article on early findings of the crash investigation

• Other Asiana plane crashes

• Other 777 plane crashes

• Accident details from Aviation Safety Network

• Wikipedia page on this accident

Update on the crash of a Gulfstream IV jet near Boston on 31 May 2014

31 May 2014; Gulfstream IV; N121JM, Hanscom Field, near Boston, MA: The aircraft was on an unscheduled flight form Hanscom Field in Bedford, MA to Atlantic City, NJ and crashed during takeoff. According to preliminary reports from the NTSB, a witness saw the aircraft attempt a takeoff, but did not see it become airborne.

After departing the runway, the aircraft struck a localizer antenna (used for instrument landing approaches) and a fence before proceeding down an embankment and coming to rest about 1,850 feet beyond the end of the runway, in a gully formed by a small river. Multiple witnesses reported hearing an explosion and seeing a fireball. The photo below from the NTSB shows that the aircraft broke up and had caught fire.

The aircraft was equipped with both a cockpit voice recorder and a flight data recorder, both of which were recovered and are currently being analyzed by the NTSB.

All seven occupants, including two flight crew members, a cabin crew member, and four passengers were killed. Although the authorities have not determined a cause of death, given the location of the crash site and the condition of the aircraft, it is likely that the fatal injuries were due to the effects of a combination of impact forces, smoke or fume inhalation, and burns.

Among the four passengers was Lewis Katz, a prominent entrepreneur and philanthropist who was a former owner of the New Jersey Nets and New Jersey Devils, and a current part owner of the Philadelphia Inquirer newspaper.

An AirSafe.com review of the online incident and accident databases of the NTSB and FAA show no prior accidents or serious incidents involving the accident aircraft. The aircraft was owned by SK Travel, LLC, of Raleigh, NC (a company co-owned by one of the passengers), and there were no indication of those same databases of any previous accident or serious incident involving this company.

According to Gulfstream Aerospace, 536 Gulfstream IV aircraft were produced from 1985 until 2002. The aircraft involved in the Hanscom Field accident was manufactured in 2000.

According to Aviation-Safety.net, a site run by the Flight Safety Foundation, there have been four fatal events involving the Gulfstream IV, including the recent crash at Hanscom Field, that resulted in the death of one or more people either inside or outside of the aircraft.

NTSB preliminary report - 13 June 2014
The NTSB preliminary report included the following key findings:

• Tire marks consistent with braking were observed to begin about 1,300 feet from the end of runway 11. The tire marks continued for about another 1,000 feet through the paved runway safety area.

• The airplane's ground roll began about 49 seconds before the end of the CVR recording.

• FDR data indicated the airplane reached a maximum speed of 165 knots during the takeoff roll, and did not lift off the runway.

• The FDR data ended about seven seconds after thrust reverser deployment, with the airplane at about 100 knots.

• The airplane was equipped with a mechanical gust lock system, which can lock the ailerons and rudder in the neutral position and the elevator in the down position, to protect the control surfaces from wind gusts while parked.

• The FDR data revealed the elevator control surface position during the taxi and takeoff was consistent with its position if the gust lock was engaged. The gust lock handle was found in the forward (OFF) position, and the elevator gust lock latch was found not engaged.

• Review of FDR data parameters associated with the flight control surface positions did not reveal any movement consistent with a flight control check prior to the commencement of the takeoff roll.

In an interview conducted shortly after the preliminary report was released, former NTSB Board Member John Goglia suggested that this lack of flight control movement prior to takeoff indicated that the crew did not complete a standard preflight checklist.

Resources
NTSB preliminary report
Video of the John Goglia interview

Can the 737 be attacked by hackers? - The FAA wants your feedback

Last Friday (6 June 2014), the FAA published a proposal for additional requirements that would make it less likely that someone could hack into critical electronic systems on some 737 models. The language is a bit dense, but the implication is that several models of the 737 (the 737-700, -700C, -800, -900ER, -7, -8, and -9 series) have an unusual design feature that allows access to the airplane's critical systems and data network by way of the passengers service computer systems.

It is not at all clear that this is a current danger, or if a 737 has already been hacked. For more details, you can review the Federal Register item that discusses this issue (Federal Register Vol. 79, No. 109, pages 32642-3), and for further details you can find out more in the docket folder for Docket FAA-2014-0302

What's the problem?
According to the FAA, the applicable airworthiness regulations do not contain adequate or appropriate safety standards to prevent inappropriate access to critical information systems. The special conditions that the FAA wants to add to the regulations contain additional safety standards that would presumably establish a level of safety equivalent to existing airworthiness standards.

The FAA wants your comments
The FAA would like to hear what you have to say, and invites everyone to contribute to this rule making effort. You can send written comments, data, or or other information to the FAA. While the most helpful comments would reference a specific portion of the special conditions, the FAA will consider all comments. The closing date for comments is 21 July 2014.

The FAA accepts comments online, by, fax, by mail, or it in person:

• Online: Visit this link to the comment page, or if that does not work, visit http://www.regulations.gov and search for docket number FAA-2014-0302-0001

• Mail: Send comments to Docket Operations, M-30, U.S. Department of Transportation (DOT), 1200 New Jersey Avenue SE., Room W12-140, West Building Ground Floor, Washington, DC 20590-0001.

• Hand Delivery or Courier: Take comments to Docket Operations in Room W12-140 of the West Building Ground Floor at 1200 New Jersey Avenue SE., Washington, DC, between 9 a.m. and 5 p.m., Monday through Friday, except federal holidays.

• Fax: Fax comments to Docket Operations at 202-493-2251.

Common questions about the comment process

• Can anybody leave a comment?: Yes

• Do I have to be some kind of computer or aviation expert: No

• Will my comments make a difference?: Hard to say

Additional resources
Overview at regulations.gov
FAA docket folder

Photo of Boeing 737-8ZS cockpit: Wikipedia