DFS AVIATION OCCURRENCES BRIEF

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1 AVIATION SAFETY SECTION DFS, UNHQ 4 JANUARY 2012 Rotary Wing INFORMATION BASED ON 24 PRELIMINARY AIRCRAFT OCCURRENCE REPORTS SUBMITTED DURING DECEMBER 2011 Bell After landing, a fluid leak was noted underneath the helicopter. Further inspections determined that the oil leak was caused by a Main Gear Box broken line (Technical GC). Mi-8 T - During the pre-flight inspection, the ground crew detected a Flight Data Recorder (FDR) malfunction. Air task was conducted after technicians replaced the faulty part (Technical GC). Mi-8 AMT - While engines start, the Auxiliary Power Unit (APU) failed and the engines start was interrupted. Smoke and fire was observed coming out from the APU exhaust momentarily. An inspection detected that smoke and fire was caused by fuel that pooled in the APU exhaust duct. No damage was reported (Technical AC). Mi-8 AMT - During the engines start, the crew detected a malfunction of the Attitude Indicator. The instrument was replaced and the flight continued after a short delay (Technical AC). DFS AVIATION OCCURRENCES BRIEF AND 4TH QUARTER REVIEW DECEMBER 2011 Mi-8 AMT - While taxiing for take off, the crew noticed the "Metal Chips in Main Gear Box" warning indication. The aircraft returned to the parking area for maintenance assistance. Maintenance inspection revealed a false indication caused by humidity in the system (Technical AC). Inside this issue: Aviation Occurrences Brief, December OHRs & PAORs 4Q Review 4 Status of 2011 DFS Accidents Investigations 7 Cabin Crew Must Capture Passenger s Attention in Predeparture Safety Briefings 8 Mi-8 AMT - During the flight, the aircraft landed 2 miles away from the scheduled Helicopter Landing Site (HLS). Apparently, during the flight planning, the crew did not check the HLS correct coordinates (Operations). Mi-8 AMT - Before starting engines, Air Liaison Officer (ALO) detected undeclared boxes containing unauthorized cargo (live stock, food and alcohol). After the ALO identified the passenger which the cargo belongs to, he requested the cargo to be off-loaded but the passenger started behaving in a unruly manner. Passenger and cargo were removed from the aircraft (Other). Information published in this report is based on preliminary aircraft occurrence reports submitted and completed by missions by the end of the month and is subject to change. For more information on selected occurrence refer to the Aviation Inspection and Recommendation Module or contact the Aviation Safety Section.

2 DFS AVIATION OCCURRENCES BRIEF DECEMBER 2011 Mi-8 MTV - Just before departing, the crew decided to reject the take-off due to a sudden drop in the right engine oil pressure. The helicopter returned to the parking area and disembarked all passengers (Technical AC). Mi-8 MTV - During the pre-flight inspection, the ground crews detected a Cockpit Voice Recorder (CVR) malfunction. The flight was delayed for more than an hour (Technical GC). Beechcraft The crew failed to familiarize themselves with a published NOTAM related to their destination which restricted the use of the airport at the time of their estimate time of arrival. As a result, the aircraft was instructed to hold for 40 minutes before they were authorize to land (Operations). Mi-26 - On engines start, the aircraft experienced an APU failure (Technical AC). Did you know? The internationally callsign Mayday-Mayday-Mayday used as a distress radio code was originated from the French m aider. "Venez m'aider" means "come help me." The callsign Pan-Pan used for urgency signal is derived from the French word "panne", which means failure or breakdown. Pan-Pan most often refers to a mechanical failure or breakdown of some kind. Fixed Wing Beechcraft During systems check before departure, the crew detected a discrepancy in the aircraft pneumatic pressure. The pressure was significantly below normal range. Flight was canceled (Technical AC). Beechcraft While engines start, the right engine failed to start after two attempts due to a faulty Ground Power Unit. The flight was cancelled (Technical AC). An-26 - During engines start-up, the left engine failed to start due to an ignition system malfunction (Technical AC). An-26 - During engines start-up, the left engine failed to start due to a recurring ignition system malfunction (Technical AC). 2

3 DFS AVIATION OCCURRENCES BRIEF DECEMBER 2011 ATR-72 - During the pre-flight checks, the Multi-purpose Control Display Unit (MCDU) was found to be inoperative. Ground technicians confirmed that the Navigation Processing Unit (NPU) had malfunctioned (Technical GC). ATR-72 - During post-flight inspection, the ground crew detected one of the right main landing gear door bolts missing. This missing bolt caused some looseness of the door (Technical GC). ATR-72 - While turning to final approach for landing, the crew received a Resolution Advisory (RA) and immediately noticed an aircraft taking off from the opposite runway. Both aircraft executed the RA provided by their TCAS. Aircraft landed safely afterwards (ATS/ATC). with the military aircraft when the aircraft caught up and to passed on the right. Aircraft landed without further incidents (ATS/ATC). CRJ After takeoff, the landing gear failed to retract after selected Up. The crew followed the appropiate procedures and decided to return for landing. The aircraft landed normally with no events. A post-flight inspection detected the nose oleo strut below normal limits (Technical AC). CRJ Shortly after takeoff, the crew detected the Flight Director # 2 Fail warning light. Simultaneously, the Autopilot and YD2 channel disconnected. The flight continued and landed safely at the planned destination. A technical inspection revealed a Flight Director computer malfunction (Technical AC). DHC-7 - Take off was rejected after the crew noticed the Master Caution light illuminated. The # 1 hydraulic system indicator showed "0" quantity. The post flight inspection revealed a hydraulic leak near the left wing root caused by a broken hydraulic line (Technical AC). DHC-7 - After the crew reported inbound 20 NM from the airfield, the ATC advised the crew on an opposite departing traffic and climbing. The crew had visual contact with the traffic but simultaneously received a Traffic Advisory from the TCAS and turned left. The crew reported no direct conflict (ATS/ATC). DHC-7 - During engines start, the engine # 2 failed to start. The inspection revealed a malfunction of the engine starting system attributed to a faulty igniter and exciter box (Technical AC). DHC 8 - After climb, ATC cleared a military C-130 to fly at the same altitude (FL 20,0) and on the same route. Since weather conditions were VMC, the crew managed to coordinate 3

4 AVIATION SAFETY SECTION DFS, UNHQ 4 JANUARY 2012 THIS SUMMARY IS BASED ON THE DATA COMPLETED IN THE INSPECTIONS AND RECOMMENDATIONS MODULE DURING 4th QUARTER OF ANY DISCREPANCIES SHOULD BE REPORTED TO THE AVIATION SAFETY SECTION, LSD/DFS. Among all OHR reported during 4Q (55), common hazards reported are attributed to Technical Hazards (91%) and Natural Hazards (9%). Among the most significant Technical Hazards, deficiencies related to: Mission s Regulatory Factors (19) such as lack of applicability and enforceability of regulations; certification of equipment, personnel and procedures, lack or inadequate supervision; Inadequate Operating Practices (11) such as lack of adherence to established procedures by flight, ground crews, ground support, and operations; Defenses (7) such as lack of detection and warning systems; Human Performances (6) such deficiencies that may lead to medical conditions and physical limitations, particularly to the lack or improper accommodations for TOTAL NUMBER OF REPORTS TOTAL 4Q / TOTAL 2011 OCCURRENCES 108 / 450 OBSERVED HAZARDS 55 / 223 OBSERVED HAZARD REPORTS REVIEW OCTOBER - NOVEMBER - DECEMBER 2011 crews at the Missions. Among the Natural Hazards (5), the majority are created by Environmental Factors such as wildlife (birds), and domestic animals (dogs). Grass next to the airstrip is too tall and limits the operational area of the airstrip to 7 Meters. (Reported by UNMIL). PRELIMINARY AIRCRAFT OCCURRENCE REPORTS REVIEW OCTOBER - NOVEMBER - DECEMBER 2011 This occurrences review is based on the categorization of the nature given to each PAOR submitted. Technical occurrences are the leading nature of occurrences. The major sources of the technical occurrences are related to discrepancies in Engines Systems (26%), Auxiliary Power Units (11%), Electric Systems (11%), Hydraulic System (8%), and Main Gear Boxes (5%). The remaining 38% are attributed to other technical causes. During 4th Quarter 2011, as depicted in the charts on page 6; Technical (67%), Operations (6%), ATS/ATC (5%), Hostile Acts (4%), Runway Incursions (4%) and Others (7%), are attributed as the leading nature of occurrences in DFS aviation. Hydraulic broken line caused the Master Caution light to illuminate during take off; the take-off was rejected (DHC-7). 4

5 Six (6) Operations occurrences were submitted during the 4Q period. Although most of them cannot be grouped together, the majority are related to the lack of pre-flight preparation when the crew did not familiarize adequately with their destinations (NOTAMs or correct HLS coordinates). This deficiency created deviation and delays in the air task orders. An unusual occurrence took place when the crew inadvertently released empty fuel tanks while in-flight. Fortunately, this events did not create any injury or damage to third parties. Four (4) Hostile Acts were reported in the Module during this period, and all were reported by UNMISS. Two occurrences involved the demand by intimidation to transport passengers (Local militia) onboard UN flights; one event related to fire from the ground during take off and one event involving the temporary detention of crew and passengers by Local militia. None of the events resulted in injury to crew or passengers. While in-flight, the crew inadvertently released empty fuel tanks; no damages were reported (Mi-35 ). Deficiencies in Air Traffic Services / Air Traffic Management still represent a serious threat to DFS air operations. In the 4th Quarter, five (5) occurrences were reported in the Module representing a significant increase in comparison with the previous Quarters. 4 of the occurrences are related to inadequate air traffic separation and 1 related to the poor traffic instructions while in the traffic pattern. During take off, a Local police staff standing nearby the HLS started firing his weapon toward the helicopter (Mi-8 MTV). 9 incidents were reported as Other. The reports included occurrences that cannot be grouped together. However, the events included a diversity of incidents such as lightning strikes; a crew injured while in-flight and after aircraft encountered turbulence; burst tires; crew incapacitation before the flight; interference from the ground by laser beam; aircraft damaged during loading operations and a passenger started behaving in a unruly manner before the flight. Quarterly ATS/ATC PAOR Comparison 2011 # of PAORs Q 2Q 3Q 4Q Period ATS/ATC events increased significantly during the 4Q During loading operations, a jack-lift caused a dent on the floor of the helicopter (Mi-8 MTV). 5

6 Preliminary Aircraft Occurrence Reports Review Oct - Nov - Dec 2011 ATS/ATC, 5, 5% Runway Incursion, 4, 4% Air Miss, 3, 3% Hostile Act, 4, 4% Operations, 6, 6% Other, 9, 7% Bird Strike, 3, 3% Ramp Incident, 1, 1% Technical, 73, 67% 80 Quarterly PAOR Comparison Technical Operations Other Runw ay Incursion Bird Strike Hostile Act Air Miss ATS/ATC Ramp Incidents DG 1Q 2Q 3Q 4Q 6

7 STATUS OF 2011 DFS ACCIDENT INVESTIGATIONS As you remember, on 4 April 2011, the aircraft type CRJ-100, registration 4L-GAE, call sign UNO-834, operated by Georgian Airways in MONUSCO, impacted with the ground during its final approach, approximately 170 meters to the left of the runway axis. As a result of the impact, the aircraft was destroyed and 32 persons among crew and passengers were fatally injured. The Accident Investigation Board is lead by the Democratic Republic of Congo Ministry of Transport as the State of Occurrence. Accredited representatives from Georgian CAA, United States National Transportation Safety Board (NTSB), Canada Transportation Safety Board (TSB) and authorized representatives from DFS are also participating in the investigation. Based on the Flight Data and Cockpit Voice Recorders (FDR/CVR), the TSB-Canada and experts from the aircraft Manufacturer (Bombardier) completed the reconstruction of the flight, and continue to analyze the available information. Information is presented solely for the purpose of improving aviation safety awareness and accident prevention efforts and may not be used in disciplinary or legal proceedings. 7

8 Cabin Crew Must Capture Passenger s Attention in Pre-departure Safety Briefings Many people believe that aircraft crashes are unsurvivable. Wrong. Over 70% of airline accidents are survivable. 71% of people who die in survivable crashes, do so after the aircraft comes to a complete stop. In many cases its because they are unprepared for the crash. In an airplane environment, passengers are passive participants who, for the most part, are unaware of "why" the safety information they are given is important. As accident investigations have pointed out, the Pre-Departure Briefing is often the only safety information they will receive in the event there is an accident. Aircraft crewmembers know what to do when they get into the aircraft - where to step, and not to step, what to touch and not touch, when and how to buckle their seatbelts, where fire extinguishers and survival kits are, and how to use them because this is their environment. However, it's just critical that passengers, whether they are civilian or military, know these things since cabin crew may face an overwhelming workload during an emergency, particularly if the passengers don t know how to use the emergency equipment. Flight Attendants cannot predict passengers behavior; therefore, the best practice is to build a foundation of shared knowledge during the pre-departure safety briefing. Passenger attention to Pre-Departure Briefing has influenced the survival of passengers in various accidents. An alert and knowledgeable person has greater probability of surviving an emergency situation in a transport airplane than an unprepared person. It is difficult for cabin crews to maintain their interest and conscientiousness in regards to attracting passengers attention to safety briefings because of the repetitive nature, workload pressure and seeming lack of interest from passengers prior departure. But there is no excuse for cutting short, amending, ignoring or omitting the passengers briefing. It would be very tragic to have someone injured during an emergency situation just because he/she did not put attention to the safety briefing or because a crew member skipped part or the entire safety briefing. Passengers are not familiar with the routine or emergency procedures that are second nature to aircrews. Passengers don't know what they don't know and is for this reason that every aircraft crew is required to ensure that all passengers, military and civilian alike, are briefed on emergency actions prior to every flight in accordance with UN Aviation Manual and International Safety Procedures. Many Civil Aviation Authorities assume that airlines know best how to attract passenger s attention, but some cabin safety specialists believe that creative and interesting methods improve attention to safety briefings before take off. Just remember, an alert and knowledgeable passenger has greater probability of surviving an emergency situation in a transport airplane than an unprepared person. (Extract in part from Flight Safety Foundation) 8