Envoy E145 at Chicago on Nov 11th, runway excursion on landing

An Envoy Embraer ERJ-145, registration N619AE performing flight AA-4125 from Greensboro,NC to Chicago O’Hare,IL (USA) with 38 passengers and 3 crew, landed on O’Hare’s runway 10L at 07:40L (13:40Z). The tower had reported medium braking action and 4000 feet RVR, when the aircraft skidded left off the runway, skidded sideways further yawing to the left and came to a stop with all gear as well as the right wing tip on soft ground about 5350 feet/1630 meters past the runway threshold, the right main gear had collapsed. A passenger commented: “I think we landed!”. The aircraft was evacuated.

The runway was closed.

The airline reported the aircraft skidded off the runway due to icy conditions at Chicago O’Hare, all 38 passengers and 3 crew left the aircraft without injuries and have been taken to the terminal.

Following the occurrence ATC changed to tell arriving aircraft that braking action was poor. The aircraft had gone around on short final to runway 10L about 25 minutes earlier after being instructed by tower to go around.

Click here to view the video

http://avherald.com/

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Canada issues Emergency AD to limit Airbus A220 engine power settings after recent incidents

Regulator Transport Canada issued an Emergency Airworthiness Directive (AD) to limit certain engine power settings on Airbus A220 aircraft following three recent failures.

Three inflight shutdowns occurred within three months: July 25, 2019, September 16, 2019, and October 15, 2019. In each case, the aircraft involved was a Swiss International Air Lines Airbus A220-300 (formerly named Bombardier CSeries 300) with Pratt & Whitney PW1524G-3 engines. These inflight shutdowns were due to failure of the low-pressure compressor (LPC) stage 1 rotor, which resulted in the rotor disk releasing from the LPC case and damaging the engine.

Investigations are ongoing to determine the root cause, but preliminary investigation results indicate high altitude climbs at higher thrust settings for engines with certain thrust ratings may be a contributor. This condition, if not corrected, could lead to an uncontained failure of the engine and damage to the aeroplane.
Transport Canada issued the AD on October 26, introducing a new Aircraft Flight Manual (AFM) limitation and normal procedure to limit the engine N1 setting to 94% while above 29000 feet. This AD is considered an interim action and further AD action may follow.

news.aviation-safety.net

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What health systems can learn from aviation

Crew resource management, an aviation strategy that can be adapted to healthcare settings, helps reduce adverse events and results in cost savings, according to a study published in American Journal of Medical Quality.

Crew resource management is a process first used by airplane crew members to spot safety threats, come up with a plan to avoid or lessen them and communicate that plan to the crew. It combines elements of teamwork, such as situational awareness, communication and task management, and human factors, such as coordination and decision-making.

Researchers examined the effect of using crew resource management training at about 3,000 health systems from July 2010 to July 2013. Employees in 12 areas were trained at a cost of $3.6 million.

They found that the total number of adverse events avoided was 735, and cost savings for the health systems ranged from $12.6 million up to $28 million.

They calculated that the overall return on investment for crew resource management training ranged from $9.1 million to $24.4 million.

https://www.beckershospitalreview.com/

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Saab 2000 – Runway Excursion (Alaska) Thursday 17 October 2019

A Saab 2000, registered N686PA, was substantially damaged when it experienced a runway excursion after landing at Unalaska Airport, Dutch Harbour, Alaska. There were no reported “major” injures to the occupants onboard. 

https://aviation-safety.net/

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Airbus A220 PW1500G engine failures prompt inspection AD

27 September 2019

The FAA issued an airworthiness directive (AD), requiring initial and repetitive inspections on certain Pratt & Whitney geared turbofan engines following two recent incidents.

The first inflight shutdown occurred on July 25, 2019 and the second occurred on September 16, 2019. In both cases, the aircraft involved was a Swiss International Air Lines Airbus A220-300 with Pratt & Whitney PW1524G-3 engines.

To prevent recurrences, the FAA requires initial and repetitive borescope inspections of the LPC inlet guide vane (IGV) and the LPC stage 1 rotor and, depending on the results of the inspections, replacement of the LPC.

Although these incidents occurred on PW1524G-3 model turbofan engines, the FAA is including PW1900 engines because similarities in type design make these engines susceptible to the same unsafe condition. The required inspections have to be performed within 50 flight cycles from September 26, and thereafter at intervals not to exceed 50 flight cycles until the engine accumulates 300 flight cycles.

The investigation into both incidents has been delegated to the NTSB.

https://news.aviation-safety.net/
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Why is cross-functional teamwork so important?

Why is cross-functional teamwork so important?
Description: Introducing cross-functional teamwork can not only help to promote a sense of cohesion across your business but also optimise your efforts Keywords: crm training courses, human factors, cross-functional teamwork short workshops.

Have you ever felt like your organisation works in silos with each department working on their own tasks, and not considering other teams’ requirements. things?

Does it seem as if one of your teams does not fully understand the needs and challenges of another team, and vice versa?

Obviously, each department will have their own function but they should all be working towards the same goal – otherwise you will find that your resources are spread too thinly and this will have a negative impact on your business. Introducing cross-functional teamwork can not only help to promote a sense of cohesion across your business but also optimise your efforts to achieve all of your goals faster with less waste. Read on to discover more about cross-functional teamwork and how it could benefit your business:


What is cross-functional teamwork?
Cross-functional teamworking, is how different teams and departments work together, and this can often be the weak link within an organisation. Individual teams or departments may be working effectively, but your organisation’s efficiency and profitability will be greatly diminished if:
The channels and links that enable communication and collaboration between teams and departments are weak, non-existent or not used effectively.

  • There is lack of mutual understanding and appreciation of the needs and requirements of other teams and departments.
  • Your teams do not understand and appreciate the need for effective cross-functional teamworking.


Why do we need cross-functional teamworking?
If your company is not cross-functional then this can be frustrating for both your own personnel and, perhaps more importantly, for your customers. Whatever your organisation is, its sole purpose is to serve the customer – and so all departments should work together to provide a comprehensive and positive customer experience.

Cross-functional teamworking helps with this by encouraging each team to communicate effectively with other teams. Bringing teams together in this way can also help with problem solving and lead to smarter decision making. Instead of teams operating independently, they will collaborate to make optimal use of time and resources, making more of an effort to improve customer satisfaction while also helping to meet your organisation goals.

Why should you build cross-functional teams?
Central to cross-functional teamworking is a model of corporate effectiveness which identifies management and worker inputs to the workplace and identifies strategies which reduce the probability of inefficient behaviour. The model applies the principle of Threat and Error Management to the corporate level of operations.

What are the key aspects of cross-functional teamworking?

  • Introducing cross-functional teamworking. When developing cross-functional teamworking the key areas on which to focus are on linking attitudes to performance, using goal-setting and other behavioural modification approaches to develop positive change, and also shaping attitudes in order to sustain workplace change.
  • Encourage a collaborative culture. Bringing together the different teams within your business to create cross-functional teamworking means you will have access to a collective knowledge base made up of people with different backgrounds and skills which can be harnessed to drive your business forwards.
  • Encourage continuous learning. Bringing people from different areas of the business together means there will no doubt be some learning and development going on, which will help with both worker satisfaction and autonomy.
  • Learn new tools. Coming together with other teams, and seeing how they do things differently is a great way to discover what tools everyone is using and whether you could benefit from using those tools as well.
  • Exercise communication skills. Communication can make or break corporate effectiveness – and it is not just about listening. You need to think about agreed upon communication channels, constructive feedback and have an understanding of human diversity.
  • Honing management skills. Placing people together and expecting them to gel immediately is not wise, especially when you take human factors into account. Managing cross-functional teams will really put your management skills to the test, and is something you definitely need to prepare for.
  • Practising conflict resolution. There are always conflicts within team, especially cross-functional ones. Conflicts can arise from differences in educational backgrounds and training, differences in work processes and tools used, and also a lack of understanding of the purpose of their role. Once you have recognised the conflict though, you can work together to overcome it.
  • Mixes things up a bit. Cross-functional teamworking will shake up your work routine a little, providing a different perspective on the operation. It can be a good way to revitalise people in your company as well, giving them a chance to break free from their mental roadblocks and daily habits as well.
  • Spark innovation. Having different team members mix with people from other teams can be a great way to spark innovation by showing them how to think a little differently. Grouping new people together will help them to think outside of the box.


Here at ITS Academy you can not only learn more about cross-functional teams but what benefits they can bring to your organisation as well. In addition, we offer a number of short workshops covering a wide range of subjects, so whatever type of business you are in, we can help you to maximise your profits by improving teamwork and minimising error. Contact us for more information, or to discuss how we might support you.

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Fuel contamination caused two emergency landings, one with two failed engines.

Fuel contaminated with diesel exhaust fluid forced two air ambulances to make emergency landings in May. Both aircraft have been declared total losses.

On May 9, both twinjets departed Air Trek’s Punta Gorda base and flew to Naples, Florida, where medical technicians, patients, and patients’ family members boarded. AOPA reported that one Citation was headed to Niagara Falls, New York, but experienced an engine flameout north of Savannah, Georgia. It then lost its second engine but landed safely in Savannah. The other Citation was bound for Chicago when it experienced an engine failure, and landed safely in Louisville, Kentucky. In all, 13 occupants escaped without injury, said Dana Carr, Air Trek’s director of operations.

The FAA determined that the two aircraft received fuel that had been contaminated with diesel exhaust fluid, or DEF, which had been added erroneously to the fuel supply in a fuel truck in Punta Gorda. DEF is a urea-based chemical that reduces diesel-engine emissions. It is not intended for use in aircraft, and when added to jet fuel, can trigger chemical reactions leading to the formation of crystals that can plug fuel filters and damage other engine components.

The incidents followed occurrences at other airports in 2018 and 2017 that had triggered FAA warnings and prompted intensive industry review of aircraft-fueling practices and personnel training.

In an Aug. 7 phone interview, Carr expressed Air Trek’s pride in the performance of the two fight crews. “They did an admirable job,” he said, noting that one of the pilots was, fortuitously, also rated in gliders.

DEF a bad fit for airports
The risk of jet fuel being contaminated by diesel exhaust fluid (DEF) is “unacceptably high,” and the Environmental Protection Agency should exempt airport vehicles from emissions requirements mandating the use of DEF “in non-road, on-airport ground support equipment and vehicles,” said AOPA and 17 other aviation organizations in an Aug. 7 letter to the administrators of the EPA and the FAA. Such an exemption was recommended in an industry-led working group’s report that addressed immediate actions that could be taken to reduce the DEF risk. While more permanent solutions, such as the complete removal of DEF from airports, are under study, the industry is voluntarily implementing the report’s other recommendations, including “education, storage, labeling, handling procedures, and limiting DEF inventory,” the letter said.

In addition to the aviation groups signing the letter to the FAA and EPA, the National Transportation Safety Board has also expressed concern about the issue, sending a safety alert in July that includes suggestions to help prevent future incidents. And in August , the Diesel Technology Forum, a non-profit group that aims to raise awareness about the importance of diesel engines, fuel and technology, is backing the aviation industry’s stance on DEF contamination.

In an Aug. 6 press release, the Diesel Technology Forum wrote, “We recommend that FBO’s follow the NTSB safety bulletin, and work with diesel engine and equipment dealers and their fuel suppliers to understand the proper use and storage of DEF. FBOs should also institute ongoing training, labeling and storage practices to help ensure aviation safety. The work done by the Aircraft Diesel Exhaust Fluid Working Group and their report in June 2019 has contributed a substantial understanding to the issue, and offers strong short- and long-term recommendations.”

The National Transportation Safety Board’s preliminary report on the double engine failure experienced by the aircraft that diverted to Savannah gives an account of a crisis aloft that unfolded in stages as the jet gradually lost power:

“According to the pilots, about 1 hour and 20 minutes into the flight from APF to IAG, while cruising at 35,000 ft mean sea level (msl), the pilot-in-command was trying to set the N1 speed around 103 [percent], but moments after adjusting power, the N1 speed would decrease. Following a few repeated occurrences of the N1 speed decreasing in this manner, all the engine gauges ‘read regular,’ then the left engine began to ‘spool down very slowly.’ After unsuccessfully attempting to recover engine power, the crew requested a lower altitude from air traffic control and began a descent with the left engine at idle power. The pilot-in-command then noticed that the left engine displayed no oil pressure and subsequently shut it down.

“Several minutes passed as the airplane descended with the right engine at 65 [percent] fan speed, and while preparing to perform a single-engine approach into SAV, about 8,000 ft msl, the right engine became unresponsive and then began ‘spooling down.’ The pilot-in-command declared an emergency and the flight crew performed a straight-in approach to runway 19. The airplane landed without incident and was towed to the ramp,” the report states.

The preliminary NTSB report revealed that “several days after the incident, the lineman realized that he had inadvertently combined a 5-gallon (fuel system icing inhibitor) bucket and a 2.5-gallon diesel exhaust fluid (DEF) container instead of two partially-empty containers of FSII.”

https://www.aopa.org/news-and-media/all-news/

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B738 at Moscow overran runway on take-off, August 5th, 2019

A S7 Airlines Boeing 737-800, registration VQ-BKV performing flight S7-263 from Moscow Domodedovo (Russia) to Simferopol (Ukraine), departed Domodedovo’s runway 32L but overran the end of the runway before the aircraft became airborne. The aircraft continued the flight for a landing on Simferopol’s runway 19 without further incident about 2:10 hours after departure.

A later runway inspection found glass debris at the runway end and detected five damaged runway end lights. A review showed 5 aircraft had taken off between the previous and current runway inspection, amongst them VQ-BKV. An inspection of the aircraft after landing in Simferopol showed three tyres had been damaged, the landing gear had glass embedded.

The occurrence aircraft remained on the ground for about 19 hours, then departed for the return flight.

One Russian Aviation Source reported the crew computed take-off performance using a take-off weight 15 tons below the real weight.
Another Russian Aviation Source claimed the crew inadvertently entered Zero Fuel Weight instead of Take-off Weight.

http://avherald.com/

https://itsacademy.com/wp/wp-content/uploads/Overran-runway-on-takeoff-B738-at-Moscow-on-Aug-5th-2019.mp4

Surveillance Video of the take-off:

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Latest version of UK CAA CAP 737

Use this link to obtain the latest version of the UK CAA Human Factors Handbook – CAP 737

http://publicapps.caa.co.uk/docs/33/CAP%20737%20DEC16.pdf

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A321neo has a fault that could cause the nose to pitch up

Operators of the Airbus A321neo have been issued with an airworthiness directive by the European Aviation and Space Agency (EASA) alerting it to a problem that could cause the nose to pitch up.

According to EASA Airworthiness Directive 2019-0171, the behaviour of the Elevator Aileron Computer unit installed on A321neo can cause ‘excessive pitch attitude’ that could result in ‘reduced control of the aeroplane’. 

The fault is most likely to occur on the final approach phase, particularly if a ‘hard manoeuvre’ is attempted, such as a large correction to the aircraft’s angle of attack (AoA).

The temporary revision instructs airlines not to load their A321neos with a centre of gravity (CoG) as far rearward as currently permitted so the weight is not towards the rear of the aircraft and the directive dictates Airlines must change the Aircraft Flight Manuals accordingly.

Whilst seemingly not as serious as the fault with the Boeing 737 Max aircraft that resulted in two fatal accidents, the news will come as a blow to Airbus that has seen orders for its single-aisle aircraft shoot up as confidence in the 737 Max drops.

As a result, Airbus has stressed that the fault with the ELAC unit can only occur “in certain and remote conditions and in combination with specific commanded manoeuvres”. 

Airbus expects to have its flight control system fine-tuned and a permanent solution to the problem in place by Q3 2020.

Unlike the Boeing 737 Max, A321neo’s will continue to be allowed to fly.

www.ukaviation.news

Airbus A321 Neo (Image: Airbus)
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