Latest version of UK CAA CAP 737

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

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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.

Airbus A321 Neo (Image: Airbus)
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Accident: Sky Express AT42, Jul 12th 2019, runway excursion on backtrack and roll back

 A Sky Express Avions de Transport Regional ATR-42-500, registration SX-FOR performing flight GQ-405 from Naxos to Athens (Greece) with 46 passengers and 3 crew, was backtracking runway 36 for departure at about 17:20L (14:20Z) when the aircraft went off the paved surface of the runway and came to a stop with the main gear in a ditch, the tail on the ground, the lower fuselage below propellers on the runway edge and the nose gear on the runway surface. There were no injuries, the aircraft sustained substantial damage.

Passengers on previous flights reported it was common to backtrack the runway, line up for departure and then roll back using back power (propellers in beta) to get as much runway available for takeoff as possible. 

Naxos’ runway 18/36 is officially 900 meters/2950 feet long. The Hellenic AIP reports TODA, TORA, ASDA and LDA all at 900 meters.

LGNX 121550Z 35007KT CAVOK 26/16 Q1011=
LGNX 121450Z 36011KT CAVOK 27/15 Q1011=
LGNX 121350Z 35011G21KT CAVOK 27/14 Q1011=
LGNX 121250Z 35010G20KT CAVOK 27/14 Q1011=
LGNX 120950Z 01012KT CAVOK 26/16 Q1011=
LGNX 120850Z 01011KT 9999 FEW025 25/15 Q1011= 
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FAA Recommends Increased Braking Performance Margins

Recent data indicates that applying a 15 percent safety margin to calculate wet runway stopping distance, as recommended by previous guidance, may be inadequate in certain conditions to prevent a runway excursion, according to a new safety alert for pilots (SAFO 19003). This new alert replaces the guidance in previous SAFO 15009.

“Several recent runway-landing incidents/accidents have raised concerns with wet runway stopping performance assumptions,” according to this new alert. “Analysis of the stopping data from these incidents/accidents indicates the braking coefficient of friction in each case was significantly lower than expected for a wet runway.” These mishaps occurred on both grooved and un-grooved runways.

Takeoff and Landing Performance Assessment (Talpa) procedures implemented by the FAA on Oct. 1, 2016, added new insight as to how flight crews can evaluate runway braking performance before landing. Talpa defines a “wet runway” as damp to 1/8-inch depth or less of water, while a “contaminated runway” is a surface covered with “greater than 1/8-inch of water.”

The FAA recommends that airports report “wet” conditions, but that is not required. Further, an airport may not be able to generate an accurate report from sudden rain showers that result in water on the runway more than 1/8 of an inch in depth (“contaminated”). The alert concludes that because “Rainfall intensity may be the only indication available to the pilot that the water depth present on the runway may be excessive, it is recommended that pilots use landing performance data associated with medium to poor braking.” However, the FAA notes that using all available data to prevent a contaminated runway excursion is moot when the landings involve delayed touchdowns, improper application of deceleration devices and landing with a tailwind.

Aviation Herald
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Accident: Jun 27th 2019, Angara AN24 engine failure, veered off runway & collided building

 An Angara Airlines Antonov AN-24, registration RA-47366 performing flight 2G-200 from Ulan-Ude to Nizhneangarsk (Russia) with 43 passengers and 4 crew on board, was on approach to Nizhneangarsk when the left hand engine failed. The aircraft landed on Nizhneangarsk’s runway 22 in the touch down zone at 10:24L (02:24Z) following a stable approach, rolled out on the center line for some distance, then veered right off the runway, went over soft ground and impacted a building, a fire broke out. The captain and flight engineer were killed in the accident, 44 people were able to evacuate or were rescued, 7 people were injured, 37 people remained uninjured including first officer and flight attendant. The aircraft was destroyed.

Russia’s Ministry Emergency Ministry reported emergency services received the emergency call at about 10:30L after the aircraft broke through a fence catching fire and collided with sewage treatment plants. 44 people were rescued, 7 of them were injured. Two people on board have been killed. A fire on board of the aircraft was quickly extinguished by emergency services. (Editorial note: these numbers suggest, in combination with the official passenger and crew count by the airline, one person is still missing).

The airline reported RA-47366 performing flight 2G-200 from Ulan-Ude to Nizhneangarsk made an emergency landing at Nizhneangarsk, veered off the runway and collided with ground infrastructure. As result of the collision a fire occurred. All 43 passengers were promptly evacuated. The captain and flight engineer were killed, the first officer and the flight attendant escaped uninjured. The captain had 34 years of experience and 15,702 hours total, the first officer 20 years of experience and 6,315 hours total, the flight engineer 35 years of experience and 13,728 hours. The Interstate Aviation Committee (IAC/MAK) have opened an investigation.

Rosaviatsia reported the crew declared “Distress” about 30km (16nm) from the airport reporting the failure of the left hand engine. Emergency services took their stand by positions for the arrival. On landing the aircraft went off the runway, collided with technical structures of the airport and caught fire. All passengers are alive, the captain and flight engineer died in the accident.

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Venezolana B732, uncontained engine failure May 30th 2019

A Venezolana Boeing 737-200, registration YV502T performing flight VNE-1303 from Port of Spain (Trinidad and Tobago) to Caracas (Venezuela) with 79 people on board, was climbing out of Port of Spain when the left hand engine (JT8D) failed emitting a loud bang. The crew stopped the climb and returned to Port of Spain for a safe landing about 23 minutes after departure.

A post flight inspection revealed the engine had suffered an uncontained failure ejecting debris radially downwards. The fuselage also received minor damage as result of the engine failure.

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Air safety institute warns about jet fuel contamination

The AOPA Air Safety Institute has issued an ASI Safety Notice calling pilots’ attention to the problem of jet fuel being contaminated with diesel exhaust fluid, which is not approved for use in aircraft and has caused engine failure or significant damage to aircraft engines and fuel systems in several instances.

The safety notice posted on the Air Safety Institute and AOPA websites was prompted by a May 9 fuel-contamination incident that caused two Cessna Citation jets that received tainted fuel in Punta Gorda, Florida, to experience in-flight failures-in one case of both engines, and in the other instance, of one of two engines. Both aircraft landed safely.

Diesel exhaust fluid, or DEF, is not intended for use in aircraft but is used to reduce emissions in diesel engines such as those in ground vehicles. When added to jet fuel, DEF can trigger reactions including the formation of crystals that can plug fuel filters and damage engine components.

In a letter to Acting FAA Administrator Daniel K. Elwell, AOPA President Mark Baker noted that the May 9 incident was the third in the last 18 months in which DEF was mistakenly added to aircraft fuel in separate locations, presumably in place of icing-inhibitor fluid. Both fluids are clear and colourless.

“We believed the first contamination event in November 2017 to be a unique situation and unlikely to reoccur. Unfortunately, a second occurred in August 2018,” Baker wrote, adding that the incidents led to the creation of an industry working group “to study factors surrounding these events, develop mitigation strategies, and recommend both short and long-term actions for industry and the FAA to implement.”

The ASI Safety Notice urges pilots to inquire if your fuel providers use DEF in ground equipment and about procedures to confirm that only the correct additives are used for jet fuel. Procedures should include separate storage, clear labelling, confirmation of correct additives at the time of insertion, and personnel training.

Noting that there are no known pre-flight procedures pilots can use to identify the presence of DEF in jet fuel, the notice raises pilots’ awareness that if engine failure occurs due to turbine flameout, DEF contamination is a possible cause. “Follow emergency checklist procedures for engine failure and realize if DEF contamination is the cause, successful restart is unlikely,” it cautions, noting that the loss of remaining engines is likely.

If DEF contamination is suspected, pilots should notify the fixed-base operator where fuel was obtained as soon as possible, and document and report the incident to the local FAA office immediately.

Baker’s letter said he expected the industry working group to issue its recommendations shortly. “Any assistance the FAA can provide to work with industry and quickly implement the mitigation strategies identified in the report will be appreciated,” he wrote to Elwell.

Photo by Mike Fizer

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Forced landing April 22, out of fuel

Asia Airways AN26 near Khartoum on Apr 22nd 2019, ran out of fuel

An Asia Airways Antonov AN-26 freighter, registration EY-322 performing a positioning flight from Djibouti (Djibouti) to Khartoum (Sudan) with 5 crew, ran out of fuel about 40nm short of Khartoum Airport and was forced to land in open terrain. There were no injuries, the aircraft sustained substantial damage however.

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Commutair E145 2019, hard landing on Mar 4th, gear collapse & runway excursion

Accident: Commutair E145 at Presque Isle on Mar 4th 2019, hard landing, gear collapse and runway excursion

A Commutair Embraer ERJ-145 on behalf of United, registration N14171 performing flight CS-4933/UA-4933 from Newark, NJ to Presque Isle, ME (USA) with 28 passengers and 3 crew, was on final approach to Presque Isle’s runway 01 when the crew initiated a go around from about 2000 feet MSL. The aircraft positioned for another approach to runway 01 and continued for a hard touch down at 12:27L (16:27Z), the aircraft veered right off the runway, all gear collapsed. A pilot and three passengers received minor injuries, the aircraft sustained substantial damage.

Photo:Crown of Maine

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Citation overflies vehicle at 1 metre after take-off without clearance at Reykjavik

CitationJet CJ2 overflies airport vehicle at 1 metre after take-off without clearance at Reykjavik

On the morning of January 11th 2018 rain showers were present, the temperature was around freezing point and the runway braking action was poor at Reykjavik Airport (BIRK). It was decided to sand both runways.

At 10:04 the controller contacted the flight crew of a Cessna 525A CitationJet CJ2, N525FF, and informed them of the braking action on runway 19. The flight crew decided to proceed and were cleared to “Hold short RWY 19.” This was read back correctly by the flight crew.

At 10:07 the Tower controller gave the flight crew of N525FF the following instructions: “525FF Backtrack line up RWY 19,” which was also read back correctly by the flight crew.

Following communications in Icelandic about the sanding of the runways, the controller cleared the flight “… right turn line up RWY 19.”
The sanding truck had finished its run down the right side of runway 13. It then turned around at the end of runway 13 to start its run down the left side of runway 13, to sand that side of the runway.

While the Tower controller was focused on communications, he did not notice that the flight crew of airplane N525FF started their take-off roll on RWY 19 after having turned at the runway end.

When the sanding truck that was sanding runway 13 was about to cross runway 19, its driver noticed an airplane very close on runway 19, on his right side, just about to lift off. According to the sanding truck driver, he did not have sufficient time to react. The sanding truck was already at the runway center line of runway 19 when N525FF reached the runway section where RWY 19 crosses RWY 13.

N525FF took off and flew over the sanding truck at 10:11. There was a serious risk of collision, as the minimum distance between N525FF and the sanding truck is believed to have been less than 1 meter.

According to the Pilot Flying (PF) of N525FF, he recalled that they had been cleared to taxi and backtrack runway 19. When they turned around to line up on runway 19, the PF also recalled that the PNF transmitted that they were “ready for departure”. At this time the PF had already increased the thrust significantly and the aircraft started to slide on the ice, so the commander (PF) said “we have to go” and commenced the take-off.

The ITSB analysis of the ATC recordings concluded that said transmission by the PF “ready for departure”, did not take place.

The ITSB believes that if all the communications on the tower frequency would have been in English, then the flight crew of airplane N525FF might have been aware that RWY 13 was being sanded

Accident investigation:

Investigating agency: TSB Iceland
Status: Investigation completed
Duration: 1 year 1 month
Download Final report:

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