2007年第3季



Flight Safety related Events

Global Report in the 3rd Quarter, 2007

Flight Safety Foundation, Taiwan, ROC

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TAM Flight A-320 overran the end of runway 35 at the Sao Paulo airport upon landing while it was raining. The 6 crew members, 162 passengers, and 18 persons on the ground suffered fatal injuries.

1. Forewords

This report has been compiled by Flight Safety Foundation-Taiwan, ROC (FSF-T) since year 2006, and issued quarterly on this publication. The sources mainly based on NTSB website, due to the NTSB data base mostly are US accidents, and no ground safety events as well, therefore, we retrieved more events from the ASN (Air Safety Network) and FSI (Flight Safety Information).

In order to meet reader’s requirements of systematic the analysis and recommendations, since this publication, we will take 4E（Engineering, Education, Enforcement, Evaluation）methods, hopefully, it will provide more consolidated and practical recommendations for the aviation industry as a whole.

2. Definition

1. Flight safety related event: It means any occurrence of aircraft accident, aircraft serious incident, and aircraft incident incurred in operations of aircraft and the occurrence of ground safety events incurred in non-operations of aircraft.

2. Aircraft Accident: It means an occurrence associated with the operation of aircraft which takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, in which a person, either within or without the aircraft, is fatally or seriously injured or the aircraft sustains substantial damage or structural failure, is missing or completely inaccessible.

3. Aircraft serious incident: It means an occurrence associated with the operation of aircraft which takes place between the time any person boards the aircraft with the intention of flight until such time as all persons aboard have disembarked, which almost result in an accident.

4. Aircraft incident: It means an occurrence associated with the operation of aircraft which takes place between the time any person boards the aircraft with the intention of flight until disembarkation of all those on board, other than what happen in the preceding two items.

5. Ground safety events: It incurred in non-operations of aircraft on the ground.

6. Accident Classification IATA (Contributing factors)：It includes Human, Technical, Environmental, Organizational factor and Insufficient. Except the Insufficient the former four factors would be broken down such as H1-H5 for Human factor, T1-T12 coping with Technical factor. (Please refer to IATA annual Report).

7. In-depth Analysis of Event IATA: It includes CFIT（Control Flight Into Terrain）, LOC（Lost Of Control）, RI (Runway Incursion), MC (Mid-air Collision), RE (Runway Excursion), FD (In-Flight Damage & Injuries), GD (Ground Damage & Injuries) and M (Miscellaneous or uncertain).

8. Methods 4E：It includes Engineering, Education, Enforcement, and Evaluation.

3. Statistics

1. In general: During 1st of July to 30th of September, 2007. There are 225 flight safety related events, including 139 accidents, the most and ground safety events with 6, the least. Please refer to the following figure:

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2. Monthly: 80 in July, the most events, 79 in September, and 69 in August. It has shown as following figures:

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3. Location: 142 at North America, 2 at Mid-East, the least. It comes out the figures as following:

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4. Phase of Flight: 113 events happened in the phase of en-route, and 2 in the taxing. As you can see the figures as following:

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5. Contributing Factors: 105 events involved Human factors and 22 events are Environmental factors. It has shown the Technical and Organizational factors as on the following figures:

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6. IATA In-Depth Analysis of Events: CFIT involved 94 events are taking the lead, MC (Mid-Air Collision) only 2 events are the least. All the figures are shown as following:

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7. Summary of Severe Fatal Accidents:

|Date |Location |Summary |Sources |

|7/17 |Sao Paulo |TAM A320-233 overran the end of runway 35 at the Sao Paulo Congonhas airport |NTSB |

| |Brazil. |upon landing. It departed the runway to the left side near the departure end | |

| |[pic] |and crossed over a road prior to impacting a cargo depot and gas station. The | |

| | |6 crew members, 162 passengers, and 18 persons on the ground suffered fatal | |

| | |injuries. The aircraft was destroyed by impact forces and fire. It was raining| |

| | |as the flight approached São Paulo. | |

|7/5 |Sinaloa, Mexico. |North American T39A airplane, Mexican registration XA-TFL, was destroyed |NTSB |

| |[pic] |during a loss of control during takeoff roll from Runway 02 at the Culiacan | |

| | |Airport, near Culiacan, State of Sinaloa, in the Republic of Mexico. The cargo| |

| | |airplane, serial number 26548, was owned and operated by Jet Paqueteria of | |

| | |Mexico City, Mexico, on a domestic cargo flight; The two commercial pilots and| |

| | |a mechanic on board the airplane were fatally injured. Two Mexican soldiers | |

| | |and four Mexican civilians were also killed on the ground. | |

|7/26 |Mojave Desert airport,|An explosion that killed three at a Mojave Desert airport during testing of a |FSI-218 |

| |USA |new space tourism vehicle. The blast Thursday at a remote test facility | |

| | |belonging to Scaled Composites LLC critically injured three other employees | |

| | |working on a propellant system for the vehicle. Firefighters head out to an | |

| | |explosion that killed two people and critically injured four others. A Kern | |

| | |County Medical Center official said two people died at the scene and one later| |

| | |died at the hospital after surgery. The three injured suffered numerous | |

| | |shrapnel wounds. Two were in critical condition and one was in serious | |

| | |condition. | |

|7/27 |Phoenix, Arizona. |Two AS 350 B2 helicopters each got two pilots and one photographer on board, |NTSB |

| |USA |mid-air collision on the Phoenix city, Arizona. It crashed into a park; their | |

| |[pic] |wrecks fell apart 75 feet, all six people on board are dead. | |

| |AS 350 B2 | | |

|7/28 |Izhevsk, CIS. |About 1430 universal coordinated time (1930 local daylight savings time) a |NTSB |

| |[pic] |Robinson R44, Russian registration RA-04203, was destroyed when it impacted a | |

| | |transmission line and descended into the Votkinskoe Reservoir in Izhevsk, | |

| | |Russia. The Russian pilot and four passengers were fatally injured. The local | |

| | |flight, which originated in Izhevsk, was conducted under Russian flight | |

| | |regulations. | |

|7/29 |CIS |A 43-year-old Russian private Atran carrier cargo plane An-12 has crashed |FSI-220 |

| |[pic] |minutes after taking off from Domodedovo airport southeast of Moscow airport, | |

| | |slammed into a field, shattering debris over a wide area. Killing all seven | |

| | |crew on board. | |

|8/2 |Easton, Washington. |Approximately 1420 Pacific daylight time, a Robinson R44 II helicopter, |NTSB |

| |USA |N7531D, was destroyed after impacting mountainous terrain during takeoff about| |

| |[pic] |three miles southwest of Easton, Washington. The commercial rated pilot and | |

| | |three passengers sustained fatal injuries. | |

|8/3 |Kendal, England UK. |About 1836 universal coordinated time, a Robinson R44 helicopter, G-OSSI, was |NTSB |

| |[pic] |destroyed when it impacted the ground near Kendal, England (United Kingdom). | |

| | |The helicopter impacted rising terrain. All four occupants of the aircraft | |

| | |received fatal injuries. | |

|8/5 |Isle of Wight, |About 1100 universal coordinated time, a Piper PA-28-140, G-AVRP, was |NTSB |

| |UK. |destroyed when it impacted trees and the ground near Sandown, Isle of Wight, | |

| |[pic] |United Kingdom. The airplane was on initial climb after takeoff. All four | |

| | |occupants of the aircraft received fatal injuries. | |

|8/5 |Ruidoso, New Mexico. |Beech E90B, NC369CD, operated by Southwest MedEvac and piloted by an airline |NTSB |

| | |transport pilot, was destroyed when it struck trees and impacted terrain while| |

| | |maneuvering approximately 4 miles southeast of the Sierra Blanca Regional | |

| | |Airport (SRR), Ruidoso, New Mexico. The pilot, flight nurse, flight medic, | |

| | |patient, and patient's mother were fatally injured. | |

|8/6 |Sitka, Alaska. |Piper PA-46 airplane, N35CX, was destroyed by impact and postimpact fire when |NTSB |

| |USA |it collided with trees and a residence during an instrument landing approach | |

| |[pic] |to the Sitka Rocky Gutierrez airport, Sitka, Alaska. The private certificated,| |

| | |instrument-rated pilot, and the three passengers, received fatal injuries. | |

| | |Instrument meteorological conditions prevailed in the area at the time of the | |

| | |accident. | |

|8/9 |Moorea, |De Havilland DHC-6 Twin Otter were lost Thursday, when the twin-turboprop |FSI-228 |

| |Tahiti |crashed in the ocean shortly after takeoff from the resort island of Moorea. | |

| |[pic] |Nineteen passengers and one pilot were onboard the aircraft which according to| |

| |DHC-6 |The Associated Press was bound for Tahiti, 10 miles away. French Navy ships | |

| | |had recovered 14 bodies. Most of the persons onboard were French tourists, | |

| | |according to high commission spokesperson Dominique Bayon. Three were of | |

| | |foreign descent. Officials say the Air Moorea regional plane carried out | |

| | |regular, seven-minute flights between the islands and Tahiti. | |

|8/12 |Busan, |The Bombardier Q400, operated by budget domestic carrier Jeju Airlines, was |FSI-229 |

| |S. Korea. |coming in to land at Kimhae Airport when it veered off. "Four or five people | |

| |[pic] |were slightly injured when the plane skidded off the runway with 74 passengers| |

| |Bombardier Q400 |aboard," one official told Agence France-Presse. The airport was closed to air| |

| | |traffic for about 40 minutes, he said, adding that an investigation was under | |

| | |way to see if there was a mechanical cause. Yonhap news agency said 10 people | |

| | |sustained "scratches and bruises." The body of the plane hit the ground as it | |

| | |skidded through a strong wind, it said, and one propeller was destroyed. | |

|8/16 |Ketchikan, Alaska. |de Havilland DHC-2 (Beaver) airplane, N345KA, collided with tree-covered |NTSB |

| |USA |terrain, about 20 miles north of Ketchikan, Alaska. Impact forces and a | |

| |[pic] |postimpact fire destroyed the airplane. The airplane was being operated as a | |

| |DHC-2 |visual flight rules (VFR) sightseeing flight under Title 14, CFR Part 135, | |

| | |when the accident occurred. The airplane was owned and operated by Seawind | |

| | |Aviation, Inc., Ketchikan, Alaska. Of the nine people on board, the airline | |

| | |transport pilot and three passengers sustained serious injuries, and five | |

| | |passengers sustained fatal injuries. | |

|8/20 |Dayton, Wyoming. |Approximately 1700 mountain daylight time, a Cessna 182R, N6109N, operated by |NTSB |

| |USA |the Civil Air Patrol as CAPS flight 4940, was destroyed when it impacted | |

| |[pic] |terrain 20 miles west of Dayton, Wyoming. A post impact fire ensued. Marginal | |

| | |visual meteorological conditions prevailed. The search and rescue flight was | |

| | |being operated under the provisions of Title 14 Code of Federal Regulations | |

| | |Part 91 without a flight plan. The commercial pilot and two observers were | |

| | |fatally injured. The flight departed Sheridan, Wyoming, approximately 1530. | |

|8/26 |Katanga, |An Antonov cargo plane has crashed in Congo, killing thirteen people on board.|FSI-234 |

| |Congo |The plane had just taken off from Kongolo, Katanga with a cargo of tin ore | |

| |[pic] |when the aircraft developed engine problems, causing the Russian pilot to | |

| | |attempt to return for an emergency landing. However, the plane instead crashed| |

| | |short of the runway, busting into flames. Although thirteen have been | |

| | |confirmed dead, the bodies’ two of whom have not been recovered two people | |

| | |were rescued from the aircraft before it caught fire. | |

|9/6 |Syria, Virginia. |About 2032 eastern daylight time, a Piper PA-28-140, N6493W, was destroyed |NTSB |

| |USA |when it impacted trees about 4 nautical miles west of Syria, Virginia. The | |

| |[pic] |certificated private pilot and the two passengers were fatally injured. Night | |

| | |visual meteorological conditions prevailed, and a visual flight rules flight | |

| | |plan was filed during the flight which departed Hartsville Regional Airport | |

| | |(HVS), Hartsville, South Carolina, destined for Winchester Regional Airport | |

| | |(OKV), Winchester, Virginia. The personal flight was conducted under 14 CFR | |

| | |Part 91. | |

|9/7 |Goma Airport, Congo. |The An-12 was transporting about 18 tons of cargo amongst others palm oil, |ASN |

| |[pic] |from Kisangi (FKI) to Bukavu with a stopover at Goma (GOM). The airplane | |

| | |crash-landed at Goma, slid into a petrified lava flow beyond the runway and | |

| | |caught fire. The crew reportedly consisted of two persons from Georgia, two | |

| | |from the Ukraine and one from Congo. The plane was owned by Georgian carrier | |

| | |Transaviaservice. The An-12's Certificate of Airworthiness had expired in | |

| | |March and had not been renewed. | |

|9/8 |Mansfield, |At 1030 eastern daylight time, a Cessna 172M, registered to and operated by |NTSB |

| |Massachusetts |Twin Cities Air Service LLC, collided with the ground shortly after takeoff at| |

| |USA |the Mansfield Municipal Airport, Mansfield, Massachusetts. Visual | |

| |[pic] |meteorological conditions prevailed at the time of accident, and no flight was| |

| |Cessna 172M |filed for the local 14 CFR Part 91 personal flight. The airplane sustained | |

| | |substantial damage. The private pilot, and front seated passenger were fatally| |

| | |injured. The two rear seated passengers were seriously injured. The flight was| |

| | |originating at the time of the accident. | |

|9/10 |Moscow, |(AP) A Russian civilian helicopter Mi-8 has gone missing in a remote Arctic |FSI-255 |

| |CIS |province, transport officials said Monday, and rescuers are searching for its | |

| |[pic] |six crew members. Radio contact with the helicopter was lost Sunday afternoon | |

| |Mi-8 |as the craft flew near the oil-industry city of Salekhard, about 2,000 | |

| | |kilometers (1,300 miles) northeast of Moscow. Russian news agencies said poor | |

| | |weather conditions and bad visibility may have caused the helicopter to go | |

| | |down. | |

|9/13 |Burlington, |Beech A-36, N1811Q, impacted a dense stand of trees about one and one-half |NTSB |

| |Washington. |mile northwest of the approach end of runway 10 at Bayview-Skagit Regional | |

| |USA |Airport, Burlington, Washington. The private pilot and his two passengers | |

| |[pic] |received fatal injuries, and the aircraft, which was registered to Textana, | |

| |Beech A-36 |Inc., was destroyed by the impact and post-crash fire. The 14 CFR Part 91 | |

| | |personal Flights, which departed Havre, Montana, approximately four hours | |

| | |prior to the accident, were on an Instrument Flight Rules (IFR) flight plan. | |

| | |There was no report of ELT activation. | |

|9/16 |Phuket, Thailand. |Approximately 1600 local time, a Boeing -McDonnell Douglas MD-82, Thai |NTSB |

| |[pic] |registration HS-OMG, operated by Orient Thai Airways as One-Two-Go flight 269 | |

| |MD-82 |from Bangkok, overran runway 27 upon landing at the Phuket International | |

| | |Airport, Phuket, Thailand. There were 89 fatalities among the 123 passengers | |

| | |and seven crews. Heavy rain was reported at the time of the accident. | |

|9/16 |Moscow |: (AP) A helicopter crash in Russia's Far East killed six people, including |FSI-262 |

| |CIS |two Polish tourists, officials said Sunday. The Mi-8 helicopter crashed in the| |

| |[pic] |Magadan region Saturday, the regional branch of Russia's Emergency Situations | |

| |Mi-8 |Ministry said in a statement. It said the helicopter's pilot survived the | |

| | |crash and was hospitalized with injuries, but six passengers, including two | |

| | |tourists from Poland, were killed. Crashes of the Mi-8 — a workhorse | |

| | |helicopter used widely in civilian aviation as well as by the military — occur| |

| | |frequently in Russia and often are blamed on poor maintenance and excessive | |

| | |age. | |

4. Analysis and Comments

Based on the above statistics, there were 225 Flight safety related events in the 3rd quarter of year 2007. 139 accidents were the highest number event in this quarter (61.8%), then, there were 48 incidents, 32 serious incidents and 6 ground safety events were the least. The most severe accident was on July 17, 2007. Airbus A-320 belong to Brazilian carrier TAM, ran left off the runway at San Paulo airport and crossed the highway hit the depot and gas station with blamed explosion, 190 people killed including 18 people on the ground.

In lights of timing, July involved 79 events were the highest, average 2.63 events per day, whether it would be the highest session in the year, better take longer time of observation. In the phase of flight, reroute phase 113 events (50.2%) would be the highest, the experts believed it will encounter the most threats in this phase, such as weather, terrain, aircraft malfunction, ATC, other aircraft, birds, bomb threat, or unruly passengers etc. We sincerely hope the crewmembers would sustain their situation awareness during this phase of flight, however, taking TEM training would be very critical for them, and apply the TEM model and counter measures to cope with it, to safeguard the aviation safety. In the regional observation, North America 142 events (63.1%) mostly were the small airplanes of part 91, such as Cessna, Piper, or R-44 helicopter. We suggest that airliner pilot had better be trained either in the region where pilot training is strict or least accident, such as Australia, British, or Canada. However, Africa region had not much number of accidents, but based on the ICAO statistics, flight safety in Africa has been worrisome, in this regard, better be careful while you are flying in the Africa region. In the respect of contributing factor, 105 events involved human factor, it’s about 46.7% of the total events, thus, we strongly recommended take close look at “Human factor training manual” which be compiled by CAA, and take part in the aviation safety human factor training course especially being conducted by IATA or FSF-T, for reducing the human factor event to the acceptable level. In-Depth Analysis, 94 events (41.8%) involved CFIT, FSF issued a CFIT/ALAR Tool Kit and distributed to their members in the world, and held regional workshop, Taiwan airliners all had a disc of CFIT/ALAR Tool Kit and applied it into their training. However, no one had initiated a CFIT forum or open discussion, so as to there is least CFIT in this region, moreover, we had met chief pilot of CAAC at Sin Kiang during cross strait aviation meteorology and safety conference, he indicated that CFIT is one of the most safety issues, we would try to hold a CFIT symposium in the near future.

In order to meet reader’s requirement of systemize the analysis and comments in this report we would like to introduce a 4E method as following:

1. Engineering:

1. Plan: Government and related company or institutes should comply with ICAO accident prevention program (Doc 9422) redact their own program and match up with ICAO SMS requirement.

2. Procedure: Apply IOSA to check all the procedures would be integrity.

3. Equipment: Including system and tools, such as SMS, and ORM etc.

2. Education:

1. Education: Aviation safety and regulation has been long term education, government is responsible for educating the public, in this end, China Aviation Development Foundation has been sponsoring FSF-T to educate aviation elites for years, so far as FSF-T has accumulated enough experience and resources to hold domestic training courses, such as Advanced Aviation Safety, MRM, Incident Investigation, CRM, Ramp Safety, Human Factor, ORM and Cabin Safety Management Class. It is confirmed by international experts of IOSA team.

2. Training: In order to deal with the trends of increasing cabin abnormal events, FSF-T new opened a Cabin Safety Management Class during November 19-21, 2007. It highlights passenger unruly, illness, injury and dangerous goods on board the aircraft, please find the FSF-T publication “flight safety quarterly” in detail.

3. Enforcement:

Human factor is the most complicate and uncontrollable issue, the above said engineering and education might not be able to solve the problem thoroughly, in case, enforcement is needed, CFIT as an example, not only comply with SOP and QRH, but the discipline of cockpit should be defined indigently to secure aviation safety.

4. Evaluation:

1. Report System: Apply evaluation mechanism to review the reporting system by risk assessment, and get the best practice to amend the original plan, again and again, to make it perfect.

2. Evaluation Mechanism: Established by FSF-T or get aviation elites to form an evaluation team, to asses the next year aviation safety plan right before the dinner of National Aviation Safety Annual Conference.

5. Conclusion

There were 225 (264) events in this quarter, 39 events less than the second quarter of the year, decreased 14.8%. Average daily 2.45 events are less than 2.97 events on the last quarter it decreased 0.52 events per day. Mainly, aircraft incident had dramatically dropped by 41 events in a quarter of a year. In addition, CFIT should be concern due to it crashed under flight controllable, in other words, human factor is the contributing factor. In this regard, CAA issued a Human factor training manual, the aviation industry have enforced human factor training as well. In conclusion, FSF-T sincerely recommends 4E methods for your reference as following:

1. Engineering: Government organizes a study group to cope with our human factor issues, such as CFIT, cabin safety and maintenance safety tasking force etc. to provide strategy and best practice step by step.

2. Education: Integrating all the resource to sustain the long term training class, such as Advanced Aviation Safety, MRM, Incident Investigation, CRM, Human Factor, Ramp Safety, ORM, and Cabin Safety Management Class.

3. Enforcement: CAA has been done widely reviewed civil aviation law, however, the process of legistration has been very slow, hopefully our congress would pass likely a Reauthorization Act in favor of CAA to shorter and quicker the legistration process, more importantly, is the law enforcement, to deter the flight safety related events effectively.

4. Evaluation: Encourage and amplify the function of report system, evaluation mechanism, review and emendate the plan, for the sake of improving aviation safety.

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