Wednesday, May 31, 2017

Michael A. MacDowell: Airlines need realignment of corporate culture

In the face of unprecedented negative airline publicity, House Transportation Committee Chairman Bill Shuster, a Republican from Pennsylvania, told airline executives that if they didn't improve customer service, "We're going to act and you're not going to like it." The threat may be real, but the timing is late.

Congress had a real opportunity to ensure better airline service between l978 and l985, the years in which deregulation of the airline industry took place. As the father of airline deregulation and chairman of the Civil Aeronautics Board, Cornell economist Alfred Kahn predicted deregulation would lead to a plethora of new low-cost airlines. This competition would in turn lower prices on all airlines.

Also, as predicted, the resulting lower airline ticket prices that followed deregulation increased the number of passengers, particularly among those who could not previously afford to fly. Kahn's theories became fact as upstart airlines forced major carriers to lower ticket prices. So many new passengers were now able to fly that while airlines made less on each passenger, they significantly increased their overall revenues.

There were two major concerns during those early years of airline deregulation. First, because the Civil Aeronautics Board had previously forced some airlines to serve smaller markets where profit margins were thin or non-existent, many thought deregulation would force those small airports out of business. With a few exceptions, this has not come to pass. New airlines spawned by deregulation often chose smaller airports to avoid high landing fees at larger airports. Lehigh Valley International Airport is a case in point.

The second concern was that deregulation would eventually lead to consolidation in the industry, which would constrict competition, raise prices and lower service. As Adam Smith, the father of market economics, said in 1776, "People of the same trade seldom meet together, even for merriment and diversion, but the conversation ends in a conspiracy against the public, or in some contrivance to raise prices."

Price fixing has not seemed to be as evident within the industry as some thought it would be. However, what has evolved is a sense of collective arrogance among airlines and their employees when companies no longer feel the pangs of competition.

These massive new combined airlines operate with a sense of indifference to customers spawned by a culture of corporate self-importance and the knowledge that passages have few alternatives. They operate under lock-step procedures sanctioned in the executive suite. They give flight attendants and agents little leeway to apply common sense.

Such was apparently the case when United physically removed a properly ticketed and seated passenger by dragging him off the plane. By the way, the use of cameras and iPhones that record such treatment is prohibited under the airline's procedures manual.

In the l980s, when the authors of airline deregulation considered what would happen if a lack of competition led to price fixing or poor service, their fallback was to say they would use existing anti-trust legislation to enforce competition, lower prices and enhance services. Unfortunately, this part of the airline deregulation game plan has never been used. Congress and the Justice Department steadfastly refused to apply anti-trust laws to airlines.

For instance, when the Justice Department and congressional committees looked at the proposed merger between US Airways and American Airlines in 2013, they found in seven of 12 markets where US Airlines and American competed that the merger would result in only one carrier serving that market, which would result in higher airfares and poorer service in those markets.

However, the case against the merger by members of Congress disappeared after the two airlines agreed to sell some landing slots to competitors. It is hardly coincidental that one of those seven markets was Reagan National Airport close to Washington, D.C., which is used by more congressmen and D.C. bureaucrats than any other.

So, when threats such as those issued by Congressman Shuster are made to airline industry officials, the public sees few changes in the service and attitude they experience when flying. The use of anti-trust laws may just be the 2-by-4 necessary to get the attention of the airlines and give their corporate culture a little attitude adjustment.

Michael A. MacDowell, who lives in Harveys Lake, Luzerne County, is managing director of the Calvin K. Kazanjian Economics Foundation and president emeritus of Misericordia University

Original article can be found here:  http://www.mcall.com/opinion

Cessna U206G Stationair, N9420R, Civil Air Patrol: Accident occurred November 15, 2014 at Brackett Field Airport (KPOC), La Verne, Los Angeles County, California

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

Aviation Accident Data Summary - National Transportation Safety Board: https://app.ntsb.gov/pdf

Civil Air Patrol: http://registry.faa.gov/N9420R

The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration; Los Angeles, California

Textron Aviation; Wichita, Kansas

NTSB Identification: WPR15LA042
14 CFR Part 91: General Aviation
Accident occurred Saturday, November 15, 2014 in La Verne, CA
Probable Cause Approval Date: 03/06/2017
Aircraft: CESSNA U206G, registration: N9420R
Injuries: 3 Uninjured.

NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

The private pilot reported that, during landing, he had difficulty controlling the airplane after the nosewheel settled onto the runway. The pilot stated that the airplane initially veered to the left; however, he was able to correct its track. The airplane then veered left a second time, he was unable to regain control, and the airplane subsequently exited the runway surface. During the accident sequence, the right wing struck the ground. 

Postaccident examination of the airplane revealed a deflated nosewheel oleo strut; however, the investigation was unable to determine whether the strut became deflated before or during the accident sequence. The airplane displayed proper nosewheel steering when weight was applied on the nosewheel strut. No further anomalies were noted with the airplane's nosewheel steering, nosewheel assembly, braking system, or tires; thus, the reason for the loss of control could not be determined.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's loss of directional control during the landing roll for reasons that could not be determined, because postaccident examination of the nosewheel assembly revealed no anomalies that would have precluded normal operation.

On November 15, 2014, about 1420 Pacific standard time, a Cessna U206G, N9420R, veered off the runway during landing at Brackett Field Airport (POC), La Verne, California. The airplane was registered to and operated by the Civil Air Patrol under the provisions of Title 14 Code of Federal Regulations Part 91. The private pilot and two passengers were not injured. The airplane sustained substantial damage to the right wing during the accident sequence. Visual meteorological conditions prevailed and no flight plan had been filed. The instructional flight departed from San Gabriel Valley Airport, El Monte, California, about 1350.

During a telephone interview with the National Transportation Safety Board (NTSB) investigator-in- charge (IIC), the pilot stated that he had difficulties controlling the airplane after the nose wheel settled onto the runway, during the landing roll. The pilot further stated that the airplane initially veered to the left; however, he was able to initially counteract the deviation and the airplane was then positioned near the right side of the runway. Subsequently, the airplane veered left a second time, and he was unable to prevent it from exiting the runway surface, where the right wing struck the ground. 

The two passengers onboard the airplane stated that the landing was normal and shortly thereafter the pilot lost directional control of the airplane.

Postaccident examination of the airplane with a certified airframe and powerplant mechanic under the supervision of the NTSB IIC, revealed that the right wing was bent upwards about 3 feet from the wing tip. The airplane's braking continuity from the rudder pedals to the brakes was established with no anomalies. Examination of the nose tire, main tires, and braking assemblies revealed no anomalies. The nose gear assembly was examined and the nose oleo strut was observed to be deflated. However, with weight on the nose wheel, provided by lifting up on the airplane's tail, the nose wheel responded appropriately to pedal steering. The investigation was unable to determine if the deflated strut was due to impact damage or a malfunction. No additional mechanical malfunctions or failures were found that would have precluded normal operation.

The airplane's nose wheel steering system links the rudder pedals to the nose wheel. According to the airplane's Pilot's Operating Manual, "when a rudder pedal is depressed a spring-loaded bungee will turn the nose wheel ... approximately 15 degrees each side of center." By applying either left or right brake, the degree of turn can be increased up to 35 degrees each side of center. 

According to the aircraft manufacturer representative, "a steerable nose wheel, mounted in a fork, attached to an air/oil (oleo) shock strut, makes up the nose gear. Nose wheel steering is accomplished through the use of the rudder pedals. A hydraulic fluid-filled shimmy dampener is provided to minimize nose wheel shimmy. The nose wheel steering system links the rudder pedals to the nose wheel steering arm, affording steering control through the use of the rudder pedals and brakes. Torque links keep the lower strut aligned with the nose gear steering system, but permit shock strut action. A properly serviced nose gear oleo will fully extend, when the nose wheel is lifted off the ground. A centering stop log is located on the upper torque link. When the nose gear oleo fully extends, the centering stop lug interfaces with a cutout near the top of the oleo to prevent the nose gear from moving when the rudder pedals are actuated. When the nose gear oleo is compressed the centering stop lug is removed from the cutout allowing the nose tire to move in response to rudder pedal input."

Federal Aviation Administration Awards Three South Jersey Airports with $5 Million in Grants: Atlantic City International Airport (KACY), Cape May County Airport (KWWD), Hammonton Municipal Airport (N81)



SOUTH JERSEY -

Three South Jersey airports are receiving federal funding to make improvements to their facilities.

The Federal Aviation Administration is awarding the Atlantic City International Airport, the Cape May County Airport, and the Hammonton Municipal Airport with $5 million in grants to enhance safety and address customers concerns.

Atlantic City International Airport will be receiving the biggest share of more than $2.6 million going towards the construction of a new perimeter fence, enhancing the its existing access roads, and funding an assessment of the potential environmental impacts related to removing on-airport obstructions on two runways.

Cape May County Airport will receive more than $2.1 million to improve its water drainage system, build a perimeter fence, and remove tree obstructions from runways and taxiways.

Hammonton Municipal Airport will also use its funding of $250,000 for the removal of tree obstructions.

Story and video:  http://www.snjtoday.com

Middle Tennessee Emergency Responders Get Direct Link To LifeFlight

Screenshot of the new LifeFlight phone app.
 


A smartphone will now become a more critical tool for nurses and EMT’s in Middle Tennessee. A new phone app makes it possible for them to request a medical flight with the push of a button.

Shaving off any time in an emergency situation is critical, says Kevin Nooner. He is the program director for medical transport at Vanderbilt University Medical Center.

“Anytime that we are getting a request from an EMS provider or a hospital provider, we’ve got a patient that really needs to move quickly to a higher level of care. Although it can sound cliché, those couple of minutes can make a big difference in people’s lives,“ Nooner said.

In the past, emergency responders would have to radio in their request to a local 911 center. The 911 operator would enter the data into their system and then call in to the LifeFlight command center. There, data would be entered into a second database. Once the location was confirmed, a helicopter would be dispatched.

With the new process, EMTs just push a button on their phone to request a helicopter directly from the LifeFlight command center at Vanderbilt.  The phone’s GPS sends their exact location, reducing the chance of mistakes. 

The person who made the request can also view a map of the aircraft’s trajectory and estimated time of arrival.

Though similar apps have been used in other parts of the country, it is the first of its kind in Tennessee. LifeFlight handles approximately 50 medical transports to Vanderbilt hospitals every week.

Story and audio:  http://nashvillepublicradio.org

Bell 206B, N43CM, DC Helicopters Incorporated: Accident occurred March 24, 2015 in Taylors Island, Maryland

Ronald Lopes of Staten Island, New York gives a thumbs up at Denny's in Cambridge, Maryland,  with Vincent Giglio of Howell, New Jersey, who safely landed the helicopter they were flying in Tuesday, March 24, 2015 after it lost engine power near the mouth of the Little Choptank River.





The National Transportation Safety Board did not travel to the scene of this accident. 

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Baltimore, Maryland
Rolls Royce; Indianapolis, Indiana
Bell Helicopter; Lexington Park, Maryland

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

Aviation Accident Data Summary - National Transportation Safety Board: https://app.ntsb.gov/pdf

DC Helicopters Incorporated: http://registry.faa.gov/N43CM 

NTSB Identification: ERA15LA179
14 CFR Part 91: General Aviation
Accident occurred Tuesday, March 24, 2015 in Taylors Island, MD
Probable Cause Approval Date: 03/06/2017
Aircraft: BELL 206B, registration: N43CM
Injuries: 2 Uninjured.

NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

The commercial pilot reported that the helicopter was in cruise flight when he heard a "loud bang," which was followed by a partial loss of engine power. He performed an autorotation to shallow water near a shore, where the tailboom sustained substantial damage. A postaccident examination of the airframe and engine, which included an engine operational check, revealed no evidence of any mechanical malfunctions or failures that would have precluded normal operation. The loss of engine power that occurred during the accident flight could not be duplicated during a test run. Following the engine test run, the fuel control unit (FCU) was removed and tested separately. Tests revealed that the FCU operated erratically due to a bellow anomaly. However, because this condition was discovered only after the engine had successfully completed its test cell runs, a direct correlation could not be drawn between the condition of the FCU and the reported loss of engine power.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
A partial loss of engine power during cruise flight for reasons that could not be determined because postaccident examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation.




On March 24, 2015, about 1730 eastern daylight time, a Bell 206B, N43CM, was substantially damaged during an autorotation near Taylors Island, Maryland. The commercial pilot and one passenger were not injured. Visual meteorological conditions prevailed and no flight plan was filed. The helicopter was registered to and operated by DC Helicopters Incorporated as a personal flight, which was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The flight originated from Monmouth Executive Airport (BLM), Farmingdale, New Jersey, about 1530.

The pilot reported that the helicopter was in cruise flight at 3,000 feet above ground level, when there was a sudden drop in altitude followed by a 90 degree rotation to the left and a loud "bang." The pilot lowered the collective and noted that the torque gauge went below 10 percent. He then rolled the throttle to idle, entered an autorotation and landed on a shore.

Postaccident examination of the helicopter by a Federal Aviation Administration (FAA) inspector revealed that the helicopter's tailboom was buckled near the tail rotor gear box. Further examination revealed that the tail rotor drive shaft was broken.

Flight control continuity was confirmed by hand movement of the controls. The cyclic exhibited free movement in all quadrants and the collective exhibited free up and down movement. Corresponding control movement was observed up to the main rotor hub assembly. The tail rotor pedals were moved and control movement was seen at the tail rotor. Drive continuity was established through the drive system with movement observed to the main mast and to the tail rotor drive system. The tail rotor driveshaft on the tailboom exhibited a torsional crack. The tailboom exhibited evidence of tail rotor blade strikes. Both fuel boost pumps were shown to operate when the battery was turned on. The airframe fuel filter was removed and found to be filled with clear and clean fuel and the filter was also clean. The fuel valve was in the off position and motored on when the battery and fuel valve were switched on. The boost pumps were then energized and a steady flow of fuel was present out the "IN" line to the airframe fuel filter.

During a postaccident examination of the engine all B-nuts and fittings were checked by hand for torque, and none were loose. The bleed valve was checked by hand for proper operation. The valve operated smoothly with no lateral play of the poppet valve. The engine mounts were intact with no apparent deformities. The engine exhibited no evidence of having been damaged during the accident sequence. The engine cowlings were removed to facilitate examination of the compressor inlet. Examination of the compressor revealed no evidence of compressor damage or failure. Both the N1 (compressor) and N2 (power turbine) rotor systems were rotated by hand. The N1 rotated smoothly with no unusual noise or resistance. Continuity from the compressor through the auxiliary gearbox to the starter/generator was confirmed. Rotation of the N2 confirmed continuity to both the main rotor and tail rotor drives.

The engine was removed to be run in a test cell in an attempt to replicate the reported loss of power. A pre-run examination of the engine found no anomalies with the engine, or any damage which might preclude running the engine on a test cell. The engine was installed on a test cell, started, ran normally and met all serviceable engine standards. The engine produced normal power and responded properly to all power demands, including wave-off and sudden throttle and load changes.

After the engine test run, the owner of the helicopter sent the engine's fuel control unit (FCU) out for testing. During testing it was noted that one of the technicians found a "slight bend" in the FCU bellow's assembly. The condition of the bellows did not warrant rejection, and the FCU was reassembled and tested in accordance with manufacturer's specifications. During the test it was noted that the FCU performed erratically on the test stand, and failed to meet serviceable standards. The bellows assembly was replaced with an overhauled bellows assembly, and the FCU performed satisfactorily. The subject bellows assembly was then installed on a serviceable FCU, tested, and failed to pass serviceable standards.



NTSB Identification: ERA15LA179
14 CFR Part 91: General Aviation
Accident occurred Tuesday, March 24, 2015 in Taylors Island, MD
Aircraft: BELL 206B, registration: N43CM
Injuries: 2 Uninjured.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

On March 24, 2015, about 1730 eastern daylight time, a Bell 206B, N43CM, was substantially damaged during an autorotation near Taylor Island, Maryland. The commercial pilot and one passenger were not injured. Visual meteorological conditions prevailed and no flight plan was filed. The helicopter was registered to and operated by DC Helicopters Incorporated as a personal flight, which was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.

According to the pilot, he was in cruise flight at 3,000 feet above ground level, when there was a sudden drop in altitude followed by a 90 degree rotation to the left and a loud "bang." The pilot lowered the collective and noted that the torque gauge went below 10 percent. He then rolled the throttle to idle, entered an autorotation and landed on a shore. 

According to the Federal Aviation Administration inspector that examined the helicopter, the tail boom was buckled near the tail rotor gear box. Further examination revealed that the tail rotor drive shaft was broken. The helicopter was recovered and is awaiting further examination.

FedEx, McDonnell Douglas MD-11, N584FE, flight FX-1407: Accident occurred February 24, 2015 at Lambert – St. Louis International Airport (KSTL), St. Louis, Missouri

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

Aviation Accident Data Summary -  National Transportation Safety Board: https://app.ntsb.gov/pdf

http://registry.faa.gov/N584FE 

The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration
FedEx
Boeing
Air Line Pilot's Association

Air Cruisers

NTSB Identification: DCA15FA073
Nonscheduled 14 CFR Part 121: Air Carrier operation of FEDERAL EXPRESS CORP (D.B.A. 3131 Democrat Rd)
Accident occurred Tuesday, February 24, 2015 in St. Louis, MO
Probable Cause Approval Date: 05/26/2017
Aircraft: MCDONNELL DOUGLAS MD 11F, registration: N584FE
Injuries: 1 Serious, 3 Uninjured.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

During cruise flight, the crew received a fire warning from the cargo compartment indicating that the fire suppression system had activated, along with hearing loud sounds from the cargo compartment. The flight crew elected to divert to St. Louis. Although the activation of the fire suppression was a false alarm, the decision to divert was prudent and correct. During the approach the crew made the decision to evacuate the airplane after landing, briefed the passengers in the courier area, and reviewed the evacuation checklist in the Quick Reference Handbook (QRH). The diversion and subsequent landing were performed without issue. After exiting the runway, and bringing the airplane to a stop in a safe area, the crew initiated an emergency evacuation using the left forward door (1L). The door opened, however, the 1L escape slide/raft did not fully deploy, appearing to be hung up on a strap. The first officer attempted to free it and the fire/rescue crew pulled on the slide and it appeared to inflate. However, because the slide inflation sequence had been interrupted, it was significantly underinflated and unable to support the weight of the crewmember, resulting in a serious injury. Post-incident examination of the 1L slide/raft was unable to determine the causes for the slide/raft to not inflate to full extension.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
A partial inflation of the 1L escape slide/raft due to undetermined reasons resulting in insufficient capability to support the weight of the crewmember.

HISTORY OF FLIGHT

On February 24, 2015, about 0616 central standard time, a FedEx MD-11F, N584FE, landed at Lambert – St Louis International Airport (STL), St Louis, Missouri following automatic activation of the main deck fire suppression system. After landing, the four crewmembers deplaned through the left main cabin door using an evacuation slide. One of the four crewmembers on board was seriously injured during the evacuation; the other three crewmembers were not injured. The flight was operating under the provisions of 14 Code of Federal Regulations Part 121 as a cargo flight from Memphis International Airport (MEM), Memphis, Tennessee, to Minneapolis-St Paul International Airport (MSP), Minneapolis, Minnesota.

The captain was the pilot flying. During cruise at FL360 about 80 miles north of STL, lights illuminated on the flight deck glareshield indicating the Fire Suppression System (FSS) had activated on the main cargo deck. About the same time two jumpseat riders in the courier compartment heard a loud metallic bang noise similar to a cargo bin door falling in the cargo compartment and observed the FSS discharge indication lights were illuminated near the forward left (1L) door.

According to the cockpit voice recorder, at 0556:57, one of the crewmembers in the courier area called the flight deck via intercom and advised they heard a sound "like a can [cargo bin] got punctured." The flight crew acknowledged and discussed the indications, and at 0557:33, they declared an emergency with Air Traffic Control (ATC) and coordinated a diversion to STL. During the diversion, the crew reviewed abnormal procedures and planned on evacuating the airplane after clearing the runway. On approach to STL, the flight advised ATC that the fire was not confirmed but the "indications are there, and they're not going away."

At 0609:39 the flight crew notified a crewmember in the courier area they would "get off the aircraft" on the taxiway, and the crewmember acknowledged. 

At 0616:00 the airplane landed on runway 12L, exited the runway at taxiway K and came to a stop at the intersection of taxiway K and taxiway F.

At 0616:29, the crew accomplished the evacuation checklist contained in the Quick Reference Handbook and exited the flight deck. The first officer performed the emergency door/slide opening procedure at the 1L door. According to the crewmembers the slide did not appear to deploy completely and one crew member stated that it appeared to be "…caught up…in the straps that are part of the slide."

Airport Rescue and Firefighting (ARFF) personnel pulled on the slide and it then appeared to complete deployment.

The first officer jumped into the slide to exit the airplane. The slide did not slow the first officer as he descended to the tarmac; he impacted the tarmac and sustained a fraction to his L1 vertebrae.

ARFF personnel held the base of the slide in place and the remaining crewmembers lowered themselves to the ground using the slide.

INJURIES TO PERSONS

One crew member received serious injury and 3 crewmembers were not injured.

PERSONNEL INFORMATION

The flight crew consisted of two pilots and two additional pilot observers.

The captain, age 55, was hired by Federal Express in January 1997 and completed initial MD-11 training in June 2011. 

The captain reported approximately 12,476 hours total time, including about 6,470 hours as pilot-in-command and 2,974 hours in the MD-11. There were no records or reports of any previous aviation incidents or accidents involving the captain. The captain held a valid Federal Aviation Administration (FAA) Airline Transport Pilot (ATP) certificate with type ratings for B-737, B-757/767, and MD-11 and a current FAA first-class medical certificate issued on September 2, 2014. Company records indicated his most recent proficiency check was June 3, 2014. Training and proficiency checks were current and the company reported that the captain had no record of failures during company training events. 

The first officer, 51 years old, was hired by Federal Express in June 2006. He reported approximately 9,695 hours total flight time and about 2,642 hours in the MD-11. There were no records or reports of any previous aviation incidents or accidents involving the first officer. He held a valid FAA ATP certificate with type ratings for the B-757/767, MD-11, and B-727 SIC privileges only, and an FAA first-class medical certificate issued on October 7, 2014. The first officer's training and proficiency checks were current and the company reported he had no failures recorded during company training events. He completed initial training in the MD-11 in October 2014 and his most recent proficiency check was completed September 13, 2014.

AIRCRAFT INFORMATION

N584FE, manufacturer serial number 48436, was a McDonnell Douglas MD-11F equipped with three General Electric CF6-80 turbofan engines. The airplane was manufactured in 1992 and the company reported that the airplane had approximately 75,064 hours total time and 16,731 cycles on the airframe. Recorded data and airline records indicated no relevant maintenance issues with the airplane.

Evacuation Slide System

The airplane was equipped with emergency escape slides installed at the two forward doors; the 1L door and the 1R door. The 1L door was equipped with Evacuation System 60289-117, serial number 0406, manufactured by Air Cruisers in April 1994. The slide/raft assembly was overhauled and recertified to zero time in June of 2013. Maintenance and testing procedures for the evacuation slide/raft were contained in the Component Maintenance Manual 25-61-31.

METEOROLOGICAL INFORMATION

The STL surface observation at 0551 CST reported wind from 210 degrees at 3 knots, visibility 10 miles, clear skies, temperature minus 10 degrees Celsius, dew point temperature minus 17 degrees Celsius, and altimeter setting 30.18 inches of mercury.

AERODROME INFORMATION

The Lambert-St Louis International Airport (STL) was located about 10 miles northwest of the city of St Louis, Missouri. The airport conducted operations using 8 runways for commercial and general aviation. Runway 12L was grooved concrete, 9,003 feet long, 150 feet wide with a touchdown zone elevation of 528 feet. The runway was served by a 4-light precision approach path indicator system (PAPI) with a 3 degree glide path on the right side of the runway, and an approach light system sequenced flashers (ALSF2).

FLIGHT RECORDERS

A Smiths Industries combi Cockpit Voice/Flight Data Recorder (CVFDR), serial number 0000038, was downloaded at the NTSB Vehicle Recorder Division. The cockpit voice portion of the recorder included 2 hours of recording on four audio channels. The audio quality of the channels containing information from the captain's and first officer's audio panels, was characterized as excellent, and the audio quality of the channel containing information from the cockpit area microphone was characterized as fair. The recording included events from the flight beginning prior to engine start in MEM at about 0417 CST, and ending when the CVR was deactivated after landing in STL as the crew performed the evacuation checklist at 0617. Timing on the CVR summary was established by correlating CVR recorded touchdown time to the touchdown time reported by the airplane Aircraft Communications Addressing and Reporting System (ACARS) and adjusting to local CST.

The FDR, a Honeywell SSFDR 980-4700-001, serial number SSFDR-08811, was downloaded at the NTSB Vehicle Recorders Division. The recorder was found to be in good condition, however, data was not extracted from the FDR as it did not record parameters applicable to evacuation slide operation.

WRECKAGE INFORMATION

The slide and girt bar were removed from the airplane. The slide and associated components were shipped to the manufacturer for further examination and testing. 

SURVIVAL ASPECTS

Video footage from an airport ramp camera revealed the airplane came to a complete stop, followed by the 1L door opening. The 1L slide/raft did not fully inflate during the deployment. The slide/raft was held up in the area of the first set of frangible links at the airplane attachment end of the slide/raft. The frangible links are designed to separate at pre-determined inflation tube forces as the slide/raft inflates allowing the slide/raft to fully extend to the ground. Aircraft rescue and firefighting (ARFF) personnel approached the partially inflated, unusable slide/raft and jumped to grab onto the slide/raft. The slide/raft then continued to unfold onto the ramp surface. The firefighter then pulled the slide/raft into an attitude consistent with normal deployment, but did not hold on to the slide/raft while the first crewmember evacuated. The crewmember jumped out of the 1L door into the slide/raft, which collapsed under his weight resulting in the crewmember forcefully contacting the tarmac. A short time later emergency personnel arrived to assist him. The remaining three crewmembers slid down the slide with the help of the firefighters supporting the slide. The 1R exit was not opened and the slide/raft was not deployed.

Post-incident examination of the 1L slide/raft was unable to determine the causes for the slide/raft to not inflate to full extension. 

TESTS AND RESEARCH

A visual inspection of the Evacuation System at the manufacturer indicated the carrying case dated December 13, 1995 was in overall good condition with no notable signs of damage. The maintenance card was not found.

The storage side straps were both found intact and snapped in place on the top side of the carrying case. The strap on the right (airplane forward) side of the slide had no signs of damage. The strap on the left (airplane aft) side showed signs of drag marks across the top of the snap, torn webbing sections, and friction burn marks and melted fibers at the torn edges. Both reservoir attachment straps were torn apart at coincident locations. The torn fibers were soiled and showed signs of abrasion.

The slide/raft system markings indicated the date of manufacture was April, 1996, Girt bar markings/placard indicated the last maintenance overhaul was completed in March, 2013 and the next scheduled maintenance was due in March, 2016.

The inflation cable was not damaged and the quick disconnect was in place. Frangible links were separated and indicated proper color coordination for their respective locations on the escape slide inflatable.

The inflation hose, manufactured October 30, 1992, had dirty abrasion marks and a placard on the hose assembly indicated it was last tested in 2005. The manufacturers CMM indicated an integrity verification test of the inflation hose was recommended to be accomplished every 3 years up to and including 15 years and annually after 15 years.

A visual inspection of the reservoir and valve assembly revealed one of the two sling webbing was torn and the sling sleeve showed signs of abrasion and several holes torn in the fabric coincident with surface scuff marks on the reservoir. The valve assembly pressure gage glass was intact and the hard sleeve gage protector was cracked.

A visual inspection of the left (aft) side aspirator found the interior nozzle array in good condition. There were two scratches tracking down the inside of the aspirator mixing tube starting from the inlet housing junction and ending at the outlet. The inlet ring had some dents and scuffing on the outer edge. The right (forward) aspirator was found to be in good condition, with some signs of denting and scuffing on the inlet ring; although less extensive than the left side aspirator. The pressure relief valves were both intact and secure.

The slide was partially inflated for a preliminary inspection and showed no apparent leaks and no notable damage was found. There were no marks or discoloration indicating slide ingestion in the aspirator. The slide was deflated and the reservoir and valve assembly were pressurized in accordance with the Component Maintenance Manual procedures and successfully completed a leak check.

The reservoir and valve assemble were re-installed on the slide and a floor run functional test was accomplished, inflating the slide successfully. The upper tube was measured at 2.54 psi and the lower tube was measured at 2.43 psi, with no leaks detected in either chamber. The CMM indicated minimum pressure for the slide measured within 5 minutes after inflation during a floor run functional check should be 2.3 psi.

During a calibration check, the valve regulator peak pressure was measured to be 497 psi. The CMM requirement for this calibration check is 550 psi (plus or minus 50 psi). The pressure transducer used to test the regulator was calibrated to an accuracy of within .08%.

The inflation hose was hydro tested in accordance with CMM procedures at 900 psi with no leaks or deformation noted.

ADDITIONAL INFORMATION

The manufacturer recommended maintenance overhaul interval for the evacuation slide/raft was listed in the CMM. The recommendation stated in part;

"For Evacuation Systems perform the following every three years up to and including 15 years. After system has been in service for more than 15 years the following should be done each year, if the inflatable and hose are not replaced at 15 years." The table of recommended tests and inspections included a Functional Deployment Test, Inflatable Integrity Verification tests, Hose Integrity Verification Test, Light System Test, a check of various evacuation system components, and verification of compliance with all Service Bulletins and Service Information Letters.

The FedEx Maintenance Specification Item contained in their approved MD-11 Aircraft Maintenance Program indicated the evacuation slide/raft was to be overhauled every 3 years.

The manufacturers CMM indicated an integrity verification test of the inflation hose was recommended to be accomplished every 3 years up to and including 15 years and annually after 15 years.

Manufacturer records indicated three previous instances of a slide/raft that did not fully deploy inflation issue. None of the three previous incidents occurred on an airplane in service.

In 2005, a slide/raft was inadvertently deployed during a maintenance procedure and did not fully deploy. An investigation by the manufacturer found that the container assembly straps had not been properly stowed during installation and prevented complete deployment of the slide/raft.

In 2011, there were two separate incidents that occurred during functional tests of the slide/raft during scheduled maintenance. In one incident, although the root cause was not determined, evidence during an investigation by the manufacturer indicated that an unsecured assembly strap led to the slide/raft carrying case partially obstructing one of the aspirators preventing complete inflation of the lower slide chamber.

In the second incident in 2011, an investigation by the manufacturer concluded that a release strap which is required to trigger slide deployment, was not correctly attached and caused a delayed deployment. The delay in deployment displaced the slide/raft carrying case close to one of the aspirators resulting in partial blockage of the aspirator and insufficient airflow to inflate the lower chamber of the slide/raft.

Warbirds take flight, perform 'missing man' flyovers




PASO ROBLES — Like clockwork, every single year, these nostalgic birds have performed the “missing man formation” flyover during Memorial Day services all over the Central Coast. Flying at 1,000 feet, the sight and sound of these rumbling, valiant vessels is both visually and physically impressive and emotional.

“We fly low enough to where is looks like a lot of airplane, but not too low where it’s not safe,” said John Garlinger, one of the pilots of the B-25 Mitchell bomber.

It’s one thing to look up and admire the longstanding tradition of the ceremonial flyover at a Memorial Day service or parade, it’s quite another to catch these birds getting fueled up on the tarmac in front of the Estrella Warbird Museum, to find out who these guys are and how they pull this feat off so successfully each year.

“We flew over seven ceremonies,” said Robin Greg, one of the loadmasters, while waiting for the B-25 Mitchell bomber to be refueled. “Some cemeteries, some parks, some parades. One of the local guys here knows all the events going on and directs us, we put him in the nose of the plane and he tell us where to go. ‘Four miles this way, turn left,’ and so on, then we pass over each service. Took us about an hour.”

The B-25, fondly named Executive Sweet, with a Trojan T-28 on the wing, flew over events in San Luis Obispo, Santa Margarita, Atascadero, Paso Robles, Santa Margarita, Los Osos to name a few.

The pilots of the B-25 were John Garlinger and Brian Keely, of the American Aeronautical Foundation, which was founded to help preserve the aviation legacy of World War II veterans and the aircraft they flew. Garlinger and Keely flew C-130s in the military together, in the same unit, and now fly for Fedex. The T-28 was flown by Estrella Warbird Museum Board President Sherm Smoot. Smoot entered Navy flight school in Pensacola, Fla. in January of 1971 and received his wings in April of 1972. After completing the F-4 Phantom RAG in San Diego, he joined VF-21 mid-cruise for the end of “Linebacker Two” ops and was there when the Vietnam War ended, flying off of the USS Ranger in the Gulf of Tonkin. Completing two cruises with VF-21 as their LSO (landing signal officer), he was then assigned to the “Indoctrination” team of the Navy’s new Lockheed S-3 Viking. Smoot left active duty in 1977 to pursue an airline career with Continental Airlines and remained in the Naval Reserves, flying F-4’s for another four years.

While the B-25 has been seen by millions of aviation fans at air shows, fly-ins and private aviation events for more than four decades, it “never actually saw combat because it was built so close to the end of the war,” Greg said. “So it was used here in the states as a trainer, then it made its way into the movie business for a while.”

Indeed, the B-25 was acquired by Hollywood’s Filmways Studios in 1968 where she became the lead “on camera” aircraft named “Vestal Virgin” in the film “Catch-22” starring Alan Arkin. She now lives at the Camarillo Airport in Southern California.

The North American T-28B Trojan was first flown in 1949, the Trojan entered production in 1950. Designed to replace the AT-6 Texan for all branches of the military, the Trojan was the heaviest and most powerful piston-engine trainer ever projected for primary training and it was also the first U.S. military trainer to have a tricycle gear.

When asked what the best part of doing this every year was, Garlinger replied, “The missing man maneuver, it’s really dramatic. When the T-28 drops off, symbolizing that someone has passed away, it’s a great thing. Gives you the chills doing it every time.”

Minutes later, the entire crew jumped in, closed the hatch, and after a few anticipatory minutes to start up the engines — which included all the drama of smoke, blasts of fire and sputtering propellers — the Executive Sweet taxied out for another journey.

To experience flying in the B-25 “Executive Sweet” yourself, you can call the RIDE HOTLINE at  805-377-2106.

Story, video and photo gallery:  https://pasoroblespress.com

Should You Beware the Air You Breathe on Planes? Despite the occasional odd odor, the air quality in cabins may actually be better than you think

The Wall Street Journal
By Scott McCartney
Updated May 31, 2017 3:29 p.m. ET


Your worst fears about breathing bad air on planes are probably unfounded.

A recent European study that monitored air on 69 flights found cabin air quality was less polluted than that of office buildings, schools and residences. Contaminants that were found were “detected at levels considered not unusual for indoor air environments,” the study commissioned by the European Aviation Safety Agency said.

That’s good news for travelers, but unlikely to eliminate fears some hold, particularly in Europe, that oil fumes in airplanes are a toxic health problem.

Airlines and aircraft manufacturers have struggled for decades to eliminate contamination from “bleed air” systems that compress air just inside the engine, before that air comes in contact with burning fuel. The fresh, compressed air mixes with filtered air recirculated within the cabin. Problems, such as leaky seals or overfilling the oil in the engine during maintenance, can arise. That can lead to pumping chemicals from hot oil to passengers.

“There’s nothing between the engine and the people breathing that air,” says Judith Anderson, an industrial hygienist who works on health and safety issues for the Association of Flight Attendants. The organization has researched this issue for decades and pushed for improvements of aircrafts and airline procedures.

Still, such events are rare. The flight attendants union says it gets two or three reports a week out of tens of thousands of flights. The lead author on the European study, Sven Schuchardt of the Fraunhofer Institute for Toxicology and Experimental Medicine in Hannover, Germany, says research that distinguishes between minor “smell events” and more-serious “fume events” show fume events happen only a few times per one million takeoffs.

Oil-related toxins “can enter the cabin more often than you think, but in amounts that are not worth mentioning,” Dr. Schuchardt says.

The study, funded by EASA, the European equivalent of the U.S. Federal Aviation Administration, measured air on 69 flights and recorded no fume events. Still, Dr. Schuchardt says in an interview that the research team calculated the maximum concentrations in a fume event and concluded there’s not enough oil in an engine to be harmful. Being behind exhaust from a stinky car or truck in traffic would be worse.

“Our opinion is: OK, it’s not nice to have a fume event, because it’s oily mist in the cabin air. But if this occurs, it’s only for a few minutes, maximum three to five minutes, and the amount of toxic compounds is never critical. No way,” he says. “I think it’s no problem to breathe cabin air in every situation.”

The aviation world doesn’t dispute that fume events happen, but there is disagreement over whether they are harmful. In some cases, some scientists believe, exposure can cause neurological issues such as loss of memory or balance, and onset of problems is often delayed. Crew members may be more susceptible to getting sick right away, because repeated exposure weakens resistance.

Boeing , Airbus and the airline industry have long maintained that their systems are safe and onboard air is clean, as the EASA study found.

Boeing’s newest design, the 787 Dreamliner, is made without a bleed air system, using an electric system for heating and compressing fresh air. The EASA study included eight 787 flights and found slightly lower levels of chemical vapors.

Since the 1990s, airplanes have been equipped with filters used in hospital operating rooms and high-tech clean rooms called High Efficiency Particulate Air (HEPA) filters. Recirculated air passes through the filters to capture viruses, bacteria, pollen and other contaminants. Air on a plane recirculates in high volume—a good health tip is open up your air vent and aim it in front of your face so you’re breathing filtered air, not the germs from the person two rows behind you.

The FAA has studied used HEPA filters and found a few samples had some contaminants, or TCP. TCP is a toxic oil additive that can cause neuropathy and gastrointestinal disorders. But the FAA says there were no high levels of TCP or other contaminants.

The European study detected TCP on three of its 69 flights. All three were on aircraft with bleed air systems. Crews didn’t smell anything unusual on those flights, the study said, and the levels weren’t considered high enough to be a risk.

The FAA plans to release a report later this year on research that began a number of years ago collecting air samples aboard 100 airplanes. Results have been delayed because researchers involved have changed jobs.

AFA’s Ms. Anderson thinks progress is being made, since several companies are trying to develop bleed air filters and sensors. And some airlines have taken a more active approach to prevention.

Ms. Anderson credits Spirit Airlines with making improvements after some serious fume events several years ago. Spirit changed pilot procedures to isolate and shorten any fume events and trained crews on better recognition of problems. In addition, Spirit is working with a filtration company on some engineering solutions.

Preventing fume events can be a cost-savings measure for airlines, reducing unscheduled emergency landings, bad publicity, workers comp claims and maintenance and ground time.

“There are some changes. It’s slow,” she says.

Original article can be found here:  https://www.wsj.com

Backcountry Super Cub SQ2, N786AB: Incident occurred May 30, 2017 in Casper , Natrona County, Wyoming; Accidents occurred October 06, 2016 in Boca Reservoir, Nevada County, California (and) September 15, 2015 in Truckee, Nevada County, California

Federal Aviation Administration / Flight Standards District Office;   Casper, Wyoming 

http://registry.faa.gov/N786AB

Aircraft on landing, wheel collapsed. 

Date: 30-MAY-17
Time: 18:14:00Z
Regis#: N786AB
Aircraft Make: BACK COUNTRY SUBERCUBS
Aircraft Model: SUPER CUB
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: MINOR
Activity: UNKNOWN
Flight Phase: LANDING (LDG)
City: CASPER
State: WYOMING
CASPER, WY

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms


Aviation Accident Data Summary - National Transportation Safety Board: https://app.ntsb.gov/pdf

NTSB Identification: GAA17CA010
14 CFR Part 91: General Aviation
Accident occurred Thursday, October 06, 2016 in Boca Reservoir, CA
Probable Cause Approval Date: 12/15/2016
Aircraft: JOE SALOMONE SUPER CUB SQ2, registration: N786AB
Injuries: 1 Uninjured.

NTSB investigators used data provided by various entities, including, but not limited to, the Federal Aviation Administration and/or the operator and did not travel in support of this investigation to prepare this aircraft accident report.

The pilot of the tailwheel equipped airplane with tundra tires, reported that after landing off airport next to a reservoir, the tires became stuck in muddy terrain. He further reported that he decided to "use power and elevator to unstick the tires". The tires loosened from the mud, however, when he applied additional power the airplane nosed over. 

The airplane sustained substantial damage to its vertical stabilizer and rudder.

The pilot reported that there were no pre impact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's decision to continue the taxi on unsuitable muddy terrain, which resulted in a nose-over.

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

Aviation Accident Data Summary - National Transportation Safety Board: https://app.ntsb.gov/pdf

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

NTSB Identification: GAA15CA244
14 CFR Part 91: General Aviation
Accident occurred Tuesday, September 01, 2015 in Truckee, CA
Probable Cause Approval Date: 10/08/2015
Aircraft: JOE SALOMONE SUPER CUB SQ2, registration: N786AB
Injuries: 2 Uninjured.

NTSB investigators used data provided by various entities, including, but not limited to, the Federal Aviation Administration and/or the operator and did not travel in support of this investigation to prepare this aircraft accident report.

The pilot of the tailwheel equipped, tandem cockpit airplane, who was sitting in the rear seat, reported that during the takeoff roll, the airplane veered off the left side of the runway and ground looped. The airplane sustained substantial damage to the right wing.

The pilot reported no preimpact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation.

The pilot reported that he did not have any experience piloting a tailwheel equipped airplane from the rear seat and he could not see the instruments with the passenger seated in the front seat.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's loss of directional control during the takeoff roll, which resulted in a runway excursion, ground loop, and impact with terrain. Contributing to the accident was the pilot's lack of experience from the back seat.

Mooney M20E, N6946U: Incident occurred May 30, 2017 at Orcas Island Airport (KORS), Eastsound, San Juan County, Washington

Federal Aviation Administration / Flight Standards District Office; Seattle, Washington

http://registry.faa.gov/N6946U

Aircraft landed gear up.

Date: 30-MAY-17
Time: 18:20:00Z
Regis#: N6946U
Aircraft Make: MOONEY
Aircraft Model: M20
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: MINOR
Activity: UNKNOWN
Flight Phase: LANDING (LDG)
City: ORCAS ISLAND
State: WASHINGTON

Velocity SUV, N399DG: Accident occurred May 30, 2017 at Pierce County Airport (KPLU), Puyallup, Washington

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf 

NTSB Identification: WPR17LA114
14 CFR Part 91: General Aviation
Accident occurred Tuesday, May 30, 2017 in Puyallup, WA
Probable Cause Approval Date: 09/06/2017
Aircraft: TAPPEN CHRIS VELOCITY SUV, registration: N399DG
Injuries: 1 Uninjured.

NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

The private pilot stated that, during the landing roll, the right brake of the experimental amateur-built airplane failed. The airplane subsequently departed the runway and impacted an airport fence, resulting in substantial damage. The airplane was equipped with a castering nosewheel and steering was accomplished through differential brake pressure; therefore, the pilot did not have any other means to either stop the airplane or maintain directional control once it had slowed to a speed below which rudder authority was available.

Postaccident examination revealed that the right brake disc had detached from the wheel hub. None of its attachment bolts were found, and the attachment bolts on the left brake disc were loose. The bolts and discs had holes to accommodate safety wires, but no safety wires were found on either assembly.

The pilot had recently purchased the airplane following the completion of a condition inspection. Before the inspection, the airplane’s builder had adjusted the landing gear, which necessitated removal of the brake discs. The builder could not recall using safety wires to secure the brake discs during the reinstallation, and the mechanic who performed the subsequent inspection also could not recall if safety wires were used. 

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The airplane builder's failure to install safety wires on the brake disc attachment bolts, and the mechanic’s failure to identify the omission during the condition inspection. The subsequent brake disc separation resulted in a loss of directional control during the landing roll.

Aviation Accident Factual Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

NTSB Identification: WPR17LA114
14 CFR Part 91: General Aviation
Accident occurred Tuesday, May 30, 2017 in Puyallup, WA
Aircraft: TAPPEN CHRIS VELOCITY SUV, registration: N399DG
Injuries: 1 Uninjured.

NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

HISTORY OF FLIGHT

On May 30, 2017, about 1600 Pacific daylight time, an experimental amateur-built Velocity SUV, N399DG, departed the runway after landing at Pierce County Airport - Thun Field, Puyallup, Washington. The pilot was not injured, and the airplane sustained substantial damage to the canard and both wings after striking an airport fence. The airplane was registered to, and operated by, the private pilot as a 14 Code of Federal Regulations Part 91 personal flight. The local flight departed Thun Field about 5 minutes before the accident. Visual meteorological conditions prevailed and no flight plan had been filed.

The pilot had purchased the airplane in Tennessee from its builder about one week before the accident, and spent the intervening period flying it back to his home base of Thun Field. He stated that during taxi after one of the return flight legs, the right brake became ineffective, and therefore he was unable to turn the airplane right. He inspected the brake system and was not able to find any anomalies, and on the next three flights, he could not duplicate the problem.

On the day of the accident, he planned to fly the airplane in the traffic pattern. He performed a preflight inspection, and reported that during the engine ground-run he checked the brakes, and they held. Additionally, the taxi route from his hangar to the runway required multiple right turns. The takeoff, climbout, and landing approach were uneventful, and he touched down just beyond the runway numbers, at an airspeed of 82 knots. He applied pressure to the combination rudder/brake foot pedals to slow the airplane down, and once it had reached about 35 knots, the resistance in the right pedal suddenly dropped, and the pedal moved to almost full travel.

The airplane immediately veered to the left, and the pilot released pressure on the left pedal. He began to "pump" the right pedal in an attempt to regain braking action, but the airplane did not slow down. As the airplane approached a runway light, the pilot applied left pedal pressure, and the airplane veered left, departed the runway, and struck the fence.

TESTS AND RESEARCH

Brake and Steering System

The airplane was equipped with a castering nosewheel, with steering accomplished through differential brake pressure once rudder effectiveness had reduced at slower speeds. The brakes were activated by the pilot through the rudder pedals. The design did not incorporate conventional toe-brakes, but instead braking action was applied directly via the rudder pedals once they had been pushed about 2 ½ inches. The main landing gear struts were equipped with Matco W600 series brake and wheel assemblies, which incorporated a triple-piston brake caliper, and a steel brake disk which was attached to a threaded aluminum wheel hub by three hex-head bolts. Each wheel assembly was enclosed in a composite wheel pant, which covered the caliper and brake rotor.

Post-accident examination revealed that all three hex bolts for the right brake disk were missing, and the disk had become detached from the wheel hub. The disk on the left side was still in place, but was loose, and the three bolts were finger-tight. The bolts and disks had holes to accommodate safety wire, but no safety wire was found on either assembly.



Maintenance

Construction of the airplane was completed in June 2012, and at the time of the accident, it had accrued a total flight time of about 138 hours. Maintenance records indicated that it failed to pass its conditional inspection on May 19, 2017, due to the lack of an emergency locator transmitter (ELT). An entry by the builder dated May 26 detailed that he installed an ELT and completed a series of repairs and upgrades including the replacement of the brake master cylinders, adjustment of the main landing gear camber and toe-in, (due to uneven tire wear), along with modifications to the avionics system.

The builder stated that the toe-in adjustment required removal of the brake assembly (including the three hex bolts) and installation of shims at the wheel axle mounting points. He could not recall if he had used safety wire to secure the hex bolts, or if he had ever used safety wire for their retention in the past. He further reported that the master cylinders were replaced because he encountered a loss of brake effectiveness in the right brake, which could be overcome by "pumping" the right pedal.

The builder stated that all the work, except for the ELT installation, had actually been completed prior to the conditional inspection on May 19, but that he did not record the entry until one week later.

On May 26, 2017, the same airframe and powerplant rated mechanic (with inspection authorization) who initially inspected the airplane, certified that it was airworthy. The mechanic reported that he had examined the brake system at the time of the initial inspection, but could not recall if safety wire had or had not been installed on the disk bolts. He did not re-examine the brakes during the follow-up inspection, as the ELT was the only item which required attention.

During the 21-flight hour period leading up to the accident no other brake-related maintenance procedures were performed.

The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Renton, Washington

Aviation Accident Preliminary Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

http://registry.faa.gov/N399DG


NTSB Identification: WPR17LA114
14 CFR Part 91: General Aviation
Accident occurred Tuesday, May 30, 2017 in Puyallup, WA
Aircraft: TAPPEN CHRIS VELOCITY SUV, registration: N399DG
Injuries: 1 Uninjured.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

On May 30, 2017, about 1600 Pacific daylight time, an experimental amateur-built Velocity SUV, N399DG, departed the runway after landing at Pierce County Airport - Thun Field, Puyallup, Washington. The airplane was registered to the builder, and operated by the private pilot under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. The pilot was not injured, and the airplane sustained substantial damage to the canard and fuselage structure after striking an airport fence. The local flight departed Thun Field about 5 minutes before the accident. Visual meteorological conditions prevailed and no flight plan had been filed.

The pilot had purchased the airplane in Tennessee about a week prior to the accident, and spent the intermediate time flying it back to his home base of Thun Field. On the day of the accident, he planned to fly it in the traffic pattern. He performed a preflight inspection, and reported that during the engine run-up he checked the brakes, and they held. The takeoff, climbout, and landing approach were uneventful, and he touched down just beyond the runway numbers, at an airspeed of 82 knots. He applied pressure to the combination rudder/brake foot pedals to slow the airplane down, and once it had reached about 35 knots, the pressure in the right pedal suddenly dropped, and the pedal moved to almost full travel.

The airplane immediately veered to the left, and he released pressure on the left pedal. He began to "pump" the right pedal in an attempt to regain braking action, but the airplane did not slow down. As the airplane approached a runway light, he applied left pedal pressure, and the airplane veered left, departed the runway, and struck the fence.