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Flight Safety Information

TopFlight Safety Information


March 13, 2019 -No. 054



In This Issue


EU suspends Boeing 737 MAX flights after Ethiopia crash

From the flight manual to automation, why pilots have complained about Boeing's 737 MAX 8


Ethiopia to Send 'Black Boxes' Abroad for Analysis

Incident: Lao A320 at Vientiane on Mar 10th 2019, nose gear steering fault after departure

Incident: Skywest CRJ2 at Lexington on Mar 11th 2019, gear problem on departure

Incident: Maldivian DH8C at Kaadedhdhoo on Mar 12th 2019, unsafe gear

ncident: THY A21N near Sofia on Mar 12th 2019, engine shut down in flight

Boeing 747-8HVF - Ground Collision (Russia)

NTSB update on Atlas Air B767 crash: nose pitched down to about 49° 'in response to column input

Atlas Air 3591 Pitched Down in Response to Elevator Deflection

FAA, United to inspect Boeing plane after engine incident

NTSB Head: Part 135 Needs Same Safety Tools as Airlines

Call for Papers - ISASI 2019...*** Deadline March 18th ***

Aviation Innovations Conference: Cargo Airships...March 14 - 15, 2019...Toronto, Canada

ISASI-Mid-Atlantic Regional Chapter (MARC) Dinner/Meeting--2 May 2019




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EU suspends Boeing 737 MAX flights after Ethiopia crash

Adds India suspension, EASA and source comments, background

  • EU countries join list suspending Boeing 737 MAX
  • Relatives await identification of 157 crash victims
  • Ethiopian Airlines Flight 302 black boxes found
  • Second disaster with a 737 MAX jet in recent months
  • Boeing shares fall another 7 percent

By Duncan Miriri and Tim Hepher


ADDIS ABABA/PARIS, March 12 (Reuters) - The European Union's aviation safety regulator on Tuesday suspended all flights in the bloc by Boeing BA.N 737 MAX planes in the biggest setback yet for the U.S. planemaker following a crash in Ethiopia that killed 157 people.


The move came after Britain, Germany and France joined a wave of suspensions of the aircraft in the wake of Sunday's crash, and was swiftly followed by a similar decision by India, piling pressure on the United States to follow suit.


Boeing, the world's biggest planemaker, which has seen billions of dollars wiped off its market value, said it understood the countries' actions but retained "full confidence" in the 737 MAX and had safety as its priority.


It also said the U.S. Federal Aviation Authority (FAA) had not demanded any further action related to 737 MAX operations.


The cause of Sunday's crash, which followed another disaster with a 737 MAX five months ago in Indonesia that killed 189 people, remains unknown.


There is no evidence yet whether the two crashes are linked.


In an unusual move, the European Union Aviation Safety Agency (EASA) said it was suspending all flights in the bloc of Boeing's 737 MAX 8 and 9 jets.


"Based on all available information, EASA considers that further actions may be necessary to ensure the continued airworthiness of the two affected models," it said in a statement.


However, it shied away from the even rarer step of pulling the safety certification for the plane itself, focusing instead on the softer process of restricting its use by airlines. The move leaves some leeway for the FAA to decide its own approach.


The decision by some states to ban not only arrivals and departures but flights crossing through their airspace surprised some regulatory sources even in regions banning the plane, since overflights are usually protected by international law.



Earlier, countries including Singapore, Australia and Malaysia also temporarily suspended the aircraft, following China, Indonesia and others the day before.

Experts say it is too early to speculate on the reason for the crash. Most are caused by a unique chain of human and technical factors.


Given problems of identification at the charred disaster site, Ethiopian Airlines said it would take at least five days to start handing remains to families. (Full Story)

The victims came from more than 30 different nations, and included nearly two dozen U.N. staff.


"We are Muslim and have to bury our deceased immediately," Noordin Mohamed, a 27-year-old Kenyan businessman whose brother and mother died, told Reuters.

"Losing a brother and mother in the same day and not having their bodies to bury is very painful," he said in the Kenyan capital Nairobi where the plane had been due.

Flight ET 302 came down in a field soon after takeoff from Addis Ababa on Sunday, creating a fireball in a crater. It may take weeks or months to identify all the victims, who include a prize-winning author, a soccer official and a team of humanitarian workers.


The United States has said it remains safe to fly the planes. Still, two U.S. senators urged the FAA to implement a temporary grounding.


President Donald Trump also fretted over modern airplane design.

"Pilots are no longer needed, but rather computer scientists from MIT," Trump tweeted, lamenting that product developers always sought to go an unnecessary step further when "old and simpler" was superior.


"I don't know about you, but I don't want Albert Einstein to be my pilot. I want great flying professionals that are allowed to easily and quickly take control of a plane!" he added.


He did not refer to Boeing or recent accidents, but his comments echoed an automation debate that partially lies at the centre of a probe into October's Lion Air crash. Investigators are examining the role of a software system designed to push the plane down, alongside airline training and repair standards.


Boeing says it plans to update the software in coming weeks.

Trump spoke to Boeing CEO Dennis Muilenburg on Tuesday, a source familiar with the matter said.


U.S. Senators Mitt Romney and Elizabeth Warren called on the FAA to temporarily ground the 737 MAX.


Anxiety was also evident among some travellers, who rushed to find out from social media and travel agents whether they were booked to fly on 737 MAX planes.

If the black box recordings found at the Ethiopian crash site are undamaged, the cause of the crash could be identified quickly, although it typically takes a year for a full probe.



The new variant of the 737, the world's most-sold modern passenger aircraft, is viewed as the likely workhorse for global airlines for decades and another 4,661 are on order.

Over 40 percent of the MAX fleet has been grounded, Flightglobal said, though many airlines still use older jets.


Still, major customers including top airlines from North America kept flying the 737 MAX. Southwest Airlines Co LUV.N, which operates the largest fleet of 737 MAX 8s, said it remained confident in the safety of all its Boeing planes.


Former FAA accident investigator Mike Daniel said the decision by regulators to ground the planes was premature. "To me it's almost surreal how quickly some of the regulators are just grounding the aircraft without any factual information yet as a result of the investigation," he told Reuters.

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From the flight manual to automation, why pilots have complained about Boeing's 737 MAX 8

In the months before an Ethiopian Airlines crash killed 157 people on Sunday, the second recent deadly crash of a Boeing 737 MAX 8 jetliner, American pilots complained to authorities about perceived safety problems with the same aircraft.

Two pilots reported their aircraft unexpectedly pitched nose down after engaging autopilot following departure. Another pilot reported a "temporary level off" triggered by the aircraft automation. The captain of a November 2018 flight called part of the aircraft's flight manual "inadequate and almost criminally insufficient."

"The fact that this airplane requires such jury rigging to fly is a red flag," that captain - who is not identified by name - wrote in a report to the federal Aviation Safety Reporting System. The captain added that part of the plane's flight system is "not described in our Flight Manual."

Records show that federal aviation authorities received at least 11 reports concerning the Boeing 737 MAX 8 from professional aviators logged between April 2018 and December 2018.

Sunday's crash in Ethiopia followed an Oct. 29, 2018, crash of Lion Air Flight 610, in which 189 passengers and crew died when it plunged into the Java Sea outside Indonesia. Both flights crashed after experiencing drastic speed fluctuations during ascent, with their pilots trying to return to ground after takeoff.

Regulators and industry experts suspect that MAX 8's Maneuvering Characteristics Augmentation System, or MCAS, may have caused the jets to make unwanted dives.

A Boeing 737 MAX 8 airliner lifts off for its first flight on January 29, 2016 in Renton, Washington.

Flight data recovered from the Indonesia crash indicated pilots repeatedly tried to get the plane's nose up before impact. After the crash, Boeing issued a service bulletin warning pilots that erroneous flight data fed into the MCAS could force the aircraft into a dive for up to 10 seconds.

Following the crash in Ethiopia, the company said it had no new guidance.

The pilot complaints, first reported Tuesday by the Dallas Morning News, emerged as aviation regulators around the world were hustling to respond to the two crashes in five months.

In one documented complaint, a pilot said the plane's downturn triggered the ground proximity warning system, which is designed to alert pilots when their planes are in immediate danger. The complaint states an alarm sounded "don't sink, don't sink" before the captain disconnected the autopilot and manually adjusted the plane to climb.

This week, the European Union, United Kingdom, China, Australia, Ethiopia, Indonesia and Malaysia grounded the MAX 8 over safety concerns. Airline officials in the United States have so far resisted pressure to follow suit, although regulators have acknowledged that there were reports of similar issues in both doomed flights.

More: Ground the Boeing 737 Max 8, members of Congress implore the FAA after deadly crash

FAA spokeswoman Lynn Lunsford declined to comment on the specific pilot complaint reports, which are logged by the Aviation Safety Reporting System. Lunsford noted the reports do not discuss MCAS, the feature suspected to have played a role in both crashes.

Kristy Kiernan, an assistant professor at Embry-Riddle Aeronautical University's college of aeronautics in Daytona Beach, Florida, cautioned against drawing conclusions from the MAX 8 aircraft complaint reports, which she reviewed for USA TODAY.

"There's nothing that really struck me as a pattern," Kiernan said. "I just don't think there's anything you can draw from it at all."

Although the reports involve the MAX 8, the issues are different than those flagged about the MCAS system in the Lion Air crash, Kiernan said. For example, two pilots raised concerns about issues after engaging the plane's autopilot, but Kiernan noted that the MCAS system is disengaged when the autopilot is turned on. Another of the reports focused on a different system, the aircraft's auto throttles.

The anonymous reports are submitted by pilots on a voluntary basis to capture safety concerns and are used by regulators to support policies aimed at decreasing the likelihood of accidents.

As aviation regulators around the world this week suspended the MAX 8, the FAA stated that its "investigation has just begun and to date we have not been provided data to draw any conclusions or take any actions."

Boeing has sold nearly 400 of the airliners, including 74 to domestic carriers, and has taken orders for thousands more. A company spokesperson stressed "full confidence in the safety" of the planes Tuesday.

"The Federal Aviation Administration is not mandating any further action at this time, and based on the information currently available, we do not have any basis to issue new guidance to operators," Boeing said in a statement.

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At this early stage in the Ethiopia crash investigation, it seems the FAA doesn't think the risk of letting the 737 MAX 8 fly justifies the cost of grounding it.



WHEN AN ETHIOPIANAirlinesBoeing 737 MAX 8 jet crashed shortly after takeofffrom Addis Ababa on Sunday morning, killing all 157 people aboard, observers quickly noted that the circumstances resembled those of another flight. In October,Lion Air Flight 610 crashed into the Java Sea, killing all 181 passengers and eight crew. Both flights plummeted a few minutes after takeoff, in good weather. And both were on 737 MAX 8 jets, the planeBoeingstarted delivering in 2017 to replace the outgoing 737 as the workhorse of the skies. Since 2017, Boeing has delivered 387 MAX 8s and 9s. It has taken orders for 4,400 more, from more than 100 customers.



As of Tuesday evening, various foreign aviation regulators and airlines had decided that after the two crashes, the plane shouldn't be in the air. Officials in the European Union, China, Indonesia, Singapore, Australia, and the United Arab Emirates have all grounded the planes. Of the 59 operators that fly the new 737, at least 30 have parked it.

In the US, though, Boeing's plane is free to fly. American Airlines, Southwest Airlines, and United Airlines are still putting their 737 MAX jets-74 in total-in the air. (So is Air Canada.) And the Federal Aviation Administration-the agency that oversees American airspace-says that's just fine.


Which might seem strange, since the FAA is notoriously safety-conscious. Planes in search of an airworthiness certificate must meet stringent standards; the certification process usually takes years. And it gets results:Just one person has diedin American airspace on a commercial airplane since 2009. But, it seems, the agency has not yet found reason to ground the new 737.


In a statement Tuesday, acting FAA administrator Daniel Elwell said the agency is looking at all the available data from 737 operators around the world, and that the review "thus far shows no systematic performance issues and provides no basis to order grounding aircraft." Elwell said the FAA "would take immediate appropriate action" should such problems be identified. The FAA and the National Transportation Safety Board both have teams at the crash site outside Addis Ababa to investigate and collect data.


The agency did note ina directivepublished Monday that it would probably mandate flight control system enhancements that Boeing is already working on, come April. And after the Lion Air crash,the FAA made a Boeing safety warning mandatoryfor US airlines.


"We have full confidence in the safety of the 737 MAX," Boeing said in its own statement Tuesday. "Based on the information currently available, we do not have any basis to issue new guidance to operators."


A number of senators, including Ted Cruz of Texas, Elizabeth Warren of Massachusetts, and Dianne Feinstein of California, have called for the US to ground the aircraft. But it's the FAA chief who has final say. (Elwell has been the acting administrator since January 2018, thoughPoliticoreportsthat the Trump Administration is close to nominating Delta Air Lines executive Steve Dickson as administrator.) He doesn't make that decision alone, says Clint Balog, a flight test pilot and human factors expert with the College of Aeronautics at Embry-Riddle University. Any grounding goes through a "semi-formal" process, full of discussions with experts on the specific aircraft and crash situation, both in- and outside the federal government.


"The FAA looks at all of this information and decides, 'OK, if it's just likely that there's a significant problem here, it doesn't matter what the cost to the traveling public is-we have to put safety first and ground this aircraft,'" Balog says. "However, if they look and say, 'Well, jeez, grounding this aircraft is going to be a monumental cost to the world and we simply don't have enough information to know what the risk really is with this aircraft, do we really want to ground it at this point in time?'"


The FAA has grounded aircraft before. In 1979, the FAA grounded all McDonnell Douglas DC-10s (and forbid the aircraft from US airspace) after a crash in Chicago killed 273 people. An investigation found the problem was maintenance issues, not the aircraft design, the FAA lifted the prohibition just over a month later.


In early 2013, the FAA grounded Boeing's 787 Dreamliner, after two lithium ion-battery related fires in the aircraft. "We are issuing this [directive] because we evaluated all the relevant information and determined the unsafe condition described previously is likely to exist or develop in other products of the same type design," the FAA wrote in its emergency airworthiness directive. It didn't let the jet take to the sky again until Boeing found and corrected its design issues. (That happened in April.)


So far, though, we have little concrete information on whatever might be going on with the 737 MAX. The investigation into the Ethiopia crash is in its earliest stages. Indonesia's civil aviation authority has released a preliminary report on the Lion Air crash, but has not issued any findings on what caused it.


Based on its directives, the FAA hasn't "seen any red flags that are significant enough" to ground the aircraft, Balog says. So he'd have no problem getting on a 737 MAX-8. "More importantly, I would have no problem having my family get on a 737 MAX-8 at this point."


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Ethiopia to Send 'Black Boxes' Abroad for Analysis

* Ethiopia will send overseas for analysis the so-called black boxes - flight data and voice recorders - recovered from the crash site of Ethiopian Airlines Flight 302, in which 157 people were killed, an airline spokesman said on Wednesday.

* At least two pilots, flying United States routes on the same model of Boeing jet involved in two recent crashes, filed incident reports with the federal government that raised concerns about safety and criticized a lack of training on the new plane, the Boeing 737 Max 8.

* Citing safety concerns, Egypt, Kazakhstan and Vietnam closed their airspace to Boeing 737 Max 8 airplanes on Wednesday, raising to 41 the number of nations that have barred the plane from operation. The European Union, China and India had previously banned all 737 Max 8 flights.

Ethiopia will ask a foreign country for help analyzing the flight data and voice recorders recovered from the wreckage of Flight 302, a spokesman for Ethiopian Airlines said on Wednesday.

The spokesman, Asrat Begashaw, said the airline had not yet decided where to send the "black boxes," which investigators believe are critical to determining the cause of Sunday's crash.

"We have a range of options," Mr. Begashaw told The Associated Press. "What we can say is we don't have the capability to probe it here in Ethiopia."

The two recorders will need to be taken to a specialized center to read their data, said Lynnette Dray, an aviation expert and senior research associate at University College London.

"If the boxes are intact, then they will be able to take the data off them and look at it immediately," Dr. Dray said.

American air safety experts are trying to persuade their Ethiopian counterparts not to send the flight data to crash investigators in London, The Wall Street Journal reported. Instead, they want it examined by the National Transportation Safety Board in the United States.

The cockpit of a Jet Airways Boeing 737 Max 8. Two fatal Max 8 crashes in five months have led to intense scrutiny of the aircraft.

Pilots on U.S. routes had reported concerns about the Max 8
At least two pilots who flew Boeing 737 Max 8 planes on routes in the United States had raised concerns in November about the noses of their planes suddenly dipping after engaging autopilot, according to a federal government database of incident reports.

The problems the pilots experienced appeared similar to those preceding the October crash of Lion Air Flight 610 in Indonesia, in which 189 people were killed. The cause of that crash remains under investigation, but it is believed that inaccurate readings fed into the Max 8's computerized system may have made the plane enter a sudden, automatic descent.

In both of the American cases, the pilots safely resumed their climbs after turning off autopilot. One of the pilots said the descent began two to three seconds after turning on the automated system.

Boeing 737 Max 8 Jets Are Grounded Nearly Everywhere
The jets typically make more than 8,500 flights per week worldwide.

"I reviewed in my mind our automation setup and flight profile but can't think of any reason the aircraft would pitch nose down so aggressively," the pilot wrote.

A pilot on a separate flight reported in November a similar descent and hearing the same warnings in the cockpit, and said neither of the pilots on board was able to find an inappropriate setup.

"With the concerns with the MAX 8 nose down stuff, we both thought it appropriate to bring it to your attention," the pilot said.

The complaints were listed in a public database maintained by NASA and filled with thousands of reports, which pilots file when they encounter errors or issues. The database does not include identifying information on the flights, including airline, the pilot's name or the location.

Another pilot wrote of having been given insufficient training to fly the Max 8, a new, more fuel-efficient version of Boeing's best-selling 737.

"I think it is unconscionable that a manufacturer, the F.A.A., and the airlines would have pilots flying an airplane without adequately training, or even providing available resources and sufficient documentation to understand the highly complex systems that differentiate this aircraft from prior models," the pilot wrote.

The pilot continued: "I am left to wonder: what else don't I know? The Flight Manual is inadequate and almost criminally insufficient."

Boeing has said the planes are safe to fly, but has pledged to upgrade their software and improve pilot training. News of the incident reports was first reported by The Dallas Morning News and confirmed by The New York Times.

More countries ban 737 Max 8 flights
Egypt, Vietnam and Kazakhstan banned flights by the Boeing 737 Max 8 aircraft on Wednesday, raising to 41 the number of countries that have grounded the planes.

Hong Kong, a Chinese territory with its own aviation authorities, also announced a ban in its airspace on Tuesday.

In addition to the countries ordering the grounding of the planes, at least 34 airlines have pulled their Max 8 aircraft.

Sunwing, a Canadian carrier, said on Tuesday that it was temporarily grounding its four planes, even though Canada's government, like that of the United States, has not ordered the move.

In a statement, the company said the step was "unrelated to safety." Instead, the airline said, the move was prompted by growing airspace bans by countries and "evolving commercial reasons."

The Federal Aviation Administration in the United States has resisted pressure to ground the Max 8.

Norwegian Air says it wants compensation from Boeing
Norwegian Air, a low-cost airline that has one of the largest Max 8 fleets outside the United States, said it would seek compensation from Boeing after European regulators grounded the aircraft.

"It is obvious that the costs incurred by the temporary grounding of brand-new aircraft should be covered by those who have made the airplane," the company said in a statement on Wednesday.

Belying its name, Norwegian flies routes all over Europe and beyond. According to the airline's website, flights to European destinations were running with moderate delays and a handful of cancellations.

In a message to passengers, the airline said that it had 18 Max 8 aircraft in its fleet of more than 160 planes.

In December, a technical error forced a Max 8 jet to land in Iran en route to Oslo from the United Arab Emirates. The jet was stranded at the Shiraz airport for months, apparently caught up in United States sanctions on Tehran's nuclear program that prohibit civilian aircraft sales, including services and parts.

That jet returned to service but is now grounded, the airline said.

After grounding planes, China's flights are delayed - as usual
Nobody has grounded more Boeing 737 Max 8 jets than China. With its order on Monday that Chinese airlines idle their fleets of the beleaguered aircraft, 96 planes went out of commission.

How did that affect flying in China? Not a whole lot, even on the first day.

Chinese airline canceled 62 flights outright on Monday as a result of the grounding, according to VariFlight, an online tracking company. For another 288, it found substitute aircraft, while five flights were completed before the grounding took effect later on Monday.

That represents a minor ripple in what has become some of the busiest airspace in the world. According to Chinese safety regulators, last year an average of 15,000 flights took off every day. Chinese airlines represent 14 percent of global traffic, according to figures from Boeing, and could account for one-fifth in two decades' time.

China has room for flexibility in other ways.

Flight delays are common in China, so airlines schedule fewer flights per day for each aircraft, leaving more available to potentially fill in. Air traffic controllers and the airlines themselves are highly cautious about allowing planes to fly in poor weather. The military controls most of China's airspace and frequently closes large areas, resulting in more delays.

For all of those reasons, many Chinese passengers may not have noticed the groundings. Of the Max 8 flights that continued to operate on Monday, mostly with substitute planes, the average delay was 70 minutes.

While regulators in much of the world have ordered temporary groundings of the Boeing 737 Max 8 as a precautionary measure, the United Nations civil aviation agency said it would await definitive findings about what went wrong on Ethiopian Airlines Flight 302.

"Once the final report into this accident is available we will have verified and official causes and recommendations to consider," the agency, the International Civil Aviation Organization, said in a statement on Tuesday.

"In the meantime ICAO recognizes the right of those national governments who may choose to act on the limited information currently available by taking immediate flight safety precautions regarding 737 Max 8 operations," it said.

The agency, based in Montreal, manages the Convention on International Civil Aviation, the agreement that ensures safe and orderly air travel around the world. According to its website, the agency, which has sanction powers to enforce compliance with the convention, works with United Nations member states and industry groups "in support of a safe, efficient, secure, economically sustainable and environmentally responsible civil aviation sector."

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Incident: Lao A320 at Vientiane on Mar 10th 2019, nose gear steering fault after departure

A Lao Airlines Airbus A320-200, registration RDPL-34188 performing flight QV-65 from Vientiane (Laos) to Shanghai Pudong (China), was climbing out of Vientiane when the crew received indication of a nose gear steering fault and stopped the climb at FL250. The aircraft descended to 15,000 feet and entered a hold to burn off fuel, then landed back to Vientiane about 2 hours after departure.

A replacement A320-200 registration RDPL-34223 reached Shanghai with a delay of 4 hours.

The occurrence aircraft returned to service after 10 hours on the ground.

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Incident: Skywest CRJ2 at Lexington on Mar 11th 2019, gear problem on departure

A Skywest Canadair CRJ-200 on behalf of United, registration N941SW performing flight OO-5830/UA-5830 from Lexington,KY to Houston Intercontinental,TX (USA), was climbing out of Lexington's runway 22 when the crew stopped the climb at 6000 feet due to being unable to fully retract the landing gear. The crew was able to extend the gear again and landed safely back on runway 22 about 35 minutes after departure.

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Incident: Maldivian DH8C at Kaadedhdhoo on Mar 12th 2019, unsafe gear


A Maldivian de Havilland Dash 8-300, registration performing flight Q2-118 from Male to Kaadedhdhoo (Maldives) with 44 people on board, was on approach to Kaadedhdhoo when the crew did not receive indication all gear was down and locked. The crew went around and entered a hold at 3000 feet for about 30 minutes, performed a low approach to have the gear inspected from the ground, which confirmed the nose gear had not extended, gear doors were closed. The crew performed an alternate gear extension, flew another low approach and subsequently positioned for a full stop landing. The aircraft landed safely on Kaadedhdhoo's runway 10.

The passengers praised the crew for the smooth landing.

The airline reported the crew performed an alternate gear extension, there was only 50% chance that the gear would hold on landing.

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Incident: THY A21N near Sofia on Mar 12th 2019, engine shut down in flight

A THY Turkish Airlines Airbus A321-200N, registration TC-LSA performing flight TK-1944 from Brussels (Belgium) to Istanbul (Turkey), was enroute at FL370 about 300nm northwest of Sofia (Bulgaria), still in Hungarian Airspace, when the crew needed to shut the left hand engine (PW1133) down due to loss of oil pressure. The aircraft drifted down to FL230 and diverted to Sofia for a safe landing on runway 27 about 65 minutes after leaving FL370.

The occurrence aircraft is still on the ground in Sofia about 5.5 hours after landing.

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Boeing 747-8HVF - Ground Collision (Russia)







Boeing 747-8HVF





C/n / msn:



Fatalities: 0 / Occupants:

Other fatalities:


Aircraft damage:



Moskva-Sheremetyevo Airport (SVO/UUEE) -Russia


Pushback / towing



Departure airport:

Moskva-Sheremetyevo Airport (SVO/UUEE)

Destination airport:

Chicago-O'Hare International Airport, IL (ORD/KORD)

During towing, the right-hand wing tip of the Boeing 747-8HVF cargo plane contacted a light pole.

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NTSB update on Atlas Air B767 crash: nose pitched down to about 49° 'in response to column input'

ADS-B track (source: NTSB)

The NTSB issued an investigation update on the February 23, 2019, crash of Atlas Air flight 3591, a Boeing 767-375BCF that killed all three on board. The aircraft entered a rapid descent from 6,000 ft and impacted a marshy bay area about 40 miles southeast of George Bush Intercontinental Airport (KIAH), Houston, Texas.

Air traffic control communications and radar data indicated the flight was normal from Miami to the Houston terminal area. About 12:30 pm the pilots contacted the Houston terminal radar approach control (TRACON) arrival controller and reported descending for runway 26L; the airplane was at 17,800 ft with a ground speed 320 knots. At 12:34, the airplane was descending through 13,800 ft, and the controller advised of an area of light to heavy precipitation along the flight route and that they could expect vectors around the weather.

About 12:35, the flight was transferred to the Houston TRACON final controller, and the pilot reported they had received the Houston Automatic Terminal Information System weather broadcast. The controller told the pilots to expect vectors to runway 26L and asked if they wanted to go to the west or north of the weather.

Radar data indicated the airplane continued the descent through 12,000 ft with a ground speed of 290 knots, consistent with the arrival procedure. The pilots responded that they wanted to go to the west of the area of precipitation. The controller advised that to do so, they would need to descend to 3,000 ft expeditiously.

About 12:37, the controller instructed the pilots to turn to a heading of 270°. Radar data indicated the airplane turned, and the automatic dependent surveillance-broadcast (ADS-B) data indicated a selected heading of 270°. The airplane was descending through 8,500 ft at this time.

About 12:38, the controller informed the pilots that they would be past the area of weather in about 18 miles, that they could expect a turn to the north for a base leg to the approach to runway 26L, and that weather was clear west of the precipitation area. The pilots responded, "sounds good" and "ok." At this time, radar and ADS-B returns indicated the airplane levelled briefly at 6,200 ft and then began a slight climb to 6,300 ft.

Also, about this time, the FDR data indicated that some small vertical accelerations consistent with the airplane entering turbulence. Shortly after, when the airplane's indicated airspeed was steady about 230 knots, the engines increased to maximum thrust, and the airplane pitch increased to about 4° nose up and then rapidly pitched nose down to about 49° in response to column input. The stall warning (stick shaker) did not activate.

FDR, radar, and ADS-B data indicated that the airplane entered a rapid descent on a heading of 270°, reaching an airspeed of about 430 knots. A security camera video captured the airplane in a steep, generally wings-level attitude until impact with the swamp. FDR data indicated that the airplane gradually pitched up to about 20 degrees nose down during the descent.

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Atlas Air 3591 Pitched Down in Response to Elevator Deflection

The Atlas Air Boeing 767 Freighter that crashed on February 23 on approach to Houston Intercontinental Airport entered its steep descent into Trinity Bay after encountering turbulence, followed by nose-down elevator deflection, according to an update issued by the U.S. National Transportation Safety Board Tuesday.

The report said data obtained from the aircraft's flight data recorder (FDR) and cockpit voice recorder (CVR) indicate Houston Approach control advised the crew of precipitation along their flight path as the aircraft descended normally through 12,000 feet mean sea level (msl) at a ground speed of 290 knots on the LINKK ONE arrival to the airport.

Following an ATC inquiry, the pilots asked to divert to the west around the weather. The controller responded that they "would need to descend to 3,000 feet expeditiously" to accommodate their request. ATC then instructed the crew to turn to 270 degrees heading while descending through 8,500 feet msl.

Approximately one minute later, controllers told the pilots to expect a northerly turn to a right base for Runway 26L after clearing the weather, which the pilots acknowledged with "sounds good" and "OK," according to the NTSB. At around the same time, the FDR recorded "small vertical accelerations consistent with the aircraft entering turbulence."

Shortly thereafter, as the aircraft flew between 6,200 to 6,300 feet msl, "the engines increased to maximum thrust, and the airplane pitch increased to about 4 degrees nose up and then rapidly pitched nose-down to about 49 degrees in response to nose-down elevator deflection," although the stick shaker did not activate.

The aircraft then entered a steep descent along the 270-degree heading, reaching approximately 430 knots airspeed. The board added that, based on FDR data, the aircraft pitched up to an approximately 20 degrees nose-down attitude shortly before impact.

The NTSB released no further communications from the flight crew and noted that it would issue a full transcript when the public docket opens. The flight crew appeared fully qualified and current in the Boeing 767, the Board added.

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FAA, United to inspect Boeing plane after engine incident

WASHINGTON, March 11 (Reuters) - United Airlines and the Federal Aviation Administration plan to inspect a Boeing 737-900 twin-engine jetliner that experienced an engine shutdown shortly before landing in Houston late on Sunday, the airline said on Monday.

Some passengers who were evacuated from the plane experienced minor injuries, airline spokeswoman Rachel Rivas said.

Flight 1168 from Newark, New Jersey, with 174 passengers and six crew aboard, experienced an engine shutdown shortly before landing around 10:30 p.m. CDT (0330 GMT on Monday), the FAA said. The agency said there was no evidence of fire or smoke from the engine. Boeing did not immediately comment.

"The FAA and the airline will be taking a closer look at the aircraft today," FAA spokesman Lynn Lunsford said.

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NTSB Head: Part 135 Needs Same Safety Tools as Airlines

NTSB Chairman Robert Sumwalt

NTSB Chairman Robert Sumwalt said the May 2017 crash of a Learjet makes the case that Part 135 operators need the same safety tools as the airlines have. (Photo: NTSB)
"If Part 135 aviation had the same tools as Part 121," including safety management systems (SMS), flight data monitoring (FDM), and crew resource management (CRM), "we might not be here today," NTSB chairman Robert Sumwalt said this morning during a board meeting on the May 15, 2017 fatal crash of a Learjet 35A during an approach to Teterboro Airport. "This accident might never have happened."

According to Sumwalt, "The pilots allowed the aircraft to stall, and they subsequently lost control of the aircraft as they were turning onto final approach while on a poorly flown circling approach." The airplane struck a building and a parking lot and was destroyed by impact forces and a post-crash fire, killing both pilots.

The accident occurred on a Part 91 positionNTSB Chairman Robert Sumwalt said the May 2017 crash of a Learjet makes the case that Part 135 operators need the same safety tools as the airlines flight operated by Part 135 operator Trans-Pacific Air Charter, but "raises important questions about what can be done to improve the safety of Part 135 operations," said Sumwalt. "This accident illustrates the potential safety benefits of applying knowledge gained in Part 121 investigations, and adapting solutions already introduced in Part 121 flight, to Part 135 operations."

Sumwalt said the accident also highlights the problem of procedural non-compliance. "The captain of the flight disregarded company policy and allowed the second-in-command to be the pilot flying," despite the latter not yet having enough experience necessary to operate the twinjet. In addition, he said, the pilot-in-command had not obtained the weather for the accident flight leg or conducted adequate preflight planning, nor did the pilots brief the approach during the flight.

"Furthermore, performance deficiencies that had been noted during the pilots' initial training, were not being monitored by the company for recurrence. Safety programs used by Part 121 operators might have detected such deficiencies," Sumwalt said. "Part 121 air carriers are required to have programs that ensure that performance deficiencies are corrected. To date, such programs are not required under Part 135."

He also cited lack of professionalism on the part of the crew. "Professionalism is a mindset that includes hallmarks such as precise checklist usage, precise callouts, and precise compliance with SOPs and regulations. Those traits were conspicuously absent on this flight."

In addition, Sumwalt highlighted the pilot-in-command's use of expletives as "just one symptom of a shocking lack of professionalism." In fact, the cockpit voice recorder transcript contained 131 hashtagged expletives in a half hour, which "averages to one expletive every 14 seconds," he said. "There are so many hashtags in this transcript, it reads like a social media feed."

A "far more problematic issue" was the flight crew's disregard for procedural compliance, noted Sumwalt. A previous NTSB study of more than 100 airline accidents "found that the highest-ranked accident prevention strategy was for pilots to follow standard operating procedures."

Operators need to detect whether their pilots are complying with SOPs, but Part 135 operations do not have all the tools they need to ensure procedural compliance. These tools include SMS, FDM, and CRM, Sumwalt said.

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Call for Papers - ISASI 2019


*** Deadline March 18th ***


Future Safety: has the past become irrelevant?



The Hague Marriott Hotel & World Forum The Hague

September 3 - 5, 2019


Suggested topics for presentations to support the theme may include:

  • Recent accidents/incidents investigations of particular interest.
  • Novel investigation techniques for aircraft, helicopter and drone accidents.
  • Human factors investigation methods, techniques and future developments.
  • Data investigation methods, techniques and future developments.
  • Airport investigation methods, techniques and future developments.
  • Investigator selection, training and future needs.
  • Lessons learned and potential future developments in recommendations.

Presentations must be in English and should be 25 minutes long. There will be an additional 5 minutes for questions at the end of each presentation.


If you who would like to submit an abstract, please download and use the ISASI 2019 abstract template, which can be found at:


Important dates:

March 18, 2019 - Last date for receipt of abstracts

May 8, 2019 - Presenters informed of acceptance

May 22, 2019 - The 2018 Seminar Technical Program will be published

July 9, 2019 - Last date for receipt of completed paper and PowerPoint presentations.


For questions related to the program: [email protected]

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Aviation Innovations Conference: Cargo Airships


March 14 - 15, 2019

Toronto, Canada


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