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Wing Clipping Incident Underscores Need For Cockpit Collision Alert

Based on the collision of an Air France A380 super-jumbo with a Comair regional jet on the evening of 11 April 2011 at New York’s JFK International Airport, this “Most Wanted” recommendation issued in 2000 by the National Transportation Safety Board (NTSB) will doubtless receive added impetus: “Give immediate warnings of probable collisions/incursions directly to flight crews in the cockpit.”

The recommendation to the Federal Aviation Administration (FAA) has been color-coded by the NTSB as red for “Open – Unacceptable Response.”

There are eight pages of fine print notes summarizing letters back-and-forth between the FAA and the NTSB since the recommendation was first issued. The last letter from the FAA, in 2009, indicated that a pilot project “will support development of requirements and an acquisition strategy …” etc. etc. The FAA response was neither timely nor promising.

It may be useful to compare the aviation industry to the automobile industry. During the past decade, automobile manufacturers have developed collision-avoidance cruise control and hands-free parallel parking. Both applications involve the detection of obstacles (e.g. cars and curbs).

The FAA, in concert with industry, is developing the Next Generation (NextGen) air traffic control system. Built around ADS-B (Automatic Dependent Surveillance – Broadcast), airplanes will broadcast their positions to air traffic control. This is known as ADS-B Out. A complementary application, called ADS-B In, would broadcast information into the cockpit. Under ADS-B In, the two aircraft involved in the collision at JFK would have been broadcasting their location to one another, providing the essence of a collision avoidance system. Under the initial concept of NextGen, ADS-B Out will be featured but not ADS-B In.

As the essence of collision avoidance the NTSB seeks, ADS-B In remains a distant dream. Application of automobile collision avoidance to taxiing aircraft as a “good enough” solution has not been even considered.

The NTSB justifiably concluded in 2009:

“This recommendation is now 9 years old, and it has been on the Most Wanted list almost since the recommendation was issued … technologies have not yet been finalized nor scheduled for deployment ….”


There has been no update since. Now the NTSB is investigating the incident at JFK and will doubtless take the opportunity to reiterate its stalled safety recommendation.

Back at the gate after colliding with the regional jet

Back at the gate after colliding with the regional jet. Photo Attribution: © Antoine FLEURY-GOBERT / Wikimedia Commons / CC-BY-SA-3.0

The Air France A380 was taxiing from the boarding gate to the runway for a flight to Paris. A Comair CRJ700 operating as Delta Connection was pulling into its gate, but had halted, waiting for ramp personnel to marshal the small commuter jet the final few yards into the gate. The CRJ700 had arrived from Boston.

The huge Air France A380, its 262-foot wingspan overhanging the 75-foot taxiway, struck the much smaller CRJ700. The impact spun the CRJ a full 90 degrees, just missing a person on the ramp who was walking out to escort the small jet to the gate. In a video of the collision, the ramp person can be seen jumping back as the CRJ700 rotated violently approximately 90 degrees. The 62 passengers aboard received quite a scare.

Grainy photograph showing the CRJ700 being spun 90 degrees

Grainy photograph showing the CRJ700 being spun 90 degrees

A pilot aboard the CRJ700 radioed the tower: “Roll emergency trucks. We’ve been hit by – uh – Air France.”

The larger jet halted after being seemingly unaffected by the collision. However, the left wingtip of the A380 was damaged and the jet returned to the terminal to offload its 520 passengers and await repairs. The CRJ700 had been struck on the vertical fin, which also required repair.

Damage to the A380

Damage to the A380

Damage to the CRJ700

Damage to the CRJ700

The A380 is equipped with a closed-circuit television system (CCTV), which apparently was of little use in alerting the pilots to the presence of the CRJ700. The CCTV features a panoramic camera mounted high in the tail and four additional cameras mounted below the fuselage to track the landing gear. The system is intended to help prevent the landing gear from rolling off the taxiway when the A380 is making wide, off-center turns. Since the A380 was engaged in straight line taxiing at the time of the incident, the pilots may not have been looking at the video feeds.

With a restricted field of view from the A380 cockpit, preventing the pilot from viewing the wing clearly past the outer engines, the pilot taxiing the A380 clearly did not see the much smaller and closer-to-the-ground CRJ700.

One pilot remarked:

“With the large aircraft, it really does not matter if you are on the center line of those taxiways – their width at JFK is 75 feet. The A380 has a 260-foot wingspan. To me that means the pilots have to be extra careful to ensure wingtip clearance.”

The role played by the tower controllers will most definitely be examined by NTSB investigators. Additionally, if the A380 was on the center line of the taxiway, what was the responsibility of the Comair pilots on the ramp to ensure proper clearance?

In automobile terms, who had the right-of-way?

JFK and other airports serving the A380 have had taxiway turns modified to allow the landing gear to negotiate the wider radius without departing the paved surface. Terminal gate areas must meet a box 262 feet on each side, or template, to ensure adequate clearance from structures.

Had the NTSB’s 2000 recommendation been adopted by the FAA, the A380 cockpit would have featured a warning of the threat that likely would have enabled the pilots to take action and prevent the collision.

Skin Rupture Explodes Myth That Safety Is Under Control

Up on the top of the fuselage, tiny hairline cracks were creeping between the rivets; suddenly, the cracks connected and a 5-foot section blew open with the sound of a thunderclap as air in the fuselage rushed out. The emergency oxygen masks dropped down to the startled and frightened passengers.

swa 5

The manner in which the cracks suddenly connected together, growing a quarter-inch or more in fractions of a second, is known in engineering parlance as the “fast fracture” phenomenon. It has been seen before, notably in an Aloha Airlines B737 in 1988, when cracks, observed outside the fuselage by passengers while boarding, connected and caused complete loss of structural integrity. The walls and roof of a section of fuselage ripped off. Stewardess Clarabelle Lansing, serving passengers at the time, was sucked out of the airplane. Her body was never found.

From a made-for-TV movie, the Aloha Airlines accident.

From a made-for-TV movie, the Aloha Airlines accident.

In the case of Southwest Airlines flight 812 on 1 April 2011, while the flight attendants were taking drink orders, the fuselage of the 15-year old B737-300 ripped open at a lap joint where fuselage panels are held together by three rows of rivets. Fortunately, no one was ejected from the airplane. Emergency oxygen masks dropped from their overhead compartments and the pilot began a rapid descent from 34,000 feet to a lower altitude where the ambient air is dense enough to sustain life. The 118 people aboard scrambled to don the masks. One passenger said, “People were dropping” (fainting). At the cruising altitude of 34,000 feet, the so-called “time of useful consciousness” is on the order of 10-20 seconds, so one does not have much time to fiddle with the unfamiliar oxygen mask.

It is not known if the emergency oxygen had been de-activated in the lavatories, or if anyone was in the lavatory at the time pressurization was lost. The airlines had until 4 April 2011 to remove or exhaust the lavatory oxygen canisters. (See Aviation Safety Journal, “ ‘Huge Favor’ to Airlines Ordering Emergency Oxygen Removed From Lavatories”)

The airplane made an emergency landing at Yuma, AZ, and passengers clapped and cheered when the captain emerged from the cockpit.

The accident aircraft in better times.

The accident aircraft in better times.

The Aloha accident set in motion the Federal Aviation Administration’s (FAA) supplementary structural inspection program (SSIP) for older jets. They were to be inspected for signs of fuselage skin cracking and patched up. Jet transports that had accumulated 75% of their design life were subject to the SSIP requirements, which meant more than 75,000 flights. This particular Southwest jet was well short of that threshold, which would have required about 20 years of hard airline service.

The SSIP clearly did not work – and did not apply – to Southwest Airlines flight 812. Investigators with the National Transportation Safety Board (NTSB) pored over the plane, using various eddy-current and other instruments to chart the extent of cracking.

Robert Sumwalt, NTSB Member on scene, said there was evidence of extensive cracking in the area of the rupture. A 9-foot section of the fuselage, covering the area of the rupture, was removed from the airplane on 3 April 2011 and sent to NTSB headquarters for detailed analysis. The rupture occurred in a different area than on the Aloha B737 but involved the same joint design: three rows of rivets, each row about ¾ inch from the next, and the rivets along each row about the same distance of ¾-inch apart from one another. As in the case of the Aloha B737, the failure began in the lowest row of rivets, where the stresses are highest. In this case, crack stopper straps halted the failure at the rib-stringer intersection.

NTSB investigators also conducted inspections of other portions of the lap joint along the fuselage and found evidence of additional cracks.

Southwest Airlines cancelled 600 flights to inspect its remaining B737-300 aircraft. There are 288 B737-300s in U.S. registry, of which 79 are operated by Southwest. As of this writing, 21 have been inspected and three of the planes were found with small, subsurface cracks.

“What we saw with Flight 812 was a new and unknown issue,” said Mike Van de Ven, Southwest’s executive vice president and chief operating officer.

The “fast fracture” phenomenon is hardly “new and unknown” for older aircraft with highcycles. By high cycles is meant take-offs and landings; during each flight the fuselage is inflated like a balloon, and the flexing is akin to the repeated bending of a paper clip until it breaks. The lap joint features three rows of rivets to contain the stress, but periodic inspection for signs of cracking is essential.

The airplane underwent overhaul in March 2010. During this so-called D-check, the cabin seats, sidewalls and other appurtenances were removed to facilitate inspection of the aluminum structure for cracking. The records of that D-check will be closely scrutinized by the NTSB, as the cracking found on the accident airplane was clearly extensive enough to predate that overhaul of a year ago. Were cracks discovered? Were they repaired?

According to the dictates of the SSIP, crack growth is slow enough such that they can be missed entirely during one teardown – as long as crack growth is detected and rectified at the next overhaul. These D-checks occur at approximately four year intervals. If the cracks were detected during the last D-check for the Southwest B737-300 but not corrected, were Southwest maintainers seduced by optimistic predictions of crack growth? If the airplane was stripped to bare metal and the cracks were not discovered, why not?

If only visual inspections were conducted – as opposed to more advanced non-destructive testing (NDT) techniques – it is possible but not plausible that cracking was not detected. Of interest, NTSB investigators employed NDT on the aircraft on the ground at Yuma and immediately concluded that widespread fatigue cracking was present. Under the controlled conditions of an overhaul, Southwest technicians should have been able to detect the cracking.

Southwest’s maintenance has been under a cloud before. In March 2008 the Federal Aviation Administration (FAA) proposed a fine of $10.2 million against Southwest for operating 59,000 flights with airplanes out of compliance with a structural airworthiness directive (AD).

On 3 April 2008 the House Transportation and Infrastructure Committee held hearings on the alleged “cozy relationship” between Southwest Airlines and other carriers with the FAA. Then committee chairman Rep. James Oberstar (D-MN) complained to top Southwest executives at the hearing, “Southwest Airlines allowed 117 planes to fly without AD compliance … the most egregious lapse of safety that I’ve seen in 23 years.”

Despite Oberstar’s concern, in March 2009 the FAA announced that the $10.2 million fine had been reduced to $7.5 million on condition that Southwest would rewrite all its maintenance manuals.

On a per flight basis, the FAA originally proposed a penalty of $172.00 for each non-compliant flight, negotiated down to $127.00 per flight – less than the price that a passenger pays for a ticket on the carrier. A token proposed penalty was reduced further based on Southwest meeting certain minor demands.

This penalty did not arrest the structural problems at Southwest. On 13 July 2009, the very next month after the reduced fine was announced, a Southwest B737-300 experienced a rupture in its ceiling, forcing an emergency landing. The NTSB removed the ruptured component and after due metallurgical analysis it was determined that the probable cause was “Fuselage skin failure due to preexisting fatigue at a chemically milled step.”

The piece from the 2009 rupture.

The piece from the 2009 rupture.

A chemically milled step is one where metal is removed during manufacturing to minimize aircraft weight.

Boeing issued a service bulletin (SB) covering inspection of the area where the rupture occurred (on the roof, near the tail) and the FAA published an AD making the inspection mandatory.

From 2009 through 2010 Southwest filed 6 Service Difficulty Reports (SDRs) with the FAA recounting depressurization events. Below is the one for July 2009 involving a B737-300 (the same model as this most recent pressurization emergency):

“Declared emergency/diversion. Pressurization event at 33,000 feet. Masks dropped, emergency descent … Found fuselage cracked between BS [body station] 827 to BS 847, STR [stringer]. Repaired skin per SWA [engineering order].”

On 28 December 2010 the FAA published AD 2010-25-06 concerning structural problems for early model B737s (including the -300 variant). The summary is instructive:

“This AD requires repetitive inspections for cracking of certain fuselage frames and stub beams, and corrective actions if necessary … This AD results from reports of the detection of fatigue cracks at certain frame section, in addition to stub beam cracking, caused by high flight cycle stresses from both pressurization and maneuver loads … This reduced structural integrity can increase the loading in the fuselage skin, which will accelerate skin crack growth and could result in rapid decompression of the fuselage.”

The inspections must be performed within 4,500 flight cycles, or within 9,000 cycles after the previous inspection. Southwest complained to the FAA that “the specified threshold will pose a significant burden [as] half of its model 737-300 and -500 fleet will require an out-of-sequence maintenance visit …”

At 4 flights per day, the 4,500 cycle threshold implies a 3-year time to accomplish the inspection.

Meanwhile, in an apparent effort to demonstrate it is on top of the situation, the FAA announced on 4 April that it will issue an emergency AD requiring structural inspections of older B737 using NDT. Randy Babbitt, head of the FAA, said, “This action is designed to detect cracking in a specific part of the aircraft that cannot be spotted with visual inspection.”

Why cracking on the top of the fuselage is not amenable to visual inspection was not explained.

From a B737-300 diagram, it appears that the skin panel which ruptured open begins around station 663 and continues past station 706 and ends before station 727. The rupture is close to, but not exactly correlated with, the location cited in AD 2010-25-06. There is a lap joint at that location. It was corrosion, a substandard repair, scribing or a similar scrape in the surface of the aluminum which cracked from pressurization cycles.

As one aviation industry insider remarked: “I would like to hang anybody I see scraping lap joints with metallic or non-approved scrapers.”

This observation is not presented to suggest that such practice was condoned at Southwest Airlines. Rather, it illustrates the sensitivity of the metal skin to unauthorized abuse when flight cycles are measured in the thousands.

Given the extreme danger presented by even a scribe line, allowing 4,500 flights – much less 9,000 – seems overly generous. Whatever “significant burden” imposed on Southwest, that mandate seems lax in the extreme. Consider the ongoing out-of-sequence inspections, the 600 cancelled flights (at least), the likely lawsuits from the passengers aboard Flight 812, and the cancelled bookings from a frightened public, not to mention the loss of confidence in FAA oversight, then the “cost” of this incident progresses to erosion of confidence in the safety of air travel. This lost confidence is not simply restored by quickly fixing this particular problem.

Deadline Looms for Arrestor Beds

With such a bona fide success record, you would think deployment would be accelerated.

I am referring to the Engineered Materials Arresting System (EMAS), which employs specially configured concrete that slows aircraft that have overrun the runway. EMAS has been credited with seven “saves” since 1999, the most recent of which occurred 1 October 2010 at Teterboro, NJ. A Gulfstream G-IV business jet ran off the end of the runway and into the arrestor bed. The EMAS, as designed, crushed under the weight of the aircraft, providing a predictable, controlled deceleration. The Gulfstream was stopped before it could break though the airport perimeter and hurdle across Route 46, a busy highway.

Runaway corporate G-IV halted by an arrestor bed.

Runaway corporate G-IV halted by an arrestor bed.

In this fortuitous case, no one was hurt and the aircraft suffered only minor damage – mainly needing a new set of tires.

In February 2005, an overrun at Teterboro had a less happy outcome. A Canadair CL-600 corporate jet attempted take off with its center of gravity well forward of allowable limits. The airplane did not get off the ground. It crashed through the perimeter fence, crossed Highway 46 and plowed into a warehouse. No one was killed. The 11 occupants of the aircraft all survived, but the badly damaged aircraft was written off. Two people in automobiles hit as the Canadair roared across the highway were injured.

Canadair jet lodged in a warehouse after overrunning the same runway in 2005.

Canadair jet lodged in a warehouse after overrunning the same runway in 2005.

After that accident, EMAS was installed in 2006 to prevent future overruns from bursting through the fence.

The light-colored area shows the installed EMAS at Teterboro. Note close proximity of the highway.

The light-colored area shows the installed EMAS at Teterboro. Note close proximity of the highway.

A witness said of the latest incident, “Just drove by and thankfully they installed those arrestors or it would have gone straight across Route 46 again.”

EMAS is produced by NJ-based ESCO-Zodiac Aerospace. The company’s Kevin Quan said:

“Both the airport and ESCO [Engineered Arresting Systems Corp.] – Zodiac Aerospace are thrilled about the aircraft arrestment from last Friday afternoon … This is our 7th successful save with the product. Both loss of lives and millions of dollars of aircraft damage have been avoided with the use of EMAS arrestor beds. Airports that have been proactive in installing arrestor beds such as Teterboro are now seeing the benefits of this technology.”

Six previous "saves" attributed to EMAS.

Six previous "saves" attributed to EMAS.

One could quibble with Quan’s enthusiastic use of the word “proactive.” The terrible 2005 accident spurred the 2006 installation that saved the plane and lives in 2010.

There is a disturbing pattern of the Federal Aviation Administration (FAA) freeing up money for airports to install EMAS after, not before, an accident. Following the fatal overrun of an American Airlines MD-82 twinjet at Little Rock, AR, EMAS was installed.

EMAS works by increasing the resistance of the aircraft tires to rolling. A concrete surface normally decreases rolling resistance through its hard surface. But EMAS consists of aerated cement blocks. Those blocks are designed to have the same effect on the airplane’s tires as gradually deepening snow would to a moving automobile. EMAS is configured for each runway, and is intended to stop a jet moving up to 70 knots (80 mph).

Close up of the crushable concrete.

Close up of the crushable concrete.

In the latest incident at Teterboro, the jet did not show obvious signs of structural damage, although its tires and landing gear struts were buried in the fractured concrete.

According to ESCO-Zodiac, “[A] Proprietary computer model predicts aircraft performance and design for the most effective solution for each runway end.” The company is the only one that presently produces an aircraft arresting system certified by the FAA for airport runway safety areas (RSAs).

Normally, an RSA consists of a grassy area, free of obstacles, extending 1,000 feet beyond the end of each runway and about 500 feet in width. But many airports were built before the 1,000-foot RSA length was promulgated by the FAA about 20 years ago. And airport locations are constrained by highways, railroads, severe drop-off of terrain – as at Little Rock – bodies of water, and populated areas (residential, office, industrial).

Where there is insufficient area for the 1,000 x 500 foot RSA, the EMAS arrestor bed can be installed. It normally extends up to 600 feet past the end of the runway, but the design is tailored for each location and for the heaviest types of aircraft anticipated to operate at the particular airport.

Under the FAA program of airport safety improvements, all runways must feature either the full 1,000-foot RSA or the EMAS arrestor bed by 2015. For some deficient runway RSAs, grading and planting will suffice if land is available and not too costly. Where this is not possible, EMAS is employed.

According to ESCO, as of October 2010, 55 EMAS configurations have been applied to runways at 37 airports worldwide (35 U.S. airports) since 1996. This works out to an average of about four installations yearly in the U.S. According to the FAA, about 80 EMAS installations remain to be completed during 2011-2014 to meet the deadline of projects completed by 1 January 2015.

emas installed

That works out to an installation rate of about 20 EMAS per year, or four times the annual rate of installations thus far.

It is doubtful the FAA will meet its goal.

The pity here is that the EMAS installation can easily be justified on cost-benefit grounds. Assume an EMAS installation price at Teterboro of $8 million. Now assume the statistical value of a life is approximately $3 million, and there were 9 passengers and crew aboard the G-IV that was stopped by EMAS. Assume $25 million for a used G-IV. Add together the cost of airplane and lives and compare to the price of an EMAS installation:

Benefit: $27 million lives saved + $25 million aircraft saved = $52 million

Cost: $8 million EMAS

Ratio of benefits to cost: 6.5 to 1

That’s one runway, one incident. The benefits nationwide clearly are in the hundreds of millions of costs avoided.

The FAA’s support of EMAS is laudable; at the same time, the agency’s definition of a “high priority” program does not square with the 2015 deadline. An accelerated limit of 2013 would be more in keeping with the FAA’s definition of the program’s importance.

Cessna 206 Medical Transport Plane Crashes in Lake Michigan

A single-engine light plane carrying a patient to the Mayo Clinic crashed into Lake Michigan on Friday, 27 July, raising concerns about the safety of general aviation. The airplane was flown by a private pilot who had volunteered to transport the patient from Alma to Rochester, MI. The airplane was not flown by an emergency medical services (EMS) company that specializes in transport/evacuation of patients. Rather, the airplane was owned by Freed Construction of Alma.

A rescue vessel receives a survivor of the crash from a small fishing boat.

A rescue vessel receives a survivor of the crash from a small fishing boat.

The Cessna 206 was regularly used on a volunteer basis to transport patients to the Mayo Clinic.

On board the aircraft was owner Jerry Freed and pilot Earl Davidson. Also on board were three other individuals, whose names are not known at this time.

The airplane crashed into the lake about 10 am off the shore of Ludington, a resort town on Michigan’s west coast. A small fishing boat rescued a survivor about two hours after the crash. At this point, the fate of the others is not known but they are presumed dead.

The airplane was equipped with an emergency locator transmitter (ELT), or radio beacon, that was activated on contact with the water. The ELT signal is detected by satellite and can be used to pinpoint the location of the wreckage.

The planned flight was some 150 miles one-way.

Pilot Davidson reported loss of engine power to an air traffic controller at Minneapolis about 10 minutes before the plane went down. The power problems apparently began about one-third of the way to Rochester; the airplane doubled back over Lake Michigan and then descended steeply near Ludington.

Coast Guard search and rescue operations are continuing.

The National Transportation Safety Board (NTSB) will be investigating the crash. Among the issue to be covered:

— The lack of cockpit voice and data recorders, and the absence of a cockpit video recorder, which would have at least captured the status of instruments, controls, and the pilot’s actions.

— The use of a Part 91 General Aviation airplane to transport the patient. Under Part 91, there are no standards regarding pilot flight and duty time, and maintenance records are also considerably less rigorous and detailed than for a Part 135 (air taxi) flight. Companies specializing in patient transport are required to transport patients under Part 135 regulations, which are considerably more demanding. Under Part 135, a risk assessment of the flight was necessary and flight following by a company dispatcher should have been routine. As a General Aviation operation, neither criteria was required.

— The use of a single engine piston transport for basically an overwater flight over a lake known for its cold water (and reduced survival time). In this case, the airplane could have flown to Benton Harbor, along the shore to Gary, and west up through Janesville, enroute to Rochester.

— The presence in the airplane of life preservers and rafts, and whether or not the preservers were donned (uninflated) before the airplane crossed into the overwater portion of its flight.

News reports of the crash involving a “medical transport plane” may give their readers the illusion that this was a formal EMS flight by a company specializing in that kind of operation. It wasn’t; it was a Part 91 operation in which the owner and pilot were performing a voluntary service for a non-paying patient.

The Part 91 accident rate is far higher than for Part 135 (air taxi) or Part 121 (scheduled airline) operations. Patients and their relatives and care givers may not be aware of the poor safety record of Part 91 operations.

Turbulence During United Flight 967 Injures Scores; After Years of Such Events, Why Do They Continue?

In the wake of the turbulence that struck United Airlines Flight 767, injuring passengers and flight attendants, the question arises: is the airline industry and is the Federal Aviation Administration (FAA) doing everything possible to prevent mayhem from convective winds? The answer: probably not.

The reason: injuries and even deaths continue to occur on a regular basis. The Tuesday, 20 July, turbulence encounter of the United B777 wide body twinjet was reportedly the third such event for the airline this year. But who knows? At least six such airline encounters have occurred worldwide this month; the annual incidence is obviously higher.

And clearly something is amiss in turbulence avoidance and injury mitigation policies, because frightening and even deadly encounters with potentially bone breaking turbulence continue to occur.

Commercial airplanes run into turbulence 5,000 times a year, according to one account. Most of the encounters are above 10,000 feet. Injury claims alone track into the tens of millions of dollars annually.

The National Transportation Safety Board (NTSB) will be investigating the event. The NTSB will reconstruct the weather at the time, the actions of air traffic controllers and the pilots. Although the NTSB is known more for investigating crashes, this turbulence encounter put people in the hospital; thus, the NTSB is empowered to investigate and make recommendations to ameliorate the hazard.

At this point, general outlines of the accident can be reconstructed. United flight 967 was en route from Dulles International Airport near Washington DC, bound Tuesday night for Los Angeles International Airport. There were 255 passengers and 10 crewmembers aboard. Over Kansas, directly in the path of the westbound jet, a rapidly forming severe thunderstorm was boiling upward. The storm climbed from about 25,000 feet to 45,000 feet in 30 minutes. It produced large hail, indicating the presence of severe turbulence. Updrafts of 50-100 mph are not uncommon.

Radar image of Kansas about the time that United flight 967 encountered severe turbulence.

Radar image of Kansas about the time that United flight 967 encountered severe turbulence.

The plane was flying at 34,000 feet, directly into a wall of convective turbulence. Flying into this wall, the airplane jumped. The rapid change in altitude, as in previous turbulence encounters, caused everything not secured by straps, locks, latches and whatnot to be hurled about the cabin. This includes people.

One passenger described the encounter as “just a huge up and down.” She said her seatbelt was tight; the woman sitting next to her hit her head on the side of the cabin, and a girl across the aisle flew into the air and hit the ceiling.

It is not known how many passengers were wearing their seat belts; the seatbelt sign was illuminated at the time. It is not known if the word had been passed from the cockpit to be seated with seatbelts latched because of impending turbulence..

Four flight attendants were injured. It is not known if they were standing at the time or were strapped into their jump seats. Flight attendant jump seats, unlike 16G passenger seats, are only 9G capable and they have collapsed in previous incidents, injuring flight attendants.

Passengers screamed as the airplane bounced in the turbulence. The uninjured flight attendants calmed everyone down fairly rapidly.

Because of the injuries, the captain elected to divert the flight to Denver for immediate medical attention of those individuals who were hurt. The airplane landed at 7:45 pm and the injured passengers and flight attendants, about 25 in all, were treated by paramedics at the scene and then transported to hospital. About 19 were released from hospital the following morning.

The airplane was inspected and found to be structurally sound. Unknown, however, is the condition of the cabin. In previous incidents, sidewall and ceiling panels have been displaced, and overhead bin doors have popped open, spilling their contents and contributing to injuries and the general sense of mayhem.

At Denver, a few of the braver passengers boarded another United flight for Los Angeles.

Given that records exist of the upwelling thunderstorms along the airplane’s route, a number of pertinent issues are sure to be explored by investigators:

— Did air traffic controllers see the convective activity on their scopes? If so, what did they tell the pilots? Additionally, controllers would be in receipt of Pilot Reports (PIREP) which should generate a SIGMET (significant meteorological activity) that’s broadcast to all aircraft in the area.

— What did the dispatcher at United operations center know about the evolving weather, and did he do anything?

— Did the pilots see the convective activity ahead on their weather radar? If so, did they attempt evasive action or continue on their flight path? Did they make a public address (PA) announcement about the turbulence ahead? Were flight attendants ordered to be seated, or were they caught by turbulence while checking passenger seat belts?

— What is the United Airlines policy to flight crews regarding convective weather activity? Is at a 10 mile avoidance policy? A greater distance? Or is there no policy at all at United? It is clear that policies run the gamut from one airline to another; a more uniform avoidance policy – established by the FAA – may make for predictability and safer travel throughout the industry.

— The vulnerability of the cabin to damage and disruption caused by in flight turbulence is unconscionable, given that these events have been occurring for years. Every seat should be stressed for 16G. Every person should be strapped in, including so-called “lap children.”

— Perhaps overhead bin doors with their flimsy latches should be redesigned, to include an electric lock activated from the cockpit on pushback to secure the bin doors until landing.

— The in-flight safety video could include two crash dummies subjected to severe turbulence while seated. One dummy could be strapped in; the other not. Passengers would see the risk of not having the seat belt affixed immediately.

— Northwest Airlines employs a Turbulence Plot System that is regarded as the gold standard for turbulence avoidance. Based on FAA data from 1980-1996, Northwest had the lowest turbulence encounter rate among six major U.S. commercial carriers. Other airlines have purchased the system, but not – according to a 2010 report – United.

The issue is not who voluntarily adapts a proven system, but whether or not the FAA has evaluated the Turbulence Plot System, found it effective, and mandated its adoption across the industry.

This latest event may have been caused by rising turbulent clouds over Kansas, but the long miasma of complacency at the FAA about cabin structure and turbulence avoidance are the root causes of continuing injury.

$6.25 Million Dollar Settlement Paid By Insurers For 57 Year Old

On July 13, 2010 Cook County Judge Donald J. Suriano approved a settlement in the amount of $6,250,000.00 for the benefit of Luis and Kathy Vasquez.  Luis Vasquez was a roofer for Knickerbocker Roofing and Paving Co. and suffered severe injuries on March 8, 2004 when he fell through a roof on the premises owned and operated by Metra known as the 51st Street Coach House. Mr. Vasquez fell straight through a concrete roofing tile some twenty feet to the concrete floor below. The general contractor for the entire project including the re-roof project was Defendant Walsh Construction Company. The roofing contractor, a sub contractor to Walsh, was Knickerbocker Roofing and Paving Company. CTE, Inc., a/k/a Consoer Townsend Environdyne and Cotter Consulting were also contractors.  Plaintiffs allege the Defendants were jointly responsible for inspection of the panels and that Defendant Walsh was responsible for safety on the job.

The $6.25M was paid by all Defendants to settle all claims.  Settlement includes waiver of the $560,000.00 workers’ compensation lien.

Luis and Kathy Vasquez are represented by Donald J. Nolan, Thomas P. Routh and Paul R. Borth, of Nolan Law Group in Chicago, Illinois.

Defendant Walsh Construction Company is represented by Thomas Boylan and Bradford Burton of Cassiday Schade, LLP in Chicago, Illinois.

Defendant Metra is represented by Michael McColl of Foran Glennon Palandech Ponzi & Rudloff, PC in Chicago, Illinois.

Defendant CTE, Inc. is represented by C. Steven Tomashefsky and Jean Gallo of Stein, Ray & Harris, LLP in Chicago, Illinois.

Defendant Cotter Consulting is represented by Bruce Lyon and Angie Grove of LaBarge, Campbell & Lyon in Chicago, Illinois.

Defendant Knickerbocker is represented by John Prusik of Prusik Selby Daley & Kezelis in Chicago, Illinois.

CASE NUMBER:        04 L 011387 Vasquez v. Walsh Construction Co., of Illinois et al.

JUDGE:                       The Honorable Donald J. Suriano

Settlement Amount:       $ 6,250,000.00

Nolan Law Group is a Chicago based personal injury law firm concentrating in aviation accidents, construction accidents, brain injury litigation, medical malpractice, premises liability, product liability, and trucking accidents.

Questions should be directed to Thomas P. Routh of Nolan Law Group at 312.630.4000

Alpine Texas Air Ambulance Crash the Latest in a Legacy of Unsafe Practices

The fatal crash of a medical evacuation airplane is certain to be investigated with an eye to unrequited recommendation to improve aerial ambulance operations.

Shortly after midnight on 4 July, in clear weather, an O’Hara Flying Service-operated twin-engine Cessna 421 aerial ambulance took off from Alpine-Casparis Municipal Airport, Texas, for a flight to Midland International Airport, Texas. The airplane was carrying patient Mary Folger, 73, who had broken her hip. She was accompanied by her husband, Guy Folger 78. Two flight nurses were aboard, Sharon Falkener and Tracy Chambers. Piloting the aircraft was Ted Caffarel, 59.

Crash scene at Alpine, Texas, of an O’Hara Flying Service air ambulance, killing all 5 aboard.

Crash scene at Alpine, Texas, of an O’Hara Flying Service air ambulance, killing all 5 aboard.

After an uneventful takeoff, the airplane experienced some sort of problem, perhaps engine related, and Caffarel was attempting a return to the departure airfield. About a mile short of the runway, a main landing gear wheel hit a rut in an open, muddy field. The airplane overturned at least once and burst into flames. There were no survivors.

In May 2009, another O’Hara Flying Service aircraft, also a Cessna 421, was substantially damaged during a forced landing following the loss of engine power shortly after takeoff near Alpine. The pilot was the sole occupant of this positioning flight and received minor injuries in the incident. It is not known if this earlier event involved the same Cessna 421 or one of its engines.

Between December 2007 and February 2010 a total of 41 patients and flight crew have been killed in EMS fixed-wing and helicopter accidents. Generally, EMS flight safety is about 30 times lower than it is for commercial airline operations.

The National Transportation Safety Board (NTSB) will be investigating this accident. The NTSB has a long record of concern about the safety of Emergency Medical Service (EMS) flights. A special investigation report was produced in 2006 that examined about 40 EMS accidents. In 2008 helicopter EMS accidents hit an all-time high, with 29 fatalities, prompting the NTSB to hold a public hearing on HEMS safety in February 2009. In addition to the four safety recommendations issued as part of the 2006 study, the 2009 forum produced an additional, and whopping, 21 recommendations. None have been fully implemented.

In February of this year, the NTSB increased the pressure to act on the Federal Aviation Administration (FAA) by adding the improved safety of EMS flights to its “Most Wanted” list of still-to-be-enacted improvements. On that “Most Wanted” list was the recommendation to install Terrain Awareness Warning Systems (TAWS) on all EMS flying machines. A technical standard order (TSO) was released by the FAA for TAWS in December 2008, but the FAA has yet to take action requiring such a system to be installed on EMS aircraft and helicopters. The NTSB has characterized its moribund TAWS recommendation as “Open – Unacceptable Response.”

It is not known at this time if O’Hara Flying Service voluntarily installed TAWS on its EMS air ambulances. Since there was no FAA requirement to do so, there is reasonable suspicion that the accident airplane was not equipped with TAWS.

TAWS might have prevented this night time crash. TAWS may have alerted the pilot to his low altitude, preventing the premature contact with the ground as pilot Caffarel was returning to the runway.

The NTSB investigation will doubtless discuss the legacy of FAA-ignored recommendations as part of its investigation of this accident.

Of interest, the NTSB has never recommended two pilots in the cockpit. Single pilots like Caffarel frequently rely on a flight nurse in the co-pilot’s seat to manage part of the radio communications and to maintain a look out the cockpit for other aircraft or terrain.

In Canada, which has not suffered a single fatal EMS accident, two-pilot operation is required. Helicopter crash law firms can come into play in these types of incidents.

No commercial airline flights would be undertaken by a single pilot. Yet here is an EMS flight, with passengers, being flown by one pilot, who had an emergency such that he was attempting to return to the departure airfield.

Any number of NTSB reports on EMS accidents have served to justify its recommendation for TAWS, but TAWS is best employed with two pilots. TAWS alerts require one pilot to be looking out the windscreen while the other pilot tracks the dangerous rising terrain on the cockpit display.

And if he had an engine problem, Caffarel could certainly have used a co-pilot to manage the overall situation. With the resources of two pilots’ trouble shooting, and TAWS to avoid premature ground contact, the fiery crash just may have been avoided.

$500 Million Jury Verdict Leveled Against Teva Pharmaceutical Industries and Baxter International in Propofol Lawsuit

A District Court jury in Clark County Nevada ordered Teva Pharmaceutical Industries and Baxter to pay a combined $500 million in punitive damages to a plaintiff  who contracted Hepatitis C during an endoscopy procedure after vials of the drug Propofol were allegedly reused on him. The verdict comes on top of the $5.1 million in compensatory damages awarded to the plaintiff and his wife.

Attorneys for the plaintiffs originally offered to settle the case for $1.7 million but the offer was rejected by the defendants.

The bulk of the verdict was against Teva Pharmaceutical who was ordered to pay $356 million in punitive damages, while Baxter International was ordered to pay only $144 million (Teva manufactures Propofol and Baxter distributes Propofol).  

The lawsuit claimed that the plaintiff contracted Hepatitis C as a direct result of product misuse related to unsafe clinical practices from reuse of 50 mL vials of propofol.

Propofol is a short-acting, intravenously administered hypnotic agent often used during the induction and maintenance of general anesthesia. It is also commonly used as sedation for mechanically ventilated adults, and for procedural sedation during colonoscopy and endoscopy.

According to attorneysfor the plaintiff, the 50 mL Propofol vials manufactured and distributed by Teva and Baxter were packaged with inadequate warnings against re-using or “double-dipping’ for more then one patient.  Nurses were alleged to have administited multiple doses of the drug one patient, then used the remaining amounts of the 50 mL vial on other patients. The plaintiffs said  that Teva and Baxter knowingly manufactured and distributed 50 ML vials of propofol to these endoscopy centers, fully aware that only 10 ML vials were needed. The plaintiffs also maintained that this encouraged multi-dosing.

At least nine and possibly as many as 114 other patients were infected with the Hepatitis C during a 2008 outbreak. Additionally fifty thousand other patients were notified that they might be infected.

Teva Pharmaceutical Industries Ltd. is a global pharmaceutical company specializing in the development, production and marketing of generic and proprietary branded pharmaceuticals and active pharmaceutical ingredients. Teva is among the top 15 pharmaceutical companies and among the largest generic pharmaceutical companies in the world.  The Company enjoys a firmly established international presence, operating through a carefully tailored network of worldwide subsidiaries. Headquartered in Israel, above 80% of Teva’s sales, which totaled US$13.9 billion in 2009, are in North America and Europe. Teva has over 35,000 employees worldwide and production facilities in Israel, North America, Europe and Latin America.

Baxter International is valued at more than $26 billion and netted $2.2 billion in 2009.

Teva and the drug Propofol were also the subject of a recent recall. On Dec 10, 2009 the FDA warned Teva Pharmaceutical of “significant” manufacturing violations in their California manufacturing facility that makes Propofol. Inspectors found that Teva had not screened every lot of their raw materials for bacterial endotoxins. 

The FDA had previously issued an alert in June of 2007 regarding reports of clusters of patients who have experienced chills, fever, and body aches shortly after receiving propofol for sedation or general anesthesia.

Teva voluntarily recalled two lots of Propofol Injectable Emulsion 10 mg/mL 100 mL vials on 7/17/2009 due to presence of elevated endotoxins. Customers were instructed to cease using the product and return it to their distributor. A shortage of Propofol followed the 2009 recall.

Untreated Crohn’s Disease Blamed for Child’s Death: Jury awards Plaintiffs estate 1.7 Million in damages

A Cook County jury returned a verdict in excess of $1.7 million in favor of the Estate of a 10-year-old girl who died in the early morning hours of November 13, 2002, just five days after seeing a local pediatrician at Advocate Health Centers, Inc., with complaints of periodic rectal bleeding for about one year, abdominal pain, vomiting, fatigue, and a bloody watery bowel movement that day.

The 10-year-old girl had been complaining of loose stools, vomiting, streaks of blood with nearly every bowel movement for the last year, and periodic abdominal pain. On November 8, 2002, after having a bloody, watery bowel movement, her mother called the pediatrician and rushed her to their office at the Advocate Health Center in Hyde Park to discuss what she believed were serious symptoms with the doctor. The pediatrician noted all of these symptoms in his chart in addition to noting that the child had an unexpected weight loss of thirteen pounds over the last few months. The pediatrician ordered blood studies and a stool culture and sent the child home with instructions to drink clear liquids.

A few days later, the lab tests were reviewed by the pediatrician and he diagnosed the child with mononucleosis. He confirmed this diagnosis in his chart as well as in a telephone message left for the child’s mother. In the meantime, however, in the early morning hours of November 13, 2002, the child collapsed. She was rushed to Trinity Hospital and transferred to Hope Children’s Hospital where notations were made that she had a gastrointestinal bleed and had blood coming from her rectum. Efforts to resuscitate her failed and she died in the hospital soon thereafter. The Cook County Medical Examiner reported the cause of death to be a massive gastrointestinal hemorrhage due to an inflammatory bowel disease known specifically as Crohn’s Disease.

At trial, the attorney for the Estate, Paul R. Borth of Nolan Law Group, presented evidence that, at the time of her single office visit with the local pediatrician, the child presented with the classic signs and symptoms of inflammatory bowel disease and the pediatrician should have referred the child to a pediatric gastroenterologist or admitted her to the hospital for diagnosis and treatment. Stephanie L. Stalter of Nolan Law Group also represented the Estate at trial.

“The pediatrician knew he could not diagnose or treat inflammatory bowel disease, so he should have sent the child to a specialist who could. This child could have survived if she had been referred to a pediatric gastroenterologist for prompt evaluation and treatment,” Mr. Borth stated.

The defense denied liability at trial and argued that referral to a gastrointestinal specialist or admittance to the hospital was unwarranted and that the blood tests and stool culture ordered by the pediatrician were the appropriate first steps in forming a plan for this child’s care. Defense experts, including a world renowned pediatric gastroenterologist from the University of Chicago who has been practicing in the field for over thirty years, and a professor of gastrointestinal pathology from the University of Chicago, opined that they had never seen a death from a gastrointestinal hemorrhage due to Crohn’s Disease, none had been reported in medical literature, and the autopsy results and independent review of pathology slides failed to demonstrate any signs of inflammatory bowel disease or Crohn’s Disease.

The defense and its experts argued instead that the child died from an acute bacterial stomach infection which came on sometime after the child’s November 8 visit with the pediatrician but before her demise on November 13. The defense called the Chief of the Division of Infectious Disease at Children’s Memorial Hospital who testified that this infection killed her within 24-36 hours and there was no indication that inflammatory bowel disease had anything to do with the child’s untimely demise. James W. Kopriva and Trisha K. Tesmer from Cassiday Schade, LLP, represented the local pediatrician and Advocate Health Centers, Inc.

The plaintiff contended that the child’s symptoms were the classic symptoms of inflammatory bowel disease, as admitted by the defense experts. “This case was won by obtaining concessions from the defendants’ experts,” said Mr. Borth. “No one could deny that this child presented to the pediatrician with these classic signs and symptoms of inflammatory bowel disease at that November 8 visit. The question for the jury was whether that single visit to the pediatrician was enough to prompt a referral to a gastrointestinal specialist and whether some intervening infection was the cause of this catastrophe.”
On February 26, 2010, the jury awarded $1,706.125.48 to the Estate of the child for loss of society, and medical and funeral expenses. The jury reportedly found the local pediatrician negligent for failure to refer the child to a pediatric gastroenterologist on November 8, 2002.

The Honorable James P. Flannery, Jr., presided over the trial. No. 06 L 7302.

Two Dead In Royal Air Freight Plane Crash Near Chicago Executive Airport

WHEELING, Illinois – A Learjet on final approach to the Chicago Executive Airport in northwest suburban Wheeling crashed into the Des Plaines River Tuesday January 5th killing both the pilot and co-pilot.

The small cargo plane was registered to Michigan-based Royal Air Cargo and was empty at the time of the accident. The flight left Waterford, Michigan around 1: 00 p.m. and had been hired to pick up a load in Wheeling, Illinois later that afternoon.

Emergency personnel arrived on the scene shortly after the accident and had to travel on-foot to reach the wreckage, which was submerged in about four feet of water. Authorities from several neighboring communities — Wheeling, Mount Prospect and others — sent crews to the scene of the crash. Members of the National Transportation Safety Board arrived around 4 p.m. and said the investigation would begin Wednesday morning.

Royal Air is a family run business which owns and operates both passenger aircraft and cargo planes. They have approximately two dozen aircraft and are no stranger to regulatory scrutiny, accidents and operational violations. In 1999, a Royal Air aircraft was involved in a crash in Pittsfield, Mass., which has some similarities to Tuesday’s accident. On March 25, 1999, a Royal Air plane plummeted almost 12,000 feet in less than a minute before hitting the ground. In both accidents there were sudden losses of communication just before the planes crashed. Pilot Brian Templeton, of Waterford, Mich., was killed in the 1999 accident.

A lawsuit related to the 1999 accident accident was filed by Nolan Law Group on behalf of the family of pilot Brian Templeton. According to the lawsuit, Royal Air Freight.was negligent in performing maintenance on the aircraft, autopilot and de-icing system and in supplying information to support an alternate means of compliance for an MU-2 Airworthiness Directive. Other Defendants include Mitsubishi Heavy Industries, Honeywell and Mid-Continent Instruments.

Royal Air was also sued by federal authorities in 1999 for cutting corners on engine maintenance and inspections. Violations listed in the lawsuit included failure to conduct scheduled inspections of engines, propellers and wing flaps and failure to produce maintenance records. The company ultimately agreed to pay $250,000 in fines for maintenance and record-keeping violations as part of an agreement with the U.S. attorney for the Eastern District of Michigan. Less than a year later, the FAA proposed $60,000 in additional fines against Royal Air for allegedly failing to investigate the backgrounds of 13 newly hired pilots.

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