MK Airlines blames others for fatal crash
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Can of worms
This case could indeed make it interesting for moe than a few airports world wide.
Not to pick on Canadian airports but the Air France incident in YYZ comes to mind. Same argument could be applied too the irrigation ditch.
How about the dykes we skim over at various airports VHHH, KLAX, CYVR etc. ? Or the hangars and terminal buildings between runways ?
While on the face of it, this law suite seems frivilous and an attempt to transfer the blame, I think that I would like as much going for me (as aircrew) as possible. I do agree that this law suit may have some large impacts.....
FG
Not to pick on Canadian airports but the Air France incident in YYZ comes to mind. Same argument could be applied too the irrigation ditch.
How about the dykes we skim over at various airports VHHH, KLAX, CYVR etc. ? Or the hangars and terminal buildings between runways ?
While on the face of it, this law suite seems frivilous and an attempt to transfer the blame, I think that I would like as much going for me (as aircrew) as possible. I do agree that this law suit may have some large impacts.....
FG
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The TSB's report on the accident indicated that the antenna was placed on a berm to bring it in line with ICAO requirements. Furthermore, the antenna was far enough down the extended centerline that the entire assembly was below the obstacle free zone.
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No, they meant 239,000kg - but this was the 747's take-off weight.
More importantly, it was actually the take-off weight at the aircraft's previous stopping point, Bradley, Connecticut.
Its take-off weight at Halifax was about 50% more, but the crew unwittingly used the previous weight data at Bradley to calculate take-off performance requirements for Halifax. The rest is history.
More importantly, it was actually the take-off weight at the aircraft's previous stopping point, Bradley, Connecticut.
Its take-off weight at Halifax was about 50% more, but the crew unwittingly used the previous weight data at Bradley to calculate take-off performance requirements for Halifax. The rest is history.
Prof. Airport Engineer
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The TSB report is very informative, and a good read. Thanks Phil Space for the link. Two questions come to mind.
1. Should the Boeing BLT be changed? The software has a feature that keeps the previous data/calculations loaded and displayed until it is "re-calculated". The TSB report discusses this at section 2.6:
.
I've had this feature appear in other software developed for me; in my case using Visual Basic and an Access database. It allowed similar errors to occur if one was not properly trained – or if one was tired and didn’t recall this exact part of the training. Annoying, but this software was not used in a risky application. However the BLT is.
The Oct 1 issue of Avionics magazine discussed the BLT in an article and made the comment
. There are probably other ways it can be done, and my thought is that the software should be made more 'fail-safe' in the sense of 'tired user-safe'..
2 Where is the oversight by Transport Canada of the Canadian freight forwarders?. Everyone's suspicion that the cargo weight was greater than assumed was not laid to rest in the TSB report. The issue was dealt with briefly in section 2.3, and with phrases like "unverified cargo weight" in the report, it is a matter that perhaps cannot be fully answered for this flight.
But have TC got a process in place for oversight of cargo weights (or any aviation authority)? It is easy enough to do, and is routine enough in other industries to check weights by audit. Needs a bit of effort and causes dirty hands though, so it not popular with office-bound types. Bring a set of scales around to the airport (it shouldn't have to be said that this should be done unannounced) and check weigh pallets. It may be expeditious to sometimes check-weigh them upon arrival. If the deviation between reported and actual weight are too high, or are always on the one side, the corrective process is easy enough to initiate.
1. Should the Boeing BLT be changed? The software has a feature that keeps the previous data/calculations loaded and displayed until it is "re-calculated". The TSB report discusses this at section 2.6:
Anytime after that, if the user opened the weight and balance page, for whatever reason, and returned to the take-off performance page, the planned weight dialogue box would be populated with the take-off weight from the weight and balance page, that is Bradley (240 000 kg). If the user did not know about this feature or did not notice the change and selected "calculate," the V speeds and EPR setting would have been identical to those for take-off from Bradley (see Figure 6).
I've had this feature appear in other software developed for me; in my case using Visual Basic and an Access database. It allowed similar errors to occur if one was not properly trained – or if one was tired and didn’t recall this exact part of the training. Annoying, but this software was not used in a risky application. However the BLT is.
The Oct 1 issue of Avionics magazine discussed the BLT in an article and made the comment
.The solution would be to amend the software so that a mandatory or willful importation of a figure from the W&B module would be required. For example, a pop-up message instructing crew members to "Click box to import W&B module data," or "Leave box unchecked to enter your own verified all-up-weight figure and center-of-gravity."
2 Where is the oversight by Transport Canada of the Canadian freight forwarders?. Everyone's suspicion that the cargo weight was greater than assumed was not laid to rest in the TSB report. The issue was dealt with briefly in section 2.3, and with phrases like "unverified cargo weight" in the report, it is a matter that perhaps cannot be fully answered for this flight.
But have TC got a process in place for oversight of cargo weights (or any aviation authority)? It is easy enough to do, and is routine enough in other industries to check weights by audit. Needs a bit of effort and causes dirty hands though, so it not popular with office-bound types. Bring a set of scales around to the airport (it shouldn't have to be said that this should be done unannounced) and check weigh pallets. It may be expeditious to sometimes check-weigh them upon arrival. If the deviation between reported and actual weight are too high, or are always on the one side, the corrective process is easy enough to initiate.
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Not sure if this question should be here but this thread promted it. I only fly piston engined aircraft and so the take off run at anything less than full power is quite alien to me. Why, please, are turbine engined a/c not set to full power for take off (except for noise abatement)? If set for noise abatement what is the criteria for the setting?
Wunderbra
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WH, as Silver hawk stated the "rated" takeoff is carried out to reduce wear and tear on the engines, and also to reduce fuel consumption. The calculations are carried out using the information available regarding obstacles in the "obstacle accountability area" along the extended runway.
It is more than a little worrying that ALL pallets are not weighed. How much time/effort would it take to have a set of scales that the pallets are placed on at some point prior to loading and the weight recorded? That way you would know exactly the weight on board for M & B calcs, and from their positions you could work out the C of G.
Any reason why this isn't done?
Surely it would be economically viable even if it saved just one hull loss? How many hull losses have been attributable to incorrect masses being used?
It is more than a little worrying that ALL pallets are not weighed. How much time/effort would it take to have a set of scales that the pallets are placed on at some point prior to loading and the weight recorded? That way you would know exactly the weight on board for M & B calcs, and from their positions you could work out the C of G.
Any reason why this isn't done?
Surely it would be economically viable even if it saved just one hull loss? How many hull losses have been attributable to incorrect masses being used?
Mistrust in Management
Matt_hooks stated: "and also to reduce fuel consumption".
Actually I don't believe this is the case because reduced take-off power inevitably increases the time to reach optimum cruise altitude. (Because the time from wheels off to acceleration altitude is increased)
However the increase in engine life considerably outweighs the additional cost in fuel.
If I am wrong then I would very much like to know.
Kind regards
Exeng
Actually I don't believe this is the case because reduced take-off power inevitably increases the time to reach optimum cruise altitude. (Because the time from wheels off to acceleration altitude is increased)
However the increase in engine life considerably outweighs the additional cost in fuel.
If I am wrong then I would very much like to know.
Kind regards
Exeng
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Thank you for the explanations. Without commenting on this particular case, at MAUW what power setting might be used and what would be the difference in T/O run distance required between that and max power? As I said earlier (I'm sure you will all remember) it is so alien to piston engined pilots to use anything less than full throttle for t/o that I am just intrigued.
Thanks
Thanks
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This makes interesting reading:
http://www.dft.gov.uk/stellent/group...foi_037744.pdf
10/05/05
Dear XXXX,
Thank you for your e-mail of 8 April (copy attached) requesting, under the Freedom of Information Act 2000 (the Act), a copy of the report of an audit of MK Airlines undertaken by the Civil Aviation Authority (CAA). Most of the information cannot be disclosed for the reasons given in the annex attached to this letter.
I have attached a copy of Part A of the audit report with personal details deleted.
With regard to those details and the remainder of the report, the Department has concluded that it cannot be released for the detailed reasons given below. Your request for information is therefore denied under section 27(1) (a) (international relations) and section 31(1)(g) and 31(2)(a), (c) and (j) (law enforcement), section 40 (personal information) and section 41 (confidence).
In reviewing your request for the audit report, the Department has considered the application of sections 27, 31, 40 and 41 of the Act. Section 27 exempts information if its disclosure would, or would be likely to, prejudice relations between the United Kingdom and another State. Section 31 exempts information if its disclosure would, or would be likely to, prejudice the exercise by a public authority of a function for the purposes of ascertaining whether any person has failed to comply with the law, ascertaining whether circumstances would justify regulatory action, or protecting
persons against risks to health and safety. Section 40 exempts personal data
subject to certain conditions. Section 41 exempts information if its disclosure would constitute an actionable breach of confidence. A copy of the full text of these exemptions is attached.
Under the Convention on International Civil Aviation (the Chicago Convention) the responsibility rests with the state in which the airline is based. During an audit of a foreign airline the UK Civil Aviation Authority will necessarily have to make judgements about the safety standards and regulatory capabilities of the airline’s national aviation authority. Such judgements will be contained in the audit reports and their disclosure would prejudice the willingness of the foreign authority, in this case in Ghana, to engage in discussion with the UK either now or in the future on the question of the regulatory oversight of airlines based in that country. The publication of the reports of such audits are therefore likely to prejudice the UK’s relations with
the State concerned. Accordingly, section 27(1)(a)applies.
It is a condition of the permit issued by the Secretary of State to foreign airlines under article 113 of the Air Navigation Order 2000 that the aircraft being used on the service comply with all relevant international standards related to airworthiness and operating standards established by the International Civil Aviation Organisation. The Secretary of State may ask the UK Civil Aviation Authority to carry out an audit of a foreign airline to ensure that the conditions of the permit are being met. The audit of
a foreign airline will normally need the cooperation of the airline itself and the
permission of its national aviation authority. During an audit of a foreign airline the Civil Aviation Authority will necessarily have to make judgements about the safety standards of the airline and regulatory capabilities of the airline’s national aviation authority. Such judgements will be contained in the audit reports. Since successful completion of an audit requires an airline’s co-operation, publication of the reports of such audits is likely to prejudice that co-operation and therefore the CAA's ability to conduct future audits on foreign registered aircraft, on behalf of the Secretary of State. Accordingly section 31 applies. The report identifies the names of the CAA personnel conducting the audit together with the names of the MK Airlines and the Ghanaian Civil Aviation Authority Staff interviewed. Accordingly, section 40 applies and the exemption from disclosure is absolute.
MK agreed to audit by the CAA on the basis that the audit results would be
confidential between the CAA, the Department and Ghanaian authorities. It is our view that the release of the audit report would be an actionable breach of confidence. Accordingly, section 41 applies and the exemption from disclosure is also absolute. Since exemptions from disclosure permitted by section 27 and 31 of the act are not absolute, the Department has also considered whether the “public interest” is served by disclosing information that relates to matters of international relations and law
enforcement. The public interest in disclosure of the information in parts B, C and D of the audit report includes: enabling the wider public to make informed decisions about the safety of air operators flying into and out of the UK; transparency and open government; the public right of access to official information held, and improving public confidence in the safety of airlines/airline operators. However, disclosure of a report of an audit which was conducted in confidence and contains assessments of another State's regulatory process is likely to prejudice the MK's relations with that State. Further, the disclosure of the report is likely to prejudice the Secretary of State's ability to exercise his functions relating to the
safety of foreign airlines and ensuring that such airlines operate in accordance with UK law whilst they are in the UK. In the circumstances of the case, the public interest in maintaining the exemption outweighs the public interest in disclosing the information contained in parts B, C and D of the audit report.
If you are unhappy with the way the Department has handled your request or with the
decisions made in relation to your request, you may complain by writing to me at the
address below (or by emailing me). Please see, attached, details of the Department
for Transport’s complaints procedure and your right to complain to the Information
Commissioner.
If you have any queries about this letter, please contact me.
Yours sincerely,
XXXX
Press Office
Department for Transport
Great Minster House
76 Marsham Street
London SW1P 4DR
Tel: XXXX
Your right to complain to DfT and the Information Commissioner
We can fill in a lot of the missing bits with Google.(why the phone number and other names missing beats me
) Interesting that MK, while being based in the UK, is still exempt because of 'flagging out' to Ghana.
here is the Canada report:
http://www.tsb.gc.ca/en/media/commun...m_a04h0004.asp
THE TRANSPORTATION SAFETY BOARD OF CANADA INVESTIGATION INTO A FATAL CARGO PLANE CRASH IN HALIFAX REVEALS THE NEED FOR SYSTEMS TO MONITOR TAKE-OFF PERFORMANCE
(Gatineau, Quebec, June 29, 2006) - The fatal crash of an MK Airlines Limited freight transport plane at Halifax International Airport, Nova Scotia, underscores the need for better systems to ensure correct take-off speed and thrust, the Transportation Safety Board of Canada (TSB) said in its final report (A04H0004) released today.
The report concluded that the speed and thrust settings selected by the crew members in preparation for their October 14, 2004 flight to Spain were incorrect for the weight of the Boeing 747-244SF, a converted jumbo jet. The aircraft did not achieve sufficient altitude, hit a berm at the end of the runway, crashed into the adjacent forest, and burned. All seven crew members died.
The investigation found that the crew did not receive adequate training on the Boeing Laptop Tool, a computer program used to calculate the take-off velocity and power necessary in light of factors such as fuel weight, payload, and environmental conditions. TSB investigators found that crew fatigue and a dark take-off environment may have compounded the likelihood of error. As a consequence, the Board called on Canadian and international regulatory authorities to ensure that crews of large aircraft will be alerted in time when there is not enough power to take off safely. The Board recommended that:
The Department of Transport, in conjunction with the International Civil Aviation Organization, the Federal Aviation Administration, the European Aviation Safety Agency, and other regulatory organizations, establish a requirement for transport category aircraft to be equipped with a take-off performance monitoring system that would provide flight crews with an accurate and timely indication of inadequate take-off performance.
A06-07
"We are asking the world's regulatory agencies to ensure that crews of large aircraft will be alerted in time when there is not enough power to take off safely," said TSB Acting Chair Wendy Tadros. "Our investigation uncovered the causes and contributing factors. We now need to work to ensure that this type of accident doesn't happen again."
OK for the company and insurers but pilots lost their lives in this accident.
We can not bring them back or compensate for their families grief.
http://www.dft.gov.uk/stellent/group...foi_037744.pdf
10/05/05
Dear XXXX,
Thank you for your e-mail of 8 April (copy attached) requesting, under the Freedom of Information Act 2000 (the Act), a copy of the report of an audit of MK Airlines undertaken by the Civil Aviation Authority (CAA). Most of the information cannot be disclosed for the reasons given in the annex attached to this letter.
I have attached a copy of Part A of the audit report with personal details deleted.
With regard to those details and the remainder of the report, the Department has concluded that it cannot be released for the detailed reasons given below. Your request for information is therefore denied under section 27(1) (a) (international relations) and section 31(1)(g) and 31(2)(a), (c) and (j) (law enforcement), section 40 (personal information) and section 41 (confidence).
In reviewing your request for the audit report, the Department has considered the application of sections 27, 31, 40 and 41 of the Act. Section 27 exempts information if its disclosure would, or would be likely to, prejudice relations between the United Kingdom and another State. Section 31 exempts information if its disclosure would, or would be likely to, prejudice the exercise by a public authority of a function for the purposes of ascertaining whether any person has failed to comply with the law, ascertaining whether circumstances would justify regulatory action, or protecting
persons against risks to health and safety. Section 40 exempts personal data
subject to certain conditions. Section 41 exempts information if its disclosure would constitute an actionable breach of confidence. A copy of the full text of these exemptions is attached.
Under the Convention on International Civil Aviation (the Chicago Convention) the responsibility rests with the state in which the airline is based. During an audit of a foreign airline the UK Civil Aviation Authority will necessarily have to make judgements about the safety standards and regulatory capabilities of the airline’s national aviation authority. Such judgements will be contained in the audit reports and their disclosure would prejudice the willingness of the foreign authority, in this case in Ghana, to engage in discussion with the UK either now or in the future on the question of the regulatory oversight of airlines based in that country. The publication of the reports of such audits are therefore likely to prejudice the UK’s relations with
the State concerned. Accordingly, section 27(1)(a)applies.
It is a condition of the permit issued by the Secretary of State to foreign airlines under article 113 of the Air Navigation Order 2000 that the aircraft being used on the service comply with all relevant international standards related to airworthiness and operating standards established by the International Civil Aviation Organisation. The Secretary of State may ask the UK Civil Aviation Authority to carry out an audit of a foreign airline to ensure that the conditions of the permit are being met. The audit of
a foreign airline will normally need the cooperation of the airline itself and the
permission of its national aviation authority. During an audit of a foreign airline the Civil Aviation Authority will necessarily have to make judgements about the safety standards of the airline and regulatory capabilities of the airline’s national aviation authority. Such judgements will be contained in the audit reports. Since successful completion of an audit requires an airline’s co-operation, publication of the reports of such audits is likely to prejudice that co-operation and therefore the CAA's ability to conduct future audits on foreign registered aircraft, on behalf of the Secretary of State. Accordingly section 31 applies. The report identifies the names of the CAA personnel conducting the audit together with the names of the MK Airlines and the Ghanaian Civil Aviation Authority Staff interviewed. Accordingly, section 40 applies and the exemption from disclosure is absolute.
MK agreed to audit by the CAA on the basis that the audit results would be
confidential between the CAA, the Department and Ghanaian authorities. It is our view that the release of the audit report would be an actionable breach of confidence. Accordingly, section 41 applies and the exemption from disclosure is also absolute. Since exemptions from disclosure permitted by section 27 and 31 of the act are not absolute, the Department has also considered whether the “public interest” is served by disclosing information that relates to matters of international relations and law
enforcement. The public interest in disclosure of the information in parts B, C and D of the audit report includes: enabling the wider public to make informed decisions about the safety of air operators flying into and out of the UK; transparency and open government; the public right of access to official information held, and improving public confidence in the safety of airlines/airline operators. However, disclosure of a report of an audit which was conducted in confidence and contains assessments of another State's regulatory process is likely to prejudice the MK's relations with that State. Further, the disclosure of the report is likely to prejudice the Secretary of State's ability to exercise his functions relating to the
safety of foreign airlines and ensuring that such airlines operate in accordance with UK law whilst they are in the UK. In the circumstances of the case, the public interest in maintaining the exemption outweighs the public interest in disclosing the information contained in parts B, C and D of the audit report.
If you are unhappy with the way the Department has handled your request or with the
decisions made in relation to your request, you may complain by writing to me at the
address below (or by emailing me). Please see, attached, details of the Department
for Transport’s complaints procedure and your right to complain to the Information
Commissioner.
If you have any queries about this letter, please contact me.
Yours sincerely,
XXXX
Press Office
Department for Transport
Great Minster House
76 Marsham Street
London SW1P 4DR
Tel: XXXX
Your right to complain to DfT and the Information Commissioner
We can fill in a lot of the missing bits with Google.(why the phone number and other names missing beats me
) Interesting that MK, while being based in the UK, is still exempt because of 'flagging out' to Ghana.here is the Canada report:
http://www.tsb.gc.ca/en/media/commun...m_a04h0004.asp
THE TRANSPORTATION SAFETY BOARD OF CANADA INVESTIGATION INTO A FATAL CARGO PLANE CRASH IN HALIFAX REVEALS THE NEED FOR SYSTEMS TO MONITOR TAKE-OFF PERFORMANCE
(Gatineau, Quebec, June 29, 2006) - The fatal crash of an MK Airlines Limited freight transport plane at Halifax International Airport, Nova Scotia, underscores the need for better systems to ensure correct take-off speed and thrust, the Transportation Safety Board of Canada (TSB) said in its final report (A04H0004) released today.
The report concluded that the speed and thrust settings selected by the crew members in preparation for their October 14, 2004 flight to Spain were incorrect for the weight of the Boeing 747-244SF, a converted jumbo jet. The aircraft did not achieve sufficient altitude, hit a berm at the end of the runway, crashed into the adjacent forest, and burned. All seven crew members died.
The investigation found that the crew did not receive adequate training on the Boeing Laptop Tool, a computer program used to calculate the take-off velocity and power necessary in light of factors such as fuel weight, payload, and environmental conditions. TSB investigators found that crew fatigue and a dark take-off environment may have compounded the likelihood of error. As a consequence, the Board called on Canadian and international regulatory authorities to ensure that crews of large aircraft will be alerted in time when there is not enough power to take off safely. The Board recommended that:
The Department of Transport, in conjunction with the International Civil Aviation Organization, the Federal Aviation Administration, the European Aviation Safety Agency, and other regulatory organizations, establish a requirement for transport category aircraft to be equipped with a take-off performance monitoring system that would provide flight crews with an accurate and timely indication of inadequate take-off performance.
A06-07
"We are asking the world's regulatory agencies to ensure that crews of large aircraft will be alerted in time when there is not enough power to take off safely," said TSB Acting Chair Wendy Tadros. "Our investigation uncovered the causes and contributing factors. We now need to work to ensure that this type of accident doesn't happen again."
OK for the company and insurers but pilots lost their lives in this accident.
We can not bring them back or compensate for their families grief.
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Not sure if this question should be here but this thread promted it. I only fly piston engined aircraft and so the take off run at anything less than full power is quite alien to me. Why, please, are turbine engined a/c not set to full power for take off (except for noise abatement)? ...
Two methods of reduction are widely recognized and used: Derate or Alternate rating (a fixed thrust decrease, usually based on an early model of an advanced engine), and Flex or Assumed Temp. Method (see here for a description).
You can also search around pprune for earlier threads on this topic.
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barit1 and others - Thanks for the answers. It looks hellish complex and probably why I stay with piston engines! By comparison my type of flying may in some ways be more complex (usually trying to find some awful place in the middle of nowhere and no ATC services within reach) but the aircraft management is so much more simple. I'll stick to what I understand.
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As I understand it, MK's Jumbos are now registered in the UK and are allowed to fly in and out at will. Their DC8's are registered in Ghana and need a permit. Does the CAA's reply mean that they are auditing only a portion of an airline? I thought the audit was supposed to be about the airline's procedures and practices.
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Hey WorkingHard & others - if you think of Flex Thrust as operating the plane at (approximately) a constant thrust-to-weight ratio it sorta starts to make sense. The details are more complex, but the objective is fairly simple.
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Well put basically we use the thrust needed to make the performance requirements, as opposed to using all the aavailable thrust.... flew turbo/supercharged recips for many years.... many times max manifold pressure (power) would have not been needed to get the airplane airborne, but no data was available, so full power it was...
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According to Catflaps, MK's Jumbos are now registered in the UK.
As far as I know, only one MK Jumbo, 9G-MKQ, has been UK re-registered. Though Mike Kruger proudly declared that after this new UK registration G-MKAA in August, we could no doubt expect every month an other to be UK re-registered, all others are still Ghana-registered.
As far as I know, only one MK Jumbo, 9G-MKQ, has been UK re-registered. Though Mike Kruger proudly declared that after this new UK registration G-MKAA in August, we could no doubt expect every month an other to be UK re-registered, all others are still Ghana-registered.
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Going back to end of runway obstacles - I would prefer EMAS to having nicely graded antenna emplacements, but that's just me.
maybe, I'm being overly presumptive, but does 35' over the threshold sound familiar? They screwed the pooch and died, the berm was the least of their problems as they struck the tail several times trying to unstick. Fact, As YHZ is my base and I saw the crash site and runway numerous times. Maybe I'm wrong, if so prove it
