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Aviation Human Factors Industry News

December 9, 2005

Vol. I, Issue 5


Fact of the Week: Unscheduled Absence

Only 38% of unscheduled absences are attributed to personal illness. The remaining 62% call in sick because of:

23% - family issues
18% - personal needs
11% - stress
10% - entitlement mentality

(Source: Rose Opengart, "Balancing sick leave policy is tricky." The Huntsville Times, November 30, 2005.)


Iran air safety hit by sanctions

A generation of international isolation has undermined safety standards within Iran's civil and military aviation fleet, experts say, increasing the likelihood of major air disasters.

The C-130 transport plane which has crashed into a residential area of Tehran came down less than three years after the country's worst-ever air disaster.

In February 2003 a Russian-built Ilyushin Il-76 transporter plane crashed in south-east Iran, killing 302 passengers and crew.

Two decades of sanctions by the West against Tehran have left the country with a fleet of mainly ageing planes, often fitted with unofficial spare parts.

"The problem is likely to be one of maintenance," Chris Yates, an aviation safety expert with Jane's Transport, told the BBC News website.

Although the Lockheed Martin C-130 is in regular service around the world, most of Iran's ageing fleet was purchased in the days of the Shah, before the Islamic revolution led to cuts in ties to US companies.

"Given that Iran operates under sanctions of various types, we understand that it has difficulty obtaining spare parts direct from the manufacturer, as it is very difficult for Lockheed to do business in Iran," Mr. Yates said.

With a lack of spares for newer aircraft, Mr. Yates suggested, Iran may be having to source parts on an unreliable black market.

Others have claimed that military engineers sometimes "cannibalize" parts from older aircraft in an effort to keep newer models in the air.

"If that is the case then they may well have put aircraft in the air with faults. That leads to this kind of accident," Mr. Yates said.

Most air crashes are attributed to one or more of three main factors: poor maintenance, poor weather (the most common reason for a crash) or pilot error.

Mr. Yates played down suggestions that poor visibility in Tehran due to smog may have contributed to the crash.

"Any decent pilot, when faced with a tower block looming in front of him, would do his utmost to swerve away from it," he said.

"It would seem from what I've have seen in this case that the pilot completely lost control of the ability to steer the aircraft."

Trade embargo

Since Iran's Islamic revolution of 1979, trade embargoes by Western nations have forced Iran to buy mainly Russian-built planes to supplement an existing fleet of Boeings and other American and European models.


Feb 04: Iranian plane crashes near Sharjah airport in UAE, killing 43 people

Feb 03: Military transport aircraft crashes in southern Iran, killing 302 people

Dec 02: Commuter plane carrying aerospace experts crashes in Iran, killing 46 people

Feb 02: Tu-154 operated by Iran Air crashes in mountains in west of Iran, killing 117 people

March 97: 80 die when a military plane crashes in north-east Iran

Feb 93: Tu-154 crashes into a military plane near Tehran, killing 132

A lack of spare parts was blamed for the Ilyushin disaster in 2003, which killed 284 members of Iran's elite Republican Guard and 18 crew, .

The Ilaircraft was a four-engine model originally designed in the late 1960s, which undertook its maiden flight in 1971.

After another Russian-made plane, a civilian Tupolev-154, crashed in south-western Iran in February 2002 with the loss of all 119 on board, Iranian authorities declared all its Russian-built aircraft grounded.

However, this edict appears to have been widely ignored.

Passengers’ Safety On Board Assured.

DUBAI— The Airbus A380, which is considered as the world's largest long-haul airplane featuring two decks, four aisles and the capability to carry 600 to more than 800 passengers on board, is also a "zero-crash aircraft".

"Technology is what we master at Airbus. We just cannot afford to crash. The A380 has been designed to be a zero-crash aircraft and we made sure that it carries passengers safely to and from their destinations," said Jacky Joye, flight test engineer of Airbus.

Set to revolutionize commercial aviation, the A380, which is one of the featured aircraft at the Dubai Airshow 2005, has an 8000-mile range, the lowest costs per seat ever, and is expected to serve as the most effective solution to the increasing number of travelers worldwide.

According to Joye, safety and security of passengers and crew on board have been the prime concern of Airbus in designing and manufacturing the A380.

"It is as safe as it can be. We have tested the aircraft fully by conducting various failure scenarios and checking the systems extensively to avoid any single failure from happening which would cause a plane to crash," Joye added. He also noted that 75 per cent of actual airplane accidents do not happen due to technical failure.
"Human error, miscommunication with air traffic controller, and bad judgment are just some of the factors that leads to air accidents," Joye said.

Fully computerized, the A380 is equipped with 100 black boxes, also known as flight data recorder (FDR) and cockpit voice recorder (CVR). The plane's system is likewise monitored regularly so that to prevent the occurrence of any problem.

Joye explained that the aircraft has been designed to last a service period of 50 years and beyond so they made sure that the systems and technology used are highly sophisticated.

"We have put in mind that the pilots who will fly this plane may not have even been born yet," Joye mused.

The flight test engineer mentioned that pilots as well as cabin crews will be trained on the A380's features as well as how to handle emergency situations.

Manufactured in the Airbus headquarters in France, parts of the A380, however, have come from various suppliers all over the world including the United Kingdom, Germany, Spain, and the United States.


Pilot reported oil leak before plane crash

Investigators give no details on problems that led to the crash that killed two near Ankeny on Tuesday.

Federal investigators will look at a possible oil leak as they search for the cause of a plane crash near Ankeny that killed two Des Moines men.

Polk County sheriff's officials said there was a radio report of engine trouble prior to the crash of a Piper Navajo on Tuesday morning that killed pilot Doug Dority, 63, and his passenger, Harold Miller, 56.
An online Federal Aviation Administration report posted Wednesday noted that "aircraft reported an oil leak shortly after departure."

It was unclear Wednesday
whether the oil problem was mechanical or the result of human error. Investigators would not comment on details of the probe.

A witness said the plane was headed away from the airport when it seemed to lose power and slam into a freshly plowed field.

error accounted for at least six of 13 fatal plane crashes in Iowa over the last four years. Five crashes are still under investigation. Twenty-three people have died in Iowa crashes since early 2002, eight this year. The most deaths in a year was 16 in 1993.

Three small-plane crashes killed six people in two days at the end of March in one of the deadliest stretches since at least 1990:

• An Easter Sunday crash near West Union that killed pilot Andrew Bryan, 28, of Maynard and Connie Stewart, 37, and daughter Sarah Stewart, 11, both of West Union, was caused by Bryan's failure to abort the takeoff or maintain airspeed afterward, the National Transportation Safety Board determined.

• In a separate fatal crash the same day, pilot David Daniel Culbertson, 38, of Shellsburg and Steven Ray Redman, 48, of Marion were killed when their plane landed in a cornfield. An official cause has not been determined.

• A March 28 crash near Bloomfield killed 68-year-old Helen Ball of Bloomfield. Her husband, pilot Vern Ball, also 68, was injured. The Balls crashed in their four-seat plane soon after takeoff from Bloomfield Municipal Airport, headed for Arkansas. No cause has been determined.

Other fatal Iowa crashes:

• Nov. 6, 2004, an experimental amateur-built plane crashed near Anita. The pilot was fatally injured. The cause has not been determined.

• Aug. 22, 2004, a small plane was destroyed when it hit the ground north of the Decorah Municipal Airport. A passenger was fatally injured; cause not determined.

• Aug. 11, 2004, a pilot was fatally injured in a crash near Moville when the plane stuck a tree. Investigators blamed "inadequate in-flight planning" and "failure to maintain."

• Dec. 17, 2003, four people were killed when a small plane crashed in Brooklyn. There were no witnesses. Federal investigators said factors included the pilot's lack of experience.

Air safety record reflects industry's commitment

USA TODAY's editorial "4 years, no plane crashes, but new risks emerge" was both misinformed and disappointing. It ignored the carefully designed, highly successful safety programs shared by the Federal Aviation Administration, aircraft manufacturers, air carriers and their employees. Our incredible record of safety performance is a direct result of the hard work and careful research that have gone into these programs (Our view, Aviation safety debate, Nov. 25).

Hundreds of thousands of aviation professionals, both in and out of government, share a profound sense of responsibility to those who fly. Because of that commitment, air travel today is by far the safest mode of transportation.

Not only are commercial aircraft designed, manufactured, operated and maintained to meet the highest safety standards, we also have developed powerful safety-related data collection and analytical capabilities to facilitate early identification of any area of concern.

Regrettably, the editorial contributes to a serious misunderstanding that offshore repair work is a dicey proposition. The assertion that contracted domestic or international maintenance perpetuates "new risks" simply is not true. All maintenance work is subject to rigorous oversight by both the FAA and the airlines. Moreover, as FAA administrator Marion Blakey points out, the administration works closely with foreign aviation regulatory authorities to ensure that maintenance on U.S. commercial aircraft performed overseas meets exacting U.S. requirements ("Historic safety record," Opposing view).

Air travelers need to know that safety is a never-ending commitment for our industry and the core principle that guides us everyday.

Are Pilots only to blame?


      The recent report of Ministry of Tourism and Civil Aviation on the non-fatal accident of Gorkha Air's Do-228 aircraft in Lukla earlier this year, has blamed the pilot, apart from other 'contributing' factors. It is most unfortunate that the deliberate misrepresentation of facts and willful disregard for fact-finding by the investigative authorities continues unabated.

Although Nepal is a signatory to the Chicago Convention of the Inter-national Civil Aviation Organi-zation, ICAO, (the reason the government forms investigation committees following air accidents even if no lives are lost.) and it is thereby required to abide by the requirements of Annex-13 on 'Aircraft Accident and Incident Investigation', in letter and spirit, more often an aircraft accident investigation is reduced to a farce and even an opportunity for the officials in the Ministry of Civil Aviation to make easy money. This is because a lot of money from the insurance companies is at stake, and even a slight suggestion in the report of any violation by the crew or the operator could result in the insurance company throwing out the claims and not paying them. Some of the reports have been nauseating enough to make the deceased pilots go wild in their graves in anger. Thus, the Ministry has consistently failed in its duties.

Take the two recent cases, (which the Civil Aviation authority of Nepal (CAAN) would like to refer as 'incidents'). The wheels of two aircraft got detached at Kathmandu airport while taking off. The investigation by CAAN in the first case, Fokker-100 is said to have blamed a lapse by the French technicians while fitting the wheel during routine maintenance the day before because of pressure to return aircraft to service as quickly as possible. The investigators, deliberately, didn't bother to analyze the organizational deficiencies that must have played a contributory role in the incident. If they indeed had, the latest incident, involving the SAAB-340, shouldn't have taken place. In aviation industry abroad, incidents are referred to as "free lessons", but sadly, in Nepal no one wants to learn from them.

The facts that it is the airline that compels the pilots to accept flights in hilly regions, even in adverse weather conditions, either by coercion or enticement, are never taken into consideration in most of the reports. In one fatal accident, the black box contents had been stolen after breaking open the shock proof casing to ensure that the real cause and circumstances leading to the accident was not found. It is highly improbable that the crash of a slow-flying Twin-Otter could have ruptured the box which can survive high-speed jet crashes. But the investigators didn't bother to file a police case for the theft of the black box. This speaks volumes about their sincerity and honesty!

The argument that Nepal has a difficult terrain and an accompanying capricious weather is being used every time to prevent the scrutinizing of the shoddy existing aeronautical infrastructure and the grossly incompetent top level management. But most of the blame is put on the poor pilots who die in the crash ('human factor'). This is something which is hard to swallow. The fact that the ICAO doesn't spell out the requirements for being an investigator doesn't mean that any person without an iota of aviation human factors knowledge should be allowed to conclude anything s/he likes.

The term 'human factor' is being used as a generic term in all the accident reports without attempting to go for the specifics, which is making a mockery of the most sensitive aspects of accidents. Nor, are the analyses of the accidents based on existing body of research on human factors and limitations. Analyses seem to be based only on the fancies and prejudices of the investigating commission members, many of who have no idea of the technical aspects of aviation system and human factor limitations. More efforts are expended in getting the punctuation of the report correct than analytically probing the findings. The autopsies of the crewmembers are performed in a haphazard and superficial manner and never have biochemical analyses of relevant tissues been undertaken. In the past, many times the investigation Commission did not even bother to visit the crash site, on grounds of absence of personal comforts and security, let alone camp at the site to gather evidence as required by the ICAO!

Though the ICAO clearly and repeatedly states that the assistance of the very best personnel should be sought in the investigation, in Nepal it has never been followed, perhaps for fear of finding out the real causes of the accident! It is also believed that no standard operating procedure exists for carrying out relief work, let alone the orderly investigation in the aftermath of the accidents. In this poor country, the majority of the people fly, especially in the hilly regions, out of sheer necessity rather than convenience. They are just not in a position to challenge the investigations in a court, let alone sue the company for unsafe practices.

And never in the past was a judicial inquiry ever ordered into accidents with dubious circumstances like that of the Lufthansa Cargo B-727 crash in 1999, where it is well accepted in Nepalese airline circles that other factors outside the cockpit were responsible.

The findings, probable causes and the recommendations in many of the reports point to diametrically opposite directions. The 'Final Reports' after being made public are out of the reach for the aviation community. This also strengthens one's suspicions towards the objectivity and veracity of the "Final Reports" of the Nepalese aviation disasters. It is even heard in airline circles that the findings and recommendations in theses reports have been often tailored to cover up the shortcomings of the involved airlines for which the Ministry officials charge hefty sums of money.

A couple of law-suits challenging the findings of the reports could compel the government to conduct genuine investigation of air accidents. It is high time that we stop putting all the blame to the pilots who cannot save even their own lives in the accidents.


END with thanks to jetBlue