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Aviation Human Factors Industry News

November 28, 2005

Vol. I, Issue 3

Industry Briefs:

US National Transportation Safety Board added a new page to its website providing the public with information on foreign aviation accident investigations in which NTSB has participated. The page may be accessed at www.ntsb.gov/ntsb/foreign.asp

Experts see no link among recent airline crashes. There are no obvious links among four plane crashes which have occurred within the past month, safety experts said. The accidents have killed more than 320 people. No one died in the crash of an Air France jet in Toronto. "Rare events can clump together -- there's an old wives' tale that accidents come in threes," said George Donahue, a former Federal Aviation Administration official who is now a professor at George Mason University. "I can't tell you that I think there's any kind of common thread."

Airlines will pay less for insurance this year, observers say. Aviation insurance premiums are expected to decline this year because the U.S. commercial aviation industry has experienced one of its safest periods in history. The industry has not recorded a major accident since late 2001, when an American Airlines flight crashed in New York. Recent crashes in Toronto, Greece and Venezuela will not boost rates for U.S. carriers, one observer said.  

New radar system will detect tiny pieces of runway debris. A new radar system will detect tiny pieces of debris on a runway and help avoid accidents similar to the crash of the Concorde in 2000 at Charles de Gaulle airport in Paris, officials at Vancouver International Airport said. The Vancouver airport has purchased four Tarsier radar units. Next year, it will become the first airport in the world to operate them.  

Poor management may have compromised flight safety. A new internal Federal Aviation Administration report found weak management at some air-traffic-control facilities may have compromised flight safety, writes The Wall Street Journal's Scott McCartney. In Dallas, controllers made numerous errors but did not report them as required. Dallas controller Anne Whiteman, who is now a supervisor, has said some of the errors were not mistakes and that controllers may have intentionally endangered planes. The FAA has said the errors are simply honest mistakes. A report by an FAA supervisor found the errors were the result of poor supervision.  

Risk of runway incidents may be rising at JFK. Some experts say the risk of runway collisions may be growing at New York's John F. Kennedy Airport. Two new air traffic control systems could reduce the risk of collisions, but it is unclear when Kennedy will have access to the systems.  


Exercise and Work Performance

In recent weeks President Bush has been criticized for the time his personal exercise program allegedly takes him away from managing the country. A recent story in the Wall Street Journal suggests that employers actually get better performance from their employees who exercise than from those who do not. Studies show that exercise provides a short-term boost to the brain’s ability to process data and perform other functions. Exercise also reduces depression and anxiety and has been shown to reduce or, at least slow down the mental effects of aging, perhaps even Alzheimer’s. (Kevin Helliker, "Studies suggest exercise boosts cognitive function" The Wall Street Journal, August 30, 2005.)


Over 75% of extended hours workers report that they do not exercise regularly. This contributes to the increased prevalence of certain health risks among the extended hours worker population:

      · Nearly 12% of extended hours workers have obstructive sleep apnea compared to 2%-4% of the regular population. Risk factors for obstructive sleep apnea include having greater than a 17" neck, being male, smoking, excessive drinking, and being overweight.

      · Up to 75% of night workers have gastrointestinal problems; peptic ulcers are up to 5 times more frequent in night vs. day time workers.

      · Extended hours workers have up to a 50% increase of cardiovascular disease.

      · 32.6% of extended hours workers report chronic or frequent back problems, 27.1% report chronic or frequent leg problems, and 18.6% report chronic or frequent wrist problems.

Excess health costs in extended hours operations total $28.3 Billion per year—14% of total excess costs—averaging to $1,181 per year per extended hours employee. These costs are recoverable but, interestingly, only 42% of all U.S. employers offer workers some financial incentive or penalty for health habits. We recommend all employers review their policies and programs and be proactive in this area. It is good for the employees and good for business.


Causes of plane crashes

Michael Uchebuaku,

November 5, 2005


Note: I do not agree with this article as it appears to subscribe to the old idea that human errors are the result of negligence only.                                                                                                                                It does make interesting reading. Gordon Dupont                                            


Human mistakes and mechanical difficulties are the common reasons that result in aviation accidents. But the aviation authorities in every country sets safety standards for pilot conduct, flight operations, and aircraft manufacture, but these guidelines are minimum safety standards that are not always enforced well enough to prevent some airplane accidents. There are many different reasons a plane crash may occur. Aviation authorities exist to set minimum safety standards for flight operations, aircraft manufacture, and pilot conduct, and aviation safety may also be governed by federal or state laws.

The more common causes of plane crashes in the world include:

Pilot Errors- Pilots are responsible for transporting the plane’s passengers from one destination to another. Pilots have a duty to follow air safety rules that have been outlined and created to better ensure the safety of everyone on board or else risk an aircraft accident.

Faulty Equipment- Faulty equipment, or even poorly maintained equipment can fail and cause an airplane to crash.

Violating Aviation rules and regulations- Aviation laws exist to protect everyone using air travel. Violations of these regulations can endanger the safety of anybody and everybody in the air.

Structural or design problems with an aircraft.

For instance, if the plane is poorly built, it would most likely crash resulting in fatalities.

Flight service station employee negligence.

All staff at a flight service station must always be alert to their responsibilities as any misinformation or faulty communication with pilots of planes in the air may result in crashes.

Federal air traffic controllers’ negligence.

The same applies to employees at the federal air traffic control. Competent professionals must be employed to play these roles as the employment of incompetent individuals may jeopardize flight safety and cause plane crashes.

Third party’s carrier selection negligence.

Maintenance or repair of the aircraft or component negligence

Lack of proper and regular maintenance of air craft can cause planes to crash as planes, like all machines, need to be serviced from time to time. Disrespect for adequate and regular maintenance considering the dangers flying pose, is too great a risk for any airline to take.

Fueling the aircraft negligence

Like cars, planes too run out of fuel. Neglecting to refuel an aircraft before takeoff is a clear recipe for disaster.

Possible aviation violations that can cause a plane crash can include:

Federal air traffic controllers' negligence

• Third party's carrier selection negligence

• Flight service station employee negligence

• Structural or design problems with an aircraft

• Maintenance or repair of the aircraft or component negligence

• Fueling the aircraft negligence

Pilots flying a plane are responsible to safely transport the people on the aircraft to the destination location by following certain air safety rules. The failure to properly do so can result in an instance of absolute fatality. In addition, when a plane has faulty or poorly maintained equipment on its aircraft it can result in the plane crashing. And whenever a plane crash occurs, it is usually due to some type of negligence or bad weather or even due to an act of sabotage or terrorism.

Pilot’s error as a cause of plane crash may include:

• a misuse of the aircraft controls

• misjudgment of altitude or the proximity of other objects

• failure to obtain a proper weather briefing

• operating the aircraft beyond its capabilities

• flying under conditions which the pilot is not qualified to handle

The human element:

That by which we have physical or mental control to recognize, change, prevent, or mitigate a situation. Approximately 80 percent of all air crashes fall into this category. While the previous definition called it "pilot error," the term has been changed to "human error" to more realistically reflect that anybody who acts in a support capacity of a flight may contribute to the error chain. Not just the pilot. Of the previously cited 80 percent, the American NTSB (National Transportation Safety Board) further breaks down human errors into the following categories:

Human error chart (USA)

Unprofessional Attitudes 47%

Visual Perception Misjudgment 19%

Pilot Technique 21%

Inflight Judgment or Decision 5%

Improper Operation of Equip. 6%

Unknown Causes 4%

Continuing with statistical data, the following tables depict the causes of accidents (in percent) from the 1950's through the 1990's. Note that "pilot error" has, and still does, account for the highest percentage of accidents.

"Pilot error (weather related)" represents accidents in which pilot error was involved but brought about by weather related phenomena. "Pilot error (mechanical related)" represents accidents in which pilot error was involved but broughtabout by mechanical failure. "Other human error" includes air traffic controller error, improper loading of aircraft, fuel contamination, improper maintenance etc. Sabotage includes explosive devices, shoot downs and hijackings. "Total pilot error" is the total for all types of pilot error (on the fourth line in yellow). Where there were multiple causes, the most prominent cause was used.

Rules Guarding Against Alcoholic Pilots and crew members

The world over, especially in developed countries, rules exist regarding the consumption of alcohol by crew members. For instance, on July 1st, 2002 in Miami U.S.A the crew of an America West Airlines Airbus 319 attempted to takeoff an aircraft while under the influence of alcohol.

According to CFR (Code of Federal Regulations) Title 14, Aeronautics and Space, Part 91.17, the rules are clear.

(a) No person may act or attempt to act as a crewmember of a civil aircraft --

(1) Within 8 hours after the consumption of any alcoholic beverage;

(2) While under the influence of alcohol;

(3) While using any drug that affects the person's faculties in any way contrary to safety; or

(4) While having .04 percent by weight or more alcohol in the blood.

(b) Except in an emergency, no pilot of a civil aircraft may allow a person who appears to be intoxicated or who demonstrates by manner or physical indications that the individual is under the influence of drugs (except a medical patient under proper care) to be carried in that aircraft.

It's interesting to note that Item 4(b) gives the pilot the right to not let a passenger be carried on his aircraft if the would-be passenger appears under the influence of alcohol or drugs.

Other causes of plane crashes and other aircraft accidents include defective design or manufacture of the aircraft and extreme weather conditions.

In the case of bad weather as a cause of plane crash, analysts also say that bad weather, like thunderstorms or fog, can compound pilot error, while small mechanical problems can affect other aspects of a plane’s ability to function. In many cases, planes have flaws that may not be discovered until after disaster strikes. Still, investigators have done useful work in making sense of perplexing crashes, and as a result many safety features are regularly added to planes.

Analysts also reveal that the poor state of equipment used in the airports of some developing countries, may also lead to plane crashes. They say that if obsolete equipment is problematic in air traffic control towers, faulty equipment in airplanes would equally be deadly and the combination of the two would definitely lead to catastrophe.

Terrorism is also among the causes for plane crashes in these modern times. On September 11, 2001 in the United States of America:

Four terrorists hijacked United Airlines flight 93, which departed Newark and was destined for San Francisco. The plane crashed in Somerset, Pennsylvania killing all 45 persons on board. The intended target of that hijacked plane may never be known, but it is believed that it was bound for the White House. It is important to point out that due to the bravery of the passengers in overpowering the hijackers on that doomed flight, the aircraft was prevented from being used as a missile.

Five terrorists hijacked American Airlines flight 77, which departed Washington Dulles Airport and was destined for Los Angeles. The plane was flown directly into the Pentagon. A total of 189 persons were killed, including all who were onboard the plane.

Five terrorists hijacked American Airlines Flight 11, which departed Boston and was destined for Los Angeles. The plane was flown directly into the north tower of the World Trade Center. On board the aircraft were 81 passengers, nine flight attendants, and the two pilots.

Five terrorists hijacked United Airlines Flight 175, which departed Boston and was destined for Los Angeles. The plane was flown directly into the south tower of the World Trade Center. On board the aircraft were 56 passengers, seven flight attendants, and the two pilots.

In the end, more than 3000 persons were killed in these four heinous attacks.

More airlines maintenance oversight needed


WASHINGTON -- As airlines cut costs by having others do their maintenance, federal safety inspectors need to keep a closer eye on the work, the Transportation Department's inspector general told Congress Thursday.

Airlines contracted out 54 percent of their repair work last year, half again as much as they did in 1996, Kenneth Mead told the Senate aviation subcommittee.

"The transition to increased use of outside repair facilities is not the issue," Mead said. "It is that maintenance, wherever it is done, requires oversight."

There are 212,188 repair stations in the United States, with 31,932 in California alone, according to the Federal Aviation Administration.

Some do routine day-to-day work, others do comprehensive inspections and overhauls. Most do maintenance on specific airplane components, according to the Aeronautical Repair Station Association.

Mead said airline maintenance officers do a lot of inspecting of the airline's own maintenance, and they're supposed to do the same for outsourced repair work.

"We found they'd show up once, twice, three times a year," Mead said. "I think that's a big issue."

More than two years ago, Mead's investigators reported that contract mechanics used incorrect parts, improperly calibrated tools and outdated manuals at 18 of 21 aircraft maintenance facilities they visited.

Following the investigation, the FAA agreed to inspect repair stations more thoroughly and more consistently, in part by adding more inspectors.

But the number of inspectors has fallen in the past two years to 3,200 from 3,400, and the FAA's progress in improving oversight of repair stations has been slow, Mead said.

Sen. Jay Rockefeller, D-W.Va., said the FAA isn't getting enough funding to do its job properly.

"I am deeply concerned that the FAA is losing a number of its most senior safety inspectors and does not have the ability to replace them," Rockefeller said.

FAA chief Marion Blakey said the agency plans to hire 80 more inspectors, but Congress may soon add money to its budget that would allow nearly 100 to be hired.

Blakey pointed out that this is the safest period in U.S. aviation history, with one fatality for every 15 million flights. There hasn't been a major commercial airplane crash in the United States in more than four years.

"We do not have any data that suggests contract maintenance is any less safe," Blakey said.

Blakey said the airlines and manufacturers are also responsible for making sure repairs and maintenance are done correctly. In some cases, she said, engine maintenance is often outsourced to the manufacturer - probably the best place to have it done.

The issue of maintenance oversight arose during the Northwest Airlines mechanics strike, when an FAA inspector raised safety concerns about the carrier's replacement workers.

After FAA inspector Mark Lund made the allegations on Aug. 22, Northwest complained about him to the FAA. Lund was reassigned to desk duty.

Since then, the FAA and the inspector general checked out Lund's allegations and discovered that some were true.

They found that the airline was using managers to do line maintenance and inspections, which didn't affect safety because they were trained and qualified. But Northwest agreed to changes to make sure that newly trained replacement workers were overseen properly.

They also found that Northwest didn't follow its own voluntary practice of examining incoming parts for repairs and maintenance. The FAA is taking an enforcement action over the issue.

The airline is still safe to fly, Mead told reporters Thursday.

Mead also said that Lund had been reinstated in his old job. However, he was being escorted by Northwest Airlines personnel when he was conducting inspections. "We think that practice should be discontinued and we have notified the FAA in writing," he said.

Northwest spokesman Kurt Ebenhoch said the airline gives more access to FAA inspectors than the government requires and what most other airlines allow.

"We generally provide unfettered access to FAA inspectors," Ebenhoch said. But, he said, since FAA still has an open investigation into Lund's professionalism and conduct, "we are requiring an escort."

Pilots slam NTSB over crash probes

Association says safety board overlooks human factors

US Air Line Pilots Association (ALPA) president Duane Woerth has accused the US National Transportation Safety Board (NTSB) of overlooking human-factors principles during the investigation of aviation accidents.

In a letter to NTSB acting chairman Mark Rosenker, Woerth urges deeper consideration from the NTSB when it cites human error as a contributing factor in crashes, accusing the agency of appearing to "favour the easy route of citing ‘crew error’ and not delving further. Since the vast majority of aviation accidents are the result of many factors, it is shortsighted and troubling to simply say, in effect, ‘the flightcrew failed to prevent the accident’," says Woerth.

The NTSB on 8 September concluded that pilot error contributed to the 9 May, 2004 crash-landing of an American Eagle/Executive Airlines ATR 72 in San Juan, Puerto Rico. The report says the captain "failed to execute proper techniques to recover from the bounced landings" and failed to execute a go-around.

Woerth says this conclusion was reached "with no apparent analysis at all of whether training, experience, or corporate safety culture may have predisposed this pilot to exceed his own ability in an effort to land on the first attempt".

An agreement "many years ago" between ALPA and the NTSB to form a ‘human performance’ investigative group to "enhance accident investigations" has since been reversed, says the ALPA head.

Rather, he says, the NTSB tendency "now is to subordinate the study of human factors issues to the operations group, or to ignore those issues altogether".

Responding to Woerth’s comments, Rosenker says the latter claim "clearly misrepresents the facts and this agency’s record". NTSB investigators have found that "human factors issues do not always lend themselves to pursuit by a single group, but instead require support and input from multiple disciplines", he adds.

Cockpit video cameras would help the agency draw human factors conclusions, says Rosenker.