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Aviation Human Factors Industry News

March 27, 2006

Vol. II, Issue 12.


March 27, 1977

Tenerife: The second deadliest airline crash in history.

At 5:06 PM, two Boeing 747 airliners collided on the runway of Tenerife airport in the Canary Islands. KLM Flight 4805 was taking off when it slammed into the side of Pan Am Flight 1736 which was taxiing after landing and had failed to clear the runway. The accident, which killed 583, was blamed on faulty communication, fog and general confusion over what turned out to be a false terrorist threat by Canary Island separatists that forced the diversion of both planes to Tenerife.

The Tenerife disaster is the second deadliest airline crash in history, exceeded only by the September 11 attacks. The silver lining: As a consequence of the accident, sweeping changes were made to international airline regulations and airplanes, including mandatory use of standard terminology by aircrews and air traffic controllers and refinement of cockpit decision making rules.

Metal Damages Fighter Jet

(KSL News) -- A small piece of metal caused millions of dollars damage to a fighter jet at Hill Air Force Base.

Air Force officials say it's the most expensive mistake since the fighter began deploying last year.

In October as a pilot started the twin engines on the jet, an airman noticed a five-inch safety pin sticking out of the landing gear. That pin was removed and got sucked into the jet's engine.

An investigation found it caused more than six and a half million dollars damage to the F- 22 fighter jet.

Regional jet with landing gear problem lands safely

ALBANY, N.Y. (AP) _ A Continental Express flight safely made an emergency landing Wednesday after losing a wheel on its landing gear, officials said.

Albany International Airport spokesman Doug Myers said Flight 2314 was traveling from Newark, N.J., to Albany with 37 people on board when the crew discovered the problem around 6:20 p.m. One of two wheels on the left side landing gear was lost on a runway at Newark.

Firefighters stood by when the twin-engine regional jet landed at 6:59 p.m.

No one was injured.

A preliminary inspection found no additional damage to the aircraft.

JAL told to ground aircraft for further checks

The Construction and Transport Ministry on Thursday ordered Japan Airlines to ground a passenger aircraft that had been kept in service without the required checks being carried out after the ministry found JAL's re-inspection of the plane was substandard, ministry officials said.

The carrier flew the plane, an MD-87, which was earlier found to have defects in its main landing gear, without confirming the integrity of the fuselage.

In the emergency inspection conducted Monday after JAL's inadequate checks were revealed and the firm was reprimanded by the ministry, JAL servicing staff failed to comply with the required inspection procedures, the ministry officials said.

JAL, which had the plane in question fly 12 flights Tuesday and Wednesday, was reprimanded by the ministry again Thursday for not conducting the inspection properly.

According to the ministry, JAL inspected the MD-87 on Monday at New Chitose Airport in Hokkaido, but failed to carry out required procedures such as using a designated chemical to check for cracks in the main landing gear.

A service staff member with a special qualification must conduct that inspection. A 44-year-old mechanic stationed at Haneda Airport who is in charge of such inspections flew to Hokkaido to check the aircraft.

Due to miscommunications between the mechanic and the department in charge of delivery of materials, however, one of the two chemicals needed for detecting small cracks was not delivered to New Chitose Airport.

The mechanic ignored the required inspection procedures and conducted the check using only one chemical.

Although the mechanic was unable to check thoroughly whether there were cracks, he used the result of another check and concluded that there was no defect in the landing gear. The mechanic finished the inspection shortly after 2 a.m. Tuesday and contacted JAL's maintenance department, saying he had found no abnormalities. Based on the report, JAL put the plane back in service, beginning with a flight from Sapporo to Akita departing at 8:45 a.m. the same day.

JAL engineer cut corners / Inspection of faulty aircraft done hastily to meet deadline

A Japan Airlines maintenance engineer was forced to quickly finish his inspection of an aircraft grounded over safety concerns, ultimately leading him to cut corners and allowing the plane to fly while the structural integrity of its main landing gear was still in doubt, a representative from the airline said.

"He was forced to complete his inspection early," the official said as he announced the findings of an interview with the 44-year old engineer.

An inquiry was launched after it was discovered that an MD-87 had been flown repeatedly without the integrity of its fuselage being properly confirmed, despite an earlier discovery of cracks in its landing gear.

Out of the chemicals required to carry out inspection of the parts was not delivered to the engineer, while corners were cut to make sure the plane could fly first thing the following morning. Internal documents, on the other hand, showed the inspection had proceeded in line with established criteria.

JAL maintenance division executives announced their findings during a press conference Thursday at the Construction and Transport Ministry. The announcement came a day after the airline announced in the same room that it had failed to stick to the legally binding inspection timetable, resulting in the mechanical problem.

"The emergency inspection we spoke of yesterday wasn't conducted according to the guidelines," the airline's maintenance department head said. "We're very sorry."

According to the airline, inspections to check for cracks in metal parts are carried out by maintenance specialists at Haneda Airport and other airports.

When the MD-87 was grounded at New Chitose Airport in Hokkaido after it was discovered to have missed the regularly scheduled inspections, the engineer was hastily dispatched from Haneda to deal with the problem as no maintenance personnel are regularly stationed there.

The engineer arrived at New Chitose Airport at 10:20 p.m. Monday. To have the plane ready to fly first thing the next morning, he began the emergency inspection of the landing gear by himself at 11:30 p.m., despite not having the necessary materials at hand. The inspection ended just after 2 a.m. The engineer stamped the paperwork with his seal, signifying that it had been completed, and returned to his hotel for a nap. He returned to Haneda on a 7:50 a.m. flight.

"At Haneda, we're careful with our repairs," a JAL executive said. "But in this case, the maintenance staffer was sent out to do the work with very little time in which to do his job."

"We thought that since the worker possessed qualifications, it would be OK," one executive said, referring to the skirting of company procedure. "He sticks to protocol 99.99 percent of the time, so this has come as a shock."

The slipshod inspection was discovered by a Japan Civil Aviation Bureau investigator looking into JAL's maintenance procedures. The airline did not even notice the warning from the investigator that the chemicals were missing from a supply list for New Chitose Airport.

A ministry official, who received a report showing an inspection Thursday had found nothing out of the ordinary, said: "We're truly relieved no cracks went unnoticed. We want JAL to put its heart into proper maintenance so it can ensure a high level of safety."

FAA: Planes aborted takeoffs to avoid collision

Two federal agencies plan investigations into how commercial planes nearly collided twice in two days on runways at O'Hare International Airport.

Pilots aborted takeoffs on Tuesday and Thursday to avoid colliding with other aircraft, the Federal Aviation Administration said. No one was injured.

"Both incidents look to be air traffic controller errors," FAA spokesman Tony Molinaro said Friday.

The FAA and the National Transportation Safety Board planned to investigate the incidents. The NTSB typically responds to fatal accidents, but considered the incidents "major" enough to send investigators, spokeswoman Lauren Peduzzi said.

"We are sending investigators because O'Hare had two major runway incursions in one week," she said.

On Tuesday, a Lufthansa plane and a Delta jet were mistakenly instructed to take off at the same time on crisscrossing runways, officials said. The planes came within 100 feet of each other before the pilots were alerted and stopped their planes.

Thursday's incident involved planes from United Airlines and its low-cost carrier, Ted. One plane was sent to taxi across a runway where the other plane already had started its take-off roll. The two planes came within about 600 feet of each other, officials said.

Seven so-called "runway incursions" occurred last year at O'Hare, out of

972,246 flights, the FAA said. Five were caused by controller errors, one by pilot error and one from an errant vehicle.

Four incursions, not counting last week's incidents, have taken place so far this year. All four have been ruled controller errors.  I guess they're human also

Helios crash was ‘waiting to happen’

Catalogue of latent errors culminated in the 737 disaster in which 121 people died, according to chief investigator

The August 2005 Helios Airways Boeing 737-300 crash, which happened after the aircraft failed to pressurise, was an accident waiting to happen because of multiple systemic faults, says the chief investigator into the accident.

The investigation has found that "latent errors have lain there for years waiting for the pilot to pull the trigger", Capt Akrivos Tsolakis, head of the Hellenic Air Accident Investigation and Aviation Safety Board (AAIASB) told the Flight Safety Foundation (FSF) European Regions Airline Association European Aviation Safety Seminar in Athens, Greece last week.  All 121 people on board the 737 died

Tsolakis made it clear that all the parties involved in the accident made some contribution to the systemic latent faults that created "a window of opportunity" for the errors made by the pilots. He did not specify those faults, or those responsible for them.

The main parties involved are the airline, the Cyprus Civil Aviation Authority and the aircraft manufacturer, Tsolakis confirmed.

Earlier information released by the AAIASB indicates that the fundamentals of the accident are the aircraft’s failure to pressurise and the fact that the crew became unconscious from hypoxia.

Before the flight, maintenance crew who had carried out a pressurisation check left the control on manual instead of automatic and the pilots failed to correct this during pre-take-off checks, so the aircraft did not pressurise as it climbed. Post-take-off checks require no further confirmation of the pressurisation control selection.When the audible cabin altitude alert sounded, the crew thought it was an erroneous configuration warning because the sound is identical, and their subsequent mindset and actions were determined by this preconception until hypoxia overcame them as the aircraft continued to climb, Tsolakis has previously reported.

Tsolakis has also noted, since beginning the investigation, that there have been numerous failures to pressurise in 737s with different airlines, but with non-fatal outcomes because the crew reacted appropriately.

The 737 was climbing out of Larnaca, Cyprus bound for Athens and flew as far as the final-approach fix under the control of the flight-management system and autopilot, ran out of fuel and crashed at Grammatikos, near Athens killing all 121 people on board.

The draft report has been prepared for the final stage of the process, in which all the parties to the accident have 60 days to comment. Tsolakis says the final report is likely to be ready for publication by June or July.

‘Doomed from the outset’

Greek paper says leaked report points to grave errors that led to crash

OVERSIGHTS ON the ground, slackness on the part of the crew during the flight, inadequate controls by the Civil Aviation Authority and faulty flightdeck consoles by Boeing – led to what has been dubbed the worst peacetime disaster in Cyprus’ recent history.

The above are the conclusions gleaned from a leaked draft of the accident report, published by Greek daily Kathimerini on Sunday. Citing its sources, the paper commented ominously that flight ZU-522, the August 14 crash of Helios Airways that claimed the lives of 121 people, was "doomed from the outset."

According to Kathimerini, chief air investigator Akrivos Tsolakis and his team of experts have found that the confusion over the decompression warning alarm "could under no circumstances have been the cause on its own…there were dozens of other omissions in air safety that contributed to the crash."

Now seven months in the making, Tsolakis’ voluminous probe should be ready sometime in April. It comprises 200 pages, divided into four chapters: the facts of the case; analysis of the facts; the findings/causes of the accident; and a list of safety recommendations. This is followed by thousands of pages of appendices with all the documents used in the investigation.

Kathimerini said the probe would apportion responsibility on all those involved with aviation in Cyprus, and would be particularly damning on civil aviation, for an "unparalleled absence of assessing air flight safety," and on the airline for "criminal negligence".

The inquiry contains some chilling details on the sequence of events.

Problems began with mistakes on the ground that were subsequently not dealt with in the air. Shortly after takeoff at 9am on the fateful day, two warnings – one for the decompression system, the other for the cooling system – were sounded almost simultaneously.

The warning horn sounded after the aircraft reached an altitude of 10,000 feet. The cabin decompression switch had been left on manual by ground crew during pre-flight checks, while it should have been set to automatic.

Still, this lapse could have been detected in time by the pilots had they properly scanned their gauges and carried out a checklist of components before takeoff. The aviators apparently did not do that.

When the decompression alarm went off, the crew – who had assumed that the decompression switch was on auto – mistakenly took this for a glitch in the positioning of the flaps, because the sounds emitted in both cases are identical. As the aircraft climbed to 34,000 feet, both the pilots and passengers gradually suffered the effects of hypoxia, or low oxygen in the blood: giddiness, loss of consciousness and finally deep slumber.

Captain Hans-Juergen Merten, who had left his seat to check the cooling system, is believed to have fainted inside the cabin.

According to the paper, all the people on board suffered irreversible brain damage from the lack of oxygen, and even if anyone had actually survived the horrific crash they would have been left in a vegetative state.

That includes flight attendant Andreas Prodromou who managed to retain consciousness using a portable oxygen mask at 14,000 feet and vainly tried to fly the plane before it slammed into a ravine at Grammatikos, outside Athens.

Moving on, the probe hauls the Cypriot Civil Aviation Authority over the coals, reportedly suggesting that its system of controls was "full of holes". Kathimerini’s sources say the agency did not carry out the necessary checks on planes and often ignored instructions from ICAO (International Civil Aviation Organisation). Moreover, it blew off recommendations periodically made by its two British consultants.

However, partial responsibility also lies with EASA (European Aviation Safety Agency) and JAA (Joint Aviation Authorities) for failing to place the local civil aviation authorities under surveillance and thus acting preventatively.

As far as Helios Airways is concerned, the probe reportedly notes the marked "lack of a safety culture" in the company. (Why we require a Safety Management System)  The airline’s employees were hired on six-month contracts, giving them no career prospects and thus no incentives. The same corporate policy extended to the pilots, as the airline tended to hire the "cheapest they could find", Aircraft manufacturers Boeing also had its share of blame. In his probe, Tsolakis notes the confusion generated over the decompression warning signal and that Boeing should have taken steps to rectify this.

What is more, the company’s manual for the Boeing 737-300 was vague.

Instead of explicitly instructing ground technicians to reset the decompression switch to auto, the manual simply said that the switch should be set "to the previous position," i.e. from manual to auto.

The manual setting is used in pre-flight checks to simulate decompression situations, but needs to revert to automatic for takeoff.

According to procedure, when completed the probe will be communicated to the US’s National Transportation Safety Board and to Helios, who then need to respond to the observations within 60 days. Once their answers are in, the report will be published, opening the way for any legal proceedings by the victims’ relatives, who for months now have been agonisingly waiting for the truth to come out.

In a related development, ICAO is considering enforcing stricter controls on the civil aviation authorities of countries that are deemed to be problematic. One proposal is to appoint a "guardian" who would monitor the authorities and ensure they comply with all safety standards.

At the ICAO summit in Montreal, Canada, the heads of civil aviation authorities around the world are being asked to authorise the publication of the results of checks on the organisation’s website.


Safety & Profitability
Company executives have historically viewed safety as a cost center that doesn’t contribute to profitability. Thanks to studies and extensive research, we now know that safety does indeed have a significant and direct impact on an organization’s financial performance.

In the meantime, here are some statistics you can cite to get your point across:

$7,000: How much a company saves for each serious injury/illness it prevents.

$28,000: The amount a company saves for each injury/illness resulting in lost workdays it prevents.

$910,000: The amount saved for each workplace fatality prevented.

Source: OSHA e-compliance assistance tools

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