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Aviation Human Factors Industry News

April 27, 2006

Vol. II, Issue 16.

Another runway incident probed

FAA investigates 3rd recent O'Hare mishap

Federal officials said Tuesday that they are investigating what would be the third runway safety breach in six days at O'Hare International Airport.

The latest incident occurred Sunday on the same two crisscrossing runways where air-traffic controller errors threatened to cause accidents last week, the Federal Aviation Administration said.

The first runway incursion, defined as two aircraft in the same area at the same time, resulted in two planes missing each other by only 100 feet, the FAA said. It marked the most serious near-crash on the ground at any U.S. airport in several years, the FAA said.

The National Transportation Safety Board decided to send investigators to O'Hare on Monday after the second incursion--a violation of required minimum spacing between aircraft--occurred in a two-day span last week.

Then on Sunday, more trouble.

About 12:20 p.m. Sunday, a Canadair regional jet was issued a takeoff clearance on Runway 9 Left. Moments later, an Airbus A320 was cleared to take off on Runway 4 Left, said FAA spokesman Tony Molinaro.

Four seconds later, the A320 was instructed to cancel its takeoff.

The distance from the end of 4 Left to the intersection with 9 Left is less than 1,000 feet.

The planes were no closer than 1,100 feet to each other, Molinaro said.

The quick radio call telling the A320 pilots to cut off their takeoff--either by the controller who mistakenly launched the two planes simultaneously or another O'Hare tower controller who caught the error--prevented the A320 from getting far along on its takeoff roll, officials said.

The incident is under investigation as a possible runway incursion, he said.

"The two planes were on the outer edges of getting closer than our separation standards allow, but this has not been determined yet," Molinaro said.

The FAA would not identify the airlines involved or disclose how many passengers were onboard.

In last week's first runway incident, on March 21, a mistake by a controller undergoing training led to a Lufthansa A319 and a Delta Connection regional jet taking off at the same time on a potential collision course on the same two runways, the FAA said.

Pilots of both aircraft aborted their takeoffs and the planes stopped only 100 feet from each other.

The second incident, on Thursday, involved a Ted A320 carrying 156 passengers taxiing across a runway on which a United Airlines Boeing 737 carrying 111 passengers was taking off.

The United pilots aborted their takeoffs, but the planes came within 600 feet of each other, the FAA said.

If Sunday's incident is classified as a runway incursion, it would be the fifth in 2006 at O'Hare, the FAA said. Seven runway incursions occurred in 2005 at O'Hare.

The FAA and the NTSB rank runway incursions as the No. 1 threat to airport safety.

There were 1,395 runway incursions between 2001 and 2004 in the U.S., an average of almost one per day, the FAA said.

Runway safety system has pilots seeing red

GRAPEVINE, Texas — As American Airlines Flight 629 rolled slowly onto the runway for departure one recent morning, it entered one of aviation's most dangerous places.

Many of the worst aviation disasters around the world have occurred on runways. Despite repeated attempts to reduce the risks, near-collisions happen in alarming numbers throughout the USA.

But on this particular day at Dallas/Fort Worth International Airport, the pilots of the American MD-82 had the benefit of a safety system now being tested that for the first time warns pilots directly of runway perils.

As Flight 629 waited for takeoff clearance from controllers, a brilliant string of red lights embedded in the runway lit up because two other jets were crossing further down the runway. If there was any misunderstanding, the red lights made it clear that Flight 629 did not yet have permission to take off.

After a year of tests at one of the nation's busiest airports, officials with the Federal Aviation Administration (FAA) are optimistic that the runway status light system can be approved for use at busy airports around the country.

Near-unanimous support   In the world of aviation, where new systems frequently run into problems and face criticism from users, the runway lights have received near-unanimous support from safety advocates, pilots and air-traffic controllers.

"It's a great system," says Capt. Jack Eppert, a regional safety coordinator for the Air Line Pilots Association. The pilots at American, which dominates the airport here, also endorse it, says Capt. Bill Mino, a safety chairman at the Allied Pilots Association.

Mark Rosenker, acting chairman of the National Transportation Safety Board, says the system appears to fulfill one of the agency's long-standing recommendations that pilots be given better warnings of potential hazards on runways. "It's one of the most important issues to us," Rosenker says.

The money-strapped FAA has not yet committed to fund the system, but Administrator Marion Blakey says she is encouraged by early results. Blakey, who headed the accident investigators at the NTSB before becoming the chief aviation regulator at the FAA in 2002, has made runway safety a priority. She calls the system "very promising."

On March 27, 1977, the pilots of a KLM Boeing 747 carrying 248 people sped down a fog-enshrouded Canary Islands runway after mistakenly thinking they had permission to take off.

The pilots did not realize that a Pan Am 747 carrying 396 people was taxiing in the opposite direction on the same runway. The two jets slammed into each other at more than 100 mph.

The fiery collision killed everyone aboard the KLM jet and 326 on the Pan Am flight, a total of 574. The accident remains the worst in the history of commercial aviation.

In the nearly 30 years since the accident, new technologies and training have dramatically lowered accident rates. Entire categories of risk, such as midair collisions and wind-shear crashes, have been virtually eliminated. The complex mix of human failures that cause runway collisions, however, remains.

At least 76 people have died in three runway collision accidents involving commercial aircraft in the USA since 1990. More than 300 incidents a year occur on runways in this country; 30 to 50 of those are categorized as most risky, according to the FAA.

Such incidents, in which FAA investigators have determined that there was a significant risk of collision, have declined since 2000, but enough occur each year that the NTSB considers the issue one of aviation's top safety priorities.

Last month at Chicago's O'Hare International Airport, three runway incidents were reported, including one that investigators considered severe. Another near-collision in Chicago in 1999 — in which two 747s came within 75 feet of a high-speed collision — prompted the NTSB to recommend a better runway warning system.

Quest to warn pilots  Current warning systems alert controllers, not pilots, if planes get too close on runways. NTSB investigators have found that the warnings are better than nothing, but they leave much to be desired.

The quest for a way to warn pilots directly goes back to the early 1990s. Scientists at MIT Lincoln Laboratory experimented with runway warning lights at Boston's Logan International Airport. The system did not work well because it was difficult to track planes on the ground with radar, says Jim Eggert, who is now the laboratory's project leader in Dallas.

In the ensuing decade, however, the technology to monitor aircraft on the ground improved exponentially. Now computers can follow planes with great precision. The system was revived in Dallas, where airport officials had spent $6.4 million on a state-of-the-art system to track taxiing aircraft.

Controllers are still in charge of choreographing departures and arrivals. Richard Loewen, who heads the National Air Traffic Controllers Association's Dallas tower branch, says controllers appreciate the fact that the lights provide additional safety without slowing traffic.

If there is a downside to the system, according to Loewen and others, it is that it may take several years to receive final permission and funding from the FAA.

The basis for the system, computers that track planes on the ground, was supposed to be put into 35 airports, but budget shortfalls have slowed its deployment.

Loewen says air-traffic controllers don't understand why it's taking so long. Those who work in a tower on the other side of the airport, where the lights are not in operation, want the system installed there, too, he says.

Kish Air crash due to human factors: probe

DUBAI — The investigations into the accident of a Kish Air Fokker 50 aircraft, which crashed into a suburb of Sharjah on 10 February, 2004, killing 6 crew members and 40 passengers, revealed that the cause of the crash involved human factors.

Mohammed Ghanim Al Ghaith, the Director-General of the General Civil Aviation Authority, announced yesterday the completion of the accident report Kish Air Fokker 50 aircraft, in which only three passengers survived.

The aircraft, which was registered in the Islamic Republic of Iran, had departed from Kish Island, Iran and, while on the final approach to runway 12 at Sharjah International Airport, was observed to suddenly pitch down and spiral into the ground. The aircraft impacted on vacant land in a residential area, but fortunately, there were no injuries to people on the ground, nor damage to property. The UAE General Civil Aviation Authority (GCAA) is the competent authority responsible for the investigation of aircraft accidents within the UAE. The GCAA immediately established an investigation to conduct full and comprehensive investigation into this accident. The team was assisted by representatives of the operator, the Iranian Civil Aviation authorities, component manufacturers, French Bureau of Accident Investigation, and the Sharjah Airport Authority.

The investigation determined that the cause of the accident involved human factors. Unfortunately, this accident was not unique and a similar fatal accident had occurred involving a Luxair Fokker 50, LX-LGB on November 6, 2002. As a result of the Kish Air accident, the GCAA has recommended that Fokker 50 pilots are made aware of the pertinent contents of this report. In addition, the State of Manufacturer (Civil Aviation Authority of The Netherlands) is recommended to ascertain the modification status of the protection devices of all Fokker F27 Mk.050 aircraft.

As a result of this investigation, and in an effort to improve flight safety generally, the GCAA has also recommended that the International Civil Aviation Organisation (ICAO) consider the installation of crash-protected video recorders on aircraft used in commercial air transport operations. The final report into this accident will be released to the appropriate authorities in accordance with international obligations.

NTSB: Plane in Gainesville crash had out-of-date inspection

GAINESVILLE, Fla. (AP) - The twin-engine plane that crashed at Gainesville Regional Airport in a deadly accident had an out-of-date inspection, an air safety investigator said.

John Lovell with the National Transportation Safety Board declined to say when the two-engine Beechcraft Duke was last inspected, but he said there were "no entries" in the maintenance log to indicate that it had the required check in the past year.

"Every year at a minimum, it has to have an inspection," he said.

The plane nose-dived near the airport's main terminal shortly after takeoff Sunday morning. It exploded into flames on impact, killing all three occupants: retired University of Florida engineering professor Giuseppe Basile, 69; Steve Varosi, 40, who studied under Basile; and Varosi's nephew Michael Varosi, 12, all of Gainesville.

When the plane crashed, Basile and Steve Varosi were testing an autopilot system they had developed.

It will be difficult to determine the cause of the crash because of the condition of the wreckage, Lovell said. No parts were found to be missing or separated from the airplane, so it does not appear that a lost part contributed to the crash.

Witnesses told investigators the plane rolled to the right before it dropped to the ground, sliding into a sport utility vehicle and pushing it through a terminal wall. No one else was hurt.

Lovell said he found that the right wing of the airplane was far more fragmented than the left, leading him to believe the plane's right side hit first. The curled, shredded edges of the plane's propellers lead him to believe they were still in motion when the plane crashed.

Crews examined the plane's left engine Tuesday and did not find abnormalities within it and were planning to examine the right engine Wednesday.

The airport terminal has reopened with a new wall.

Stopping Human Error in Medicine

Practicing Perfection Institute to unveil strategies and tools in Boston on May 23rd that can put a quick end to many medical mistakes.

Brattleboro, VT (PRWEB) April 18, 2006 -- The Practicing Perfection Institute, Inc. (PPI), an organization dedicated to the elimination of human error, announces the availability of tools and strategies that can quickly eliminate many of the human errors currently occurring in medicine. By infusing proven work behavior tools and organizational strategies into their cultures, medical organizations can cut human error by half in as little as thirty days.

"We’ve adapted the tools and strategies developed by the commercial nuclear power and aviation industries," commented PPI’s Founder and President Tim Autrey, "and are making them directly available to the healthcare community. While medical professionals are working diligently to solve longer term safety and quality issues, these tools and strategies can be quickly implemented. Once they’re in place, a large percentage of the mistakes currently occurring will be eliminated."

The Practicing Perfection Institute, Inc. was founded in 2005 with a profound vision: Error-free world-wide, one life at a time. Drawing from the successes and lessons learned over the past 20 years within the US commercial nuclear power and aviation industries, PPI is making rapid human error reduction a reality for the healthcare industry.

The study of human error can be very complex; however, when it comes to stopping the majority of mistakes people make, according to Dr. James Reason, "Low-level (and largely hard-wired) postural correcting mechanisms work extremely well." The tools and strategies offered by PPI work at this base level. They are fundamental. They are extremely effective.

"We want to prevent as many errors as possible as rapidly as possible," explains Tim Autrey. "There is no question that these tools and strategies work. The question is…how can you effectively get them into the culture of a healthcare environment? We are hosting a One Day Intensive in Boston, MA on May 23, during which we will give participants everything they need to quickly and effectively infuse these strategies and tools into their healthcare organizations."

The error reduction tools and strategies developed by PPI are part of a process known as Practicing Perfection. In addition to the Error Elimination Tools, elements of this process designed to raise the human performance of any organization to the highest possible levels include the Culture Profile, a tool that identifies organizational core elements that are setting people up to make mistakes; the Performance Enhancement Matrix (PEM), an on-line error reporting, tracking and trending database; and the Code of Honor (COH), an incredibly powerful means for achieving worker synergy and sense of ‘team’.

Sleeping Pills

About 42 million prescriptions for sleeping pills were filled in the United States in 2005, an increase of almost 60 percent since 2000, according to research company IMS Health. Some experts worry that sleeping pills are being overused and that prescribing doctors may be ignoring depression and other conditions that cause sleep problems. In the first 11 months of 2005, drug makers spent $298 million on sleeping pill ads in the United States, more than four times the amount spent in all of 2004. It is reported that 10 percent of Americans say they regularly have trouble falling asleep and staying asleep. (Forbes.com, " U.S. Sleeping Pill Use Growing Rapidly" February 7, 2006.

Given the obstacles of attaining restorative sleep during the day, you might assume that sleeping pills would be more popular among shiftworkers than day workers. However, the limited data on the subject does not support this claim. While the use of stimulants among workers in extended hours operations is reported to be twice that of the general population, the use of sleeping pills is about the same as the general population. Regardless, before a shiftworker seeks a prescription sleeping pill to help with sleep, they should be informed of strategies they can take to improve daytime sleep.

END thank you jetBlue