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Aviation Human Factors Industry News

May 16 2006

Vol. II, Issue 19.

This Day In History

On May 16, 1977, a landing gear failed on a Sikorsky S-61 taking on passengers at the Pan Am building. It tipped over, and its spinning rotor blades killed four passengers and sent debris into the streets below, injuring pedestrians. The accident precipitated the closure of the heliport for good. The accident was caused by the gear collapsing due to a fatigue fracture.

Chinese Worker Sucked Into Jet Engine

A ground crew member was killed after being sucked into the engine of a Boeing 737 plane in Harbin, reports said.

An investigation is being held into how the man was sucked into the engine of the Shanghai Airlines plane on Saturday, the Beijing Times said.

The incident occurred as the parked plane was preparing to take off for a flight to Shanghai.

Long landing leaves jet off runway at N.Y. airport

An AV-8B Harrier attack jet from Cherry Point experienced a long landing and ran off the runway at the Republic Airport in Farmingdale, N.Y., Friday at about 6 p.m. There were no injuries to the pilot or ground personnel.

The single-seat aircraft assigned to Marine Attack Squadron 231, 2nd Marine Aircraft Wing based at MCAS Cherry Point, was conducting training in the area.

The cause of the mishap is currently under investigation.

Precautions Needed After Birdstrikes

To date, Highly Pathogenic Avian Influenza H5N1 (HPAI), or bird flu, has not been detected in North America and the only documented cases of transmission to humans are from poultry according to the National Wildlife Health Center. But even though there are no documented cases of bird flu disease resulting from contact with wild birds, precautions should be taken when handling the remains of dead birds especially during clean-up after a bird strike.

A set of guidelines has been developed by Dr. Carla Dove with the Smithsonian Division of Birds and Dr. Richard Dolbeer, Wildlife Services, national coordinator, airport safety and assistance program. These guidelines are provided for those who routinely collect bird remains from runways or aircraft components for bird strike identification. They are advisory in nature to provide guidance for those concerned about highly pathogenic avian influenza.

To reiterate, currently, bird flu has not been reported in the United States but operating under the following guidelines, which may be updated periodically, is highly recommended.

First, when handling even apparently healthy wild birds in areas where bird flu is not suspected, use the following recommendations:

Work in well-ventilated areas if working indoors.

When outdoors, work upwind of birds, to the extent practical, to decrease the risk of inhaling aerosols such as dust, feathers, or dander.

Thoroughly wash hands with soap and water (or with alcohol-based hand products if the hands are not visibly soiled). This is a very effective method for inactivating influenza viruses, including HPAI. These viruses are also inactivated with common disinfectants such as detergents, 10% household bleach, alcohol and other commercial disinfectants. The virus is more difficult to inactivate in organic material such as soil.

When possible, wear rubber or latex gloves that can be disinfected or disposed.

Wash hands often as described above, and disinfect work surfaces and equipment between sites.

Do not eat, drink, or smoke while handling animals.

If there is any concern about airborne particles, wear a face mask and safety glasses when handling bird remains.

Spray the aircraft impact area with 70% ethanol (not water) and wipe with a paper towel. Place the paper towel in a Ziploc bag.

If you are involved in removing large numbers of birds or bird feces in a confined space such as when clearing pigeons or their feces from a hanger, wear a protective suit and a respirator.


US. Geological Survey Wildlife Health Center: www.nwhc.usgs.gov

World Health Organization:


Centers for Disease Control and Prevention: www.cdc.gov/flu/avian/gen-info/facts.htm

FAA Debuts Online 'Human Factors' Training

The Federal Aviation Administration Tuesday announced the debut of an online training program on the importance of "human factors." The Web Course consists of 10 self-guided lessons about the role that sensory, mental and physical capabilities and limitations should play in the design and development of machines.

"Improvements to aviation safety and capacity are dependent on developing a national aviation system that is not only technically sophisticated, but also human performance-based and human-centered," Joan Bauerlein, FAA's aviation research and development director, said in a statement.

The Web course is designed for people who support FAA system acquisitions, but it is open to the public. FAA employees can receive a training certificate for successful completion.

FAA requires systematic integration of human factors at every critical step in the design, testing and acquisition of new technology introduced in the U.S. aviation system.

The Web course adds breadth to a continuing human factors program whose beneficiaries, according to the FAA, are spread throughout government and industry. Knowledge of human factors, the agency said, is resulting in aircraft that are safer and easier to fly, and air traffic control systems that are quicker with decision support and more resistant to errors. To open Web Course left click on Web Course in paragraph 1, then select "open hyperlink".

Pilot in Black Sea Air Crash Highly Experienced - Armavia

YEREVAN, May 6 (RIA Novosti) - The pilot of an Airbus jet that crashed into the Black Sea early Wednesday, killing all the 113 people on board, was one of the airline's most experienced pilots, a company representative said Saturday.

The Russian Emergency Situations Ministry said in the immediate aftermath of the crash that stormy weather was the most likely cause of the crash of Armavia Airlines' A-320, though other officials indicated that human error was still being considered.

However, Grigory Airapetyan, in charge of Armavia's A-320 Airbus fleet, was skeptical of this theory.

"Forty-year-old Grigory Grigoryan, the pilot of the Airbus A-320 that crashed near Sochi, was one of the most experienced on the company's staff," he said.

Grigoryan had 5,700 hours of pilot flight time to his credit, including 1,200 hours flying an Airbus, and was one of the company's first pilots to complete a training program run by the Swedish air carrier SAS in Stockholm, Airapetyan said.

He expressed doubt that human error might have caused the crash.

"Judging from the evidence available now, this is highly unlikely."

Bad Repair Noted in Fatal 2004 Air Crash

A faulty repair appears to be largely to blame for a plane crash that killed Tahir Cheema, the founder and president of a locally based cargo airline, more than 17 months ago near St. Louis.

While a "factual" report issued by the National Transportation Safety Board does not identify a probable cause for the Nov. 30, 2004, crash near Chesterfield, Mo. that killed Mr. Cheema and a co-pilot, it shows that investigators focused on a system called the "elevator trim tab" that had just been repaired on the Hansa 320 aircraft that was to be flown from Spirit of St. Louis Airport to Toledo Express Airport.

Testing done on a Hansa 320 at Grand Aire's Toledo Express headquarters showed that when the controller for its elevator trim tab - part of a system that determines whether a plane pitches up or down or flies level - was rotated forward, it caused the tab to go into a position that would cause the aircraft to nose down.


But on the plane that crashed, similar motion of the controller moved the tab in such a way that the aircraft would nose up.

The report noted that the control cables for the elevator trim tab had been freshly replaced by a mechanic at Midcoast Aviation, a repair shop at Spirit of St. Louis Airport. The aircraft was not flown between the cable replacements and the crash flight.

Dick Williams, president of Aviation DataSource in Denver, said regardless of whether Mr. Cheema, who was piloting the fatal flight, was trying to go higher or lower, getting the opposite result from what he expected would have caused an immediate problem.

If the plane nosed down unexpectedly, a crash was imminent, he said, while if it nosed up unexpectedly, it could go into an aerodynamic stall that would cause it to lose airspeed.

"He doesn't have correct control of the pitch position, and he doesn't know why," he surmised.

The report also said Mr. Cheema needed to get the plane to Toledo that night to avoid the expense of obtaining a "check ride" coming due for him as a pilot of that aircraft model.

Mr. Cheema's "current" status as a certified Hansa 320 pilot expired the day of the crash.

Medical testing, meanwhile, found Mr. Cheema had diphenhydramine - the active ingredient in the cold medicine Benadryl - in his blood, lungs, and kidneys at the time of the crash.

"In therapeutic doses, the medication commonly results in drowsiness, and has measurable effects on performance of complex cognitive and motor tasks (e.g., flying an aircraft)," the safety board wrote.

Ted Lopatkiewicz, an NTSB spokesman, said agency officials would not elaborate on the report, since doing so would constitute analysis. A finding of "probable cause" for the crash could be issued by the end of this month, he said.

Mr. Cheema, 50, of Perrysburg, and co-pilot Eko Pinardi, 40, of Fort Wayne, Ind., died when the plane, which was being flown under a special "ferry permit," crashed two miles west of the airport on the edge of an island in the Missouri River.

According to an initial flight plan the NTSB cited, takeoff was originally scheduled for 3:30 p.m. St. Louis time for a 45-minute trip to Toledo. But Mr. Cheema postponed the departure several times - including one aborted takeoff when the plane's airspeed indicators didn't work - and the flight did not depart until 7:55 p.m. The plane crashed less than a minute after takeoff.

The tardy departure meant the flight was in violation of Federal Aviation Administration regulations. Mr. Pinardi had no training or experience flying a Hansa 320, which meant he was qualified to be second-in-command only during a daytime flight, the safety board reported.

The delays also meant that the flight took off in bad weather. Rain was falling and the temperature was 36 degrees at 7:28 p.m. As of the next report at 8:02 p.m., the rain had changed to light snow, but an airport official told investigators that there was no indication of any snow or ice sticking to surfaces at the time.

Mr. Williams said the combination of negative factors - the recent repair, the delays and bad weather, Mr. Cheema's apparent need to take cold medicine - suggest the flight was unwise.

NTSB: Flight Company That Crashed Missing Proper Permits

HONOLULU -- The company whose plane crashed on Molokai last month did not have the proper credentials to fly tour operations, according a preliminary report from the National Transportation Safety Board.

On April 30, a plane operated by Tora Flight Adventures crashed while trying to depart from Molokai at night. The plane was carrying five passengers.

The pilot and one passenger suffered serious injuries. The remaining three passengers suffered minor injuries.

The company did not hold an air taxi or commuter certificate from the Federal Aviation Agency, the NTSB stated in its report.

The company claimed it was not required to since the passengers did not pay for the flight since it was part of a tour offered by the ranch they were visiting on Molokai.

United States Air Force Thunderbirds Continue to Soar in 2006

Nellis Air Force Base, NV – May 2006 – The United States Air Force Air Demonstration Squadron (Thunderbirds) continues a busy and historic season in 2006, including more than 70 demonstrations in 27 states.

The team has been making history with the first female demonstration team pilot in the United States. Capt. Nicole Malachowski from Las Vegas, Nev., flies in the Number 3 position, as the right wing, and helps the team to represent the more than 530,000 Airmen throughout the U.S.

The team’s first performance was June 8, 1953, at Luke Air Force Base, Ariz. Since then, the Thunderbirds have flown before more than 400 million people at more than 3,800 air demonstrations in all 50 states and 59 foreign countries.


"Our job is to demonstrate the professional qualities the Air Force develops in the people who fly, maintain and support the aircraft," said Maj. Jeremy Sloane, the team’s operations officer. "We are a mirror-image of every other front-line fighter unit in the Air Force. Every member of the team is critical to the success of the mission."

"Because of military budget cuts and downsizing, a perception exists that the Air Force is out of the hiring business. Quite the contrary. That’s why the Thunderbirds are here. Our red, white and blue jets are a vivid reminder to young people that the Air Force is still hiring," said Major Sloane. "We need more than 24,000 new recruits this year alone."

The team is assigned to the 57th Wing at Nellis AFB and made up of eight pilots (six demonstration pilots), four support officers, four civilians and more than 120 enlisted in 28 career fields. Between March and November, the Thunderbirds average nearly 70 demonstrations, keeping them on the road more than 220 days.

"During the demonstration, the pilots fly some of the same maneuvers that every Air Force pilot learns in initial training," said Major Sloane. "Safety is paramount and key to planning the demonstration maneuvers."

The Thunderbird diamond formation, flying an average distance between 18 inches and 3 feet apart, represents the skills and training of every U.S. Air Force pilot.

"Because of the aircrafts’ proximity to each other, there’s little margin for error," explained Captain Malachowski, right wing. "We have tremendous confidence and trust in each other and our capabilities."

Thunderbird solo pilots’ job is to highlight the capabilities and max perform the F-16C Fighting Falcon to the world.

More than 90 aircraft maintainers ensure the Thunderbirds’ fleet of 11 F-16s are mission capable and the pilots strap themselves into a safe and reliable aircraft every time. Without their dedication, attention to detail and long hours of preparing for the performance, the demonstration may not be possible, said Major Sloane.

"It’s an honor for us to represent the Air Force," said Master Sgt. Tim Bollinger, the team’s sortie support flight chief. "It means a lot to all of us representing the quality of the pilots, maintainers and aviation support people who continue to make the U.S. Air Force the best in the world."

Twenty-two maintainers who show they have the initiative and the drive it takes to keep the team’s F-16s mission ready are assigned directly to an aircraft as a crew chief.

In addition to pilots and maintainers, there are an additional 30 people behind the scenes supporting the Thunderbird mission in operations, communications, administration, supply and public affairs.

Watching a Thunderbird performance provides only a small glimpse into how 530,000 Air Force professionals perform every day.

Tackling Human Error in the Workplace

BETWEEN 70% and 90% of workplace errors are attributed to ‘human error’, but did you know that many of these human errors are actually due to a mismatch between the way that human beings think and work, and the design of the systems with which they are required to work?

We need to start with a good understanding of the different types of human errors and their causes according to Filomena Sousa, CEO of Talsico International, to able to move to designing workplace systems and processes that minimize the potential for human error.

"Human beings have undergone no real significant changes in their brains or bodies in the last 100,000 years, whereas the human workplace has changed completely – from cave to office," Sousa said.

"We’ve had a 100,000 years of evolution to teach us to work in an open environment with natural light. The way our senses have evolved means that they are not designed to work in an office environment with square walls and artificial lighting. So there are some things about the workplace that can make us more error prone. We can’t do much to change our brains, but we can make changes to the workplace."

Systems and documentation too can be adapted to make them more aligned with how Sousa’s research has shown that the brain functions. "One pharmaceutical company I worked with was using a 49-page document to ensure that processes in a manufacturing line were covered off. Errors were being made with this documentation, which were having a huge impact on the company, with drugs prevented from being released onto the market because the documentation wasn’t right. A product recall in that area can cost millions of dollars," she said.

"As different people followed the same process, we found that a high proportion of the errors were the same, so here we could see that document design was the problem. We worked with the company to change the document and we were able to reduce errors by 74% without retraining the people and without changing the process."

The starting point with error reduction is to be able to categories the types of human error that are taking place within an organization. "I realized that organizations put all human errors together in one lump," Sousa explained.

"When something went wrong, people would ask what it was due to. Was it the machine? Was it the material? Or was it human error? They decide it was human error, but unless you can look at that lump called human error in much more specific categories, you can’t actually solve the errors because there isn’t just one thing that is causing them."

"So I had to find categories for these errors that would be useful… and once I’d done that, things started to become easier. I could look at what the symptoms are of each different type of error, and what can you do about it. This has become the basis of the work we are doing with organizations in error reduction now."

The six major types of error that Sousa identified are:

• Learning gap errors – Why didn’t people know what to do?

• Memory gap errors – Why did people know what to do but didn’t remember properly?

• Inconsistency errors – Why can there be variability in how people do things, even when they know and remember what to do correctly?

• Application errors – When people know what they are doing, why can they still make mistakes and apply the wrong action or information?

• Omission errors – Why do people miss out a step in paperwork or procedures?

• Decision errors – Why are inappropriate decisions made in a given situation?

In her seminar "Error Reduction: The Human Factors" Sousa works through these types of errors with organizations, looking at the symptoms and causes, and how they can be prevented.

"Like anything, the theory can be great, but without application it’s pretty useless. In the seminar we also build in real case studies of problems that have happened within people’s own organizations. Then, with the learning from the seminar, we help them come up with how they would fix it. This makes people feel so empowered, and so much more confident because this is their problem and they are solving it."

"We tend to start working with the senior leaders in an organization, because, unless they understand what we’re doing, it’s hard to make any changes," she said.


Which Kills More Women?

Pink Bats used by ML’ers yesterday to raise money for breast cancer.

By Catherine Jones

If you watched a baseball game on TV (or at the ball park) yesterday, you probably saw something you had never seen before at a Major League game: Pink baseball bats. In addition to adding some Mother’s Day color, the pink bats raised money to fight breast cancer. Good for baseball.

But here’s a trivia question: Which kills more women every year, breast cancer or stroke?

Answer: Stroke

According to the National Stroke Association (NSA), more than 100,000 women die from stroke every year, nearly twice the number of women who die from breast cancer. May is National Stroke Awareness month and the NSA wants to spread the word about how women are uniquely affected by strokes. Here are some other facts:

While men may suffer more strokes than women, women are more likely than men to die from stroke.

African American women are significantly more prone to stroke than Caucasian women

According to the NSA, 80% of us — men and women — can prevent strokes from ever happening. How? By:

Knowing your blood pressure

Not smoking

Drinking alcohol only in moderation

Exercising regularly

Sticking to a low salt, low fat diet

And, most importantly, having an annual physical exam and talking to your doctor about your stroke risks.

Source: National Stroke Association.


Cell Phones & Accidents

Motorists who use cell phones when they drive are up to four times more likely to get into accidents than motorists who concentrate exclusively on their driving.

Source: New England Journal of Medicine

END with thanks to jetBlue