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Aviation Human Factors Industry News

May 29, 2006

Vol. II, Issue 20.

This Landing Was The Pits –Lack Of Communication!

Accidents happen, but it certainly appears that something went off the USAF paper trail to cause an accident like this. First, we can't confirm exactly what happened here (and we'd love to hear from anyone who can) but based on the number of sources from which we obtained these photos and text, it sure looks like somebody removed a section of runway in Iraq and didn't inform the people who might expect to use it. The C-130 was landing on the night of Dec. 29 (it may have been a special-forces plane) when it hit the pit and instantly became a runway hazard itself. No one was killed but there were several injuries and the plane is a goner. Those of you with PowerPoint will want to see it with your own eyes. According to our sources, the existence of the pit had been reported earlier by the crew of another aircraft, but apparently no NOTAM was issued. The accident rated a couple of paragraphs in an American Forces Press Service report, which termed it a "landing accident." The report said 11 people were on board, there were injuries, and that an investigation is underway. Click through to download the content-unconfirmed (PowerPoint) file. It includes images. Not recommended for slower connections.

Rash of Jet Tire Failures Perplexes Experts

(Akron/Tire Review) A recent rash of blown aircraft tires – particularly on passenger jets – has experts concerned and perplexed.

While it is not unusual for aircraft tires to deflate unexpectedly – the usual culprit is debris on the runway – the number of incidents over the last month has been noticed.

Earlier this week, one regional jet aborted its takeoff from Albany International Airport after one of its main landing gear tires blew out, and another regional jet made an emergency landing at Washington National Airport after suffering a similar problem. There were no injuries in either event.

The week before, another regional jet suffered a tire failure on its main landing gear while taking off from Washington National for Dallas. That flight diverted to Dulles Airport and made a safe landing.

Experts quickly note that a tire failure on a commercial aircraft during takeoff or landing is not usually a major problem, as pilots are well trained to handle the ground stability problems an aircraft suffers after losing a tire.

There were two other incidents in early May, one captured on CNN and other news networks. A regional jet taking off from Houston suffered double tire failure on its main gear, leaving bare wheel exposed. The jet flew around the Houston area to burn off fuel before making a successful landing.

At Chicago’s O’Hare International, a regional jet that had just touched down on landing suddenly veered off the runway and into a grassy area. Air traffic controllers saw a huge plume of smoke from the main landing gear when the jet touched down, a telltale sign that the tires failed. No one was injured.

Tire problems have not been restricted to North America. On May 5, a large commercial jet skidded off the tarmac at Jakarta Soekarno-Hatta International Airport after it suffered tire failure while on takeoff. A number of passengers were injured and taken to area hospitals.

On May 4, an Airbus A320 with 180 passengers suffered dual tire failure on landing at Zamboanga International Airport in Manila. Pilots brought the aircraft to a safe stop in the middle of the runway.

Three months earlier, the same airport suffered a similar incident. Again, no one was hurt.

Newspaper: weight distribution factor in West Caribbean MD-82 accident

French newspaper Le Figaro, quoting an anonymous source, reported that the West Caribbean MD-82 that crashed in Venezuela, August 2005, was overloaded.

It reportedly had a takeoff weight of 70,300 kilos, where mtow is 67,600 kilos. The cargo was badly distributed as well. Another factor would have been human factors with the captain declining suggestions from the copilot to switch on engine anti-icing. (El Universal)


NTSB investigating reported fuel-tank explosion on Boeing 727 in India

The National Transportation Safety Board (NTSB) is sending a team of investigators to Bangalore, India, to assist in the investigation of a reported wing fuel-tank explosion on a Transmile Airlines Boeing 727-200. Transmile is a Malayasian air-cargo company. The incident occurred May 4 while the airplane was on the ground in Bangalore. There were no passengers and no one was injured. The investigation comes just ahead of the 10th anniversary of the loss of TWA-800 off the coast of New York state, with the deaths of all 230 people aboard that Boeing 747.

Fault found with crash investigation

New crash report clears engineers

Engineers originally blamed for a helicopter crash that claimed three people's lives may sue investigators following a new report which proves they weren't responsible after all.

The company says the accusation nearly destroyed their business and the that a letter expressing its regret from the Transport Accident Investigation Commission is not enough.

Witnesses saw a tail rotor blade fly off seconds before the former US military helicopter plummeted to the ground.

Now the commission admits it its first investigation was flawed.

"Getting it wrong in circumstances where there is a technical mystery is not a matter of embarrassment, what is important is putting it right," says TAIC chief commissioner Bill Jeffries.

The coroner rejected the initial accident report, and a similar helicopter crash prompted the second inquiry.

Now a bent pin in the tail rotor is being blamed as the prime cause.

"We don't know when the bend occurred, but it occurred fairly close to the actual accident itself," says Ken Mathews, TAIC investigator in charge at a press conference on Thursday.

For the maintenance company, initially held responsible for the triple fatality, it's been a guilt fuelled five years.

The engineers have fought hard to clear their name and save their business.

"Bloody unfair isn't it...they can just come along and screw up your life and walk away and say oh sorry," says Air Repair Taranaki Mark Saunders.

Their supporters are also delighted with the latest admission.

"Oh we're delighted for Mark...Mark would have been in jail if it hadn't been for this new report that vindicated him and Air Repair Taranaki," says friend Helene Green.

The families of the three dead men have always worried about the adequacy of the daily inspections of the helicopter.

The Civil Aviation Authority admits there was a misunderstanding about who should do those inspections, but says there's no evidence this contributed to the accident.

And its implemented more stringent maintenance procedures for ex-military helicopters.

Some Controllers Not Getting Enough Sleep, NTSB Says

The NTSB says that fatigued air traffic controllers caused two near misses at O'Hare International Airport, The Associated Press reported on Tuesday.

The incidents reveal a recurring pattern of fatigue, and officials should "emphasize the importance of sleep management," the NTSB said. On March 21, two airliners were cleared to take off from intersecting runways, and came within 100 feet of each other before stopping. Two days later, an airplane was cleared to taxi across a runway where another jet was on its takeoff roll. They missed by 600 feet. In one case, the controller had just four hours of sleep the night before, and in the other case, a trainee controller had an untreated sleep disorder, authorities said. A union rep told the AP that controllers will call in sick if they feel they haven't had enough rest to work safely.

Report blames human error for Cypriot crash - media

ATHENS (Reuters) - Human error led to a Cypriot airliner crashing near Athens last August, killing all 121 people aboard, according to an official report leaked to the Greek media on Friday.

The report indicates technicians in Cyprus, checking the decompression system following problems on an earlier flight, forgot to switch on its automatic activation.

Once airborne, pilots forgot to check whether the system was switched on automatic or manual, according to the draft report by the Greek accidents investigation committee.

As a consequence, the higher the plane flew the less oxygen was in the cabin, causing everyone aboard, except for a steward, to fall unconscious.

The report said even if the steward, using portable oxygen bottles, had managed to land the plane all the passengers would have been dead because of a lack of oxygen.

There was no comment from Cypriot authorities on the report.

The committee was investigating why the Helios Airways Boeing 737-300 had crashed on a flight from Cyprus to Prague.

The committee delivered the dossier to Cypriot authorities on Thursday. The Cypriots have 60 days to include their own findings before a final report is published.

Long suspected to have suffered a loss of cabin pressure, the plane was on autopilot for more than two hours. A steward with a trainee pilot's license was grappling at its controls.

Trailed by two Greek fighters which scrambled when the plane lost radio contact, it crashed into a mountain north of Athens after running out of fuel.

Leaked to several newspapers, the report blames the Cyprus civil aviation authority for not following international safety checks and criticizes the airline for a lack of attention to air safety.

Ajet, the successor company to Helios, said it would comment on the draft report within a specified 60-day deadline.

"Our commitment to cooperate fully with the accident investigators stems from our sincere desire to establish the true causes of this tragic accident," it said in a statement.

"We are required to keep the contents of the draft report confidential, hence we shall not be commenting on any issues that may be reported, until the publication of the final report."

NTSB: Human error to blame in '04 Med Flight crash near San Diego

Errors by flight crew and air traffic control were to blame in the deadly crash of a medical air ambulance in Southern California mountains near the Mexican border on Oct. 24, 2004, the National Transportation Safety Board said Tuesday.

The crash killed the captain, co-pilot and three medical crewmembers and destroyed the Learjet 35A operated by Med Flight Air Ambulance. The accident occurred shortly after takeoff from Brown Field Municipal Airport near San Diego.

The board said the air traffic controller failed to alert the crew to altitude warnings as the plane was on track to fly into a mountain. The flight crew also did not follow the recommended departure procedures for taking off at night and in mountainous terrain, the board determined.

The captain and co-pilot took off straight, heading toward the mountains at an altitude of 2,300 feet, the board said. The controller identified the airplane on the radar screen and instructed crew members to expect clearance above 5,000 feet, but then issued a heading that resulted in a flight track directly into the mountains, the board said.

"The controller had the knowledge and opportunity to alert the flight crew to an unsafe condition, but failed to take appropriate action to do so," the board said in a press release. The controller was not identified in the NTSB press release.

"The board has seen too often in its investigations where the flight crew and/or controllers are not performing their duties as they should," said NTSB Acting Chairman Mark Rosenker. "We cannot emphasize enough the importance of following the appropriate procedures to help ensure safety."

The board also said that the pilots' fatigue was a contributing factor, though their rest and duty time were within allowable limits. At the time of the accident, the captain had been awake about 17 1/2 hours, and the co-pilot had been awake about 16 hours, and both pilots had accumulated about 11 hours duty time.

NTSB urges approval rethink

Calls for safety-critical assessments follow investigations into ‘preventable’ disasters

The US National Transportation Safety Board (NTSB) is calling for the US Federal Aviation Administration to amend procedures for addressing and documenting safety hazards and provide ongoing assessments of safety-critical systems.

The board’s recommendations follow the investigation of four crashes between 1999 and 2004 that "raised questions about the certification process used by the FAA to determine compliance with airworthiness standards".

In its recommendations, the NTSB says the FAA should require that a list of safety-critical systems be drafted during type certification; provide for ongoing safety-critical assessments during the life of the aircraft; and consider the impact of human factors and structural failures in such assessments.

"The policy, practices, and procedures put in place for continued airworthiness do not ensure that the underlying assumptions made during design and type certification about safety-critical systems are assessed in light of operational experience, lessons learned, and new knowledge," says the NTSB.

The NTSB’s recommendations follow several accident investigations where questions were raised into how a modified certification process could have prevented the disasters. These include the USAir Boeing 737-300 accident in September 1994 in which the NTSB focused on the rudder actuator; and the TWA Boeing 747-100 crash in July 1996, which was blamed on the centre wing fuel tank.

Other investigations noted were those into the Alaska Airlines Boeing MD-83 crash in January 2000, caused by the horizontal stabiliser screwjack assembly, and the American Airlines Airbus A300-600R accident in November 2001, which focused on the rudder system.

Too close for comfort at LGA?

There is a call for action by airline pilots after an Eyewitness News investigation discovered a growing problem at a major New York Airport.

Aborted landings are on the rise as pilots try to avoid colliding with other planes.

The Airline Pilots Association is responding to our investigation. They say the heavy reliance on aborted landings at LaGaurdia could be a sign that planes are flying much too close for comfort.

Everyday, 1100 planes take off or land at LaGuardia. Since the airport has intersecting runways, that means landing and departing planes are literally pointing at each other.

It's usually not a problem. But sometimes it can be close and when it is, pilots are forced to abort their landings to avoid collision as was the case with a Delta 727.

Air Traffic Control: "Delta 1764 go around traffic departing left to right, expedite your climb up to 2,000."

Pilot: "We're heading to 2000, we're expediting."

To prevent collision, the controller then radios urgent instructions to the plane taking off:

Air Traffic Control: "Fox trot keep it low through the intersection, departure correction go around, right to left."

Pilot: "We'll keep it down low, 5/50 fox."

Bob Ober, former commercial pilot: "That is a very hazardous situation, so they tried to separate the two airplanes vertically and in that situation with one departing and one arriving you really don't have that much control vertically on either airplane and it's a dangerous thing."

An examination of hundreds of daily operation logs shows that aborted landings are occurring on a regular basis at LaGuardia, six, eight and even 12 times a day.

During a six month period last year, pilots flying into LaGuardia had to abort their landings 488 times -- that's more than three times the number at Newark and more than eight times as many as JFK.

Captain Larry Neuman, Airline Pilots Association: "We think it's a symptom of an airport that's over utilized."

Neuman says the FAA needs to act.

"We need to take a close, systematic risk-based look at their operation there and see in fact that the demand that they are putting on that airport, the number of flights that have been scheduling in and trying to get out of there are just basically exceeding the capabilities of the controllers," he said.

Marion Blakey, FAA administrator: "Yes, we are running aircraft at LaGuardia very tight because you can."

The head of the FAA sees no need to investigate aborted landings at LaGuardia.

Blakey: "The overall track record at LaGuardia is very, very good. In terms of operational errors, they are relatively few. In terms of pilot deviations, again, you don't see a big spike in problems there."

Yet, pilot complaints to the aviation safety reporting system shows the airport has a history of close calls. One pilot calls LaGuardia "a hot spot" and another complains about there being "little margin left for human error."

Mitchell Seber, pilot: "The traffic is dense, the communications are very rapid paced and the environment is very intolerant of any kind of deviation. So you really need to be on your game when you fly in this airspace."

Air traffic controllers at LaGuardia admit they are often pushed to the limit but say they can handle it and aborted landings are a safe way to keep planes apart.

Bill McLoughlin, Air Traffic Control at LaGuardia: "We always work at the absolute minimum standard of separation established by the FAA. Once we can no longer do that, out only option is to send an aircraft around or have it go missed-approached."

The National Transportation Safety Board has for years been urging the FAA to increase space between arriving and departing planes at LaGuardia, claiming that failure to do so could lead to "catastrophic accidents."

Field Report: Shiftwork Myths

Nobody likes to work the night shift.

FACT: Typically 15% to 20% of a shiftwork population prefers working the night shift. The reasons for this are various. One frequent reason for preferring the night shift is that the shiftworker will always have the option to have time during the day to run errands and take care of other tasks when traffic and crowds are lower.

Many shiftworkers prefer the night shift because it allows them the chance to be at home when their children are coming home from school or their partners are coming home from work.

Another less frequently mentioned reason is that night shifts minimize interaction with management and they don’t have to deal with any of the extra stress that management may present to them.

Some also simply prefer the later hours of the night shift. Some people show strong circadian "personalities" either as people who strongly prefer the early morning (lark) or strongly prefer the late night (owl). For a shiftworker who already has an owl personality, the night shift is simply the shift that best fits his or her personal circadian rhythm.

Beating Tension Headaches

Headaches don’t start in the brain, as many people think. They are actually the products of malfunctioning blood vessels, nerves, — and in the case of tension headaches — muscles in the head.

Tension headaches usually develop in the afternoon, usually causing mild or moderate pain. It may envelop your entire head or be limited to the forehead or to the back or top of your head. Many people describe the sensation as a dull tightness or pressure that occurs in a band like pattern.

Experts believe that the pain of a tension headache is caused by tightness in the muscles of the scalp and the back of the neck. A variety of emotional and physical factors can trigger this muscle tightness. One survey reported that stress was the most common trigger of tension headaches. Other triggers include missed meals, lack of sleep, and fatigue. Physical problems, such as eyestrain, whiplash, or poor posture, can also act as triggers.

Treating tension headaches

The muscle tightness of a tension headache is often difficult to reverse. Over-the-counter (OTC) and even prescription pain relievers usually don’t help much because they target only the symptom of tension headache (pain), without addressing the underlying cause (muscle contraction). Rely on them too much and you may find that your tension headaches gradually increase in frequency. To make matters worse, taking pain relievers more than two days a week, especially those containing caffeine, may make other medications less effective at relieving your tension headaches. So, the best way to stop the pain of tension headache is to target its major cause: muscle contraction.

Talk to your doctor about medications other than painkillers. Certain tricyclic antidepressants are particularly effective for preventing tension headache. Because they cause drowsiness, tricyclic antidepressants are particularly useful for those who have both tension headache and insomnia.

Your doctor might prescribe a fast-acting but short-lived muscle relaxant, which can loosen head and neck muscles. While these medications don’t relieve pain any more effectively than OTC analgesics, they do address the cause of the tension headache. They work quickly, taking effect within 15–30 minutes. They may cause drowsiness and fatigue, so avoid driving, operating heavy equipment, or performing other hazardous tasks while taking these medications.

A long-acting muscle relaxant can stave off tension headaches. Side effects are similar to those of short-acting muscle relaxants. To reduce the likelihood that side effects will disrupt your routine, these medications should be taken only once, before bedtime.

Identify and treat pressure points. Some people with tension headache have very sensitive areas, known as trigger points, at the back of the neck or shoulders. When touched, these tender areas sometimes prompt a headache. If your doctor identifies such trigger points during the physical exam and other treatments fail to provide relief, injecting a local anesthetic into these areas may eliminate the pain and prevent the headache from occurring again. This option has limitations, though. First, you must receive the shot at a clinic, hospital, or your doctor’s office. Second, many people are uneasy about receiving a shot in the neck or shoulders.

Try nondrug/alternative therapies. You can also try various types of physical and relaxation therapies to prevent tension headache, although these techniques only work if you practice them on a regular basis, preferably every day. The simplest strategy is to apply a heating pad to your neck or shoulder, to relax the muscles. Your doctor may be able to provide examples of suitable exercises or a referral to a physical therapist.

Preventing tension headaches

To keep tension headaches at bay:

Don’t skip meals.

Get enough sleep.

Pace yourself to avoid excessive fatigue.

A headache may be more serious when…

About 95% of headaches aren’t caused by an underlying disease or structural abnormality. However, because the following symptoms could indicate a significant medical problem, seek medical care promptly if you experience

a sudden, severe headache (with or without a stiff neck)

a headache with fever


a headache following a blow to the head

confusion or loss of consciousness

a headache along with pain in the eye or ear

a persistent headache when you were previously headache-free

a headache that interferes with routine activities.


END  thanks to jetBlue