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Aviation Human Factors Industry News

July 06, 2006

Vol. II, Issue 23.

Authorities say lack of fuel caused crash

The pilot's son says his dad and the co-pilot may not have realized the aircraft was not prepared to fly before an accident in February 2005 that killed both of them.

CLEARWATER - A careful pilot, Ralph Carl Herrlin typically made a point of checking his airplane's fuel and water before taking off in his Beech 35-C33.

Even if he had watched the plane get fueled, "he would check it himself," his son, Richard Herrlin, 54, said this week.

But Herrlin may not have made that check before taking off on Feb. 15, 2005, the day his plane crashed into a Clearwater neighborhood. The crash killed Ralph Herrlin, 78, of Clearwater and Jim Edward Smith, 63, of Palm Harbor.

A note found in the wreckage said the plane had been waxed but not fueled, Richard Herrlin said. He said he thinks the note fell off the dashboard and to the floor before either man saw it.

Instead, Richard Herrlin said, each man flying that day might have assumed that the other had checked for fuel.

And that could have been a fatal error. An investigation by the National Transportation Safety Board determined the plane crashed after apparently running out of fuel.

Witnesses told investigators that they heard the engine "cutting in and out" before the crash, according to the NTSB, which recently released a report on the incident.

Federal investigators concluded the probable cause of the accident was the "loss of engine power during initial climb due to fuel exhaustion, the pilot's failure to refuel the airplane, and the pilot's failure to maintain minimum airspeed, which resulted in an inadvertent stall and uncontrolled descent into a residence."

Smith, also a private pilot and a certified aircraft mechanic, was in the left front seat, which indicates he was acting as the pilot in command of the plane. The report did not specify who was controlling the plane when it crashed.

The fuel truck operator at the city-owned airport told investigators he hadn't fueled the airplane on the day of the accident.

The NTSB report said there were no fuel stains or fuel residue on the house at impact and only a slight smell of fuel. No fuel was found when the fuel injection manifold valve and associated fuel lines were disassembled.

Families Of Chalk's Plane Crash Could Receive $51 Million Settlement

MIAMI -- The families of the 20 people killed in the crash of Chalk's Ocean Airways flight 101 could split $51 million in a tentative settlement of a wrongful death lawsuit.

The wing separated from the fuselage during takeoff Dec. 19, 2005, sending the plane plummeting into the water off Government Cut. All 20 people on board the plane, a 1940s era twin-engine Grumman G-73T, were killed. Investigators found fatigue cracks in the right wing of the plane.

Earlier this month, the National Transportation Safety Board released its report of the investigation about the crash. In the report, it stated some Chalk's pilots became so worried about maintenance in 2004 that three captains quit.

One of the pilots who quit, Grady Washatka, said in his resignation letter released by the NTSB that there was "blatant neglect" in many maintenance areas, including engine problems, corrosion and cracks and issues with the airplanes' weight.

"We love this company and we are trying to avoid the inevitable disaster that will ensue if these issues are not addressed," Washatka wrote on Jan. 13, 2005 -- less than a year before the crash.

The husband of the fatal flight's captain, Michele Marks, told investigators that his wife frequently complained about maintenance of the seaplanes and that the company wasn't spending enough money on the aircraft.

"Michele was becoming scared and talked about maintenance concerns all the time," the NTSB quoted Mark Marks as saying. "They were having close calls that were becoming more frequent."

Chalk's, which has flown between Florida and the Bahamas since 1919, has lost hundreds of thousands of dollars in recent years, according to figures from the federal Bureau of Transportation Statistics. Owner Jim Confalone bought the airline after it was forced into involuntary bankruptcy in 1999 under previous management when creditors sued the carrier.

The settlement still needs to be finalized for the families to receive the $51 million.

TSB: Crew fatigue, human error, led to crash

HALIFAX -- Incorrect data entered into takeoff software was partly to blame for the fiery crash of a Boeing 747 cargo plane in Halifax that killed seven crew members, the Transportation Safety Board said Thursday in its final report into the accident.

The board found that crew fatigue aboard the MK Airlines Ltd. jet "increased the probability" of making such a crucial mistake.

It also finds that the company didn't provide "formal training" on the software, and it's likely the crew member involved "was not fully conversant with the software."

The report says the crew failed to notice the error and the result was the throttles for the engines were set too low before the crash occurred in October 2004.

"Our investigation . . . underscored the importance of well-rested, attentive and fully trained crews," said Wendy Tadros, the board's acting chairwoman. "It also showed us that airline companies must actively ensure that their crews adhere to proper procedures."

MK Airlines, a British-based company which flies aircraft registered in Ghana, has said it believes the crew received adequate rest and that it provided them with training.

Investigators had earlier concluded the heavily laden aircraft simply didn't have enough speed or power to make it off the runway.

The board's sole formal recommendation is that international aviation authorities require cargo aircraft to be equipped with a device that would sound an alert when there is not enough power to take off safely.

"This investigation has shown that the problem we are addressing today is a pervasive problem," said Tadros. "Our recommendation has the potential to make air travel safer, not only here in Canada, but around the world."

Tadros said the board found evidence of 12 similar accidents worldwide that cost 300 lives.

"This is why we believe we need an additional line of defence - a mechanism to catch the unexpected errors," she told a news conference.

The MK Airlines plane, carrying lobsters and tractor parts, failed to lift off and dragged its tail along the runway before breaking up and erupting into flames in a wooded area near Halifax International Airport.

The board's analysis states that factors involved in the incorrect take-off data included, "flight crew fatigue, non-adherence to procedure, inadequate training on the Boeing laptop tool, and personal stresses."

A news release from MK Airlines says the report's findings cannot be regarded as conclusive because there was no cockpit voice recording of the pilots and first officers final words.

The report, "would always contain a significant element of conjecture," said the release from the firm.

Dave Wilson, a spokesman for the company, insisted the training on the takeoff software was sufficient.

"When we took the (software) we actually asked the manufacturer for guidance and we unilaterally developed a self-study training program, which included a 46-page guide for flight crews," he said.

As for the crew's fatigue, referred to repeatedly in the report, Wilson said the firm was "operating within legal (rest) time limits, using an approved flight scheme that is deemed acceptable by our industry."

The report noted that at the time of the accident, the crew had been on duty for 24 hours, the maximum allowed under MK's own operating manual.

However, the board adds that had the flight taken off successfully, the flight would have been in the air six hours more than allowed.

Wilson responded that when at the point of the crash, "they (the crew) were within their time limits at the time."

"Former employee says Jazz Maintenance is amongst the best"

This letter to the editor of the Toronto Star was published today.

Dear Editor:

RE: Economics trumps safety Jazz staff; Mechanics cite pressure to cut

corners 'I'm nervous flying on my own airline'

I feel compelled to respond to what is now a train of articles on aviation safety in Canada in order to bring some balance and objectivity to the reporting that has been offered to-date by the Toronto Star. I hope you have the courage to print this prominently and take accountability for the misleading pot-shots being taken at a innovative organization in a country that is a leader in civil aviation safety. Having worked for Air Canada Jazz in the past, partly during the period that was referred to by some of its current maintenance staff, I can speak with first-hand knowledge. Several of the examples being sited in the article are not only extremely dated (obviously had a difficult time finding anything truthful that was recent and relevant), they are not factual. Having been the director responsible for maintenance quality and engineering at the time, I was there and heavily involved in the follow-up to the leading edge incident. They also characterize the results of a Transport Canada audit completely erroneously.

The fact is that the audit results reflected only minor deficiencies that were mostly administrative in nature. I also find it telling that the maintenance staff quoted in the article actually admit that they knowingly released aircraft they considered to be unsafe or out-of-limits. Any true maintenance professional (all of the ones I had the privilege to work with) would never do such a thing, regardless of alleged pressure by supervisors!

Jazz was one of the first and most aggressive airlines in Canada and North America to begin implementing several safety-related innovations, such as human factors training and non-punitive safety reporting. These things are hallmarks of a healthy safety culture. They also treated safety with prominence within the senior ranks of the organization and formalized the monitoring and reporting of safety issues in many ways. There were a number of people who promoted this safety culture under the complete support and insistence of the president and others. Of course there are always improvements that must be pursued in any organization, but is should be acknowledged that Jazz has always been ahead of the regulatory curve by implementing safety-related policies and processes well before they were mandatory. Jazz has also been a true partner with Transport Canada, who have themselves been very innovative and proactive in regard to industry safety.

The Atlantic Region Transport Canada staff I worked with are among the best in the country.

It is terribly ironic that obviously disgruntled employees would inaccurately and unfairly trash their own organization when most other air carriers stood by and waited while a company like Jazz played a leadership role in safety. Even other aviation jurisdictions across the world recognize that Canada's approach to aviation safety ranks among the best, along with countries like Australia and the UK.

Perhaps the most disappointing aspect of this reporting is that is soils the reputation of perhaps the highest caliber aviation maintenance workforce in the country (coast-to-coat). Aviation maintenance professionals have fought very hard for many years to be seen as what they are - highly trained, motivated, critically important, and conscientious professionals. The pilot, in-flight , and other staff that work at Jazz are the same - true professionals who put safety first. The individuals who offered this misleading information for their own agenda have done a great disservice to their colleagues who have a lot to be proud of. I, for one, would put the safety of my family and friends in the hands of Air Canada Jazz any time, and I am proud to have been associated them.

David T. Deveau, P.Eng., MBA

Lucasville, Nova Scotia

ATSB releases Australian study into depressurization accidents and incidents.
The Australian ATSB published a study regarding depressurization accidents and incidents involving Australian civil aircraft. The purpose of this study was to determine the prevalence and consequences of aircraft decompression events. The aim was to document the prevalence, nature, type, degree and extent of decompression events, as well as the consequences of such events, especially hypoxia and pressure-related medical effects. A total of 517 pressurization failure events were found (two accidents, eight serious incidents and 507 incidents). Only one pressurization failure event was fatal. Mechanical factors were responsible for the majority of pressurization system failures (ATSB)

Surgeons take pilot training to cut number of mistakes
 SURGEONS in Scotland are taking tips from techniques used by pilots to avoid accidents, in an attempt to reduce errors in the operating theatre.

The move comes as a study carried out as part of the Notss project, published in this month’s RCSEd journal Surgeon, found that nearly three- quarters of consultants admitted to making errors in the operating theatre. In addition, 68% of trainee surgeons and 44% of nurses also said they had made mistakes.

Researchers have found that, like serious incidents in the aviation industry, mistakes during surgery often occur because of human error. They ranged from technical mistakes, such as the way a surgeon made an incision, to errors caused by poor handwriting, incomplete records, communication breakdowns and equipment not being available.

Now pioneering training is being developed for surgeons in Scotland to improve their thinking and teamwork skills, based on accident prevention strategies which pilots have recognized for more than two decades.

Health chiefs say it could also eventually be expanded to include staff working in other areas of the NHS where teamwork plays a vital role, ranging from accident and emergency departments to intensive care units.

Rhona Flin, professor of applied psychology at Aberdeen University, is heading the non-technical skills for surgeons project (Notss), which is being carried out in conjunction with the Royal College of Surgeons of Edinburgh (RCSEd) and NHS Education Scotland (NES).

She said that evidence had shown mistakes during surgery were often due to failures in communication or decision making, rather than poor technical skills or a lack of clinical knowledge.

"All the kind of psychological factors contributing to aviation accidents are found in other high-risk workplaces, like nuclear plants or operating theatres," she said. "What we are doing is taking techniques from high-risk industry and applying them to patient safety now. They have been doing training in aviation for non-technical skills for 25 years. These are thinking skills and teamwork skills."

The research also revealed that one-fifth of consultant surgeons did not think that they performed less effectively when they were stressed or tired, and only 40% said they would let other team members know when their workload was becoming too much.

Flin said that this attitude of a "sense of invulnerability" had been recognized as a problem for pilots as far back as three decades ago.

"Pilots have had a lot of training now, emphasizing that if you are tired or stressed this is very likely to impact on your performance," she said.

"There is not always something you can do about it if you are working shifts, but you need to be aware of it."

She added that teamwork could help prevent mistakes and also lead to better detection of errors.

A new handbook offering guidance on non-technical skills for surgeons is due to be published shortly. A similar booklet, developed by the same team for use by anesthetists, is now being used in other countries around the world, including Australia and Canada.

Even the least dangerous skin cancer is no trivial matter, says Harvard Women’s Health Watch

BOSTON, MA — Basal cell carcinoma is the most common skin cancer and the least dangerous—but it’s far from a trivial matter, reports the Harvard Women’s Health Watch. The good news is that basal cell carcinoma rarely spreads (metastasizes), and it can easily be treated and cured when discovered early.

Basal cell skin cancers almost always occur in areas exposed to the sun: 80% show up on the head and neck. The face is particularly vulnerable. The most common form—nodular—usually shows up as a shiny bump and may bleed easily. It often ulcerates and crusts over. Superficial basal cell carcinoma forms a red, scaly, sometimes itchy spot and may have flecks of dark pigment. It’s often mistaken for a patch of dermatitis. Morpheaform, a rarer and more aggressive type, has a waxy white or yellow scarlike appearance and poorly defined borders.

Basal cell carcinoma grows slowly and occurs mostly in people over age 55. Sun exposure is the biggest risk factor. Treatment options include freezing, surgical removal, radiation, and topical creams. Each has a cure rate of 90% or more for first-time cancers. 

The article also discusses the trends in tanning, which has not always been in fashion. Before the 20th century, for example, tan skin suggested outdoor labor and a lower social status, says Harvard Women’s Health Watch. The switch to tanning as socially desirable and fashionable came in the 1920s, after French designer Coco Chanel returned from a Riviera holiday sporting a bronzed look.

END with thanks to jetBlue