Our Mission: "To assist our clients in developing the best possible Safety System to meet their needs".

Aviation Human Factors Industry News

July 11, 2006

Vol. II, Issue 24.

 Russia investigates Airbus crash on day of mourning

IRKUTSK, Russia (AFP) - Investigators were working to determine what caused an Airbus passenger plane to overrun the runway and crash in the Siberian city of Irkutsk, as Russia marked a day of mourning for some 130 people killed in the accident.

Transport Minister Igor Levitin, after chairing a meeting of a commission set up to investigate the cause of the accident, told reporters here Monday that so far 122 bodies had been recovered and six were still unaccounted for while 57 people were being treated in hospital for injuries.

The crash of the Airbus A310 occurred Sunday when the plane, on a flight from Moscow, landed at Irkutsk airport but failed to slow down sufficiently and careered off the end of the runway, ramming into a building and bursting into flames.

There have been three more serious incidents involving Russian passenger planes in 36 hours following the crash. In the latest incident on Tuesday, a plane carrying the Russian navy's chief of staff and other officers crash-landed and caught fire at an airfield in Ukraine.

No fatalities were reported in any of the other incidents but several people were hospitalized with injuries in the accident of the Tupolev 134 twin-engine plane carrying Admiral Vladimir Masorin, a spokesman for Russia's Black Sea fleet said in a statement.

The plane was destroyed in the incident.

Flight data and voice recorders from the Irkutsk crash were sent to Moscow for analysis and investigators were quoted in Russian media as saying that a problem with the braking system or human error were among potential causes of the wreck they would be looking at.

Obtaining a precise figure for dead and injured was complicated by the fact that different officials and media reports gave varying numbers for how many people were on board, while some survivors appeared to have left the scene of the accident without being accounted for.

Most sources, however, put the number of bodies recovered so far at 122 and the number of victims still unaccounted for at between six and nine, putting the death toll from the accident at between 128 and 131.

Tents were erected outside the Irkutsk morgue for the temporary storage of bodies as the morgue itself was not large enough to hold them all. Around 200 members of victims' families were there to identify the bodies of their loved ones on Monday, officials said.

President Vladimir Putin declared Monday a national day of mourning and flags throughout Russia were ordered flown at half-mast while public entertainment events were cancelled.

Authorities announced victims' family members would receive an initial payment of around 2,000 euros (2,500 dollars) to cover some immediate costs associated with the accident.

The Irkutsk airport was described by Russian pilots as among the most challenging in Russia due to a combination of its altitude, relatively short runway and proximity to the city of Irkutsk.


Climbing to new heights

Technological advances and lessons of the past have eliminated much of the risks of commercial airline travel

In the decade since TWA Flight 800 exploded off Long Island's South Shore, flying on commercial airlines has grown so much safer that the risk of dying in a plane crash has plunged to its lowest level in history.

Improvements in technology and training - and an added focus on safety spawned by Flight 800 in July 1996 and the ValuJet crash in Florida two months earlier - have helped usher in an unprecedented period of air safety, experts say.

In the past five years, the accident rate "has been brought to the brink of extinction," said Arnold Barnett, a professor at the Massachusetts Institute of Technology who has done extensive studies of aviation statistics.

"Air safety is a process; it usually moves at a snail's pace. But it is increasing. We are learning from our mistakes," said Michael Barr, who runs the aviation safety program at the University of Southern California.

The last major crash of a commercial airliner in the United States was in November 2001, when Flight 587 crashed in the Rockaways. That span without a major accident is the longest in modern aviation, Barr said.

Excluding the loss of life on Sept. 11, 2001, the chance of perishing in a domestic flight in the United States has been virtually nonexistent in the past five years. Of the 46 million flights of U.S.-based airlines from 2000 to 2006, only two crashed, including 587, en route to the Dominican Republic, and Alaska Airlines Flight 261, off the California coast in January 2000.

"By every measurement the industry is safer today than it has ever been," said John Cox, a former safety chief for the Air Line Pilots Association and now a Washington, D.C.-based consultant.

Flight 800 had focused attention on stricter airline safety, and Vice President Al Gore convened a commission a few weeks after the TWA 800 crash, saying the nation should aim to reduce airline accidents by 80 percent. Since that time, better pilot training and procedural changes have helped put that goal within reach, experts say.

Also, newer planes make up a greater percentage of the commercial fleet, after airlines parked some of their older models when Sept. 11 caused a slowdown in air travel.

In response to the TWA crash, the Federal Aviation Administration has ordered new procedures to prevent sparks that can cause a fuel tank explosion, and has increased its focus on aging wiring.

Ongoing push for safety

In the 1990s, the risk of being killed in an accident on a random domestic jet flight, excluding underdeveloped countries, was 1 in 13 million. At that rate, you'd have to take a flight every day for 36,000 years before dying in an accident - an example Barnett uses to illustrate the level of safety. In the past five years, with no domestic jet accidents in which passengers died, that risk is essentially nonexistent.

"A passenger could travel on an infinite number of flights" before facing the risk of death, Barnett said.

On international flights between developed nations, including the United States and much of Europe, the risk of dying went from 1 in 6 million in the 1990s to 1 in 8 million between 2000 and now, according to Barnett's analysis.

Despite the added attention on safety in the past decade, the groundwork for some of the improvement in the safety record had been laid decades ago.

The wind shear that was a major cause of accidents in the 1970s has been all but eliminated with new technology. The risk of midair collisions also had been drastically reduced when regulators in the mid-1990s began to require new cockpit devices that alert aircraft to nearby traffic.

Other improvements, including installation of a ground proximity warning system in aircraft worldwide, are helping the rate go down. For nearly two decades, the leading cause of plane crashes worldwide was the phenomenon of a pilot accidentally flying the plane into a mountainside or the ground, called "controlled flight into terrain" - a category of accidents that has been nearly eliminated.

Barr said he doesn't believe the credit can go to any one group or initiative. "The FAA didn't do it, the pilots didn't do it, the maintenance guys didn't do it, the air traffic controllers didn't do it. But when you put them all together, you get the best of each and you get the increase in safety we are seeing."

Keeping guard up

"Relative to most things, it's very safe to fly on commercial jetliners. Is it safer now? Of course it is," said Bernard Loeb, former head of aviation safety for the National Transportation Safety Board. "But it is naive to believe that the last five years is what we should expect in the future.

"There are major disasters and lots of hand-wringing, and a little something is done, and then there's a period when there's no major crashes. And nothing gets done."

Even technology offers no guarantees it will work properly. In the Boeing 737, for instance, engineers designed what Loeb called an ingenious device to control the rudder, one that saved weight and space over previous models. "But the problem was, it was so complicated that they couldn't understand all the failure modes," Loeb said. Problems with the device became apparent in the crash of USAir Flight 427 in Pittsburgh in 1994.

Maintaining good record

Cox also cautioned that increasing dependence on composite structures instead of aluminum for airframes is one area regulators will have to watch, as well as the new dependence on computerized cockpit systems that can fail.

"Is the trend going to continue? That's going to be based on decisions we make today," Cox said. "If we rest on our laurels, the rate will stagnate or get worse."

In fact, many experts point out that the one fix that could have prevented the fuel tank explosion that brought down Flight 800 still is not required of airlines on existing fleets. The FAA has required only that new-design airplanes - such as Boeing's new 717 - have fuel tanks that would prevent a buildup of flammable vapors. Another rule proposed by the FAA, requiring the new standard on planes now flying, is not expected to become final this year, and the agency is expected to give airlines seven years to comply.

Over the past 40 years, there have been 17 fuel tank explosions aboard aircraft, including Flight 800.

Expanding their approach

What's the next frontier? Cox said the industry must look more closely at issues such as pilots losing control in flight, the potential for runway collisions, and smoke and fire in flight.

And with fewer accidents to investigate, resources should be put on incidents that don't make headlines but could be considered precursors to a deadly crash, he said.

Last month, NTSB investigators went out to California to investigate an engine explosion on an American Airlines Boeing 767 that was undergoing maintenance. The explosion, which sent metal shards into the fuselage, occurred on the ground at Los Angeles International Airport; no one was injured. But it could have been a different story if it had happened in midair.

Despite the dramatic drop in the number of major accidents, top safety officials at the FAA literally knock on wood when someone mentions the crash-free years. The perfect safety record they strive for, the only acceptable figure, will always be elusive. And they'll tell you that the only guarantee a plane won't crash is to never take off.

Bombardier Learjet Safety Stand-down 2006

The "War on Error" continues. The Bombardier Learjet Safety Stand-down will be held October 2 - 5, 2006 in Wichita at the Hyatt Regency Hotel. This year marks the 10th anniversary for Safety Standdown with added importance.

This year FAA and NBAA will partner with us in the presentation of Safety Stand-down. This partnership between industry, government and operators is an important step in integrating knowledge-based training with skill-based training in an effort to reduce the number of accidents due to human error.

Mr. Nick Sabatini the Associate Administrator for Aviation Safety will represent FAA and Mr. Ed Bolen President and CEO will represent NBAA.

DGCA Reports Pins Fault On Pilots, Maintenance Error

Maintenance failure and human error caused the helicopter crash that killed the then Haryana Agriculture Minister Surender Singh and Power Minister O P Jindal in March 2005. This is what the inquiry report of the Directorate General of Civil Aviation (DGCA) says. The DGCA has submitted its final report to the government, which was yet to ratify it.

‘‘Investigations reveal turbine failure and the inability of the pilot to notice the increase in temperature because of the failure. So, in effect, the crash was a combination of a maintenance problem and human error,’’ said a senior DGCA official.

The chopper pilot TS Chauhan was also killed in the crash in Saharanpur district of Uttar Pradesh.

Human error is a prime reason for chopper crashes. In an analysis of accidents involving civil registered helicopters in India between June 1990 and April 2005, the Rotary Wing Society of India (RWSI) has stated that 22 out of the total 41 major helicopter accidents during the period were due to pilot error, 12 were due to improper maintenance and five were avoidable ground accidents. The RWSI analysis is based on DGCA data.

Presenting the analysis before the International Helicopter Safety Team (IHST) at a regional conference on helicopter safety, RWSI president AVM K Sridharan said 19 of these 41 helicopters belonged to state governments and Public Sector Undertakings. ‘‘Non-compliance with Standard Operating Procedures was the cause of most of the accidents,’’ Sridharan said. ‘‘In some cases, pressure to complete the mission to beat competition was the major factor,’’ stated the RWSI analysis report.

Education key to aviation safety (New Zealand)

The aviation industry says further enforcement in the sector is not the solution to improving public safety.

The Civil Aviation Authority is promising to implement all the recommendations made in a Coroner's report on the fatal Air Adventures crash in June 2003, and in a separate Audit Office report.

Minister of Transport Annette King says enforcement in the sector has not been good enough in the past.

But Aviation Industry Association chief executive Irene King says there has been a 30% reduction in accidents in the past three years.

She says that was achieved through better education, instead of more rules and regulations.


Hot Tips for the BBQ

Unwatched BBQs can ruin more than a meal

With national holidays being celebrated on both sides of the border in the next few days, it's timely to discuss with your workers the safety aspect of a popular summertime ritual — the BBQ.

According to the US Fire Administration, every year BBQ grills cause approximately 6,500 fires. The peak month for grill fires? July.

The top ignition factor, accounting for 43% of grill fires, is mechanical failure or malfunction, such as part failure, leak, break or lack of maintenance. Other ignition factors include:

      · Misuse of heat of ignition — such as lack of control of open fire and abandoned materials

      · Misuse of material ignited — such as combustible material being too close to heat

      · Operating deficiency — primarily leaving the grill unattended

The USFA believes that with proper maintenance, inspection and vigilance, many outdoor grill fires can be prevented. Here are some top BBQ do's and don'ts:


      · Operate BBQ outdoors only, 10 feet from house, garage and trees

      · Maintain your BBQ by replacing rusted or worn hoses and fittings

      · Test for leaks and check tubes for blockage

      · Keep lid open when lighting gas grill, to prevent flash off from gas build-up

      · Turn BBQ off if you smell gas and don't attempt to relight until the leak is fixed

      · Keep alcohol away from grills

      · Use baking soda on grease fires – not water – and keep the proper fire extinguisher handy

      · Cap lighter fluid immediately and place it a safe distance from the grill


      · Leave an operating barbecue unattended

      · Move an operating BBQ

      · Wear loose or flowing clothing while tending to the BBQ

      · Use gasoline or kerosene as a starter

      · Store LP cylinders indoors

      · Store spare cylinders near the grill or appliances

In case of fire:

      · For propane grills – turn off the burner

      · For charcoal grills – close the lid

      · For electric grills – turn off power

If the fire involves a propane tank:

      · Leave it

      · Evacuate the area, and

      · Call the fire department immediately (911)

A "Teak-It" to Ride—A Bad Idea on the Water

Don’t hang ten in the danger zone

Here's a new thrill to warn your employees against: "teak surfing." Teak surfing is the deadly practice of hanging by your fingertips from a boat and skimming along on the wake.

As every safety professional knows, all gas and diesel engines produce deadly, invisible carbon monoxide. Boat engines build up fumes just above the wake, where teak surfers usually hang. They can quickly — and unknowingly — inhale deadly amounts of the poisonous gas. Due to the growing number of fatalities, some states have banned teak surfing and impose heavy fines on violators.


END - Thanks jetBlue