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Aviation Human Factors Industry News

August 3, 2006

Vol. II, Issue 27.

Small cracks caused JAS landing gear Accident

Small cracks caused landing gear on JAS MD-81 to break in 2004 accident Small cracks that were overlooked by mechanics during inspections caused the main landing gear of a Japan Air System (JAS) MD-81 to break when it landed at Tokunoshima Airport (TKN) on January 1, 2004, according to the investigation report released by the ARAIC. Three cracks were found, believed to be the starting points of the break. Inspectors suspect that the cracks, measuring between 3 and 5.2 millimeters long, developed as a result of metal fatigue. The committee concluded that cracks probably developed as a result of stresses generated during a gear walk (serious fore and aft oscillations of the gear) before restrictor plates were installed.

From a Technician on Microsleep

Hi Roger,

You hit it on the head again!!!!

Shame on me this past weekend I was foolish enough to think I could make

the trip from Long Island to Queens without pulling over. Fortunately I made it without incident, however

I experienced the micro sleep you described. For some reason the mind rationalizes our ability to perform.

I’m not drunk-no just dead asleep. I drove down an exit ramp approx ¼ mile eyes open but no sensory perception.

I appreciate the articles and I am working on changing my personal behavior. The train or a night sleeps on the Island have become my best options.

Please keep hammering home the HF information. I’m sure it has and will continue to prove invaluable.  (I couldn't agree more)

Loss of Situational Awareness cause of Peruvian Crash in 2005

Loss of situational awareness in hailstorm quoted as cause for Peruvian 737 crash.
According to the Peruvian accident investigators, the August 2005 accident involving a TANS Boeing 737 near Pucallpa was caused by a
loss of situational awareness in a severe hailstorm on approach to Pucallpa. The flight crew failed to abort the unstabilized approach and continued their fast descent despite the GPWS warnings and the severe storm that they were penetrating. It also appeared that a copilot under instruction was in the right hand seat while the regular copilot was in the passenger cabin at the time of the accident. (CIAA)

IA grounds 12 A-320 aircraft for maintenance

NEW DELHI, JULY 27: As many as 12 A-320 aircraft of state-owned carrier Indian Airlines have been grounded for major maintenance or want of engines, the House was informed on Thursday.

"The exact loss of revenue is difficult to compute as different aircraft are under scheduled maintenance or otherwise for different periods of time," civil aviation minister Praful Patel said in reply to a question.

He said normally about six A-320s remain grounded for maintenance, but currently there were 12 aircraft.

He also said there was no shortage of pilots in Indian, but its subsidiary Alliance Air had a shortage of pilots.

NTSB: Spectrum 33 Controls Misrigged In Fatal Accident

                          Emergency personnel examine the Spectrum 33, which crashed on takeoff Tuesday at Spanish Fork Airport. The pilot and co-pilot were killed.

The National Transportation Safety Board has just released its Preliminary Report on last week's fatal accident involving the prototype Spectrum 33 very-light-jet in Utah.

In its report -- which is published in its entirety below -- the NTSB says the aircraft's ailerons were apparently misrigged... so that control inputs for roll control would have had the opposite effect than the plane's pilots intended.

"Examination of the translation linkage on the aft side of the aft pressure bulkhead revealed that it was connected in a manner that reversed the roll control," say the Prelim. "Specifically, the linkage was connected such that left roll input from the side sticks would have deflected the ailerons to produce right roll of the airplane, and right roll input from the side sticks would have deflected the ailerons to produce left roll of the airplane."

The NTSB also reports the airplane had undergone maintenance prior to the accident, during which time the main landing gear was removed in order to stiffen the struts. When workers reinstalled the MLG, the NTSB says they found the modifications resulted in inadequate clearance between the left MLG strut, and the aileron upper torque tube V-bracket. The V-bracket was removed and redesigned to allow proper clearance of the gear... which also required a portion of the aileron linkage to be removed, and subsequently reinstalled.

Witnesses report the aircraft entered a right roll just as the plane was lifting off from runway 30 at Spanish Fork-Springville Airport in Spanish Fork, UT in July 25. As Aero-News reported, Spectrum's Glenn Maben and Nathan Forrest were lost in the accident.

Armenia's A-320 crash down to last-second crew panic - official

The plane plunged into the sea as it tried to land

YEREVAN, July 28 (RIA Novosti) - Armenia's top civil aviation official said Friday that the May crash of an Armenian Airbus into the Black Sea had been largely because the crew panicked in the last few seconds of the flight.

"The A-320's flight modeling showed the flight was stable until 17 seconds before the crash," said Artem Movsisyan, head of the Civil Aviation Agency.

The jetliner, operated by Armenian carrier Armavia, crashed in the early hours of May 3 as it was preparing to land at the airport of Adler, off Russia's Black Sea coast. All 113 passengers and crew died.

Movsisyan's comments follow a report from the Interstate Aviation Committee into the cause of the crash. The report said human error was to blame for the accident.

Movsisyan did not reject this conclusion, but said stormy weather and inadequate ground control had to be factored in as well. He said flight recordings suggested that the air traffic controller's instructions had made the crew angry and nervous.

Along with Russian and Armenian aviation officials, the Interstate Aviation Committee includes representatives of Toulouse-headquartered Airbus, the manufacturer of the A-320.

A bandage, not a cure

USA TODAY is wise to issue a wake-up call about fatigue as a growing safety concern for the nation's passenger and cargo pilots. Allowing pilots to take structured naps while on duty might help in the short term, but it would amount to a bandage when we need a cure to make certain that pilots are rested and ready to perform their jobs.

If the Federal Aviation Administration decides to approve napping as a measure to bridge current policy gaps in duty and rest regulations, the public might view it as a permanent fix for pilot fatigue, and the FAA would be able to postpone real rulemaking once again. I can almost guarantee that many airline managers might point to sanctioned shut-eye as a reason not to act to reform rest and duty regulations.

Naps do not allow human beings to close their sleep deficits. Science from NASA and other sources backs this truism. Further, many of us cannot go to sleep on demand, making it impossible to use napping as any kind of solution for sleep deprivation.

People need adequate, extended periods of sleep. Let's get the public focused on helping bring pilot rest and duty regulations into the modern era, leveraging the reams of data that science has yielded. While it may make sense, under careful conditions, for pilots to take advantage of controlled rest, the FAA can never rest when it comes to ensuring safety.

Human Errors in Aviation Maintenance

Airline flying is becoming less safe, and maintenance errors are playing an increasing role in the reduced level of operational safety, according to a study directed by professor Gary Eiff at Purdue University's Department of Aviation Technology in Lafayette, IN.

The findings -- that maintenance errors were a contributory factor in far more incidents and accidents than previously thought -- come at a time when financially-strapped operators are contracting out more maintenance to save money, and in a period when federal oversight of repair stations has been found lacking.

The Purdue study found that while incidents are trending toward fewer per year, the accident trend is in the opposite direction. The total number of accidents and incidents remains relatively the same, but "the criticality of [the] outcome of such events is becoming more severe."

Eiff and his graduate students, who did the grunt work in the Purdue study, looked at all accidents and incidents in the National Transportation Safety Board (NTSB) database over a 20-year period from 1982 to 2002. The Purdue study focused on scheduled passenger operations; it excluded cargo aircraft, where there are known cases of unairworthy aircraft being returned to flight service, and the study excluded charter operations.

The purpose of the study was to determine if maintenance played a more prominent role in aviation accidents and incidents than previously thought.

The Purdue researchers analyzed roughly 1,300 NTSB records of airline accidents and incidents. The study found that maintenance problems were factors in nearly a third (29 percent) of the events. One of the key assumptions in the study was that mechanical failures were maintenance-related. "While the reports do not directly link these mechanical failures to maintenance, it is reasonable to believe that many result from maintenance shortcomings," the report said.

The study found that maintenance was a contributory factor in more cases than previously thought. For example, a Boeing safety summary attributes only about three percent of crashes to faulty maintenance. The Purdue study suggests that maintenance problems may be some 10 times greater. (the difference may lay in the causes versus contributes but we must and can do better if trained how to avoid human error)

A major reason for the difference is that the Boeing data includes only hull losses, whereas the Purdue study included accidents below the severity of hull losses as well as incidents.

Does the Purdue study paint a picture that's closer to reality? Well, the data collection was a straightforward exercise: extracting what the NTSB said and compiling it. Moreover, the Purdue study findings may be consistent with other inquiries. For example, an engine manufacturer found that 50 percent of engine-related turnbacks (return to departure airfield) were caused by installation error.

What is to be done? Eiff argues that both managers and maintainers can do better. "The industry has put a lot of time and effort into increasing compliance with procedures for pilots. We need to do that for mechanics," he maintained. As for the mechanics, he said, "[Some] don't look at the policies and procedures as an error defense, as a way to stay out of trouble. So there's an educational process here."

Crash survivors want answers

The Air France probe is over, but they will have to wait a while longer for the results.

TORONTO -- One year after all of the crew and passengers of Air France Flight 358 survived the crash of the airliner at Pearson International Airport, the preliminary probe into what caused the near tragedy has been completed.

Still, passengers anxious for answers to questions that have haunted them since the plane skidded off a runway last Aug. 2 will have to wait a while longer.

The Transportation Safety Board announced yesterday its investigators had fully examined whether the crash was caused by human error, mechanical failure or bad weather and filed their conclusions -- but the findings will remain confidential until they're approved by board members. The TSB won't say when that will be.

"(Investigators) may have to go back and do more research," said spokesperson Genevieve Lamarche, adding the report will be made public once it is finalized.

Some survivors say they're tired of waiting.

Eddie Ho is still haunted by the smell of jet fuel, the pounding of rain and the terrified screams.

The 20-year-old university student, who was on the flight from Paris while returning from South Africa, said he will spend the anniversary in a counsellor's office in the hopes of one day coming to terms with his experience.

But Ho said he can't put the nightmare behind him until he understands why the crash happened. The investigator's report should be made public, along with a transcript from the cockpit's black box, he said.

"There should be more communication and more transparency. We should really get to the bottom of this."

Ho hasn't been on an airplane since the crash.

The third-year business student at Queen's University still remembers the applause after the plane initially touched down during intense thunderstorms that afternoon. He remembers his seatmate turning to him and saying, "That was a good landing."

Mostly, he's haunted by the feeling of the plane hurtling along the runway at nearly 150 kilometres an hour. He remembers praying as passengers screamed around him.

"It was terrifying -- like hell had broken loose," Ho said.

"No one died, but people were seriously hurt, either physically or psychologically."

Lawyer Paul Miller, who is leading a class-action lawsuit on behalf of the passengers, said everyone is looking for answers.

The group is conducting its own investigation into the extent of damages, as well as liability, with the help of former pilots, air traffic controllers and runway design experts, said Miller. Regardless of what those investigations uncover, Miller said few of those who lived through the crash will ever be the same.

"There are still people afraid to get in elevators, who still won't get on a plane."

The benefits of breakfast

A healthy breakfast that includes high-fiber cereal can not only help keep diabetes, heart disease, and stroke at bay, it can also help you achieve and maintain a healthy weight.

Research suggests that breakfast eaters are leaner than those who skip the morning meal, with one study reporting that missing breakfast was associated with a fourfold increase in the risk of obesity. High-fiber cereals are central to breakfast's health benefits and can help you reduce the risk of heart disease, stroke, diabetes, and even intestinal polyps and colon cancer. Look for breakfast cereals that provide at least 6 grams of fiber per serving, but make sure your choice is low in sugar (less than 10 grams per serving). Add nonfat milk and bananas, berries, or apple slices to create a tasty meal.

You needn't limit your morning menu to high-fiber cereals, but wise choices are important. Stick to whole-grain or pumpernickel breads for toast; opt for trans-fat-free soft margarines or cholesterol-lowering spreads that contain plant stanols. Eggs needn't be banned from the breakfast table, but are better reserved for the occasional brunch, particularly for people with diabetes. In one study, men with diabetes who ate more than one egg a day were twice as likely to develop cardiovascular problems. To date, there is no solid evidence that organic eggs or brands high in omega-3 fats offer any particular health benefits—and they still count as eggs. Many typical breakfast foods (hash browns, bacon, croissants) have too much fat or salt—and fast-food breakfasts have too much of everything, except the fiber that adds the real punch to breakfast's health benefits.

A little experimentation—a whole grain cereal one day, pumpernickel toast with peanut butter the next—can help you find the combination of foods that make breakfast a welcome start to your day.

END - thanks jetBlue