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Aviation Human Factors Industry News

August 10, 2006

Vol. II, Issue 28.

Swiss charged over 2002 air crash

The children on board were going on holiday to Spain A Swiss prosecutor has filed manslaughter charges against eight employees of an air traffic control firm over an air crash in July 2002.

The Winterthur prosecutor called for jail terms of six to 15 months, alleging "homicide by negligence".

The collision killed 71 people, most of them Russian schoolchildren. It involved a jet of Russia's Bashkirian Airlines and a DHL cargo plane.

Swiss firm Skyguide controlled flights over southern Germany at the time.

The accused, who were not named by Swiss media, denied responsibility for the collision.

An air accident inquiry last year concluded that a catastrophic chain of human error was to blame. It accused Skyguide of organizational failures contributing to the crash.

The collision happened over a German village near Lake Constance.

The investigators found that a single Skyguide air traffic controller on duty had given the pilots just 43 seconds to act.

The controller was fatally stabbed by a Russian man in 2004, in a suspected revenge attack.

The controller had told the Russian pilots to descend, while their onboard collision avoidance system had told them to climb to avoid the DHL cargo plane.

Inexperience Cited In Ground Mishap

Embraer 170, Minor damage. One Fatality

A 5,900-Lb mobile baggage belt loader was driven beneath the airplane while it was being prepared for a US Airways Express flight from Washington Reagan National Airport on June 6, 2005. The driver was wedged into her seat by the lower fuselage of the airplane and the belt loader’s steering wheel, which had been bent back and down on impact. She died of asphyxiation due to thoracic compression, said the NTSB report.

A witness told investigators that he believed the driver’s foot might have sipped off the brake pedal when she attempted to stop the belt loader. The report said the driver was wearing leather shoes with hard rubber foam soles. The sky was overcast, but no precipitation was falling on the ramp; temperature was 68 degrees F.

The driver had not driven a belt loader before being hired by the airline as a fleet service agent about a month before the accident and receiving driver training. NTSB said that the probable cause of the accident was "the inexperience of the driver (fleet service agent) in the operation of the belt loader."

Service Truck Hits United Airlines 737 At DIA

(CBS4) DENVER A servicing truck ran into a United owned Boeing 737 at Denver International Airport Thursday morning. The crash happened outside the east side of the United Airlines hangar.

The food service truck was driving at about 20 mph when the crash happened, according to United Airlines officials.

"The plane was facing west and was pushed about 90 degrees and is now facing south," Robin Urbanski, a spokeswoman for United Airlines said.

The driver of the truck was hurt. His injuries were not believed to be serious.

Airport officials said there was damage to the plane's fuselage. The truck apparently hit a ladder that was attacked to the front of the plane.

Mechanics checked the damage and found that the fuel lines were secure and there was nothing leaking from the aircraft.

The plane was scheduled to serve as the aircraft for flight 112 from Denver to St. Louis. Another plane was set to be used.

FlightSaftey Introduces Master Technician Management Endorsement Program

LA GUARDIA AIRPORT, NEW YORK (July 13, 2006) – FlightSafety International has launched a new Master Technician Management Endorsement training program. Developed in conjunction with Global Jet Services, this innovative training program is designed to enhance the management skills of aircraft maintenance professionals and introduce management concepts to technicians aspiring to supervision levels.

As with FlightSafety's comprehensive Master Technician course of study, this new program is a five-step process that includes two required courses and three others from among seven elective courses.

"Just as maintenance technicians must keep up with constant changes in aircraft systems, current and those aspiring to be managers must stay up-to-date on the skills needed to effectively direct their department and to provide the ultimate in customer service," says Doug Bowen, Director Worldwide Maintenance Training Sales, FlightSafety International.

The required courses are Aviation Interpersonal Maintenance Management, providing the basic skill sets needed for dealing with co-workers and management on a daily basis and either an aircraft-specific update or aircraft-specific maintenance manager course.

Elective courses include the Repair Station Training Program that helps to prepare managers to meet the new FAR-145, Aviation Customer Service, Corrosion Control, Principles of Advanced Composite Structure Repair, Human Factors in Aircraft Maintenance, Maintenance Resource Management, and OSHA and EPA Compliance Practice.

"Today's aircraft maintenance professionals have to be leaders and administrators that can effectively manage highly technical and precise aircraft maintenance programs, the needs of customers and the overall company goals," says J.D. McHenry, President, Global Jet Services.

FlightSafety International is the world's premier aviation training organization. Over 75,000 pilots, technicians and other aviation professionals train at FlightSafety facilities each year. The company designs and manufactures full flight simulators for civil and military aircraft programs and operates the world’s largest fleet of advanced full flight simulators at over 40 training locations.

NTSB Probes Laptop Batteries in Jet Fire

Did laptop batteries aboard a UPS cargo plane ignite, causing the aircraft to catch fire?

The National Transportation Safety Board began looking into the question at a hearing Wednesday.

All three crew members on the plane were treated for minor injuries after it made an emergency landing shortly after midnight Feb. 8 at Philadelphia International Airport.

Several other incidents have occurred in recent years in which lithium batteries -- used in laptops and cell phones -- have caught fire aboard airplanes.

Less than two months ago in Chicago, a spare laptop battery packed in a bag stored in an overhead bin started emitting smoke, chief crash investigator Frank Hilldrup of the NTSB testified Wednesday.

A flight attendant used an extinguisher and the bag was removed, but the bag caught fire on a ramp, Hilldrup said.

Investigators in the Philadelphia fire found that several computer laptop batteries were on board the plane, and that in many cases portions of the laptop batteries had burned, he said.

"It is not known at this time the role these batteries may have played in the fire," Hilldrup said.

Lithium ion batteries are sometimes referred to as "rechargeable" or "secondary" lithium batteries. They, along with primary or "non-rechargeable" lithium batteries, can present fire hazards because of the heat often generated when they are damaged or suffer a short circuit.

It is expected to take several months for the NTSB to reach a conclusion about the cause of the fire in Philadelphia, although several hazardous materials on board the plane have been determined not to be the cause. The NTSB is also examining other related issues, such as what can be done to make cargo flights safer and the overall emergency response to the incident.

In 1999, a shipment of lithium batteries ignited after it was unloaded from a passenger jet at Los Angeles International Airport. Another shipment erupted into flames in Memphis in 2004 when it was being loaded onto a FedEx plane bound for Paris.

In the case of the UPS cargo plane, the crew declared an emergency on approach into Philadelphia. Fire and rescue crews met the four-engine jet, a DC-8 that originated in Atlanta, when it touched down shortly after midnight.

Firefighters said the blaze was under control about four hours later, although the charred plane smoldered for hours.

Seventeen Lost In DRC Antonov 28 Accident

Plane Impacted Mountain In Stormy Weather This is a story which is becoming depressingly familiar. An aging Russian-made airliner is down in the Democratic Republic of Congo, with all 17 people onboard lost... including the three Russian crew members.

Local officials say the plane went down on approach to the airport in Bukavu, on a flight from the mining town of Lugushwa about 80 miles to the south. Initial reports say the aircraft impacted a mountainside in bad weather.

The twin turboprop was still on fire when search teams arrived at the crash site.

Crashes involving old, poorly-maintained, Russian-made aircraft are fast becoming the norm in the DRC. The UN says many of the 50 or so private carriers in that country don't even license their planes -- one reason that half of all airlines listed on the European Union's "blacklist" of forbidden or restricted carriers are from the region.

Armenian Airline Rejects Russian Verdict On Plane Crash

Armenia’s main airline, Armavia, dismissed on Thursday Russian officials’ claims that the May 3 crash of one of its passenger jets, which killed all 113 people on board, was caused by pilot error.

Russia’s Transport Minister Igor Levitin said on Wednesday that the Airbus A-320 plunged into the Black Sea as it approached the Russian resort city of Sochi because of a "human factor," effectively laying the blame on its crew. He said this is the conclusion drawn by a Russian-led inquiry into the worst air disaster in Armenia’s history.

A special commission formed by the Interstate Aviation Committee of the Commonwealth of Independent States also took part in the inquiry. The Russian head of the body, Tatyana Anodina, endorsed its findings, saying that the A-320’s main pilot "did not ensure control of the plane as far as angle and altitude were concerned."

Senior Armavia executives strongly disagreed with this, saying that other factors such as conflicting instructions reportedly given to the A-320 crew by Russian traffic controllers and stormy weather were also at play. Armavia’s Russian-Armenian owner, Mikhail Baghdasarian, insisted earlier that the plane would have safely landed at Sochi airport had it not received a last-minute order to veer away from the runway and make a second approach.

"We do not deny that the crew made some mistakes during that flight," said Arshak Nalbandian, head of the private carrier’s flight safety department. "Yes, it did. But was it those mistakes that led to the plane’s collision with the sea? That has yet to be proven."

Russian and Armenian officials had initially suggested that bad weather was the most likely cause of the crash. Also, the Russian traffic controller who was in charge of the fatal Yerevan-Sochi flight was reportedly placed under investigation in the wake of the disaster.

Nalbandian claimed that the commission set up by the Interstate Aviation Committee had no right to endorse any conclusions before issuing its own report on the crash signed by all of its members, among them two Armavia executives. "The commission has not yet finished its work," he told a news conference.

"If we are not satisfied with the further work of the commission, we may well appeal to a third party to conduct an independent inquiry," Nalbandian warned.

The Armenian government has not yet officially reacted to Levitin’s statements which most Armenian pilots and other aviation specialists find unconvincing. The leadership of its Civil Aviation Department was scheduled to discuss the matter at a special meeting later on Thursday.

Levitin and Anodina were widely expected to publicize the findings of the Russian inquiry when they visited Yerevan earlier this month. However, they avoided doing so after talks with Armenian leaders.

Runway accident kills Canadian man

A 63-year-old man from Canada was killed Sunday when a Navy warbird's propeller hit a Canadian-registered homebuilt aircraft on a taxiway at Wittman Regional Airport at about noon Sunday.

A Grumman TBM World War II Navy airplane taxied up behind a homebuilt R.V.6 and as it caught up with the significantly smaller homebuilt, the Grumman's propeller sliced into the R.V.6. The passenger in the side-by-side seat

R.V.6 was pronounced dead at the scene while the pilot of the aircraft was not injured, authorities said.

Neither the name of the R.V. 6's passenger nor the two pilots were released Sunday. Winnebago County Deputy Coroner Chuck Hable said the victim's name will be released today, following notification of his family.

The accident was the second fatal incident on the airport grounds during the one-week AirVenture convention.

Clifford and Betty Shaw of Edmonds, Wash., died when their Europa XS homebuilt airplane crashed at 8:45 a.m. July 23 while on approach to the east-west runway at Wittman Regional Airport.

"Whether at the open, close, middle, two months before or two months after the event, there's always a concern when there's loss of life," Poberezny said.

The Grumman TBM is a tail-wheel aircraft in which the cockpit angles up, restricting the pilot's sightlines. EAA Spokesperson Dick Knapinski said it's important in such aircraft to be very aware of the surroundings and that any recommendations out of the NTSB and FAA investigations will be considered carefully.

Air France crash probe completed, one year on

One year after Air France Flight 358 skidded off the runway in Toronto, the preliminary report into the crash has been completed, but the survivors of the accident still have no answers as to what might have caused it.

Though investigators from the Transportation Safety Board have completed their preliminary probe, they will not be releasing the results until they are approved by the TSB's board members.

The investigators have filed their conclusions on whether the crash was caused by human error, mechanical failure or bad weather.

There have been hints, however, that the report is not yet conclusive.

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

The A-340 passenger jet was carrying 12 crew and 297 passengers when it went off the runway at Pearson International Airport on Aug. 2, 2005, landed in a ravine and burst into flames. The plane had been trying to land in stormy weather.

Two crew members and 10 passengers were seriously injured, but miraculously, all survived.

Some of those survivors are still haunted by the terrifying crash -- and the lack of answers they've received to date.

Adella Bellone told CTV's Canada AM she is still haunted by the memories. She said she is unable to ride in elevators, is scared to put her seatbelt on, and sometimes wakes up in the middle of the night mistakenly convinced she has heard rain falling.

She also said she has lost her business, has been forced to move, and her marital status has changed -- all since the crash.

"Everything is different," she said Wednesday. "I'm starting to deal with everyday stuff but it's still hard for me. I do see my psychologist and my doctor on a regular basis, and I just have hope that it's going to get better."

An explanation of what caused the crash would be a major step on the road to recovery, she said.

"That's what I'm struggling with. Every day I'm questioning myself. Whose fault was it, who was in charge that day with the decision to end up the way it happened?"

Caroline Diezyn, who was also on the flight, has a markedly different response.

"My life has changed because I want to be able to tell my story to as many people as possible because I feel it's actually really a positive experience that's come from this," she told Canada AM, adding that her example proves it is possible to overcome your deepest fear.

However, Diezyn is also anxious for answers, and wants to know why the plane attempted to land that day instead of rerouting to Montreal.

"Really I'd just like to see a speedy resolution to anything that's going to happen," she said. "I realize that it's a lengthy process and there's a lot of investigation that has to be done, but a year later it's like nothing has changed. I'm still in the exact same position, mentally, financially, emotionally, everything like that."

A class-action lawsuit is being prepared on behalf of many of the passengers, and the group has commissioned its own investigation into the damages caused by the crash, and liability.

Paul Miller, the lawyer representing many of the passengers, said a number of the survivors will never be the same, noting that many still won't ride elevators or travel by plane.

"I know a number of clients who think about the crash every single day. It's not something that goes away very quickly.''

The class-action suit is seeking monetary compensation for physical and emotional trauma, as well as compensation for personal property lost as a result of the crash, Miller said.

He said it is too early to estimate what that will amount to, but said individual payouts could range from several thousand to hundreds of thousands of dollars.

Scott Armstrong, a spokesperson for the Greater Toronto Airport Authority, said the crash is the biggest "on-airport incident we've seen."

He said airport officials are also still in the dark about the contents of the report, but will be sure to quickly implement any recommendations it may contain when it is released.

The Maintenance Issues of Bad Wiring on U.S. Navy Aircraft Are Staggering

"Although the U.S. military's challenges with electrical wiring are not as well publicized as those from the commercial sector [e.g., the TWA 800 and Swissair 111 accidents, both attributed to a wiring failure], the issues still exist. For instance, during a recent 30-month period, the U.S. Navy lost two aircraft due to electrical wiring failures ...

"The problem is also evident in the roughly two and one-half electrical fires that occur on U.S. navy aircraft each month ...

"With the safety issue aside, the maintenance and reliability issues are staggering as well. The U.S. Navy expends approximately one million maintenance hours per year at the OMA [organizational maintenance activity, or squadron level] alone on wiring related repairs ...

"The problem with wiring failures are also seen in the approximately 1,400 mission aborts (540 in-flight aborts) and an average of 125 non-mission capable aircraft ... With only 4,700 aircraft in inventory for the U.S. Navy [roughly the size of the commercial U.S. fleet before 9/11], this means that between two and three percent of the fleet is out of service due to wiring problems at any one time.

"Wiring system maintenance on U.S. Navy aircraft has historically been viewed as a reactive maintenance task. In other words, `If it ain't broke, don't fix it.' To compound the problem, the validation of the integrity of the conductive path is only sought if all other maintenance actions have been ruled out. This includes the replacement of a possibly good Weapons Replaceable Assembly [WRA, or in commercial parlance, a line replaceable unit, LRU] into the system to validate the WRA's inoperability. If the maintainer replaces a `suspect' WRA with a `known good' from supply, both the `No Fault Found' rate and unnecessary man-hour rate increases. Again, these `No Fault Found' incidents that are caused by wiring is another reason that the metrics are believed to be underreported. ...

"Although the challenge has been great in solving problems with wiring on U.S. Navy aircraft, the Naval Air Systems Command has chosen not to ignore the problems but to move in a direction of finding innovative solutions to the problems. These solutions include better training for the maintainers, insuring that quality wiring components are in the supply system, and inserting technology into the hands of maintainers that will help them do their jobs better."

Pilot Error Behind 2005 P-3 Accident

A P-3 at an Aero Union hangar in Chico, is from the Spanish Air Force and will replace the crashed Tanker 26.


Investigation Says Airframe Not To Blame It wasn't an airframe problem that brought down a firefighting P-3 Orion in California last year... it was pilot error. That's the conclusion of an investigation by the San Mateo County Times... whose reporters talked with industry experts, pilots, and aviation consultants.

As Aero-News reported, the aircraft (file photo of type, right) went down in April of last year while on a training mission near Chico. The paper's investigation indicates Aero-Union Tanker 26 was flying down the middle of a valley when it strayed east.

Experts consulted by the newspaper say it appears to have been a case of controlled flight into terrain... an assertion they back up with Navy radar data showing the Orion's flight track.

No one's sure which of the three men killed in the crash was flying the plane -- Brian Bruns, Paul Cockrell, or Tom Lynch -- was actually in command of the aircraft when it went down, and the crew issued no distress call.

The Orion wasn't equipped with any sort of flight recorder.

The official NTSB finding of probable cause is still months away. But if the board does cite pilot error as the cause of this crash... it would clear Aero-Union's aging fleet of P-3s... which make up about half the country's entire firefighting tanker fleet.

Purdue Gets A New 727!

Armstrong's Seat Preserved

An Aero-News reader -- and Purdue University alumnus -- sent along new information in regards to our story Wednesday, concerning Purdue's decision to scrap a Boeing 727 aviation lab because it was too costly to maintain.

Fortunately, the Purdue Exponent reports not everything is being shredded by giant metal jaws. Former astronaut Neil Armstrong's captain seat from the Boeing 727 is being preserved, and will be waiting for him at the university if he ever wants to sit in it again.

Armstrong, himself a Purdue graduate, flew the 727 to Purdue in 1993 when the plane was donated to the school by United Airlines.

The news gets better, however... for while it's true the old plane is being ripped apart, its replacement has arrived. A new 727 -- one that brings with it more advanced technology for students to study -- was delivered to Purdue Airport Tuesday.

The plane was donated by FedEx, and was flown in from Indianapolis by two graduates.

As a small crowd met the new 727, the old 727 lay in ruins not far from the airport’s main runway. The new 727 will be unveiled to the public in September.

The Secret Cost of Fatigue  (This is a must read)

On the surface of things, fatigue seems fairly straightforward. We all get tired, do what we need to do to get through it, and then catch up on our sleep when we can. We still harbor a cultural mentality of mind over matter, and of human failing if one allows themselves to get tired to the point of being unfit for duty. After all "if our people spent more time in bed getting their proper rest (and less time watching TV, sitting in a bar, or allowing themselves to be compromised by family life and personal activities), then they wouldn't be tired on the job." In other words, from a management perspective, fatigue is often perceived to be a behavioral problem, caused more by personal irresponsibility than by other factors (and certainly not by our operating policies and procedures). Well, those of us who have lived and worked shiftwork know better. Just try sleeping in the daytime and see how much "proper rest" YOU can get!

Similarly, we have this notion that, like our machinery, employee work capacity is a lineal function. In other words, one can work as many days in a row as they (or we) would like without any significant problem, and we're happy to let them do it. Overtime saves having to hire more people and paying all their costly benefits, and it sure makes a supervisor's job a whole lot easier to fill absences, vacations, and other benefit days off by dishing out the overtime to those who want it. Plus, we rationalize, people are happy to have the extra money. I used to think this way too, when I worked and managed shifts, but after several close calls, I realized that I was kidding myself and putting myself and others at risk.

Over the past 25 years, extensive research has confirmed that fatigue, as related to shiftwork, is fundamentally a physiological problem, not a behavioral one. Certainly, one's behavior can induce or compound fatigue, but with most shiftworkers this is the exception and not the rule. Rather, shiftworker fatigue is driven primarily by four factors:

1. Our biological clocks/circadian rhythms (i.e. basic human physiology)

2. The operational necessity to keep the equipment running 24-hours per day (i.e. automation, continuous process, asset utilization, reduced unit costs, improved customer service, etc...)

3. Counter productive management attitudes, policies, and operating procedures that detract from human performance, rather than supporting it (i.e. lack of knowledge/understanding)

4. Lack of employee knowledge and understanding on how to manage shiftwork, in general, and fatigue and alertness levels, in particular (i.e. lack of training).

Having said all that, let's define what we mean by fatigue and look at some of its consequences and costs:

What is Fatigue

      · Impaired alertness

      · State of impaired mental/physical performance

      · Reduced vigilance/attentiveness

      · Loss of cognitive/logical reasoning skills

      · Impaired judgment

      · Reduced motor coordination

      · Slower reaction time

      · Diminished ability to communicate and/or process communications

      · Loss of environmental awareness

Consequences of Fatigue

      · Increased Human Error

      · Reduced Ability to Work Safely

      · Reduced Productivity/Customer Service Quality

      · Inadequate/Ineffective Communications

      · Increased Turnover/Absenteeism

      · Reduced Morale/Poorer Labor Relations

      · Increased Health/Wellness Costs

      · Reduced Operating Efficiency/Reliability

      · Increased Costs, Risks, and Liabilities

      · Reducing Operating Profit

Costs of Fatigue

Accidents $8.5 Billion

Lost Productivity $79.7 Billion

Health Care $ 28.3 Billion

Total $116.5 Billion

So how, as a company or as plant mangers, can we objectively and systematically eliminate fatigue from our operations, thereby reducing our costs, risks and liabilities to achieve an overall improvement in operational efficiency....while at the same time improve employee health, safety and quality of life to create a win-win proposition? Perhaps this sounds far fetched, but it’s already being done. With the current knowledge base that exists today, dramatic improvements can be achieved in the way people live and work, to the betterment of both the employees and the business.

The first, and most important step, is to recognize the serious cost of fatigue and make a corporate commitment to fix it. Too many companies are losing money and risking the safety of their employees by not recognizing the importance of fatigue management. This is evident by the fact that over 90% of shiftworkers receive no training on how to manage their schedule and shiftwork lifestyles. I see too many shiftworkers who are well trained and great at their jobs, but who have never been shown how to deal with fatigue and adapt to the unique physical and social challenges of shiftwork. As a consequence, they fall into common shiftwork pitfalls that compromise their ability to perform to their full capabilities. This is just one of the many reasons shiftwork employees cost companies roughly $8,600 per person per year in excess costs over and above their daytime counterparts.

Once a company has made a commitment to reduce fatigue and optimize the productivity and safety of their workforce, they need to develop a comprehensive fatigue management plan. To be successful this program must at the very least:

      · Ensure that work schedules and overtime policies do not cause excessive fatigue.

      · Provide training for employees to assist them with reducing fatigue and coping with working at difficult times, especially with new hires.

      · Reinforce the commitment to reduce fatigue by providing educational support publications and practical shiftwork tips on a regular basis.

      · Evaluate lighting, temperature, sound and other environmental modifications to reduce fatigue

      · Optimize staffing levels to maintain manageable overtime levels

      · Reevaluate policies, practices and procedures that may no longer be valid.

As responsible managers and operators, we strive to keep our machinery well oiled and well maintained. We ensure that it is operated in full accordance with the design specifications, in terms of operating temperature, pressure, speeds, etc… To do otherwise would ensure premature failure, costly downtime, high maintenance, and lost productivity/capacity.

It would thus seem to make sense to keep what we all tout as our most important asset – our people – equally well oiled and maintained. Yet, ironically, our people are asked to operate outside their design specs every day to support our continuous production requirements. The net result, as you might guess, has been premature failure, costly downtime, high maintenance, and a well documented 2-3 time increase in cardiovascular disease, digestive disorders, sleep disorders, and human error. Neglecting this most important asset can be costly, if not catastrophic. It is crucial to know that these costs, risks and liabilities no longer have to an accepted part of doing business. With today’s knowledge base and fatigue/shiftwork interventions, they can be converted into a new source of operating profit and reliability that we never knew existed before.

END with thanks to jetBlue