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"Dedicated to assisting companies to operate Safer by reducing human error"
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Aviation Human Factors Industry News August 23, 2006 Vol. II, Issue 29. UNDERSTANDING HUMAN ERROR: By Michael D. Topf, MA Exploring Causes and Strategies for Prevention, Part 1 of 4 ![]()
Human error can adversely affect many aspects of what we do each day, at home or at work. And the results can be costly, even tragic. Ships running aground, explosions, spills, incorrect shipments, patients receiving the wrong medication, damaged equipment hampering production and profits ─ these are only some of the possible results. For over 25 years, I’ve studied and addressed the various human factors that cause errors. Let me share some of my findings and suggest some skills needed to reduce, and even eliminate, them.How Understanding Error Can Improve Business Business leaders today need to identify methods to prevent errors in all aspects of their operations. Understanding the causes of human error and how to reduce them can improve:The quality of systems, products and services; and The safety, health and well-being of employees, customers and the public Regardless of their position or level of experience, everyone operating in the marketplace needs to work optimally, with the least chance for error. In this way, organizations become more successful and better able to carry out their missions, minimizing negative consequences.Corporate Contributions to Human Error People respond to their environments and your corporate culture may be contributing to an error-prone workplace. For example:1 . A Demanding MarketplaceToday’s business climate is demanding and fast-paced. Competition is fierce and businesses need to deliver in all circumstances. This creates a challenge for preventing errors. Personnel must be highly trained, capable and aware. They must be able to think in a multi-dimensional manner, focus, respond to changing situations, make good decisions and perform under pressure.2. Organization-Based Confusion Thus far, the 21st century has been characterized by near-constant organizational change and uncertainty. Flux, in the form of mergers, reorganizations, re-engineering, downsizing, upsizing and "right-sizing," not to mention "dot-coming" and "Enron-izing," are the norm. Levels of distraction and errors in judgment are compounded when employees are worried about their company’s and their own future.3. Industry Changes It’s not only negative changes that distract employees. Increased production demands, new equipment, increased responsibilities, cross-training and new management initiatives also play a part.4. A Culture of StressStress is at record levels in many workplaces. When researching the causes of incidents for a major chemical company, my colleagues and I found stress to be a contributing factor in incident causation. Whether related to personal or organizational concerns, stress can cause people to become distracted, as well as lose confidence and can feed into distrust of their co-workers and management. Stress can also erode employee relations, communications, cooperation and teamwork, ultimately affecting the quality of work, safety, health and environmental performance and increase the likelihood of error.Conclusion These are the effects of business on human errors. Of course, there are other factors, too. We’ll take a look at those next week.Report: Russia airliner with 171 aboard crashes
MOSCOW, Russia (CNN) -- A Russian plane with 171 people aboard crashed in eastern Ukraine Tuesday, after the pilot reported a fire on board and heavy turbulence, emergency officials said. At least 30 bodies have been pulled from the wreckage, about 40 kilometers (25 miles) northwest of Donetsk in a hard-to-reach area, the Ukrainian Emergency Situations Ministry told CNN. CNN's Matthew Chance, quoting Ukraine officials, said the plane had 160 passengers -- including six children -- and 11 crew members on board. The officials added that there was "no likelihood of any survivors," Chance said. "The plane is on the ground and is ablaze," Ihor Krol, director of the ministry's press service, told the Russian news agency Interfax. He said rescuers from the ministry, including fire brigades, were heading to the crash site. Flight 612 was en route from the Black Sea resort town of Anapa to St. Petersburg. Interfax said the Tupolev Tu-154 aircraft crashed shortly after 3:30 p.m. Moscow time (1130 GMT). "Early reports say the plane crashed 45 kilometers (28 miles) north of Donetsk," Irina Andrianovaa, a senior spokeswoman for the ministry, told Interfax. "At 3:37 p.m. Moscow time the plane sent an SOS signal and at 3:39 it disappeared from radar screens," Andrianova said. Andrianovaa said the plane belonged to Pulkovo airlines, which is based in St. Petersburg. The three-engine Tu-154 is the workhorse of Russia's commercial fleet, carrying about half of all Russian air passengers. It was designed as the Soviet counterpart to the Boeing 727 and the European-made Trident, but with the added ability to operate from short, rough runways. About 1,000 were produced. Although a popular aircraft, it has had a checkered history and has been involved in at least 30 air disasters since it went into service in 1968. The former Soviet air fleet has been plagued by chronic safety problems since the 1991 collapse of the country. Experts have blamed poor maintenance, safety violations and cost-cutting for a high accident rate. Asiana airplane takes off minus its cabin attendants An Asiana Airlines domestic flight from Incheon in South Korea to the southern Jeju islands was in the air for 30 minutes before the captain discovered to his surprise that the plane had left without its cabin crew on Tuesday, the Seoul Times reported.After emergency communications with the control tower, the plane hurriedly returned to pick up the cabin attendants. Due to this rare incident, the plane was about 50 minutes behind schedule. Aviation authorizes have started an investigation into the case. The plane, which was flying to Jeju islands via Daegu airport, was due to pick up passengers from another Asiana Airlines domestic flight which was crippled shortly before e departure for the Jeju islands. Asiana Airlines, South Korea's second air carrier after Korean Air. Aspiring Chinese air-hostesses must be kung fu masters! New Delhi, Aug 21: With the objective of securing aviation safety, an airliner in China has made it mandatory for young women taking up air hostess jobs, to be experts in Chinese martial arts like kung fu.This is for the first time that such a stipulation has been mandatory for women aspiring to be flight attendants, said sources in the Sichuan Airlines. According to the China Daily, next Thursday the airline would be recruiting 70 hostesses from Chengdu and Chongqing to work for a new flight route from Chengdu to Seoul in South Korea. One of the priority conditions for candidates would be knowledge of kung fu, the paper added. --- ANI NTSB says FAA regulations flawed WASHINGTON, July 26 (UPI) -- The National Transportation Safety Board says U.S. aviation regulators are taking a risk by failing to require additionalinspections of aging planes. USA Today said the NTSB is concerned that older planes -- like the 1947 Grumman G-73T Mallard seaplane that crashed in Miami last year -- won't be subject to new federal rules designed to protect the safety of older aircraft. The Aging Airplane Safety Act passed by Congress in 1991 requires the Federal Aviation Administration to mandate improved inspections and maintenance. When the FAA issued new regulations last year, it exempted
planes with fewer than 30 passenger seats, as well as planes designed before 1958, the newspaper said. "The safety board is concerned that the exemptions ... exclude airplanes such as the accident airplane," the NTSB said in a letter sent to the FAA. The letter said the NTSB also is concerned that the rules will not take effect until 2010. Airport blackout caused by maintenance ST. LOUIS, Aug. 16 (UPI) -- Investigators looking into the failure of three generators at Lambert Field Airport in St. Louis determined that the equipment had not been properly maintained.The internal investigation said employees at the airport had falsified logs of monthly inspections and tests that hadn't actually been performed, the St. Louis Post-Dispatch reported Wednesday. The failure caused a lengthy blackout at the airport's main terminal July 19."Pre-disciplinary hearings have been scheduled for the employees involved," Airport Director Kevin Dolliole told the Post-Dispatch. Dolliole did not say how many employees were involved. The generators had been evaluated by St. Louis consultant Ross & Baruzzini, which recommended the airport replace most of the old equipment with a new $9 million system. However, Lambert cited financial concerns and declined to take the advice, said Deputy Airport Director Gerard Slay. "We understand we made the decision not to replace the generators for financial reasons," Slay told the newspaper. "We didn't load test them for financial reasons. But we believed they were being test-operated."
US FAA issues safety alert for General Electric jet engines ![]()
LOS ANGELES (AFX) - Federal regulators are tightening inspection and repair schedules for some General Electric Co engines widely used on jetliners, following an engine failure during ground testing in June that badly damaged an American Airlines Boeing 767, the Wall Street Journal reported.The Federal Aviation Administration said the new directive, set to be implemented at the end of the month, mandates a 70 pct reduction in the interval between inspections and repairs for the oldest General Electric CF6-80 engines. Newer engines will face an average 40 pct cut in the number of permitted takeoffs and landings before such work must be done. The engines, about 4,100 in use worldwide, are installed on a wide range of Boeing Co passenger jets and two Airbus models, the paper said. Turkish charter jet lands at wrong airport in Poland, sparks terror alert A planeload of Polish tourists found themselves in the middle of a terrorist alert late Wednesday, when a Turkish pilot bringing them home mistakenly landed on a NATO airstrip in western Poland.The plane, a Boeing 737 operated by a Turkish charter company, was supposed to land at a civilian airport, Lawica, in Poznan. Instead, it touched down at a military airfield, Krzersiny, 15 kilometers away, where anti-terror security forces immediately surrounded the aircraft. Military authorities say security police checked the crew and passengers for several hours. The French news agency quotes authorities as saying the female pilot told them she must have made a mistake in choosing where to touch down.The aircraft was later cleared to fly to the civilian airport for its scheduled landing. Captain risked aircraft to teach first officer safety lesson: investigators Investigators have criticised the captain of an Embraer EMB-120 Brasilia turboprop after he deliberately allowed the aircraft to descend to just 475ft above water, during a scheduled passenger flight, to highlight a safety point to a trainee first officer.The French-registered aircraft (F-GFEO) was approaching the Isle of Man off the northwest UK mainland and, at the time of the low-level flight, was heading for 600ft-high terrain only 1nm away. It had been conducting a shuttle flight from Manchester, with seven passengers and three crew, on 31 March last year. During preparations for approach to runway 08 at Ronaldsway Airport, the captain realized that the aircraft’s instruments were not tuned to the instrument landing system (ILS) frequency but instead to the airport’s VOR frequency. The captain was training an inexperienced first officer at the time, and deliberately did not point out the error, or retune the ILS instrument to the correct frequency, in order to use the oversight to highlight safety issues. At a distance of 5.2nm from the runway the captain initiated a descent. Visibility was around 4,000m with scattered cloud at 600ft. The aircraft continued to descend until it was just 475ft above the surface of the sea. Its primary and secondary radar returns briefly vanished and air traffic controllers, concerned about the aircraft’s height and position relative to high ground, contacted the crew to ask if they had the terrain in sight. Once satisfied that the first officer had realized the ILS tuning error, the captain executed a climb to bring the turboprop back up to 1,600ft. "Originally it was considered that the most likely reason for this incident was that the pilots had made a genuine mistake," says the Air Accidents Investigation Branch (AAIB). "However, later in the investigation the commander was insistent that he was fully aware of his actions, wishing to use the mistake as a training point for the first officer. "It is considered that to knowingly take such action – on a scheduled passenger flight – was highly inappropriate and runs counter to accepted practices."The AAIB says that the deliberate deviation potentially endangered the aircraft and "raises concerns" about the training and oversight of the flight crew.But investigators were unable to made a recommendation to audit the operator, because the company – unidentified in the AAIB report – was sold and renamed, before losing its air operator’s certificate in December last year over "unsafe operations". The company subsequently ceased trading. Investigators have studied a number of events during which aircraft have been at risk of colliding with terrain while attempting an approach to the Isle of Man. Previous inquiries highlighted the fact that the island’s main navigation beacon, used during landings, was sited several miles away from the airport. Although the airport has since installed ILS on runway 08, the glideslope was out of service at the time of this latest incident.Air-cargo crashes more apt to be fatal MIAMI -- Crashes of cargo planes are more likely to kill people than crashes involving passenger planes, yet federal regulators have largely ignored pleas to improve their safety, a newspaper's investigation has found.Critics say that because often the only deaths in cargo crashes are of the pilot, safety regulators simply don't pay much attention to the industry, The Miami Herald reported yesterday in an extensive investigation of the business. ``I'm not sure why we need to wait until one crashes in the middle of Disneyland before people are going to take notice of the fact that these planes are going down," said Lara Goldman Lennon. Her husband, Thomas, died when he crashed a cargo plane in 2004 near Baltimore. The newspaper said it documented several cases of cargo planes flying with questionable maintenance and of pilots being pushed to fly when exhausted and without proper assurance that their planes were safe.It said several cargo plane crashes over the five years it analyzed could be linked directly to a lack of appropriate maintenance or oversight of the pilot's ability to fly safely.Air cargo crashes are 50 percent more likely to kill people than crashes of similar planes carrying passengers, although crashes of large passenger planes would have higher death tolls, the newspaper said. The Herald analyzed National Transportation Safety Board data from 2000 to 2005, internal company memos, and documents from court cases, investigations, and inspection files. It also conducted extensive interviews with pilots and others in the industry. Safety advocates complained that the Federal Aviation Administration has failed to address the industry's problems.``The Federal Aviation Administration spent very few resources on cargo oversight," said Mary F. Schiavo, former inspector general of the US Department of Transportation. ``It equals a greater risk, and sometimes it means a loss of life." The FAA said it has established a new unit to explore safety issues involving cargo and other aircraft besides the big passenger jets. The FAA also said that its regulations provide a high level of safety, but
that ``the primary responsibility for compliance with regulations and safe
operations lies with the air carrier." Jet bridge lifts airplane off the ground at Blue Grass Airport Firefighters and other officials gathered around a Continental Express jet at Blue Grass Airport . A jet bridge accidentally lifted the nose of a Continental Express jet about three feet higher than normal at Blue Grass Airport early yesterday.The plane had minimal damage. None of the three crew members on board was injured, said Kristy Nicholas, a spokeswoman for the airline. The accident occurred about 6:30 a.m., as preparations were being made for the plane's first flight of the day. No passengers were on board, Nicholas said. "While it looked pretty amazing, it really is not something that's going to cause a lot of damage to the aircraft," she said. "It's similar to a very minor fender bender, if you will." Nicholas said damage to the plane was near the passenger door that the jet bridge was being placed against. "I don't have a full understanding of what happened," she said, adding that the airline was still trying to figure out how the jet bridge could get into a position to lift the plane. Continental Express had to call in extra help to get the jet bridge and plane separated. The job took several hours. "The plane has been ferried to our main location in Knoxville, Tenn.," Nicholas said. The plane and its flight crew left Blue Grass Airport for Knoxville about lunchtime, she said. Passengers scheduled for the early morning flight on the 50-seat jet were rebooked on other flights, Nicholas said Cargo truck runs into Qantas jet at Los Angeles airport LOS ANGELES (AP) - A Qantas airliner with more than 300 people on board was damaged when it collided with a cargo truck on a taxiway at Los Angeles International Airport, officials said.The Boeing 747 jumbo jet had just arrived from Australia and was rolling toward the terminal Monday when it was struck by the cargo truck, damaging one of its engines, according to an incident report by the Federal Aviation Administration. Airplanes always have the right of way on the taxiways at the airport, said airport spokeswoman Nancy Castles.No one was hurt. The 291 passengers and 19 crew members were taken off the plane and removed from the airfield by bus. The jet was towed to a maintenance hangar, where it remained on Tuesday. The plane was expected to be back in service on Wednesday after mechanics received a replacement part, said Qantas Airways spokesman Mike Abraham. He said the engine didn't suffer any major damage. The FAA said in its report that damage to the engine was "substantial." Abraham declined to provide more details about the accident. "We're investigating the circumstances and it would unfair to describe anything until we know more," he said. Abraham said passengers who were booked on a 10:30 p.m. flight to Sydney on Monday were assigned to other Qantas flights. SUMMER SAFETY
Safety by Candlelight There are few things more relaxing or romantic than a summer evening on the patio — the hammock, the friends and the mood lighting made possible by pretty torch candles positioned around your garden. Not to spoil the mood, but be careful with these things. Health Canada has issued a reminder that as with all candles, torch candles — whether used for ambiance or bug control — must be handled with care. Remember that embedded in the wax is a support stake, a fragile piece of wood that may catch on fire or break and allow a lit candle to fall.Keep the flame contained — and your evening relaxed — by following these few pointers: · Don’t use torch candles indoors. They’re for outdoor use only.· Secure torch candles in a bucket of sand and place them far from any object (including flowers, shrubs or trees) that may catch on fire.· Keep kids and pets away from burning candles.· Don’t use torch candles in windy conditions.· Don’t group torch candles.· Before moving a candle, extinguish it and wait for the wax to cool.· Watch for signs that the candle is not burning correctly. If your torch candle emits a high or intense flame or starts crackling, put it out immediately.· Don’t blow out the candle. This can spread sparks and hot wax. Instead, use water or a snuffer to extinguish the flame.· After extinguishing the flame, turn the candle upside-down in a bucket of water. Even candles with little smoke and no flame can start a fire.· When the candle has only 2 inches of wax left, put it out.· And, of course, never leave a burning candle unattended.Source: Health Canada END With Sincere Thanks to jetBlue
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