Aviation Human Factors Industry

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Aviation Human Factors Industry News

September 01, 2006

Vol. II, Issue 30.

UNDERSTANDING HUMAN ERROR Part 2

Exploring Causes and Strategies for Prevention, Part 2 of 4

Michael D. Topf, MA is the President and CEO of Topf Initiatives. This article originally appeared In SafetyXChange.org and copyright is held by Bongarde Media.

Last week, we looked at how the business environment and corporate culture can cause error incidents to occur. Naturally, human error is also a result of individual actions. Let’s take a look at some of the other factors that can increase the incidents of errors in the workplace.

The Individual Factors that Cause Human Error

As we discussed last week, people respond to distractions in the workplace. Whether it’s an increased workload or employment uncertainty, these distractions play a role in error-related incidents. That’s looking at the big picture. To assess all the factors related to human error, we now need to narrow the focus down to the individuals — the line employee, whether in production, maintenance or administration, and their supervisors and managers.

Inattention

A primary cause of communication errors and misinterpretations is loss of focus. Any number of factors can lead to inattention and loss of focus, including:

Daydreaming;

Repetitive tasks;

Stress; and

Distractions.

Pre-Meditated Risks

Another individually-rooted cause of errors is conscious or pre-meditated behaviors such as when individuals talk themselves into taking shortcuts, deliberately go around a machine guard or fail to read through a job safety analysis or procedural instructions before beginning a task.

These pre-meditated risk behaviors tend to be supported by rationalizations and justifications and are often ascribed to factors such as time, comfort and convenience. Often, the attitude or belief that "I’m experienced and capable and I know what I’m doing" can lead to decisions to take shortcuts or bypass safety procedures. The risk is particularly acute in companies where downsizing or fear of downsizing exist. The fear of layoffs can pressure employees to take shortcuts to get their jobs done faster because they do not want to be perceived as slow.

Insufficient Training

Errors often occur because inadequately trained personnel are placed in positions that require levels of experience and expertise they don’t possess. (Systems don’t work unless people do!)

Also contributing to error-making are ingrained attitudes such as, "We can't afford to spend the money or time on training people completely; we need to focus on production and profits."

Insufficient Measurements

Using injury statistics to track errors and incidents the way many safety professionals do, does not measure levels of awareness or behaviors. Nor does it ensure all levels of employees are working towards preventing errors and incidents. In fact, low incident rates can cause people to become complacent and place their attention and energies elsewhere.

To ensure continual improvement, attention and energy must be consistently applied to quality and safety, health and environmental performance. We can wait until we get sick before we go to a doctor, or we can go to the doctor before we get sick to find out what is the best way to stay well. I believe that a "holistic" approach to error prevention is the most effective way to go.

Conclusion

Now that we’ve identified corporate and individual causes of human error, next week, we’ll start to explore strategies for preventing them.

NTSB: LEX Controller Had Two Hours Of Sleep Prior To Accident Shift

A group stands under umbrellas in a light rain at a temporary memorial to the victims of Comair Flight 5191 at the Blue Grass Airport Wednesday, Aug. 30, 2006, in Lexington, Ky. The crash killed 49 people on Sunday. (AP Photo/Ed Reinke) (Ed Reinke - AP)

The National Transportation Safety Board is wrapping up its on-the-scene investigation into Sunday's loss of a CRJ-100 in Lexington, KY... and at the final public briefing Wednesday night, board member Debbie Hersman shed new light into the work schedule of the sole controller in the tower at the time of the accident.

According to Hersman, the air traffic controller in the tower had worked a six-hour shift on Saturday, from 6:30 am to 2:30 pm. He then had nine hours off -- during which time, he told investigators, he slept for two hours -- before returning for the overnight shift at 11:30 pm.

The controller told investigators he was handling the accident's flight clearance, as well as vectoring an earlier flight around weather, as the Comair RJ took the runway.

Hersman also told reporters that investigators are checking surveillance tapes of taxiway Alpha as Flight 5191 headed to the runway. Hersman said that from what she had seen of the tapes so far, however, the actual moment the plane takes the runway is out of the camera's field of vision.

The NTSB is also interviewing airport staff who interacted with the plane's flight crew... including workers who had to alert Captain Jeffrey Clay and First Officer James Polehinke they had initially boarded and powered up the wrong aircraft, and direct them to their plane.

Hersman states the NTSB is now working with revised performance estimates for the accident aircraft, as earlier estimates were based on a CRJ-100 with uprated engines the accident aircraft did not have.

According to the revised figures, Flight 5191 would have needed 3,744 feet of runway to reach its rotation speed of 138 knots. Runway 26 is 3,500 feet long.

Hersman said the memorial service for the victims of Flight 5191 is scheduled for Thursday... after which time most of the NTSB team will head back to Washington for the next stage of the investigation.

Family members of the victims of Comair flight 5191 that crashed on takeoff at Lexington's Bluegrass Airport early Sunday morning console each other as they arrive at the Campbell House Hotel Sunday Aug. 27, 2007 in Lexington Ky. A commuter jet taking off for Atlanta crashed just past the runway and burst into flames, killing 49 people before dawn Sunday and leaving the lone survivor in critical condition.

NTSB: Wrong runway wasn't Comair crew's only preflight error

LEXINGTON, Kentucky (CNN) -- As Comair Flight 5191 began rolling down the wrong runway, the lone air traffic controller on duty at Lexington's Blue Grass Airport was busy with paperwork. And the 47 passengers onboard were unaware that the flight crew had started that Sunday morning by mistakenly getting onto another plane.

Seconds later, the commuter jet crashed, killing everyone onboard except the co-pilot, who remains in critical condition at a Lexington hospital.

The Federal Aviation Administration on Tuesday acknowledged that only one controller was in the tower, in violation of the agency's policy, when the Comair jet crashed.

The revelation came after CNN obtained a November 2005 FAA memorandum spelling out staffing levels at the airport. The memo says two controllers are needed -- one to monitor air traffic on radar and another to perform other tower functions, such as communicating with taxiing aircraft.

When two controllers are not available, the memo says, the radar monitoring function should be handed off to the FAA center in Indianapolis, Indiana.

The FAA told CNN that the lone controller at Blue Grass was performing both functions Sunday in violation of the policy.

The controller's last look at the Comair CRJ-100 occurred when it was on the taxiway, according to National Transportation Safety Board investigators.

"He had cleared the aircraft for takeoff, and he turned his back and performed administrative duties in the tower," said Debbie Hersman, the NTSB member in charge of the investigation.

She said the controller cleared Flight 5191 to take off on Runway 22, the 7,000-foot lighted runway used by commercial jets.

Instead, the crew tried to take off on the unlit Runway 26, which was about half as long. (Airport layout)

The controller told the NTSB he had an unobstructed view of both runways, Hersman said, but because he was not looking in that direction, he was unaware of a problem until he heard the crash.

Air traffic controllers are not responsible for making sure pilots are on the right runway, John Nance, a pilot and aviation analyst, told The Associated Press. "You clear him for takeoff and that's the end of it,"

Nance said, according to the AP.

The Lexington Herald-Leader reported Tuesday that in 1993 a plane mistakenly lined up on Runway 26 instead of Runway 22, but the tower noticed the error in time.

Turning onto the wrong runway was not the only mistake the crew made Sunday, according to the NTSB. When they arrived at the airport at 5:15 a.m., (still in their circadian rhythm low for alertness) the captain and first officer boarded the wrong plane and turned on the power before a ramp worker pointed out their mistake.

Hersman said it was the flight's captain, Jeffrey Clay, who taxied the aircraft into position at the start of the wrong runway. Clay then turned over the controls to the co-pilot, James Polehinke, who was flying the plane when it crashed. Hersman said that was standard procedure since only the captain can reach the tiller used to steer the plane while it's on the ground.

Hersman said both crew members were familiar with the Lexington airport but that neither had been to the airport since a repaving project a week earlier altered the taxiway route.

She said investigators will continue to gather information on how the pilot and co-pilot spent the 72 hours before the flight. She said toxicology testing for alcohol and drugs is routine.

Staffing boosted after crash

Andrew Cantwell, regional vice president of the controller's union, said he could not say with certainty whether additional staffing would have prevented the crash, but a second person would have allowed the controller to focus on operations.

In a statement Tuesday, the FAA suggested that a second controller would not have prevented the accident.

"Had there been a second controller present on Sunday, that controller would have been responsible for separating airborne traffic with radar, not aircraft on the airport's runways," the statement said.

The FAA this week increased overnight staffing at Lexington as well as at airports in Duluth, Minnesota, and Savannah, Georgia, Cantwell said.

Doug Church, spokesman for the National Air Traffic Controllers Association, said there has been a net loss of 1,081 controllers in the last three years, due largely to a wave of retirements, the AP reported.

Tire marks indicate the plane's wheels went into grass beyond the end of the runway. It became airborne after hitting an earthen berm, clipped a perimeter fence and struck a stand of trees before hitting the ground, said Hersman.

A longtime pilot familiar with Blue Grass Airport told the Lexington newspaper that the airport is confusing and getting onto the wrong runway is easier than it sounds.

Russ Whitney told the paper that Runway 22, the one Flight 5191 should have been on, has a hump in the middle, so pilots cannot see the whole thing as they begin takeoff. Runway 22 and the much shorter Runway 26 can appear to be the same length, he said, according to the newspaper.

On Wednesday, victims' families were scheduled to tour the crash site before a memorial service, the AP reported.

NTSB: Mechanical Problems Downed Firefighting Helo

Tailrotor Assembly Fell Off Before Impact

There is strong evidence it was equipment failure (It sounds more like maintenance failure) that brought down a helicopter fighting the Happy Camp Complex Fire in Northern California on August 4.

In its preliminary report, the NTSB found that the number one engine on the Sikorsky CH-54A (file photo of type, above) had been replaced the night before the accident.

Crews with the US Forest Service and operator Heavy Lift Helicopters returned the helo to duty the next morning, after a series of uneventful flight checks.

The helicopter then flew several missions afterward, until it went down in the Klamath River while in the process of refilling its water tanks for a run just before 8 pm.

One witness told the agency that he saw a large piece of equipment fall from the helicopter just before the copter went down. That piece, the NTSB says, was the Sikorsky's tail rotor gearbox... with three of the four tailrotor blades still attached.

Two pilots were lost in the crash... and the investigation continues.

Oshkosh 2006 Passenger Killed In Taxi Accident
Shortly after noon as this year's AirVenture was nearing its close, a passenger in an RV-6 homebuilt was killed when a Grumman TBM Avenger ran into it from behind while taxiing at the Oshkosh airport. Both the Avenger (a very large WWII taildragger with limited forward visibility) and the RV were in line for departure at Wittman Field, on the taxiway on the west side of the airport's main runway, 18-36. The propeller of the Avenger sliced into the RV and passenger Gary Palmer, 63, of Nepean, Ontario, was killed. Palmer was president of EAA Chapter 245 in Ottawa. The pilot of the RV, Donald Reed, 58, of Carp, Ontario, was unhurt, as were the two on board the Avenger. "It's always a very difficult situation when there is a loss of life," EAA President Tom Poberezny said in a statement on Tuesday. "Our sincere sympathy goes to the families and to all involved." The NTSB is continuing its investigation into the accident.

NTSB Urges More Frequent CF-6-80 Inspections

US National Transportation Safety Board issued "urgent" recommendations upon conclusion of its investigation into the uncontained CF6-80A failure in June on an American Airlines 767 parked at Los Angeles International Airport NTSB, in finding that the high-pressure turbine stage 1 disk rupture resulted from a rim-to-bore radial fracture originating at a "small dent" at the bottom of the blade slot and that the disk, which had accumulated 9,186 cycles in service, had two additional cracks, proposed that FAA require that disks be removed for inspection every 3,000 cycles.

FAA recommended that the disks be inspected after 6,900 cycles (they have a service life of 15,000 cycles) following the LAX incident. "This significantly more stringent standard would not permit disks to remain in service without inspection beyond the earliest known number of cycles at which cracks have been detected or failure has occurred," NTSB said.

The National Transportation Safety Board's probe of an uncontained engine failure on an American Airlines Boeing 767 in June has led the board to urge FAA to act more stringently in requiring inspections of General Electric CF6-80A/80C2 and some 80E1 engines.

The high-pressure turbine (HPT) Stage One disk in the Number One CF6-80A engine experienced an uncontained failure and broke into several pieces, which punched holes in the wing, with some pieces scattering as far as 3,000 feet from the aircraft.

Both GE and FAA have issued service bulletins and airworthiness directives following previous uncontained HPT Stage One disk failures on a US Airways Boeing 767 in 2000 and an Air New Zealand 767 in 2002.

But the safety board believes the failure of the disk in the engine powering the American Airlines plane "indicates that further actions are necessary." The board's benchmark in its recommendations for various reinspection and rework is 3,000 cycles since new, with different guidelines applying to engines that are above and below that threshold, and have undergone various tasks included in GE's service bulletins.

A 3,000-cycle benchmark is also used for engines that have been inspected previously to ensure they're removed for the proper re-inspection and rework if necessary.

NTSB explained that HPT Stage One disks from engines in the American, US Airways and Air New Zealand incidents ruptured several thousand cycles short of their 15,000-cycle life limit, and some disks with 5,144 cycles had cracks uncovered during routine inspections. "To establish a conservative margin for these disks, inspection and rework should occur well within the 5,144 cycles since new where fatigue cracks were found or the 7,547 threshold, where the US Airways disk failed," NTSB said.

Earlier this month, FAA released a rulemaking to tighten inspection intervals.

The safety board also believes FAA should require a design review of the CF6-80 Stage One high-pressure turbine disk to determine whether a sufficient material property margin exists to prevent cracks, and if that margin is absent, a redesign or material change should occur. Also on NTSB's list of recommendations is that the cockpit voice recorder should be running during engine ground tests, or if a plane is involved in a reportable incident the CVR should be removed to preserve data and replaced with another to conduct ground tests.

Russia air safety questioned after deadly crash

MOSCOW –– The latest crash of a Russian airliner was the third plane disaster in or near Russia in the past four months and has raised fresh questions about air travel safety in the country, experts said Wednesday.
Aviation officials have suggested that Tuesday's crash in eastern Ukraine was caused by severe weather, a possible explanation that raises as many questions about the crash that killed all 170 people aboard as it answers.

But whatever cause is ultimately assigned to the crash of Pulkovo airlines flight 612, the fact is that large civilian jets packed with passengers have fallen from the sky with alarming frequency recently.

"The pool of Russian planes is generally old," said Yefim Gordon, a respected Russian aviation historian. "The plane that went down yesterday was a good plane, most likely well-maintained. But aircraft age is a factor in many other accidents" in Russia and other countries that once constituted the Soviet Union, he said.

Tuesday's crash of a Russian-built Tupolev-154 plane was preceded on July 9 by the crash in the Siberian city of Irkutsk of an Airbus A310 owned by Russia's S7 Airlines.

Two months before that, on May 3, another Airbus A310 owned by Armenian carrier Armavia crashed into the sea off Russia's southern coastal city of Sochi.

A total of 244 people have been killed in aviation accidents in Russia so far this year -- not counting the 170 killed in Tuesday's crash -- a sharp increase over the 56 people who died in 2005 and 50 the previous year.

In addition to those killed in air accidents in 2004, another 90 people died when two commercial airliners were brought down simultaneously after bombs planted in the planes by Chechen rebel sympathizers exploded in mid-flight.

Gordon and other experts said a combination of ageing aircraft, squeezed budgets in a fiercely competitive sector and human errors in the air and on the ground were all factors in Russia's aviation safety performance.

Because the first two major crashes this year involved Airbus planes, it was Western planes -- usually second-hand and leased by Russian companies at low cost -- that have come in for criticism. "But now the list is growing," the government daily Rossiiskaya Gazeta commented Wednesday, citing the Tupolev-154 and Tupolev-134 models, workhorses of the Soviet-era fleet, as planes also coming under close scrutiny. –– AFP

A Passenger Door Flies Off a Fokker in the Climb

Legions of seasoned travellers will tell you that it's laughable to panic over an air rage incident where a passenger runs amok and tries to open a door inflight. That's of course because unlike cargo doors that must open outwards to maximize cargo-hold space, passenger aircraft doors all open inward (sideways or rise up into the ceiling) and are plug doors. That is to say that, after take-off, aircraft pressurization will oppose any attempt by a berserker to open the doors with a counter-force of several thousand pounds per square inch. It's a physical impossibility because the plug doors are being forced into the door cutout inner recess by cabin pressure.

Consequently, on August 9, the 79 passengers aboard TAM flight JJ3040, a Fokker 100 jet, were probably taken aback when the front left main boarding entry door, known as L1, suddenly disappeared as the aircraft passed around 6,000 feet in the climb.

The aircraft, regn: PP-MQN, landed safely back at Congonhas Airport in Sao Paulo Brazil 18 minutes later, even though the door smote its wing and tail surfaces in passing. The door ended up falling 6kms from the airport in the grounds of Ipiranga Museum, after bouncing off the roof of the Exra supermarket in the Avenida Ricardo Jafet.

The Brazilian Air Safety Authority (ANAC) is investigating. Early reports indicate that the pilots had an indication in the cockpit and advised a cabin crew-member who then tried to secure the door. Luckily, she didn't depart with the door. Some reports indicate that she strapped into a seat next to the door before checking the handle.

Obviously, it is possible to open a Fokker door in flight. For some of the above-mentioned seasoned passengers, that might be a very scary concept. It was TAM's 7th major F-100 incident and its second such Fokker 100 door incident. It's one of many such portal departures that have occurred to F28's and F-100's over the years. In a well-known Canadian F28 incident, the crew was able to lift the bottom sill-hinged door slightly so that it would not be ripped off on landing back in Calgary.

Of course, there's a reason why the door is bottom-hinged and opens outwards. When smaller airliners operate to many regional airports without any infrastructure, it's easier to have self-support like integral airstairs and APUs. However, other manufacturers seem to have thought it through a little more sensibly, as aircraft such as the 717, Dornier 328 jet and 737 come with optional integrated airstairs that stow in a compartment beneath the main entry door and fold out hydraulically when needed. It's a weight penalty but better than the integral airstairs built into the door, which require the door to be outward opening, non-plug and potentially lethal. Airstairs that are built into the door like the F-100's now seem to have "fallen" from favor.

Fokker released a Service Bulletin after the doors started regularly flying open [(SB) F100-52-069 Revision 3 dated 18 December 2002]. However, as with all manufacturers' Service Bulletins, it's up to the national regulators to enforce them by airworthiness directives. Australia's CASA did that (see http://www.casa.gov.au/airworth/airwd/ADfiles/over/f100/F100-052.pdf). However, the measure blames the door openings on improper closure and goes no further than installing cockpit warning lights and cabin placards. That's akin to chalking a circle around a deep pit in a road. You still catch those in a hurry.

Reportedly, other operators have carried out an optional Fokker modification due to the door design being similar to the older F28 -- i.e., with the longer fuselage on the F100, some aircraft fuselages were prone to distort a few mms, causing the main latches to not line up accurately. It involves an electrically actuated pin that locates into the airframe at the top of the integral stairway door and, as a bonus, it helps align the latchings. This pin slides into the airframe when the door is closed shut and only retracts once the locking handle has been put full to the lock position, thus completing a pin-retract circuit.

This pin should hold the unlocked door in place even if the handle is inadvertently left in the unlocked or partially locked position. The solenoid-actuated pin was designed to hold everything square, and then retract electrically (and noisily) only when the door was properly latched.

A two-stage locking process would seem to be eminently sensible. It seems to keep car engine compartment hoods from flying open. However, it does sound as though TAM never went that extra mile. They're unlikely to do so now, because their 22 F100's are being progressively replaced by A319's and ERJ190's. Such is life. One door opens, another closes.

NTSB: Loose Components May Have Led To Walton/CGS Hawk Accident

An investigation into the fatal crash of John Walton’s experimental light sport airplane revealed a key control device was displaced more than 3 inches from its proper location.

A nine-page narrative by investigator Aaron Sauer of the National Transportation Safety Board focuses on the improper position of a "locking collar" that is part of the aircraft’s link between the control stick and elevators and ailerons. Sauer’s report is a "factual" one only and does not list a probable cause for the accident.

But the scrutiny of the controls suggests keen interest in whether Walton was able to properly guide his aircraft when it crashed into the ground at a steep angle just north of the Jackson Airport June 27, 2005. In noting the improper location of the locking collar, the investigator reviewed assembly instructions for the aircraft and conducted tests to recreate scratch marks the collar and its components made on adjacent parts. He observed that the collar in question was held in place with a screw that was lightly torqued and not coated in any tightening compound that would cement it.

Among his observations, Sauer notes that instructions for assembling the kit aircraft do not say how tightly to torque the screws on the locking collar.

Sauer also notes that Walton made several modifications to the CGS Hawk Two Place Arrow and had repaired it after a crash in Nebraska. That incident occurred when Walton attempted to fly the plane from West Virginia to Jackson Hole last summer.

He put the plane on a trailer and drove the craft here from Burwell, Neb. because of damage.

Still to be determined is how or why the locking collar was moved into its improper position, possibly rendering the control stick useless in some directions. Sauer said Friday his report is a comprehensive examination of the plane wreckage, but that the probable cause will be determined by others sitting on a board in Washington, D.C. That will occur in three to four weeks, he said.

Walton, a philanthropist and heir to the Wal-Mart family fortune, was a commercial- and instructor-rated pilot whose only flying restrictions were that he wear corrective lenses. Sauer reported he did not locate either Walton’s pilot log book nor the construction log that is supposed to be kept when building aircraft such as the Hawk Two Place Arrow.

In examining the aircraft ruins, Sauer noted several modifications and reinforcements in the area around the critical control stick. One section of the aircraft had been replaced following the crash in Nebraska, according the report.

The NTSB investigator attempted to recreate scratch marks that the locking collar made on a tube to which it was supposed to be securely fastened. He made several attempts to recreate the marks and came closest when forcing a similar collar along a similar tube by driving it with blows from a hammer.

Sauer reported several modifications to the plane, including the removal of a skin covering, including a "gap" covering that completed the surface of the wing in the center of the aircraft above the pilot. Walton had riveted a wind screen onto the plane in place of the window contained in the skin covering and had moved around several components, including a battery.

Sauer located a bent and marked inspection mirror casing at the crash site and probed the possibility it had somehow become lost in the aircraft and jammed controls. He could not reproduce the damage on a similar mirror casing by lodging it in controls, according to his report.

The investigator also discounted weather and Walton’s health as factors in the crash, although no carbon monoxide or cyanide tests were performed on the pilot’s blood.

Sauer writes that Walton requested a landing from the control tower "shortly after departure" on his fateful flight. There was no other communication. It was the third flight following repairs for the Nebraska crash damage.

During his first flight, Walton reported a "tail-heavy" feeling and figured it was due to his removal of a heater and the shifting of the plane’s center of gravity. He installed a heavy battery forward from the original battery location and made a second flight, only to have his engine overheat.

Walton then attached air scoops, originally part of the fabric cover but since removed, directly to the craft using rivets, Sauer reports. The aircraft was supposed to be registered with the FAA but Walton had yet to do that.

Recent Accidents Involving Airline Workers

Selected injuries and deaths of airport ground workers over the past five

years:

June 9, 2006 -- A construction worker at the Oklahoma City airport was

injured after he was pinned inside the baggage belt while performing

maintenance on the system.

Jan. 8, 2005 -- During a heavy snowstorm, an airport worker in Gunnison,

Colo., was injured when he crashed a snowplow into an aircraft operated by

Continental Airlines. An investigation by the National Transportation Safety

Board also revealed that the snowplow driver had used excessive speed.

Dec. 14, 2005 -- A tug driver was injured when a FedEx Corp. aircraft

collided with a tug during pushback at Memphis International Airport. An

NTSB investigation attributed the accident to "improper" towing of the

airplane.

Oct. 25, 2004 -- A ground employee at Dallas/Fort Worth International

Airport was seriously injured when he was struck in the head at least twice

by the propeller of an aircraft operated by an American Airlines regional

carrier, American Eagle. According to the NTSB investigation, it was the

first time the employee had performed a pushback alone. The worker was not

wearing a ground-to-cockpit headset because it was not working properly.

July 16, 2002 -- A ramp worker had a thumb and two fingers severed by the

propeller of a Mesaba Airlines at Tupelo Regional Airport in Mississippi.

March 23, 2001 -- A ground employee at Miami International Airport received

serious injuries while working on an aircraft's landing gear. The worker was

blown over by a jet blast. The NTSB cited other employees' failure to follow

safety procedures and alert the injured worker while the employee was

working around the aircraft.

Sept. 23, 2001 -- A parked United Airlines aircraft rolled forward when it

was disconnected from its tow, pinning and seriously injuring a ramp worker.

The NTSB ruled that miscommunication between the worker and the aircraft's

crew contributed to the incident.

SOURCE: National Transportation Safety Board

Safety On The Ground

For the ground support worker, safety first is the required mantra for a competitive industry .

It was early evening on September 12, 2003 at the Norfolk International Airport in Norfolk , Virginia. Denise Bogucki was nearing the end of her shift, but had to complete operations for one last takeoff.

Northwest Airlines Flight 1569, bound for Memphis, Tennessee was preparing for takeoff. Denise Bogucki was at the wrong place at the wrong time. She was riding on a pushback tug, which was to push the aircraft away from the gate. Sadly, she was crushed against the nose of the plane while she prepared to push the jet back.

The exact detail of why and how the tragic accident happened is under investigation. Many suspect that the accident could have been prevented had there been another worker involved in the operation. At the same airport, U.S. Airways, Delta, Southwest and Continental told the Virginia Pilot that they use two workers for the same operation.

Why a reduced level of manpower for the operation at Northwest? Competition may be one explanation. (How about bankruptcy?) There is a growing consensus that pressure from the competitive airline environment has strained the number of ground support employees that would be optimal for ground support operations.

Harry Becker, Training Manager and Health, Safety and Environmental Coordinator for the Signature Flight Support division of Aircraft Services International Group (ASIG) believes that the number of flights operating during a particular window of time has strained the level of manning when multiple operations are underway.

"These peak periods may stretch the work force, and then during other times they may have more than enough employees on staff" says Becker. "As airlines continue to operate more regional jets on their routes these cities tend to be on smaller regional aircraft with more flights operating into hub cities."

Becker adds that filling their labor requirements has become difficult for airlines. "Turn over rates of airline employees are becoming a problem for those airlines using more part-time workers who are less committed and may have less ramp experience as well as lower hourly wages," he says.

Clear and constant communication between ground handlers and pilots is imperative. It's The Training.

One possible solution to improve ground safety is one you've heard of time and time again: training. Ground vehicle training programs currently in place at airports vary from only on-the-job training to comprehensive formal training programs with license requirements. Most airports have a formal ground vehicle-training program. They generally involve a two-tiered level approach to training of drivers who operate on the movement area and those who only drive on the apron areas. "Management has the responsibility to monitor their employees and the rush factor as well as insuring they are properly staffed with qualified employees," says Harry Becker.

Another important element of a formal ground vehicle-training program is recurrent training. "Shift briefings and safety related operational training needs to be continually relayed to all employees," adds Becker of Signature Flight. Recurrent training is necessary to ensure that vehicle operators remain familiar with vehicle procedures and any changes related to ground vehicle operations that occurred in the previous year.

Becker emphasizes the importance of sharing accident knowledge and mishap information with the work force to inform other workers of ramp safety issues.

He advises and advocates for the formation of safety teams. "Safety teams from within the work force can be a big help to identify safety issues and concerns and then addressed to management through safety meetings with minutes taken for corrective actions," says

Becker. "These teams can be the eyes and ears of what is actually happening on the flight line and have a true sense of reality that can help guide the work force to a safer operation. Peer pressure can have a big impact on worker performance and improved safety."

What can happen when an aircraft is taxiing too fast from another area of the ramp.

The Highly Visible Worker

The FAA believes there is another factor that may greatly reduce accidents., the ability to see the worker and the visibility of the worker to see objects and people.

In a 2002 report to Congress, the FAA analyzed OSHA data to determine whether visible clothing may have prevented any of the fatalities.

Between 1985 and August 2000, OSHA had reported nine fatal job-related "struck by" injuries to workers on airport aprons, only two of which occurred after 1995.

Lighting conditions may have been a factor in at least six of the fatal accidents. All accident summary reports that listed the time of the fatal injuries showed the accident occurred during darkness or low-light conditions.

A vehicle backing up-an activity during which an operator's field of vision is limited, killed five of the nine fatally injured workers identified in the OSHA database. For example, in 1998, a ground worker was struck in the back by a fuel truck that was backing up after fueling an airplane. Some explanations believe the accident could have been prevented had the fuel truck had a spotter.

In 1988 a fuel truck struck a wing walker wearing a yellow rain slicker and raising lighted wands to signal vehicular traffic to stop for an aircraft. The weather was rainy and foggy and the accident was caused by poor visibility.

Both the FAA and OSHA databases listed the March 27, 1997 fatality of a wing walker for a major airline who died after being run over by an aircraft he was helping to push back. A pilot's visibility relative to apron workers on the ground is extremely limited, so radio communication is used. The wing walker was killed when he walked in front of the plane's nose gear to retrieve the headset cord used in radio communication with the flight crew. High visibility clothing would probably not have made any difference in this accident.

According to the NTSB, a worker killed on December 8, 1992, was using a 15-foot headset cord, which restricted his ability to stay clear of the nose wheel, tug, and tow bar. The tug operator reported seeing the worker fall in his peripheral vision and being unable to stop the tug before it struck the worker.

None of the OSHA accident reports listed whether the above mentioned fatally injured worker was wearing high visibility clothing, making it difficult to determine the impact such clothing might have had on the accidents.

Due to the fact that many companies over the past several years have required or enforced existing company policies requiring that apron workers wear high visibility clothing, some of the fatally injured workers may have been wearing high visibility clothing when struck.

When the FAA surveyed major airlines they found that that 11 airlines used reflective belts and reflective lettering on shirts and jackets; 5 airlines did not have any high visibility clothing requirements. The 7 that did included Airtran, American, Comair, Continental, Delta, Midway, Northwest, Southwest, TWA, United, and US Air.

The visibility issue is often considered the root cause of a wide variety of ground accidents. The majority of these accidents seem to be akin to the type that caused the death of the Norfolk, VA worker.

In a study of a specific major airlines "struck by" reports, the FAA found that 42 injuries in total between 1985 and 2000 had occurred on the ground. Most injuries occurred from tractors and tugs. The percentage of the airlines were as follows: Tractor/Tugs - 22 injuries, Cargo/Jet Veyor - 6 injuries, Van - 5 injuries, Dolly - 3 injuries, Cart - 2 injuries, Truck - 2 injuries and other causes - 2 injuries.

The Well Heeled Safety Management Program

Worker visibility is key in preventing an accident. In order to incorporate visibility equipment and practices into the workers' process, it's important to have a well-heeled safety management program. Becker believes that safety and accident prevention begins and ends with vigilant safety management. Safety management encompasses the down line of accountability from supervisor to training manager to worker.

"Managers need to be held accountable for their workers actions and be a part of their performance evaluations as well," he says. "They need to be observing their workers to see that short cuts are not taken and safety practices are being followed."

Safety management takes discipline. This discipline often takes the form of a process for tracking and documenting what has been covered and addressed and what hasn't. Trainers need to document this training so that there is a record to show all training has been completed.

Says Becker, "Training status reports need to be made available to supervisors so they know who has been trained to do what. This insures that those employees who have not been trained are not operating equipment or performing tasks they are not qualified to do."

Smart safety management is preventive and anticipates problems before the problem occurs. A Virginia Pilot news article describing the death of Bogucki from the tragic accident on that Northwest ramp, quoted Anne Mancini, Bogucki's aunt and a Northwest employee as saying that employees at staff meetings often raised staffing and safety issues. She said Bogucki had expressed concerns to supervisors in a meeting eight days earlier.

If safety isn't first, its consequences can haunt your ground support staff. According to Mancini in that Virginia Pilot article, "I don't care how many times they power wash it, Dennie's blood is still on that ramp."

Airlines, FAA to focus on ground worker safety
WASHINGTON - They fix planes (I don't think so) and load and unload heavy bags in sweltering heat and frigid cold. For many passengers, they are invisible, though they toil right underfoot. Airport ground workers do their jobs amid the deafening roar of aircraft engines and the arrival and departure of tanker-size jetliners. They must avoid stepping in oil slicks and watch out for baggage carts whizzing by.

Now the ground workers' tough conditions are coming under closer scrutiny.

For the first time, airlines and the Federal Aviation Administration will co-host a three-day symposium focused on improving safety on the tarmac at the nation's airports. Participants in the gathering, which begins Sept. 6, will analyze data on accidents to help airlines identify dangers and adopt strategies for reducing risks.

"It's next in line to be dealt with," said Basil J. Barimo, vice president of operations and safety for the Air Transport Association, a trade group that represents major U.S. airlines.

Although serious injuries and death sometimes occur, the most common injuries among ground workers result from heavy lifting, which in many cases causes severe back strain. According to figures from the Bureau of Labor Statistics, there were 4.53 injuries and fatalities per 100 airport ground workers in 2004, the latest year for which data are available. By comparison, coal miners had a rate of 6.58 injuries and fatalities per 100 workers. In construction, the rate was 5.77.

So far this year, four ground workers have been killed or seriously injured, according to data collected by The Washington Post. In one case, a mechanic died in January when he was sucked into the engine of a Continental Airlines aircraft at El Paso International Airport. A month later, a baggage handler for Comair, a Delta Air Lines regional carrier, was killed when he was struck by a baggage cart at the Detroit airport. Three serious or deadly accidents occurred in 2005 and two in 2004.

Through the busy summer season, ground workers have been under increased pressure to load and unload bags swiftly and to ensure that aircraft are prepared for safe travel. Many financially strapped carriers have reduced their staffs, leaving more work for the remaining employees. Some airlines have been hiring ground workers at lower wages to cut costs.

Several airlines said training and supervision of workers remained as much a priority as passenger safety.

Many workers and their families say more needs to be done to ensure a safer environment, and they urge more oversight. FAA officials said the agency reviews each airline's safety guidelines for the workers, but that it was up to the individual carriers to enforce those rules.

Jim Ballough, director of the FAA's flight-standards service, said the agency sends inspectors to airports to assess flight preparations and safety on the ground. But some airline officials said those random inspections focus more on flight matters than on ground safety. The officials added that more safeguards are needed to protect workers.

Workers complain that oversight tends to shift among agencies. After an accident occurs, the government agency that leads the investigation varies depending on the type of accident.

Further, no one entity -- not the FAA, the National Transportation Safety Board, Occupational Safety and Health Administration, the Bureau of Labor Statistics, the airline association or unions -- keeps comprehensive records of injuries and fatalities among ground workers.

The involvement of multiple agencies hinders record-keeping and can keep some cases from getting the attention they need, industry experts say.

Paul Kempinski, director of ground safety for the International Association of Machinists & Aerospace Workers District 141, said unions have urged government agencies to more rigorously monitor ground operations. OSHA "only comes out when something happens," said Kempinski, who represents baggage handlers at United and Aloha airlines and US Airways. "Something needs to be done sooner. Someone needs to be in charge of oversight."

Several high-risk industries have special federal agencies that oversee working conditions. For example, the Labor Department created the Mine Safety and Health Administration in 1978 to oversee mine safety. This year, there have been 34 miner fatalities out of 108,734 workers.

That no one entity oversees workplace injuries within airlines does not surprise those who study such accidents. Kenneth Rosenman, a physician and professor at Michigan State University who in May published a three-year investigation on workplace injuries and illnesses in Michigan, said only about 40 percent of job injuries or fatalities are reported. He said employees and companies think there's little incentive to report accidents to federal authorities.

"Our national system of counting injuries and illness is inadequate and misses more than half of the injuries and illness in the workplace,"

Rosenman said.

Yolanda Corbett, 32, was attracted to a subsidiary of US Airways during a hiring fair in 2005. She liked the free travel offered to employees and a chance to take her two young daughters to Disney World. The pay, about $9.75 an hour, was low, but it represented steady work for the single mother who had held such odd jobs as baby-sitting after being laid off from an accounting position at a Welfare to Work office.

For two weeks, US Airways baggage handlers instructed the D.C. resident on the proper way to lift bags and navigate the busy runways of Reagan National Airport in a baggage-loading cart. She received a 100 percent accuracy rating in her training tests.

In her third week on the job, Corbett was killed when she lost control of a baggage cart. It rammed the side of a regional jet, pinning her under the aircraft and severing her spine.

The NTSB attributed the accident to Corbett's inexperience with driving the cart.

Corbett's mother, Mary, said her daughter had been trained to operate the baggage cart, but the day she was killed was the first time she had driven it by herself. "She wasn't trained properly. She wasn't ready to drive that vehicle. It just wasn't safe," she said.

US Airways officials have declined to comment on training and safety situations before the 2005 merger with America West, citing the company's new management team.

TRAPPED ON FLIGHT 63

EXCLUSIVE Police called to stop riot as packed jet is kept on runway for SEVEN HOURS

POLICE boarded a jumbo jet yesterday amid fears furious passengers would riot after being stuck in their seats for seven hours.

The 352 travelers were kept cooped inside Virgin Atlantic Flight 63 on the ground after a technical problem. Take-off was finally aborted as the Boeing 747 taxied up the runway with a car driving alongside frantically signaling that the jet had an over-inflated tire. Passenger Philip Robinson said: "You could feel the plane going bump, bump. God knows what could have happened if it had tried to take off.

"When we got back to the terminal we still couldn't leave. We were told police were coming on in case we started a riot."

Another passenger Peter Sidebottom, 57, added: "Tensions were rising and one woman was abusing the staff. Another passenger said if she didn't shut up she'd punch her teeth in."

The flight was due to leave Gatwick for Havana at 9.30am. Some passengers boarded at 8.45 and all boarding was finished by 10. An engineer was still working on one engine.

At 11, the crew announced a technical problem would be fixed in 15 minutes.

The plane taxied but then stopped. Passengers were told the crew were waiting for a spare part.

At 1pm, the captain said the spare part had arrived. At 2.45 passengers were told that if the part could not be replaced by 3.30 the crew would exceed their legal operating hours.

At 3.25, the plane taxied again towards the runway, ready for take-off. Then air traffic control spotted the misshapen tire.

The Boeing was taken back to the terminal and police were called over fears the passengers, who included a young couple on a £5,000 honeymoon, could erupt in fury.

They were not allowed off the flight until 4.30pm, when they were told it was cancelled.

Businessman Mr Robinson, 53, of Maidenhead, Berks, said: "It was appalling.

No one apologized or knew what was happening.

"Because of security we couldn't take drinks on board and were only given two glasses of water. No one even had any food." (A few free drinks would have helped here)

The flight is re-scheduled for today. All passengers were offered hotel accommodation.

Virgin Atlantic said: "This was a unique set of circumstances and we'd like to apologies for any inconvenience caused."

Police confirmed officers boarded the plane but said no arrests were made.

What you can do about the bacteria and viruses on your hands

Human skin — even in the most healthy of us — is teeming with bacteria. Most of those bacteria only cause disease under special circumstances. But everyone also carries potentially dangerous germs from time to time, such as staph, strep, and the intestinal bacteria that cause food poisoning and diarrhea.

Sad to say, health care personnel — including your doctors and nurses — are particularly likely to carry the most troublesome bacteria, especially on their hands. And although viruses don’t set up shop on the skin the way bacteria do, the viruses that cause diarrhea and respiratory infections — from the sniffles to the flu — can hang around on the hands long enough to spread from person to person.

If your skin is covered with so many germs, why don’t they make you sick more often? Although the skin is a hospitable resting place for bacteria, it is also a tough barrier that prevents hostile bugs from reaching the body’s vulnerable internal tissues. Ironically, perhaps, some of the traditional methods of removing bacteria from the skin can disrupt its very defenses. Scrubbing can produce tiny abrasions that allow bacteria to sneak into tissues. Detergents and even plain water can remove the skin’s oils, which have important antibacterial properties.

Good handwashing, then, involves two potentially conflicting goals, removing microbes while still keeping your skin healthy.

Preached but not practiced

Handwashing is good advice — but do Americans (or Canadians) follow it?

Often, we don’t. When investigators surveyed public restrooms around the country, they found that only 83% of people washed up after using the toilet. (If you have Skydrol on your hands, you will before or wish you had because its a big ouch) Do posted reminders to "Please Wash Your Hands" help? When researchers tested this simple strategy, they found that handwashing improved in women but not in men.

The gender gap applies to hospitals, too. In one study, female physicians washed their hands after 88% of patient contacts, but male doctors washed after just 54%.

Does it work?

Yes. Just 30 seconds of simple handwashing with soap and water reduces the bacterial count on health care workers’ hands by 58%. And there is an even better way: Alcohol-based handrubs reduce counts by 83%.

What’s best?

Soap and water is the time-honored technique, and it does work. In fact, it’s still the best way to remove visible dirt. But as the public has become concerned about the risk of infection, soaps with antibacterial additives have gradually taken over 45% of the market. It’s understandable, but it’s not helpful; antibacterial soap is no better than ordinary soap, and the additives actually increase the risk of allergic reactions and other side effects.

Plain soap will do the job — and so will plain water. Tap water is excellent, and cool or lukewarm temperatures serve as well as hot water. If soap and water are not available, antibacterial wipes can help. Although they are not as effective, they will reduce bacterial counts.

Washing with soap and water is the best way to remove dirt, but waterless, alcohol-based handrubs are even better at killing germs. Handrubbing is faster and more convenient than handwashing, and it’s also easier on the skin. Hospitals are switching to handrubs because they kill more bacteria and viruses and they are used more regularly.

When and how

How should you wash? Wet your hands with water, then apply the soap to your palms. Rub your hands together briskly for at least 15 seconds before rinsing. (My kids were trained to sing Happy Birthday to get the time right - Try it)

Wash your hands before each trip to the dining room and after each trip to the bathroom. Wash after handling diapers and animals. Wash before and after you handle food. Wash after you take out the trash, work in the yard, clean the house, repair the car, or do other messy chores. Wash before and after sex. Wash after you come in contact with anyone who is sick. If you follow reasonable guidelines you’ll be washing often, but you won’t become obsessive or compulsive. Be careful, not fearful.

END thanks once more to Roger and jetBlue - this issue is 2 weeks worth