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Aviation Human Factors Industry News

October 13, 2006

Vol. II, Issue 35

New report puts some blame on equipment in 2003 airport fatality

Denise Bogucki

NORFOLK ó Three years after an airline worker died in an incident at Norfolk International Airport, federal investigators released some conclusions but said a full report will take another year or more.

Denise Bogucki , a 13-year veteran of Northwest Airlines, was crushed against the nose of an airplane in September 2003 . Bogucki, 43, was driving a small tractor preparing the DC-9 for push-back when she struck the plane.

The National Transportation Safety Board posted findings on its Web site Thursday that blame Bogucki for failing to operate the equipment properly. The post also says the design of the airlineís equipment was a contributing factor.

The findings also speak to the staffing issue raised by employees before and after the incident.

Bogucki was doing the push-back job alone. The airline now requires two people for push-backs.

For months before the incident, Northwest employees complained to company officials that staffing in Norfolk was dangerously low.

The safety board, however, said staffing levels "had no direct bearing" on the incident. It also said that although there were fewer workers than usual that night, staffing was consistent with the companyís model.

In its first report, more than a year and a half ago, the safety board blamed only Bogucki for the incident. Officials reopened the case when it became clear that inaccurate information was used to reach that finding.

Boguckiís mother, Jeanne Earley , who has been waiting for closure in her daughterís death, was disappointed with the latest findings.

"This didnít need to take three years," she said. "They havenít changed much. I donít know what to do or say now because itís clear nothingís going to change."

The NTSBís original report said Bogucki chose the wrong equipment to push back the plane.

After union officials complained, saying she was using the only equipment the airline provided, the board reopened the case.

Union officials said it is typical in accident investigations for the worker to shoulder some of the blame.

"An accident happens, youíre there, you have some blame," said Bob Bennek , who was until this week the safety director of the International Association of Machinists and Aerospace Workers Air Transport District 143 , which includes Norfolk.

"How much of the blame you put on her is what the debate is," he said. "The only blame I put on her was that she was an extremely conscientious employee because she was out there alone. I wish she would have said, 'No, Iím mad as hell and Iím waiting for help.í"

The most recent report said the probable cause was Boguckiís failure to properly control the push-back tug or maintain adequate clearance from the airplane. A contributing factor, it says, was the lack of a protective enclosure over the tugís cab.

After Boguckiís death, Northwest replaced the open-cab tug in Norfolk with a closed-cab one and installed protective roll bars on its tugs nationwide.

The report also said Bogucki did not have updated paperwork in her file that indicated she was qualified or authorized to do push-backs.

Earley, who recently retired from a job at the airport, said Bogucki was well-qualified and should not be faulted because her file was not kept up to date.

Northwest officials declined to comment.

NTSB spokesman Keith Holloway said the findings are preliminary and subject to change. He said a final report will be issued in 12 to 18 months.

Helios Airlines 737-300 pilots failed to notice warning signs

Wednesday October 11, 2006

Greece's Air Accident Investigation and Aviation Safety Board said yesterday that the August 2005 Helios Airlines 737-300 crash was caused primarily by the pilots' "nonrecognition" that the cabin pressurization mode selector was switched to "manual" and their subsequent misreading of warning signs.

The errors led to the flightcrew's incapacitation "due to hypoxia" when the aircraft failed to pressurize on ascent. It flew for more than 90 min. on autopilot before its fuel was exhausted and its engines flamed out. "The aircraft continued descending rapidly and impacted hilly terrain...approximately 33 km. northwest of the Athens International Airport," said the Greek government report issued yesterday. All 121 passengers and crew were killed.

The Larnaca-Athens-Prague flight was doomed by a variety of human errors, investigators concluded. The pilots were at fault for not recognizing the cabin pressurization switch's incorrect setting before takeoff and "nonidentification" of warnings once the plane was airborne. Maintenance workers were at fault for failing to return the pressurization mode selector to the "auto" position after performing nonscheduled maintenance.

The Cypriot airline, now called Ajet Airways, was plagued by "deficiencies in...quality management and safety culture." Regulators were guilty of "inadequate execution" of safety oversight. Finally, Boeing was called to task for "ineffectiveness of measures taken by the manufacturer in response to previous pressurization incidents in the particular type of aircraft."

The report said the Cyprus government, Boeing, the Greek Civil Aviation Authority and US FAA have implemented "improved procedures" based on recommendations the Greek safety board issued during the course of its investigation.

Helios Crash Produces Extra Layer Of Pressurization Warnings

The investigation into the crash of a Helios Airways 737 in August 2005 spurred FAA to mandate changes in procedures for pre-flight set-up of the aircraft model's cabin pressurization system to ensure crews have the settings configured properly, and that they receive sufficient alerts if the pressurization switch is set incorrectly.

Authorities yesterday in a final report detailed direct causes for the plane's smashing into hilly terrain northwest of Athens Airport. The Helios crew was flying the plane from Larnaca, Cyprus, to Prague via Athens. All 121 people onboard were killed.

Unheeded Warnings

Causes cited by the Hellenic Ministry's Air Accident Investigation and Aviation Safety Board (AAISB) include the cabin pressurization switch being set in a manual position during preflight checks, before start checks and the after-takeoff checklist. Warnings of low pressurization, including the cabin altitude warning horn and the dropping of passenger oxygen masks, weren't heeded. Last, the crew suffered hypoxia -- depletion of oxygen in the body -- which left control of the plane to the aircraft's autopilot system and flight management computer. As a result, fuel depletion and engine flameout occurred, causing the plane to crash.

Other "latent" factors cited by AAISB were operator deficiencies in quality management and safety, weak crew resource management, inadequate safety oversight by regulatory authorities and "ineffectiveness of measures" taken by the airframer in response to previous 737 pressurization incidents.

FAA released a rulemaking in June requiring interim revisions to 737 flight manuals to alert crews of improved procedures for pre-flight set-up of the cabin pressurization system and responding to the pressurization warning horn. Boeing said it was making changes to its manuals prior to the accident.

FAA pointed to other occurrences in 737s when reactions by flightcrews to warning horns were delayed "either because the flightcrew misinterpreted the horn as a takeoff configuration warning horn, or because they did not immediately don their oxygen masks." FAA further explained that crews could have delayed reactions to those warnings as a result of warnings being issued only through the horn and not accompanied by a cabin altitude warning light.

Boeing is adding a light to the flightdeck alerting crews to check pressurization.

NTSB: Lt. Gov. Bauer's plane had wrong bolts

The wreckage of Bauer's plane

(Columbia) October 3, 2006 - A federal report says Lieutenant Governor Andre Bauer's plane had the wrong sized bolts holding some engine parts when it crashed in May in Cherokee County.

Bauer and a friend were injured in the crash near Blacksburg as the lieutenant governor tried to take off.

The expanded report by the National Transportation Safety Board says the plane had the wrong size bolts holding engine induction tubes.]

The report also says Bauer needed a longer runway to take off safely, given the temperature, elevation and weight of the aircraft.

The plane carrying Bauer and passenger went down seconds after leaving the private airstrip near Blacksburg. The surface of that strip is grass and dirt, a soft surface which would generally mean a plane taking off would need more distance.

The report says the owners manual for a Mooney M20E aircraft, like the one Bauer was piloting, does not specify a specific distance requirement for soft field takeoffs.

But a former Mooney test pilot told the NTSB the plane would need about 15 percent more distance. In this case, that comes out to 1,560 feet.

The airstrip Bauer was attempting to leave is 1,383 feet long.

Bauer told investigators he did not personally research how long the strip was, but his passenger, who is an experienced pilot, did know.

Bauer and his passenger both have said they believe a mechanical failure caused the crash.

Bauer says he doesn't want to talk about the investigation until the final report is issued. He's still recovering from injuries.

The safety board must still rule on what caused or contributed to the accident. Again, the final report on the accident is not out yet.  

Bombardier says thanks with Safety Standdown

The principal cause of aviation accidents is not mechanical failure, it's pilot or crew error, experts say.

Bombardier Aerospace wants to give jet operators additional safety training to counter those errors. That's why about 460 pilots and crew members from around the world are scheduled to participate in Bombardier's 10th annual Safety Standdown at the Hyatt Regency Wichita. The Standdown runs through Thursday.

The popular event, which is free to participants, received 937 applicants for less than 500 spots. It's open to operators regardless of whether they fly Bombardier aircraft.

Aircraft today are much more sophisticated, and pilots depend more and more on the plane's technology, said Gene Cernan, the last astronaut to walk on the moon and one of the event's hosts. But pilots must be prepared for any situation, Cernan said.

"Computers and microprocessors are only as smart as we are," he said.

At Safety Standdown, participants attend lectures and workshops on fatigue countermeasures, nutrition and psychological factors, managing the unexpected, icing, advanced aerodynamics and other topics.

They also have opportunities for hands-on training for situations they've not experienced before. They learn evacuation procedures for air and water, how to use a fire extinguisher on an in-flight fire, and CPR and defibrillator training.

Safety Standdown's "vision is to integrate knowledge-based training with skills-based training to reduce human error," said Bob Agostino, director of flight operations for Bombardier Business Aircraft.

He said Bombardier makes a six-figure investment in the event.

"The industry's been good to Bombardier," Agostino said. "This is our way of saying thank you."

Gulfstream, RJ Involved In LAX Runway Incursion Incident

Planes Nearly Collide On Runway

A Skywest regional jet departing last Saturday from LAX to San Antonio reached 100 kts before aborting takeoff, to avoid a Gulfstream business jet taxing across the active runway. The planes missed by less than 100 feet.

The near-accident occurred around 6:00 pm, when the UK-registered Gulfstream taxied from a hangar on the south side of the field and was given instructions to cross the outer runway but hold short of the inner runway, the Los Angeles Times reported.

The pilot read back the instructions, but missed his assigned taxiway... and had to make a U-turn to get back to it. After repeating his initial instructions, the Gulfstream pilot took the correct taxiway, but did not stop short of the inner runway as instructed. As the Gulfstream crossed the active runway, the departing Skywest aircraft, carrying 39 passengers and crew, had to slam on its brakes to avoid the collision.

The Gulfstream pilot told officials he was certain the controller had cleared him to cross both runways, even though he twice read back the "hold short" instructions correctly, Ian Gregor, an FAA spokesman, told the Times.

FAA officials said the SkyWest pilot, the tower controller and the ground radar that alerts controllers to impending collisions all noticed -- at the same time -- the Gulfstream crossing the runway.

"We had three layers of redundancy," continued Gregor, "This is just a clear and clean pilot mistake."

According to tapes released to the LA Times, the shaken controller called out, "SkyWest 6430, I apologize. We never talked to the Gulfstream. He crossed without a clearance. I apologize. If you could make a right turn, please, and exit the runway."

The SkyWest pilot is heard responding, "Exiting right," exhaling heavily.

The controller was so traumatized by the near-collision that she left her post seconds later.

Pilots familiar with LAX acknowledge it is one of most complex fields in the nation, with two sets of parallel runways flanking to the north and south the tower and terminals. Pilots landing or taking off from an outer runway must follow a complicated taxi route across the inner runway.

"You're having controllers working too long and too hard on position," said Mike Foote, a controller in the LAX tower and a spokesman for the National Air Traffic Controllers Association. "This was all pilot error -- you can't say it wasn't -- but the fact is this didn't use to happen. People would catch it. We still do Ö but more frequently it's not being caught."

The FAA disagrees, saying staffing issues played no role in Saturday's incident. The tower controller who instructed the SkyWest jet to take off had been on duty only 65 minutes when the close call occurred, reports the Times.

"Controller workload and controller staffing had nothing to do with this,"

Gregor said. "It's disingenuous to suggest otherwise. The system worked exactly as it should."



Components of a Disaster Kit

Pack essentials to provide for your family for three days, including:

      Bottled water (4 liters/1 gallon per person per day)

      Non-perishable foods, including comfort foods such as cookies and coffee


      First aid kit

      Medicines and vitamins

      Flashlight and portable radio


      Pocketknife, manual can opener and bottle opener


      Waterproof matches

      Duct tape

Be sure to check the contents of your kit periodically and replace batteries and water.


7 Steps of a Family Escape Plan

Step 1: Sketch out your homeís floor plan

Step 2: Mark two escape routes from each room

Step 3: Designate a meeting place safely away from the house where family members will assemble after escape

Step 4: Review the escape plan with each family member and make sure they understand it

Step 5: Post your plan on the fridge

Step 6: Post the fire departmentís phone number on every phone in the house

Step 7: Conduct family fire drills twice a year and vary them so that alternative escape routes are used


END with thanks to jetBlue