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Aviation Human Factors Industry News

January 30, 2005

Vol. II, Issue 5.

Workplace Distractions Costly

According to a recent study the average office worker spends a quarter of their day consumed by interruptions that cost the American economy over $500 billion a year. The most common interruptions were: receiving an e-mail, coworkers visiting, leaving one’s desk, and receiving a phone call. The time considered lost included unimportant interruptions and distractions and the time it took to get back on task. Some experts believe this work environment of constant distractions is creating a new form of attention deficit disorder. Thus a new term has appeared in our computer-age: online compulsive disorder. ("Workplace interruptions cost US economy $588 billion a year" The Financial Express, January 10, 2006).

Heart Health

According to a new study from the University of Toronto, nine risk factors account for 90 percent of the heart disease in every population on Earth. The study suggests that if you change your lifestyle to address each of these nine factors you can shrink your chances of developing heart disease dramatically. The nine risk factors are: abdominal obesity, alcohol, cholesterol, diabetes, eating fruits and vegetables, exercise, high blood pressure, psychosocial stress, and smoking. (Steve Sternberg, "Nine factors that affect your heart’s health," USA Today, January 8, 2006)

Worker Suffers Electrical Shock On Alaska Airlines Plane

SEATAC, Wash. -- A mishap on board an Alaska Airlines jetliner sent one worker to the hospital Sunday night, KIRO 7 Eyewitness News reported.

The man was testing some equipment in the cockpit of an Alaska Airlines plane when he suffered an electrical shock, an Alaska Airlines representative told KIRO 7 Eyewitness News.

The airline called for medical aid. The man was taken to a hospital, treated and released.

The man is an Alaska Airlines employee, so there appeared to be no connection to a series of recent incidents with employees of Menzies Aviation, the company that handles baggage operations for Alaska Airlines.

JAL plane wreckage from 1985 crash to go public in April. Maintenance induced accident.

Japan Airlines will set up a center to display the wreckage of the JAL Boeing 747 that crashed in a mountainous area in Gunma Prefecture in August 1985, claiming 520 lives. The center to be established inside a building at Tokyo’s Haneda airport is to put some 30 items before the public, such as the ruptured bulkhead believed to have been the direct cause of the accident, the cockpit voice recorder and part of the main wing. JAL`s president Shimmachi said he hopes the center will be used to educate its company employees and contribute to nurturing an emphasis on safety for the entire aviation industry. All Nippon Airways is also planning to set up a facility to display the wreckage of its plane which collided with a Self-Defense Forces plane in midair over Shizukuishi, in July 30, 1971, killing all 162 people onboard.

NTSB cites crew actions in Corporate Airlines crash

Fatal crash of a Corporate Airlines Jetstream 32 on Oct. 19, 2004, outside Kirksville, Mo., was owing to "the pilots' failure to follow established procedures and properly conduct a nonprecision instrument approach at night in instrument meteorological conditions," the US National Transportation Safety Board said yesterday. Errors by the cockpit crew included "their descent below the minimum descent altitude before required visual cues were available and their failure to adhere to the established division of duties between the flying and nonflying pilot." Both pilots and 11 of the 13 passengers onboard the turboprop aircraft were fatally injured in the accident, which occurred on a scheduled flight from St. Louis. Two passengers received serious injuries. The aircraft struck trees and crashed short of the runway at Kirksville Regional Airport. Likely contributing factors were "the pilots' failure to establish and maintain a professional demeanor during the flight" as well as fatigue. NTSB noted that the pilots' nonessential conversation below 10, 000 ft. was contrary to established sterile cockpit regulations.

NTSB says pilots used flawed technique to land plane

CHICAGO - Pilots of a Southwest Airlines jet that skidded off a runway at Midway International Airport relied on a flawed landing technique that federal aviation authorities should ban, investigators said Friday.

The Dec. 8 accident killed a 6-year-old boy inside a car crushed by the plane when it skidded off a snowy 6,500-foot runway, crashed through a fence at the Chicago airport and plowed into the street.

The National Transportation Safety Board Friday said the pilots should not have factored the plane's thrust reversers - which help slow the plane - when they calculated how long it would take the plane to stop.

The airplane touched down with about 4,500 feet of runway remaining, but snowy conditions and other factors meant the plane needed about 5,300 feet of runway to stop, the NTSB said in a preliminary report last month.

According to flight recorder data, the thrust reversers did not deploy until

18 seconds after landing, Friday's report said.

The NTSB is trying to determine what steps the pilots could have taken to avoid the accident, said agency spokesman Keith Holloway. Friday's report recommends that the Federal Aviation Administration prohibit planes from using thrust reversers in such landings.

The NTSB has previously said the jet's actual stopping distance was about 5,000 feet. It said a tail wind contributed to the accident because it caused the plane to land faster than normal.

Southwest is based in Dallas.

Pilots of crashed MD-80 may have missed key directive

The wreckage of the crashed West Caribbean MD-82 is seen in this file photo. Investigators looking into the crash of a Boeing MD-82 that killed 160 people in August said that the accident occurred after the plane made the kind of rapid climb that Boeing had warned in 2002 should be avoided because the autopilot might power engines back too much when the plane leveled off.

Most of the victims of the Aug. 16 crash in northern Venezuela of the West Caribbean Airways flight from Panama to Martinique were residents of the island territory, which is part of France.

Investigators, who spoke on condition of anonymity because official statements are supposed to come from Venezuela, said that the plane appeared to react just as a 2002 Boeing service bulletin said an MD-82 would react after making a rapid climb from 31,000 feet to 33,000 feet, or 9,450 to 10,000 meters.

The investigators said records they had examined indicated that, after the plane reached 33,000 feet, the autopilot kept working for about six minutes to keep the craft flying at the proper altitude. When the autopilot could do no more, it abruptly shut off as it is designed to do and the crew was suddenly confronted with a jet that needed a larger dose of power and a steady hand to keep it flying.

Investigators said the crew apparently did not notice anything amiss, and may not have been familiar with the 2002 service directive.

As older jetliners are released by major airlines, they are often sold to countries in South America and Africa where training may be less profound than in Europe or the United States, and where such directives do not always reach everyone. The plane was built in 1986 by McDonnell Douglas, which later merged with Boeing.

A Nov. 22 interim official report from the Comite de Investigation de Acci-dentes Aereos of Venezuela, approved by assisting investigation agencies in France, the United States and Colombia, did not mention the 2002 Boeing bulletin because it had not yet been discovered in the normal investigative process. The report did not reach any conclusions about what caused the crash of the twin-engine Boeing MD-82. A 2002 Boeing bulletin warned that planes in the MD-80 family, including the one that crashed, should not be set on autopilot to climb at too high a rate. After leveling off, Boeing said, the engine power setting could be slightly too low, and "the airplane could decelerate into a stall warning before the autopilot trips off."

That can happen in such a subtle way, the bulletin said, that several minutes could go by while the autopilot is trying to compensate for deteriorating speed, and pilots might not notice until stall warnings suddenly begin sounding. The investigators said that while it was too early to draw any conclusions, that sounds very similar to what happened to the West Caribbean aircraft.

Investigators and aviation professionals, who said they could not be identified because of rules forbidding any information to be released except in official statements, said it was clear that whatever happened, the crew then took actions that would never allow the plane to recover.

The interim report contained a wealth of details from the plane's flight data recorder and cockpit voice recorder, showing that the crew was incorrect in saying that the plane had experienced a "dual engine flameout,"

and that the crew took the opposite action to recover from an aircraft stall than action that is taught to every beginner pilot. That suggests that the crew did not recognize that the plane was, in effect, stalling.

According to evidence found in the wreckage, the crew pulled the control yoke back toward their chests as they went down, which would raise the nose and lower speed, preventing air from flowing over the wing properly.

The official report said that about 20 minutes before the crash, the plane made a routine climb from 31,000 feet to 33,000 feet. The engines were operating properly at that time, the report said.

About 90 seconds after the plane reached 33,000 feet, it began to slow down for reasons that are not clear. The plane's autopilot began to point the plane's nose up slightly in an effort to compensate for the slowing speed and keep the plane at 33,000 feet. During this time, both engines still appeared to be operating normally, the interim re-port said.

About eight minutes after first leveling at 33,000 feet, the autopilot disengaged and the plane began to descend. The autopilot is designed to disengage on its own if it cannot control an air- craft in extreme situations.

This was about three minutes and 30 seconds before impact. That means the plane was descending at an average of almost 10,000 feet a minute, almost a free fall. A controlled but rapid descent would be about 3,000 feet a minute.

The right engine went to idle shortly after the descent began, although there is no indication why, according to the interim report. It is possible the crew reduced the engine to idle for a moment while trying to troubleshoot their problem. Because of the problem with the flight data recorder, it is unclear what the power settings were on the left engine during this time, although both engines were turning at high speed later at the time of impact.

Almost a minute after the descent began, or two minutes and 46 seconds before impact, the loud stall warning sounded, according to the interim report which has been made public.

After a stall warning sounds, crews are trained to bring the nose of the plane down to allow the plane to gain speed. Stall warnings are designed to engage well before an actual stall, loudly warning the crew of the potential danger.

But the flight data recorder indicated that the crew kept pulling the control yoke backward, reaching a maximum 12 degree nose-up position and holding the yoke there all the way to the ground. The attention of air traffic controllers at Maracaibo was aroused by the crew's sudden and continuous requests for lower altitude.

"The flight crew states that they had a dual engine flameout when asked by ATC if they had a problem," the report said. ATC refers to air traffic control. That was one of the last reports from the plane.

Report Blames Flawed NASA Culture for Tragedy

In Broad Indictment of Practices, Shuttle Panel Says Safety Suffered

The shuttle Columbia and a crew of seven were lost on Feb. 1 because NASA, for the second time in its recent history, allowed its engineering to grow careless, its safety system to wither, its communications to become muddled and prudent professional curiosity to become stunted.

Those conclusions were part of a far-reaching indictment issued yesterday by the Columbia Accident Investigation Board, in a comprehensive and unsparing assessment of the human spaceflight program. Laying at least part of the blame for NASA's failings on persistent budget and other pressures flowing from Congress and the White House over several administrations, the plainspoken 248-page report is designed to provide the foundation for an unprecedented national debate on the future of human spaceflight, which the board said is long overdue.

A 1.7-pound chunk of foam insulation that struck Columbia's left wing at more than 500 mph during the Jan. 16 ascent was "the direct, physical action that initiated the chain of events leading to the loss of Columbia and her crew," the board wrote.

But, in chilling echoes of the environment that produced the 1986 Challenger tragedy, the board found that NASA's management and cultural mind-set were as culpable because they paved the way for the foam strike to do its deadly work. Before the mission, managers did not heed foreshadowing’s of the potential threat; and during the mission, they allowed deadline pressures to squelch the aggressive pursuit of information about the possible damage and its implications.

"Management decisions made during Columbia's final flight reflect missed opportunities, blocked or ineffective communications channels, flawed analysis, and ineffective leadership," the report said. "Perhaps most striking is the fact that management . . . displayed no interest in understanding a problem and its implications."

Unless the agency makes fundamental changes this time, the board warned, "the scene is set for another accident." At the same time, the investigators repeatedly said that, based on NASA's past performance, they expect the NASA bureaucracy to resist such a transformation. "The changes we recommend will be difficult to accomplish -- and will be internally resisted."

There were bits of good news for NASA scattered throughout the board's grim verdict, however. Among them, the board did not find the shuttle to be "inherently unsafe."

Retired Adm. Harold W. Gehman Jr., the board chairman, said at a briefing for reporters, "If this board had set out to spend seven months listing all the good things that NASA does, the report would be thicker than this one.

Unfortunately, that's not what our task was."

To make certain that NASA implements not only the 15 actions it recommended before the next shuttle flight, but also the more basic and difficult long-term changes, the board called for a system of long-term external policing.

While the panel had signaled many of its findings in advance, there were some surprises. For example, the report offered the first direct criticism in the investigation so far of NASA Administrator Sean O'Keefe. Citing unsolicited comments from NASA personnel, the report said employees blamed O'Keefe for a seemingly "arbitrary" buildup of pressure to meet a deadline of February 2004 for the launch of a key space station component -- at the same time top management was denying there was schedule pressure.

The board found that the four flights scheduled in the months from October

2003 to February 2004 would have required a shuttle processing push comparable to the much-criticized pattern that led up to the Challenger accident 17 years ago.

President Bush appointed O'Keefe, then deputy director of the White House Office of Management and Budget, in early 2002 to implement a plan he had developed to improve management of the struggling, over-budget International Space Station. The space station program and NASA were "on probation," the board wrote, and the strategy for regaining credibility focused on the early

2004 date for completing the U.S. portion, or core, of the orbiting laboratory.

Concern about the schedule "may have begun to influence" managers' decisions regarding the foam shedding during Columbia's launch and one of Atlantis last October, the report said. The rigorous shuttle schedule "had no margin to accommodate unforeseen problems," and with flights coming in rapid succession, there was no assurance that anomalies on one flight would be identified and resolved before the next.

Yesterday O'Keefe reiterated his intention to "comply with the full range of recommendations released today" and said the agency has set up a special team to help "change the culture." NASA has already removed several top shuttle managers from their jobs and mobilized its workforce to begin implementing a number of the board's previously released recommendations.

O'Keefe has set a target date of next March for resuming shuttle flights, but a launch next summer is considered more realistic.

Bush issued a statement yesterday that implied continued support for his appointee, saying, "The next steps for NASA under Sean O'Keefe's leadership must be determined after a thorough review of the entire report, including its recommendations." He added, "Our journey into space will go on. The work of the crew of the Columbia and the heroic explorers who traveled before them will continue."

Addressing the painful subject of the crew's fate, the board, working with a NASA team, found that the seven astronauts died in the final seconds of their vehicle's breakup over Texas as the result of "blunt trauma and hypoxia. The exact time of death -- sometime after 9:00:19 a.m. Eastern Standard Time -- cannot be determined because of a lack of evidence. The failure of the crew module, the report noted, was "a rapid catastrophic sequential structural breakdown rather than an instantaneous 'explosive' failure."

During its seven months of exhaustive investigation, working seven days a week, the 13 board members always kept the crew members' names and faces in mind, they said. "If this board has any impact whatsoever, we felt that the loss of their lives had better make a difference, or both them and us have wasted our time," Gehman said at the briefing.

Board members personally delivered copies of the report to the astronauts' families.

In Houston, Jonathan Clark, the widower of Columbia astronaut Laurel Clark, called the report "extremely comprehensive and blunt, bold and directive in its scope. Like the board members said, this is not about what is right about NASA. This is about what is wrong. So it is inherently critical -- not in a bad way or destructive but in a way to take into consideration everything that happened and make sure this never ever happens again.

"I think the comfort comes in knowing that this is a road map to the future.

It's a blueprint for the continuation of high-risk space exploration. It's either do this or don't do it at all. This is what needs to be done if you're going to fly humans in space."

As the board had previously documented during its public hearings and tests, the report said the insulating foam that came off Columbia's external propellant tank during the ascent smashed the heat shielding along the underside of the leading edge of the left wing. When the shuttle reentered the atmosphere on Feb. 1, superheated air at temperatures as high as 8,000 degrees penetrated the wing structure, melting it from the inside and leading to the vehicle's disintegration.

NASA is redesigning the external tank to eliminate the most serious source of foam shedding -- a problem the board said engineers had wrongly come to accept as routine, much as engineers did almost two decades ago when they accepted problems with the O-ring seals of the shuttle rocket boosters before the Challenger disaster.

But because it is unlikely that all debris impacts on the shuttle can ever be eliminated, the board also has called on NASA to harden the shuttle's protective heat shielding to better withstand minor impacts, and to develop in-flight inspection and emergency repair capabilities before the next flight.

The panel detailed a list of both immediate and long-term recommendations.

Among the 15 items it said should be done before the next flight are:

* Adjusting the ambitious shuttle schedule to fit available resources and make sure any risk incurred to meet a deadline is "recognized, understood and acceptable."

* Expanding the training program that puts managers through various simulated emergencies, such as potential loss of vehicle or crew, and forces them to "assemble and interact with support organizations across NASA/contractor lines and in various locations."

The report's 29 recommendations included some that would apply only if the shuttle is to keep flying beyond 2010. These include improving the onboard sensors that monitor the orbiter's performance and a way to inspect all wiring as the fleet ages.

The board criticized "the nation's poor record of developing either a complement to or a replacement for the space shuttle," but said the blame for this extends well beyond NASA.

In a sharp blow to an agency that has always prided itself on its engineering prowess, the board focused heavily on what it called substandard engineering practices. They were the result, it said, of officials prematurely declaring the shuttle an "operational" vehicle rather than treating it as the highly risky, experimental space plane it really is. This meant that funding for further shuttle research dried up.

In the category of fundamental organizational change, the board called on NASA to set up a powerful, independent Technical Engineering Authority that would be responsible for all shuttle technical requirements and any waivers that relax them. This team should "build a disciplined, systematic approach to identifying, analyzing and controlling hazards," including deciding what is or is not an anomaly and independently verifying that a shuttle is ready to launch.

To ensure its independence, this new group should be funded by and report to NASA headquarters, not the shuttle program managers, and presumably would not be influenced by scheduling pressures.

Similarly, the board said, the NASA headquarters safety office should be given direct line authority over the shuttle program's safety organization, with its own independent funding.

These and other recommended organizational changes do not have to be achieved before the shuttles fly again, the board said, but NASA must develop a detailed plan for the changes by then and must report its progress annually to Congress, as part of the NASA budget review process.

In its assessment of what went wrong during Columbia's flight, the report was especially tough on Linda Ham, who headed the mission management team.

"Most of Linda Ham's inquiries about the foam strike were not to determine what action to take during Columbia's mission, but to understand the implications" for the next flight, the report said.

During a managers' meeting on Jan. 21, five days after Columbia's launch, she reviewed the rationale put forward the preceding October, the last time a significant foam chunk had come off the tank. She e-mailed shuttle program manager Ronald D. Dittemore that day, saying, "Rationale was lousy then and it still is. . . ." The board found that shuttle engineers' initial estimates of the foam debris size, speed and origin were "remarkably accurate." That is, they had the information they needed to appreciate the danger -- but did not. In their analysis, the engineering team used "judgment" rather than hard data or rigorous analysis, as they underestimated the probable damage to the shuttle's heat shielding, the report said.

In the managers' meetings run by Ham, "no Mission manager appeared to 'own'

the Team's actions," the report said. This meant the managers provided no direction for the engineers, nor did they consult formally with the team's leaders. Ham also vetoed requests for spy satellite imagery of the wing.

Among the more damning lines in the report was the board's conclusion that NASA had managed to re-create an atmosphere that officials had sworn would be banished forever after the Challenger exploded -- one in which "engineers had to produce evidence that the system was unsafe rather than prove that it was safe."