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Aviation Human Factors Industry News

February 08, 2006

Vol. II, Issue 6.

Insomnia Costing Companies

Employees who suffer from insomnia have a significantly higher rate of absence at work than those who sleep well, according to a study published in the February 1, 2006 issue of the journal Sleep. The study found that insomniacs miss an average of 5.8 days of work per year, while good sleepers miss only 2.4 days. Additionally, not only did insomniacs miss work more frequently, but their absences lasted longer. Overall the work absences of employers with insomnia cost an average of $3,025 per employee each year, while the missed days of good sleepers cost an average of $1,250. (U.S. Newswire, "Study in the Journal Sleep Shows that Insomnia Leads to Higher Rate of Absence at Work" January 31, 2006)The traditional approach to people management focuses on aptitude, training, and experience. Missing from this approach is alertness, which is critical to performance in all operations, especially extended hours facilities. Even the most experienced, senior operator can suffer from insomnia related fatigue. And it is often fatigue that causes someone who has completed an operation safely thousands of times to make a seemingly "rookie" mistake. By stressing alertness at your facility, you can improve safety, productivity and costs.

NTSB Releases Prelim On El Paso Mechanic Fatality

The NTSB has released a preliminary report on the tragic accident that occurred last month in which a mechanic was killed when he inexplicably stepped in front of a 737 engine during a high-power run-up.

NTSB Identification: DFW06FA056

Scheduled 14 CFR Part 121: Air Carrier operation of Continental Airlines (D.B.A. operation of Continental Airlines) Accident occurred Monday, January 16, 2006 in El Paso, TX

Aircraft: Boeing 737-500, registration: N32626

Injuries: 1 Fatal, 119 Uninjured.

This is preliminary information, subject to change, and may contain errors.

Any errors in this report will be corrected when the final report has been completed.

On January 16, 2006 at 0905 mountain standard time, Continental Airlines flight 1515, a Boeing 737-524 airplane, N32626, was preparing for departure from El Paso International Airport (ELP), El Paso Texas when a mechanic was fatally injured while performing a maintenance trouble shooting procedure for a suspected engine oil leak on the number 2 engine. The aircraft was being operated as a scheduled domestic passenger flight under the provisions of Title 14 Code of Federal Regulations Part 121. The flight was scheduled to depart at 0910 with a destination of George Bush Intercontinental/Houston Airport (IAH), Houston, Texas. Visual meteorological conditions existed at the time, and an instrument flight plan was on file for the flight. The 5 crew members and 114 passengers were not injured.

During a walk around inspection conducted by the First Officer, a puddle of fluid was noticed on the tarmac under the number 2 engine. The First Officer met the Captain and brought it to his attention. Both the Captain and the First Officer went to the number 2 engine and agreed that it appeared to be an oil leak. The Captain notified El Paso operations from the cockpit to request authorization for contract maintenance to check for problems on the engine.

At approximately 0845, El Paso operations contacted Continental maintenance control and was advised to have the contract maintenance personnel investigate the Captain's report. Three mechanics arrived and began to investigate the oil leak. Both sides of the engine fan cowl panels were opened to conduct the checks. The mechanics made a request to the Captain for an engine run to check for the leak source since they determined that the leak appeared not to be a static leak.

One mechanic positioned himself on the inboard side of the number 2 engine and the other mechanic on the outboard side of the engine. The third mechanic was positioned clear of the engine and the inlet hazard area observing the procedure as part of his on the job training. The engine was started and stabilized at idle RPM for approximately 3 minutes while the initial leak check was performed. One mechanic then called the Captain on the ground intercom and requested a run to 70 percent power for additional checks.

Approximately 1 and 1/2 minutes after reaching the requested RPM setting the Captain reported sensing a slight buffeting that rapidly increased in intensity followed by a compressor stall. At that time the Captain immediately retarded the throttle back to the idle position. The First Officer stated to the Captain that something went into the engine and immediately cut off the start lever ending the engine run. The mechanic on the outboard side of the engine had stood up and stepped in to the inlet hazard zone.

JAL submits revised safety measures
Japan Airlines submitted to the Japanese transport ministry a revised set of measures to prevent operational errors, following a series of mishaps since late last year. In the latest package, JAL has set up a group in charge of human errors within its safety promotion department and increased the number of employees in the department from 30 to 40. It also pledged to reinforce supervision of the department while promoting information sharing between maintenance personnel. (Kyodo)

Families Mark Anniversary Of Alaska Flight 261 Crash

PORT HUENEME, Calif.(AP) -- Clutching white roses, helium balloons and each other, about 40 friends and family members prayed for the 88 people killed when Alaska Airlines Flight 261 spiraled into the sea six years ago.

"It's where we want to be. We're glad to be here and visit," said Steve Campbell, the former Port Hueneme chief of police who helps the families on their annual treks to the beach eight miles away from the crash site.

They gathered there Tuesday, just as they have every Jan. 31 since the first anniversary of the 2000 crash.

At 4:21 p.m., the time the plane went into the sea, they released white helium balloons honoring the victims and held a moment of prayer. Then they walked to the water's edge and left a rose in the surf.

The group gathers each year around a sundial-with-leaping-dolphins monument that cost $350,000, money raised through donations from the community, family members and Alaska Airlines.

"It's such a beautiful monument. We're all family now. It does ease a lot of the pain to come here," said Ralph Pearson who drove 1,000 miles from his Mount Vernon, Wash., home to attend the half-hour ceremony.

His son Rodney died in the crash.

A bell rang as each of the 88 names was read and a single white rose was placed on individual victim plaques that encircle the monument.

Many people exchanged hugs as they reminisced about their lost loved ones, rekindling friendships forged with other survivors after the tragedy.

"We told our families we were going to be here every year and, wow, they keep coming," said victim relative Anarudh Prasad.

"Six years. Gee, doesn't it seem like yesterday?" asked Jay Ryan, whose brother died in the crash.

The Alaska Airlines MD-80 went down near Anacapa Island, one of the chain of Channel Islands northwest of Los Angeles, while en route from Puerto Vallarta, Mexico, to San Francisco and Seattle-Tacoma International Airport.

The National Transportation Safety Board determined the crash was caused by the failure of a jackscrew in the plane's horizontal

FAA Signs Off On Alaska Airlines' Jackscrews

'Dry' Parts Still OK Per Guidelines

Despite inspectors' reports of 15 incidents of "dry" jackscrews since 2003 on Alaska Airlines' fleet of 26 MD-80 airliners, FAA investigators announced Friday the airline is complying with regulations for maintaining the critical part.

"The current assessment did not find any jackscrews on (Alaska) aircraft improperly or inadequately lubricated," the FAA summary said, adding there were "no safety issues" found.

All 15 incidents were found by airline maintenance workers during routine checks in Seattle, according to the Seattle Post-Intelligencer. Crews at Alaska's facility in Seattle, as well as workers at AAR Aircraft Services in Oklahoma City, repaired the problems.

AAR has performed heavy-maintenance work for the airline since Alaska closed its Oakland, CA facility in September 2004.

The jackscrews are two-foot-long components that control movement of the T-mounted horizontal stab on the MD-80.

While calling the jackscrews "dry" implies the components weren't properly lubricated -- as was the case in the January 2000 downing of Flight 261 off the coast of Southern California -- wear tests conducted on those parts found their range of movement still fell within the limits set by the FAA, according to the Post-Intelligencer.

"Based upon our analysis, no additional mitigation strategies related to jackscrews are required," the FAA said in its summary, which was released on Alaska Airline's employee website Friday.

The airline is also fully complying with the Airworthiness Directive issued by the FAA calling for regular inspections to be performed after no more than 650 hours of flight, and the wear test performed after no more than 2,000 flight hours.

Last October, Aero-News reported maintenance crews had found an unlubricated jackscrew on an Alaska MD-80 as recently as January 2004.

In its report, the FAA also stated its ground tests of some of the dry jackscrews showed the condition that concerned Alaska's inspectors -- no grease residue -- was duplicated even when the component was properly lubricated.

Alaska isn't the only airline with ground-safety troubles

On Tuesday in Chicago, a United Airlines jet was damaged on the runway when it collided with a baggage loader.On Monday in El Paso, Texas, a mechanic was killed when he was pulled into the right engine of a Continental Airlines 737 while checking an oil leak.And Jan. 12 in Philadelphia, a Southwest Airlines 737 was damaged when a baggage loader banged into one of its engines. Airline accidents on the ground are so common that aviation experts have a term for them: "ramp rash." It's hard to quantify them because reporting requirements are vague, but a panel of safety experts who studied the problem in 2004 estimated ground accidents cost the world's airlines $5 billion a year.

Although several Alaska Airlines mishaps have made headlines in the past month, national and local aviation experts say accidents are a problem for all airlines. Seattle residents and Alaska passengers have taken a keen interest in what happens to aircraft on the ground since Dec. 26, when a ramp worker hit an Alaska Airlines MD-80 with a baggage loader. The worker failed to report the accident. Flight 536 was allowed to depart, and the small crease in the fuselage eventually ruptured into a 1-foot-by-6-inch hole, causing the cabin to depressurize at 26,000 feet. The plane returned safely to Seattle-Tacoma International Airport. The worker responsible for that incident was an employee of Menzies Aviation, the contractor Alaska hired in May to handle its baggage and other ramp operations at Sea-Tac. The airline hired Menzies after laying off 472 union workers who previously handled the duties.

January incidents
Since an Alaska Airlines MD-80 was damaged by a baggage loader at Seattle-Tacoma International Airport on Dec. 26, the FAA has received reports of at least six similar incidents at airports around the country, including one more at Sea-Tac and one in which a worker died.

Jan. 5, Seattle: An Alaska Airlines 737, parked at the gate, was accidentally pulled forward by a tug. The plane's fuselage was scratched in the accident, but no injuries were reported.

Jan. 7, Boston: An Astar Air 727 was struck on the right wing by a truck. The truck driver was taken to a hospital, but the extent of any injuries was not reported.

Jan. 8, Boise: A fuel truck ran into the engine of a United Airlines 737 that was parked at the gate. There were people on board at the time, but no injuries were reported.

Jan. 12, Philadelphia: A Southwest Airlines 737 was hit by a baggage loader as the jet was being moved into position on the ramp. The plane's engine cover was damaged. No injuries were reported.

Monday, El Paso, Texas: A mechanic was killed when he was pulled into the engine of a Continental Airlines 737 as he checked an oil leak.

Tuesday, Chicago: A United Airlines A319 collided at the gate with a baggage loader. One engine had minor damage. No one was injured.

Source: Federal Aviation Administration

NTSB: Bad Maintenance Downed C177RG

Thu, 02 Feb '06

The NTSB has released the probable cause for an April 20, 2004 Cardinal accident that took the lives of a pilot and passenger. The NTSB determined the probable cause(s) of this accident as "Improper maintenance by other maintenance personnel, and the reinstallation of an unserviced magneto during an engine overhaul, which resulted in the magneto malfunctioning, a loss of engine power, and the airplane being ditched into the water."

Excerpts of the Probable Cause report are attached below.

NTSB Identification: MIA04FA076.

14 CFR Part 91: General Aviation

Accident occurred Tuesday, April 20, 2004 in Tampa, FL

Probable Cause Approval Date: 1/31/2006

Aircraft: Cessna 177RG, registration: N1910Q

Injuries: 2 Fatal.


On May 4, 2004, the NTSB examined the Bendix fuel flow divider installed on the accident airplane. During the course of the examination the Fuel Flow Divider was noted to have not been maintained and updated with the latest diaphragm change, as specified in Bendix Fuel Systems Service Bulletin RS-86, dated December 23, 1983. Examination of the spider/fuel nozzles revealed a fuel flow consistent with manufacturer specifications, and no anomalies were noted.

Under the supervision of an FAA Inspector, on August 18 and 19, 2004, a detailed examination of the magneto installed on the accident airplane was performed at Teledyne Continental Motors, Mobile, Alabama. The examination revealed that the magneto's cam did not have proper lubrication, and the magnetos' points had seized.

The accident airplane was equipped with a Teledyne Continental Motors single-drive dual magneto, part number 10-38255-1, serial number 22402. The magneto was originally manufactured in August 1978 and records indicate that Electrosystems, Inc., last overhauled it in October, 1997. The magneto harness had visible areas of wear. The magneto cover was removed and it was noted that the points had little or no movement. According to the aircraft's engine logbook, the magneto was reinstalled on July 21, 2003, the time in which the engine was overhauled, however, no records were found to indicate that a magneto overhaul had been performed.

According to the Teledyne Continental Motors Service Bulletin SB643B dated February 25, 1994, "...magnetos must be overhauled when the engine is overhauled. ...Magnetos must be overhauled or replaced at the expiration of five years since the date of original manufacture or last overhaul, or four years since the date the magneto was placed in service, whichever occurs first, without regard to accumulated operating hours." In addition, Lycoming Mandatory Service Bulletin SB240R, dated November 10, 1999, specifies mandatory parts replacement at overhaul and during repair or normal maintenance.

FAA Wants to Fine Cessna $840K

Proposes $840,000 Civil Penalty

The FAA has proposed a civil penalty of $840,000 against the Cessna Aircraft Company, Wichita, Kansas, for allegedly failing to comply with Federal Aviation Regulations.

The FAA alleged Cessna could not ensure that 42 new aircraft had been manufactured in accordance with the FAA-approved type design and were in condition for safe operation.

The FAA found several discrepancies in flight control rigging on aircraft under construction during an inspection of Cessna’s Independence, Kansas, facility on February 23 and 24, 2005. After that inspection, Cessna found several more cable problems on March 3, 2005.

Because the proper assembly of these 42 aircraft could not be assured, the FAA issued an Emergency Airworthiness Directive March 5, 2005 requiring the inspection of the flight control system of these aircraft prior to further flight. Subsequent inspections conducted under this directive found 12 aircraft that were not in compliance with regulations.

Cessna has responded to the notice and has requested an informal conference with the FAA.

SAS Aircraft Flew Without Inspections

STOCKHOLM, Sweden (AP) - Scandinavian airline SAS flew 10 Airbus aircraft on several occasions last year even though the required engine inspections had not been performed, aviation and airline officials said Monday.

The aircraft hadn't been inspected according to international regulations after engine installations, said Swedish Civil Aviation Authority chief executive Nils Gunnar Billinger. He said the company's international operation permit could be limited or withdrawn as a result of the misconduct.

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"All airlines must comply with airworthiness demands and if they don't they will simply not be allowed to fly," he said.

SAS itself reported the missed inspections to the aviation authority but stressed that no faults were found when the inspections were finally carried out.

"Aircraft must be checked and maintained and we had not done that. When we inspected the aircraft they were airworthy. But of course it is serious that we did not have the administrative control over this," SAS spokesman Bertil Ternert said.

"Together with the authorities, we have already started to take a number of measures to improve our routines," he said.

SAS said the problem could partly be due to the fact that some of the maintenance had been outsourced to other companies.

SAS is the joint carrier of Sweden, Denmark and Norway.

SAS To Boost Aircraft Checks After Inspection Delays

Scandinavian airline SAS said on Monday it was tightening up the inspection and servicing of its planes after Swedish authorities identified gaps in its safety checks on 10 aircraft.

The worries were aired by Nils Gunnar Billinger, head of the Swedish Civil Aviation Authority, to daily Svenska Dagbladet.

"SAS has taken liberties with the safety margins. These airplanes should not have been in traffic," he told the daily.

He was referring to 10 planes where the airline had not carried out required inspections and service which meant the aircraft did not meet air safety standards.

The flag carrier, which has forecast a return to profit in 2005 after four years of losses, said it had itself reported the omissions to the authorities and that later inspections of the planes in question had showed that none was unsafe.

"We have received serious criticism for not having serviced and inspected some of our Airbus planes at the right time," SAS spokesman Bertil Ternert said. "We have said that we have to get the administration regarding these inspections in order. Now we have, together with the authorities, held negotiations about 17 new positions in our... organization which will work with these kinds of questions."

8 Tips for Writing Better Email Notes

By Barbara Manning Grimm

Effective communication is an essential skill for safety professionals. Whether you're communicating through an internal memo, safety training or in person, it's important to ensure that your message is understood. This is just as important when you're sending a message electronically. Email has become commonplace. But that doesn't mean that everyone uses it effectively. This article will give you eight guidelines to help you write clearer and more effective email notes.

1. Write a Specific Subject Line

Your recipient may receive hundreds of emails in a day and doesn't have a lot of time to spend trying to decipher your message. He needs to be able to tell at a glance:

      · What your message is about; and

      · Whether he needs to open it now or can wait until later.

Having a subject line that reads "Must see you now" or "Let's meet next week" will help the recipient prioritize your message.

2. Get to the Point Fast

State your main point first and summarize the message in a sentence or two. Then you can expand on the topic. "We need to replace the Number 3 kiln. Let me give you 4 good reasons." Don't save vital information for the end of the message. Sometimes the end of an email can be lost when copying from one format to another. And your reader might just lose interest before reaching the end of your note.

3. Use Plain Language

Unless you are writing to someone who understands the jargon, use only everyday words. If you can't figure out how to write something, try saying it aloud first. The straightforward approach and simple language we use when we speak generally translates well into writing.

4. Be Courteous

Generally speaking, email doesn't do justice to wisecracks, criticisms, touchy topics, enthusiasm and other emotions. Communications involving these matters are best handled in face-to-face conversation, or at least on the telephone.

5. Be Professional

Take the time to spell-check and proofread your message. Double-check any dates and figures.

6. Provide Sources

Refer your reader to sources for additional information. Indicate where to find the financial report, chemical analysis or building specs you are discussing. If you're providing a website address as a source, be sure to include the entire format (e.g., http://www.safetyxchange.org).

7. Include Your Current Contact Information

Let recipients know how they can reach you right now. "I'm on the plant floor today until 4 p.m. at extension 123." If appropriate, include your full name, mailing address and company phone number.

8. Avoid Email Acronyms

Certain acronyms such as BTW (by the way), CWOT (complete waste of time) and IMHO (in my humble opinion) have become trendy. The problem is that not everybody knows what they mean. So try to avoid using them. As a longtime email user you may have BTDT (been there, done that), but that may not be the case for your reader. So if you use acronyms you may find that YOYO (you're on your own).


Email has certainly sped up communications. But that doesn't mean it's improved communications or replaced the rules governing traditional forms of communication. You still need to pay attention to ensure that your message is read and is clear. And that is the EOD (end of discussion).

END with thanks to jetBlue