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Aviation Human Factors Industry News

February 14, 2006

Vol. II, Issue 7.

Anger in the Workplace

A recent study published in the Annals of Family Medicine reports that being angry more than quadrupled a person’s odds of being injured and being hostile increased those odds six fold. Not surprisingly the study also reported that being angry at work increased the odds of a workplace injury occurring. Additionally, men are at more risk to sustain an injury while angry than women. The results from the study add to a growing body of research about the health risks of being angry. For example, multiple studies report that anger can trigger coronary heart disease and heart attacks. (Steve Sternberg, "Study: Angry people are a danger to themselves" USA Today, February 5, 2006) Now there’s a real good reason to control the Child.

Two injured when plane slides into jetway at Sea-Tac airport

Two passengers aboard a United Airlines plane from Chicago were injured Sunday night when the airplane slid into a jetway at Seattle-Tacoma International Airport.

United spokesman Jeff Green said the plane arrived at the gate, N-6. It came to a stop and parked and the engines were being shut down. The seatbelt light was turned off and passengers began moving out of their seats when the airplane moved forward another 10 feet and hit part of the jetway.

It struck the engine cowling outside the engine, said Green, and caused minor damage to the engine. Passengers were jostled and one passenger and a flight attended were treated for minor injuries. The flight attendant was taken to St. Francis Hospital in Federal Way and was treated and released, Green said.

He said he didn't know why the airplane rolled into the jetway and is being examined by maintenance crew. The airplane is out of service.

Green said the airplane was carrying 145 passengers and six crew members.

Rule possibly violated in airport death

Rules for accelerating jet engines during maintenance procedures called "run-ups" appear to have been violated last month when an airplane mechanic was sucked into a jet engine and killed at El Paso International Airport, documents show.

The airport's aircraft engine run-up procedures state that engines should not be revved up for testing purposes in the terminal area, according to documents obtained by the El Paso Times under the Texas Public Information Act. The documents specifically state that maintenance tests requiring more than "idle" engine power have to be conducted in a designated area away from the terminal.

Procedures for accelerating aircraft engines have come under scrutiny following the Jan. 16 death of mechanic Donald Gene Buchanan, 64, who was sucked into the engine of a Continental Airlines Boeing 737 that was at the terminal boarding passengers. Buchanan, an employee of Julie's Aircraft Service, which services Continental planes, was killed while working with of a four-person crew that was trying to determine what caused a fluid spill near the Boeing 737.

El Paso airport Aviation Director Pat Abeln declined to comment because of a National Transportation Safety Board investigation. Officials for Continental also declined comment.

According to airport documents, jet engine power is restricted to "idle" one engine at a time for a maximum of five minutes. The only exception to this procedure applies to aircraft that need more power "for the specific purpose of commencing taxi," the documents state.

"Operational or maintenance requirements that necessitate longer or higher power must be accomplished at designated run-up areas," documents state.

The designated run-up area for turbo jet aircraft, such as a Boeing 737, is about 2 1/2 miles away from the terminal in the holding bay of Runway 22, documents state.

Another JAL Maintenance Error Committed.

07 FEB 2006 JAL 777 operated without emergency exit door batteries
It turned out that a Japan Air Lines Boeing 777 was operated for five days without batteries for the `Emergency exit door operation auxiliary system`. During maintenance the battery cases were replaced with cases; seven of the eight cases did not contain batteries. Another mechanic who should have checked the existence of the batteries had reportedly misread the English manual. (Yomiuri; Kyodo News)

How Stress Affected Comprehension
NTSB Go-Team Sent To Investigate PHL Cargo Plane Fire

Plane Makes Emergency Landing As Flames Shoot Out A team of investigators with the National Transportation Safety Board are rushing to Philadelphia International Airport, where the charred remains of a UPS DC-8 await their scrutiny.

UPS flight 1307, a regular night-time package flight from Atlanta (ATL) to Philadelphia (PHL), departed Atlanta at 22:42 EST. Just after receiving clearance to land at runway 27R, the DC-8 crew reported that they had a smoke warning light come on: "Cleared to land, and ah listen we just got a cargo smoke indicator come on can we have the equipment?". The Tower controller replied: "Okay, I’ll do that ..the cargo smoke indicator....ah... souls on board and amount of fuel Sir?" UPS1307 reported three souls on board and two hours worth of fuel. About a minute later the controller cleared the fight to land at runway 27L, which is 1006 feet (308

m) longer than runway 27R. The crew confirms the clearance, but continues their approach to 27R. The tower controller notices this and queries:

"..1307 Heavy just confirming that your are lined up to the left side and it appears you are lined up to the right." UPS1307 replies: "I am sorry I thought we were cleared for the right..uh.. are we cleared to land on the right?" The tower controller then clears them to land on 27R and informs the fire department about this. Smoke was coming from the aircraft as it landed.

The crew evacuated and the fire services started fighting the fire. The blaze was reported under control by about 04:00.

Fuel Truck Clips Aircraft, Two Injured

A fuel truck clipped the wing of a United Express Flight 8006 at 6:25 a.m. today at Richmond's airport, injuring two workers but not resulting in any fuel spills or fires, airport officials said.

"Apparently it was a pretty strong strike," said Troy Bell, spokesman for Richmond International Airport. He was commenting on the fuel truck's collision with the right wing tip of the aircraft operated by a regional subsidiary of United Airlines.

The aircraft, bound for Washington Dulles International Airport, had 42 passengers on board at the time. The jet was quickly evacuated, with no passengers injured, Bell said.

The truck, which carried 4,000 gallons of fuel, struck the plane less than two feet away from the aircraft's fuel tank.

The fuel truck driver was trapped inside his cab and had to be cut free by fire and rescue personnel from the airport and Henrico County.

The truck driver was treated and released for minor injuries at the Virginia Commonwealth University Medical Center, Bell said. The driver, whose name was not released, works for Million Air, a private fuel and aviation services company at Richmond International.

A United Air Lines employee was shaken up while working inside the aircraft's cargo bay. The woman, whose name was not released, was treated for minor injuries and released at a local hospital, Bell said.

Tired Air Traffic Controller Blamed in Near-Crash

(AP) A tired air traffic controller directed a departing airliner onto a Los Angeles International Airport runway where another jet was about to land, according to a National Transportation Safety Board report on an incident 1 1/2 years ago in which disaster was avoided by a pilot's quick action.

The report released this week said the probable cause of the incident was the controller's "failure to appropriately monitor the operation and recognize a developing conflict," with contributing factors including fatigue and tower procedures.

The Aug. 19, 2004, incident involved a Southwest Airlines Boeing 737 and an Asiana Airlines Boeing 747-400 carrying a total of 446 people.

Human Factors Conference in Canada

This will be well worth attending if you can. More information can be found at www.tc.gc.ca/civilaviation/systemsafety/CASS/menu.htm Gordon

Human and Organizational Factors: Pushing the Boundaries! April 24-26, 2006

Casino Nova Scotia Hotel

1919 Upper Water Street

Halifax, Nova Scotia

Traditionally, we have focused on individual human abilities and limitations of aviation personnel. Human behavior and performance are cited as causal factors in the majority of aircraft accidents. If the accident rate is to be decreased, Human and Organizational Factors must be better understood as encompassing the entire human system interaction. This broader scope of human factors presents the aviation community with one of the most significant opportunities to make aviation both safer and more efficient.

Through a series of interactive workshops and plenary presentations including keynote speaker, Lund University’s Professor of Human Factors and Aviation Safety, Sidney Dekker, CASS 2006 will demonstrate how to apply Human and Organizational Factors in a practical and meaningful way.

Transport Canada is also pleased to present banquet speaker, John Pottinger, Chief of Air and Surface Movement of the United Nations (UN) Department of Peacekeeping Operations in East Timor. With the title, Lions in the Hangar; Guerrillas on the Runway, Mr. Pottinger will take a humorous as well as a serious look at aviation safety and security issues in the UN peacekeeping air operations.

Jet Manufacturer Fails to Remedy Known Problem

Deadly Crash in Colorado of Plane Carrying Ebersol Family Is The Second Attributed to Wing Icing

Pilot's Family Responds to NTSB Report Issued Today

NEW YORK, Feb. 2 /PRNewswire/ -- The factual report issued today by the National Transportation Safety Board (NTSB) makes tragically clear that the crew flying NBC executive Richard Ebersol and his sons had no idea that ice had accumulated on the wings of the high performance jet before it crashed on takeoff in Montrose, Colorado, according to attorneys for the family of the pilot flying the plane. Three people were killed in the crash on November 28, 2004, including the pilot, Luis A. Polanco-Espiallat, whose family is

represented by attorney Brian Alexander of Kreindler & Kreindler LLP in New York.

"Pilot Polanco-Espiallat was a highly experienced commercial airline pilot with more than 10,000 hours of flight time accumulated in various jet aircraft over 30 years," said Mr. Alexander. "A review of the NTSB materials confirms that the flight crew performed all required pre-flight and take-off procedures. Significantly, the crew observed that the wings were in 'good' and 'clear' condition before takeoff. The cockpit voice recorder also indicates the captain and first officer had activated the wing and engine anti-ice systems."

In a nearly identical crash in January 2002, another Canadair Challenger 600 crashed on takeoff in England. British aviation investigators highlighted the need for improved procedures for ice detection and ice contamination. But it was not until nearly three years later, after the crash in Colorado, that Bombardier, the manufacturer of the Challenger jet, revised its procedures and warnings to pilots to avoid this unsafe condition. They called for a tactile inspection in addition to visual inspections for ice, snow, slush and frost because potentially dangerous contamination might be too small to see.

The NTSB notes that non-slatted turbo jet transport aircraft (like the Challenger) have been involved in a disproportionate number of crashes on takeoff where ice was a contributing factor. It wrote, Despite the accident and research evidence indicating that small, almost visually imperceptible amounts of ice accumulation on the upper surface of a wing can cause the same aerodynamic penalties as much larger (and more visible) ice accumulations, recent accidents indicate that the pilot community still may not appreciate the potential consequences of small amounts of ice.

"Knowing the particular susceptibility of these wings to loss of control from ice, snow and slush, the manufacturer had an obligation to make sure pilots had an effective way of determining whether ice is on the wings,"Attorney Alexander said.

"The bottom line is, Bombardier never told pilots that even if the wings appear to be clean, small traces of ice could cause a loss of control on takeoff," Mr. Alexander said. "They owed it to the pilots to give them this information."

Ryanair incidents prompt call for low-cost safety audit

A leading aviation magazine has called for a safety audit of low-cost airlines following two recent incidents involving Ryanair planes.

An editorial in the latest edition of Flight International says the human stresses involved in operating aircraft under the low-cost model have never been properly investigated.

The magazine's editor David Learmont said today that he was not making any allegations against low-cost airlines, but felt the lack of any proper safety audit was a cause for concern.   "This is a business model which has never been investigated in its own right," he said.  Ryanair defends safety standards

Irish airline Ryanair is defending it's safety standards.  It says it’s procedures are rigorously and frequently audited by the Irish Aviation Authority and the National Aviation Authorities in every country it operates in.

The statement is a response to an aviation industry journal study on the dangers associated with low-cost airlines.

Flight International says the human stresses involved in operating aircraft under the low cost model have never been investigated and could be a relevant safety factor.

Why now, and why Ryanair? There are several reasons: Ryanair is now a mature operation that has worked out how it does things, so it is a stable business model – a fixed rather than a moving target. And all the vibes coming from the big low-cost carriers indicate that the target for an operating review should be human-factors centered rather than the traditional checks on manuals and adherence to standard operating procedures. Human factors are more difficult to check, to measure, and more difficult to prove, but most accidents are caused by human factors.

In the last year Ryanair aircraft faced two anomalous approaches that came close to ending in tears. In one of them the Irish Air Accident Investigation Unit ventured that the pilot flying’s out-of-character conduct was the result of stresses outside – but related to – the workplace: in the other, an internal investigation by Ryanair concluded that a bereavement had affected the captain’s capacity. Meanwhile a Ryanair pilot’s demotion after refusing to fly extra sectors at the end of his rostered duty day is being examined in the courts. Safety experts always talk of the iceberg model for incidents and accidents: the accidents are the tip, the incidents are the bulk of the iceberg and the indicators that it is time to look for trends.

The bereavement-related incident is to be investigated by the Italian ANSV. Now the IAA should lead the world by commissioning an academic study of the human factors of low-cost operations.

Definition of the ICEBERG MODEL( Heinrich Ratio)

Fatal accidents are only the tip of the iceberg. Think of an iceberg where 90 percent is submerged under water. The visible tip representing a fatal accident. The submerged section is divided into three layers. The bottom layer is the non reportable incidents followed by the middle layer reportable incidents followed by the accident layer.

So here is the scoop on the Heinrich ratio: For every 600 non reportable incidents there will be 30 reportable incidents, 10 accidents and one (1) fatal accident. A reduction of non reportable incidents (events at the bottom of the triangle) should lead to a reduction in the number of events at the exposed top of the iceberg.

END with thanks to jetBlue