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.
TESTS AND RESEARCH
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).
Conclusion
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
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