Aviation Human Factors

Industry News !
Volume XIII. Issue 05, March 05, 2017

Hello all,
To subscribe send an email to: [email protected]
In this weeks edition of Aviation Human Factors Industry News you will read
the following stories:

★What the Fire Service can Learn ★5 Sleep-Deprived Disasters

from the Aviation Industry
★Industry Asks FAA To Clear Up
★Improper installation of oil filter Drug-testing Confusion
adapter brings down Bellanca
★Aviation Maintenance Technician
★Airline safety questioned: Six out Handbook - General
of 10 Pilots are falling asleep in
Europe ★An-12 fire inquiry reveals doubts
over APU maintenance
★Pilot Error Common Thread in
Recent Marine Corps Crashes: ★AOPA Opens Up To Drone Pilots
General

Human Factors Industry News 1

What the Fire Service can Learn from the Aviation
Industry

"In so many areas of life, you need to

be a long-term optimist but a short-
term realist. That is especially true
given the inherent dangers in aviation.
You cannot be a wishful thinker. You
have to know what you know and
don't know, and what your airplane
can and can't do in every situation."
That quote is from Captain Chesley
“Sully” Sullenberger.
Substitute “firefighting” for “aviation” and “available resources” for “airplane” and you
have a quote that would serve any incident commander at a fire scene well.Aviation
has transitioned from a daredevil pastime to the safest mode of transportation. Yes,
there are still terrible air crashes, but overall, commercial aviation is the safest way
to travel. According to Flight Global, an industry newsletter, in 2014 aviation was
twice as safe as it was in 2004. It is 5 times safer than it was in 1984, 10 times as
safe as in 1974, and 300 times safer than in 1950. I think you would agree that this
is an amazing aggressive record of risk reduction
Are there risk management lessons that the fire service can learn from aviation?
Aviation changed its culture to make this safety improvement.
The fire service has already adopted some concepts from aviation. Many of you are
no doubt are familiar with Crew Resource Management and Situational Awareness
as they apply to the fire service. Check the Suggested Reading section at the end of
this article for more information.
The fire service needs clear rules of engagement for high-risk operations.
Aeronautical engineering informs flying; Fire science needs to inform fireground
operations
Pilots get frequent check rides to monitor their proficiency. Why not the same for
incident commanders? The purpose of proficiency checks is to identify needed
training, not to discipline.
Aviation is a highly regulated industry with procedures that need to be followed
carefully before an aircraft moves. Freelancing is definitely not allowed. Imagine a
pilot taxiing an airliner to the runway without clearance. The fire service needs to
have a zero tolerance for freelancing.

Human Factors Industry News 2

The top three priorities of flying are aviate, navigate and communicate. Three
priorities of fireground command are manage, plan and communicate. Management
of the incident includes span of control, accountability and scene safety. Planning
includes gathering information, making forecasts of future events, and planning
actions using strategic tools. Communicate includes making sure that everyone is
aware of the plan and safety zones.
When things start going wrong in the air, remember to fly the aircraft. When things
start to go wrong on the fireground, remember to manage the incident.
Captain Sullenberger had a fortune from a fortune cookie taped neatly in his
Jeppesen Airway manual for years. It read: “Better a delay than a disaster.” In trying
to meet the response guidelines of NFPA 1710 and 1720, some firefighters do not
wear seatbelts or complete PPE and figure they don’t have time to do a 360. Would
it make you feel secure if the captain of your flight skipped checklists in order to
maintain an on-time schedule?

Crew resource management

The road to a safer aviation industry began in earnest after the worst air disaster in
history. On March 27, 1977, two 747’s crashed in Tenerife, Canary Islands. A KLM
747 was cleared to hold on the only runway while a Pan Am 747 taxied on that
runway. The KLM captain thought he was cleared for take-off. The co-pilot
apparently did not want to contradict a senior captain. As a result, 583 people died.
Out of the tragedy came crew resource management (CRM), which gave flight
crews the ability to question the actions of a captain without fear of retribution.
Previously, the captain was beyond question in the hierarchy. Substitute fire chief for
captain and you have the structure of some fire departments. CRM is a team
approach to danger recognition and workload allocation. Initially, some pilots derided
it as “charm school” but it has proven itself a very effective tool for accident
reduction. What would things look like if the incident commander and another senior
officer were trained to manage the scene together within the hierarchy like a captain
and first officer?
In the cockpit, there is a clear division of functions. The Pilot Flying (PF) is
responsible for flying the aircraft, even if the autopilot is on. Any functions other than
flying the aircraft are handled by the Pilot Monitoring (PM). The transfer of roles is
done verbally with confirmation. The PF looks at the PM and says “your aircraft.”
The PM responds “my aircraft.”
What might this look like on the fireground? The IC Managing would turn over
control to the IC Supporting any time he or she needed to do something other than
actively managing the scene. This may be as simple as taking a bathroom or food
break. “Your fireground” and “my fireground” would positively transfer control. At
smaller incidents, the Incident Safety Officer could fill this role.

Human Factors Industry News 3
Of course, the functions of the ISO still need to be done. At a larger incident,
someone who has no other responsibilities would fill this position. In the cockpit, the
flight plan is the agreed upon course and on the fireground it’s the incident action
plan.

Human factors analysis

After every aviation accident, there is an investigation that goes beyond what
happened and looks at why it happened. What was the crew’s state of mind prior to
the accident? Did fatigue, distraction, or any other human factors play a role. Saying
that the aircraft was too low and struck the mountain is not sufficient any more then
saying that firefighters were in the fire building when it collapsed without looking at
why they were there at that time.

Five dangerous attitudes

The FAA commissioned a study by Embry Riddle Aeronautical University. They
discovered that five attitudes keep showing up in incidents involving poor pilot
decision-making. I have added examples of similar attitudes that some in the fire
service have and the antidote to those attitudes.
Anti- Authority: “You can’t tell me what to do!”
Fire Service: “Forget what they told you at the academy, kid, we’ll teach you how we
do things here!”
Antidote: “We are disciplined professionals.”
Impulsivity: “Do something quickly!”
Five Service: Quick attack mode without doing 360 first.
Antidote: Gather information quickly and make an informed decision
Invulnerability: “It can’t happen to me (us)”
Fire Service: “We have been doing it this way for years without any problems.”
Antidote: “It can happen to us! We need to always be looking for ways to manage
risk better.”
Macho: “I can do this!”
Fire service: “We can do anything!”
Antidote: “Let’s see how we can do this safely.”
Resignation: “What’s the use?”
Fire Service: “This is a dangerous job, we just have to accept 100 LODDs a year,
and we can’t do anything about it.”
Antidote: “We can protect our own better. There is always room for improvement.”

Human Factors Industry News 4
Confirmation bias
Confirmation bias is the human characteristic of searching for, and interpreting
information in a way that confirms one's preconceptions. On September 3, 1989,
Varig flight 254 to Belem ran out of fuel and crashed in the Amazon jungle. The crew
had entered the wrong heading into the flight computer and ignored any evidence
that they were not where they thought they were, including common sense
observations such as the location of the setting sun. They were convinced that they
were close of Belem, when in fact they were 600 miles away. The parallel in the fire
service is being convinced that the fire is on the ground floor when in fact, it is in the
basement.

Checklists
Before the crew of an aircraft moves from the gate, takes off, or lands, a checklist is
completed. They are also used in any emergency. Would the fireground be a safer
place if the IC and Co-IC completed a quick checklist before committing firefighters
to an interior attack? A little known fact is that even before he became famous for
the Miracle on the Hudson, Captain Sullenberger was consulting with hospitals on
crew resource management and checklists to make surgical procedures safer.

High-reliability organizations
One of the characteristics of a High-Reliability Organization (HRO) is the
preoccupation with failure. Pilots are constantly checking instruments and looking for
a place to land if the engine(s) suddenly quit. Would the fireground be safer if the
command team was always thinking about what could go wrong and what they
would do about it?
The fire service is historically not an HRO. Reading NIOSH fatality reports reveals a
small cluster of issues that are repeated over and over. Following a tragic airline
disaster, imagine the airline industry saying: “Catastrophic airline crashes are the
unfortunate cost of doing business in a high-risk environment.” Raise your hand if
you would be comfortable flying your family across the country.
Every time there is a crash, it is thoroughly investigated, even going so far as to
rebuilding the aircraft in a warehouse. The FAA, the manufacturer, and the airline
unite with a single mission: To make sure what caused the crash never happens
again. It is this attitude, that passenger fatalities are unacceptable, that has made air
travel as safe as it is. The other component is that after the cause is determined,
action is taken. The aircraft manufacturer may change the design of a part or
system, change a maintenance procedure, or make some other modification that will
make their aircraft safer. Airlines will change crew training and supervision because
of an accident. The FAA will send out Safety Alert for Operators (SAFO) as needed.

Human Factors Industry News 5
The purpose of all of these measures is to make sure that everyone affected knows
what to do in order to make sure that the accident isn’t repeated. The fire service
has a way to go in this regard. Battalion Chief. Mark Emery looked at NIOSH reports
and found that the same causes were present over and over again (“13 Fireground
Indiscretions,” Firehouse, March 2006). There are no new ways to crash an
airplane. There are no new ways to kill a firefighter.
Chief Eric Tomlinson wrote an excellent article in the April 2016 issue of Firehouse
about using aviation-like accountability on the fireground. There are clearly more
things that can crossover.

Call to action
Quote from Highest Duty by Captain Sully Sullenberger:
“I am trained to be intolerant of anything less than the highest standards of my
profession. I believe air travel is as safe as it is because tens of thousands of my
fellow airline and aviation workers feel a shared sense of duty to make safety a
reality every day. I call it a daily devotion to duty. It’s serving a cause greater than
ourselves.”
The old days of cowboys in the cockpit were certainly more exciting and fun than
today with compliance being the criteria upon which pilots are judged. That being
said, I don’t think anyone would seriously advocate for a return to “the good-old
days.” Across the fire service, we need to make sure that we are, at all times,
disciplined professionals. No more freelancing cowboys or non-compliance with
safety rules. Adapt CRM whole-heartedly. Make training and recertification
mandatory. Just because someone has been doing something for 30 years does not
automatically make it a best practice.
How can you be an agent for change? Gandhi said, “Be the change you want to see
in the world.”
Firefighters: Wear your PPE and fasten your seatbelt. Know and follow your
departments SOPs. Do not speed or race other companies to the call. Be prepared
to respectfully point out safety concerns to company officers and chiefs. Seek out
training opportunities.
Company officers: Use Crew Resource Management principles. Make sure your
crew follows SOPs. Lead by example. Bring up safety concerns immediately.
Chief officers: Make sure that cultural practice is in accordance with your SOPs; if
not change one or the other. You are responsible for your department’s culture—
own it!
One of the maxims of aircraft accident investigation is: “There is always more than
one cause.” Generally, there is a chain of events that lead to an accident.

Human Factors Industry News 6
If any one of them had not occurred, the accident would not have happened.
Redundancy, checklists, warning systems and constant monitoring are employed to
break the chain that could lead to an accident. An example of this we already use is
cross-checking your partner’s PPE before entering the hazard area. Review your
department’s procedures to see if you can insert other chain breakers into your
operations.
Everyone should review Close Calls and NIOSH reports to see what you can do to
prevent a repeat. Initiative and creative problem solving should be encouraged. The
question you should be asking yourself before making a decision is: Will this action
increase or decrease firefighter safety?
Is the fire service ready to make the same evolutionary change? The job is exciting
and fun without rounding safety corners. We owe it to those who are counting on us
at home, at the fire station, and on the streets to make sure that every call is a
roundtrip for everyone.

http://www.firehouse.com/article/12170764/aviation-like-accountability

Improper installation of oil filter adapter brings down

Bellanca

During the approach at night, the Bellanca

17-30A experienced a total loss of engine
power, and the pilot performed a forced
landing into trees near Monroe, Ga.,
seriously injuring two.Subsequent
examination of the engine revealed that the
oil filter adapter was loose and that it was
installed incorrectly with two copper crush
gaskets rather than with one copper crush
gasket and one fiber gasket per the manufacturer’s installation instructions.

Human Factors Industry News 7
The fiber gasket would have held the required torque for the fitting; however, the
copper crush gasket did not hold the required torque.

Because the oil filter adapter was loose, oil leaked from the engine, which led to the
failure of the Nos. 4 and 5 connecting rods due to a lack of oil lubrication.

The oil filter adapter was not original equipment on the engine. Although it could be
installed under a supplemental type certificate, a review of maintenance and aircraft
records did not reveal any entry or record pertaining to the installation of the oil filter
adapter.

The airplane had been operated for about 70 hours since its most recent annual
inspection, which was performed about a year before the accident.

It could not be determined when the oil filter adapter was incorrectly installed.

Although the pilot stated that he had fueled the airplane with 100 low-lead aviation
gasoline, automobile gasoline was recovered from the fuel tanks.

The higher-compression ratio engine was not designed or approved to operate on

automobile gasoline, and engine examinations revealed that it had been operating
at higher temperatures due to the use of automobile gasoline.

If the engine had not failed due to oil starvation, it is likely that it would have soon
begun to detonate due to the use of the improper fuel.

The NTSB determined the probable cause as the improper installation of the oil filter
adapter at an unknown time, which resulted in an oil leak and subsequent oil
starvation to the engine.

NTSB Identification: ERA14LA436

This September 2014 accident report is provided by the National Transportation

Safety Board. Published as an educational tool, it is intended to help pilots learn
from the misfortunes of others.

Human Factors Industry News 8
Airline safety questioned: Six out of 10 Pilots are falling
asleep in Europe

Pilots are responsible for

hundreds of passengers.
Their life depends on the
man in a cockpit of an
aircraft when flying. The
18th February 2017 marks
exactly one year of
European airlines flying
under the new EU Flight
Time Limitations (FTL) rules – which were introduced to prevent pilot fatigue from
endangering flight safety. However, widely differing interpretations of the rules, lack
of official guidance on correct implementation, immature Fatigue Risk Management
(FRM) systems in the airlines, and persistent fatigue problems in Europe’s cockpits
are the current state-of-play. Aviation stakeholders are therefore called upon to
jointly address these shortcomings.This 1st anniversary confirms that the complexity
of the new EU FTL rules results in them being widely (mis)interpreted and incorrectly
implemented.

Many airlines and National Aviation Authorities (NAAs) are struggling how to
interpret the rules and how to integrate essential points of the regulation into flight
operations. As a result, some are opting for interpretations that simply fit their
operations, schedule and productivity targets, irrespective of the fatigue impact on
their crews.

“Particularly at risk are night flight duties of 10 hrs or more, extended flights of 14
hours, and standby-flight combinations with pilots being awake for more than 18
hours – but being expected to land their aircraft and passengers safely after such
duties,” says ECA President Capt. Dirk Polloczek. “Although we have new rules, the
old problem persists: many fatigued pilots in Europe’s cockpits.”

Human Factors Industry News 9
“Half of airline pilots report fatigue which could jeopardize passenger safety” warned
just 2 months ago the London School of Economics (LSE) – a key finding of a new
Safety Culture study, carried out jointly with EUROCONTROL. It highlights that
fatigue strikes 6 out of 10 European pilots – but that only 2 out of 10 pilots think that
fatigue is taken seriously by their airline. This confirms previous surveys among
pilots, which showed that fatigue is a reality in Europe’s cockpits.

“These findings are serious enough to serve as a wake-up call for European and
national aviation authorities,” continues Polloczek. “But the problem is that many
national authorities have insufficient resources and knowhow to properly oversee
the new rules and their correct application. This is why EASA – the European
Aviation Safety Agency – has a central role to play: one of guiding the work on a
harmonized interpretation and implementation. We therefore call upon EASA to be
more active and to provide clear interpretation guidelines to authorities, airlines and
aircrew alike.”

This 1st anniversary also shows that proactive Fatigue Risk Management (FRM)
systems need to play a more prominent role in airlines’ efforts to reduce crew
fatigue. FRM is, in its essence, complementary to the prescriptive FTL rules,
allowing airlines to ‘customize’ some aspects of the regulation. Those two
components taken together were supposed to reconcile adequate fatigue protection
and flexibility for airlines to operate efficiently.

“In reality, however, Fatigue Risk Management remains either misunderstood, poorly
handled, inadequately overseen or simply used as a smokescreen to cover ongoing
malpractice,” says Philip von Schöppenthau, ECA Secretary General. “Our own
benchmarking among almost 30 airlines shows that too few operators have actually
implemented a functional and effective system to manage their crews’ fatigue risk. It
is therefore crucial that EASA and the NAAs invest more in training and auditing of
the operators. Otherwise, FRM risks remaining a paper-tiger exercise with no real
effect on fatigue.”

This 1st anniversary is also the start of a new scientific review of Europe’s FTL rules.
Next month, a consortium of research institutes will kick-off their work, which is
expected to result in a final report in Feb. 2019.

Human Factors Industry News 10
 “This is review is crucial,” says von Schöppenthau, “because already several years
ago leading scientific fatigue experts had warned that the new FTL rules would be
insufficient to counter the safety risks associated with pilot fatigue. We therefore
welcome this study and hope it will help EU regulators to finally close the safety
lacunae of today’s rules.”

Pilot Error Common Thread in Recent Marine Corps

Crashes: General

In the last 12 months, the Marine Corps has

sustained a troubling nine major aircraft crashes,
resulting in 14 fatalities -- most of which occurred
in a tragic January 2016 helicopter collision -- and
11 lost aircraft.

While many of these incidents remain under

investigation, the head of Marine Corps aviation
said findings so far reveal human components to
the mishaps.

"I look at them all in great detail," Lt. Gen. Jon

Davis told reporters in Washington, D.C., on
Wednesday. "We are not seeing a material failure component to those aviation
mishaps. It's mainly human error."

The January 14, 2016, collision of two CH-53E Super Stallion helicopters that
resulted in the deaths of all 12 Marines aboard was the result of failure to maintain
adequate distance during the night training flight, according to an investigation
released in October.

The findings of other mishap investigations have yet to be released, but Davis said it
appears they involved aircraft that were in fine flying condition.

Human Factors Industry News 11
In December, two crashes occurred within days of each other in the Pacific. On Dec.
7, an F/A-18C Hornet crashed off the coast of Iwakuni, Japan. Its pilot, Capt. Jake
Frederick, ejected but did not survive. On Dec. 13, an MV-22 Osprey disintegrated
off the coast of Okinawa after crash landing in shallow water. The five-Marine crew
survived with varying injuries.

"They're still being investigated, but there was nothing wrong with those airplanes,
mechanically," Davis said. "These were -- they were qualified, they were proficient --
these were crews that had been flying a fair bit, flying in some pretty challenging
conditions."

Davis acknowledged that the wreckage of the crashed Hornet had yet to be
recovered, adding complexity to the investigation and making it difficult to rule out a
mechanical cause.

In an earlier mishap that occurred Sept. 22, an AV-8B Harrier went into a spin during
a combat training exercise and crashed off the coast of Okinawa, the pilot ejecting
successfully. The crash prompted Lt. Gen. Larry Nicholson, the commander of III
Marine Expeditionary Force, to briefly ground all Harriers in the Pacific.

In that case, Davis said, the aircraft had been "perfectly serviceable" and the
incident had prompted him to instruct Harrier pilots not to fly with heavy drop tanks
during air combat training.

"The airplane's supposed to be very spin-resistant," Davis said. "I've never spun a
Harrier, and I've got 3,300-some hours flying a Harrier."

These crashes in October and December, along with a mid-air collision of two F/
A-18A Hornets off the coast of San Diego in November, all came after Marine Corps
officials said they had made changes to increase pilot flight hours and proficiency.

"We're about three hours per pilot per month better than we were [in May 2015], but
that's not good enough," Davis said. "We're still shy of our target. [But] I was
surprised with the mishaps we had in October."

Davis said the Corps has taken steps to be more structured and provide better
supervision for sortie planning and execution, among other changes.

Human Factors Industry News 12
In addition to efforts to produce more ready basic aircraft for pilots to train on to
meet their flight hour targets, he said, he has stressed to commanding officers that
"we have a group of aviators who have not flown as much as we did when we were
growing up, and we just have to be more structured and more pedantic about how
we fly."

Virgin Atlantic experiment has pilots conserving fuel

Researchers find that it's

surprisingly easy to
motivate pilots to meet fuel-
saving targets.

Air travel has soared in

recent years, and all those
flights create global
warming pollution. By
saving fuel, pilots can help
reduce emissions … and
research shows they’re easily motivated to do so.To reduce fuel without
compromising safety, pilots can avoid over-fueling, adjust speed and altitude, and
shut down extra engines while taxiing.

Grosnell: “So we approached Virgin Atlantic with an idea that could improve
environmental efficiency and also maximize airlines’ profits.”

That’s Greer Grosnell of the London School of Economics. She says that Virgin
Atlantic pilots were divided into four groups.

A control group received information about the study, but no other support. Other
pilots got data about their fuel use. Some were given goals and encouragement.
And the last group had an incentive: money would go to charity if they met their fuel-
saving targets.

Human Factors Industry News 13
The pilots who received goals saved the most fuel. And those also given a charitable
incentive reported better job satisfaction. But all the groups cut back on fuel … even
the control.

Grosnell: “Simply knowing their efficiency was being monitored led to drastic
improvements in fuel efficiency.”

That, she hopes, is a lesson other airlines can learn from.

5 Sleep-Deprived Disasters

We tend to think of being very sleepy as, well, just being very sleepy. But if you’re in a
position of serious responsibility—really bad things can happen. Here are a few examples.

1. SPACE SHUTTLE CHALLENGER

Disaster: On January 28, 1986, the NASA space shuttle Challenger exploded 73
seconds after taking off from Cape Canaveral, Florida, killing all seven crew
members on board.

Sleep Deprivation: The night before the

disaster, NASA officials held a call with
officials from Morton Thiakol, the company
that designed the shuttle’s rocket boosters.
One of Thiakol’s engineers recommended
canceling the launch, due to the cold
weather forecast for the next day, telling
NASA officials that cold temperatures could
adversely affect equipment in the boosters
—which could cause an explosion. NASA
declined to cancel the launch. An
investigation into the disaster found that it
was indeed caused by the cold weather. The investigation also found that sleep
deprivation, caused by a culture of overwork at NASA, played a critical role in the
decision by the managers to ignore the engineer’s advice: two of the top managers
involved in the conference call had been awake for 23 hours straight at the time of
the call, and they had slept for only three hours the previous day.

Human Factors Industry News 14
 “The willingness of NASA employees in general to work excessive hours, while
admirable,” the official report into the disaster said, “raises serious questions when it
jeopardizes job performance, particularly when critical management decisions are at
stake.”

2. AIR FRANCE FLIGHT 447

Disaster: On June 1, 2009, during a flight from Rio de Janeiro, Brazil, to Paris,
France, Air France 447 crashed into the Atlantic Ocean, killing all 228 people on
board.

Sleep Deprivation: Captain Marc

Dubois, 58, the pilot on the flight with
the most experience by far, had just
one hour of sleep the night before. “I
didn’t sleep enough night,” he can be
heard saying early in the flight on the
plane’s cockpit voice recorder (which
wasn’t recovered until May 2011).
“One hour, it’s not enough.” And when
his two younger copilots encountered
trouble about three hours into the
flight, Dubois was asleep in a bunk
located just behind the cockpit. It was, it must be noted, a scheduled nap, because
all pilots on especially long flights are required to take naps. But when the copilots
started experiencing problems—including “STALL!” warnings blaring in the cockpit—
and called for Dubois on the plane’s intercom, it took Dubois more than a minute to
respond. And when he finally did get to the cockpit, he seemed confused and failed
to take control of the situation, which a pilot of his experience should have been able
to do. (The least experienced of the copilots, for example, was pulling back on the
control stick during the ordeal—the exact opposite of what’s supposed to be done
during a stall.) The plane crashed into the ocean less than three minutes after
Dubois got to the cockpit. The time it took him to respond to the calls for help, and
his subsequent inability to figure out what was going on, were determined by
investigators to have been caused by fatigue.

3. EXXON VALDEZ

Disaster: Just after midnight on March 24, 1989, the oil tanker Exxon Valdez ran
aground on a reef just a few hours after leaving port in the town of Valdez, in Prince
William Sound on the south coast of Alaska.

Human Factors Industry News 15
Sleep Deprivation: We’ve written
about the Exxon Valdez disaster
before and reported, as others have,
that the main fault lies with the ship’s
captain, Joseph, who had at least
three vodkas (and possibly more) just
a few hours before setting off from
Valdez, Alaska. But there’s more to the
story: investigators found that fatigue,
once again caused by a culture of
overwork, also played a significant
role in the disaster. Hazelwood had left
the third mate, Gregory Cousins, alone on the bridge shortly before the ship ran
aground—a violation of regulations, which state that at least two officers must be on
the bridge at all times—so that he could sleep off his intoxication. Cousins had been
awake for more than 18 hours when he took the wheel, and he’d had only five hours
of sleep the night before that. Because of his drowsiness, investigators said,
Cousins failed to notice that the enormous, 987-footlong ship had gone dangerously
off course…until it was too late to stop it, leading to the ship’s striking a reef, and the
subsequent spilling of 10.8 million gallons of crude oil into Prince William Sound.

4. METRO-NORTH

Disaster: On the morning of December 1, 2013, a crowded Metro-North Railroad

passenger train derailed in the New York City borough of the Bronx. The crash killed
four people and injured another 61, and caused $9 million worth of damage.

Sleep Deprivation: An
investigation by the National
Transportation Safety Board (NTSB)
concluded that the train had jumped
the tracks as it sped around a sharp
curve at 82 mph. (The speed limit
was 30 mph.) Why was it going so
fast? The, William Rockefeller, had
fallen asleep at the controls.
Rockefeller, the investigation
revealed, had been reassigned from
the afternoon shift to the morning shift
just two weeks prior to the crash, and had not yet adjusted to his new sleep pattern.

Human Factors Industry News 16
In addition, Rockefeller was later diagnosed with a severe form of the disorder sleep
apnea, which causes high carbon dioxide levels in the bloodstream and can result in
fatigue and slow reaction time. Rockefeller was also found to have taken an
antihistamine at some point prior to the crash, which also could have contributed to
his sleepiness. (Authorities considered filing criminal charges against Rockefeller,
but ultimately decided not to.)

5. UPS FLIGHT 1354

Disaster: In the early morning hours of August 14, 2013, an Airbus A300 cargo
plane owned by UPS Airlines (the airline of the United Parcel Service) crashed
during its approach into Birmingham-Shuttlesworth International Airport in Alabama.
Two pilots were on board; both were killed.

Sleep Deprivation: The investigation

into the crash by the NTSB found that
both pilots made a series of errors during
their approach into the airport. They failed
to properly configure the plane’s computer
for a landing, they descended too rapidly,
they failed to abort the landing attempt
when it was clear that it was not safe—all
of which led to the plane clipping treetops
before the runway, which in turn caused
the plane to crash into a hillside and
explode. The mistakes were attributed to fatigue. In the days leading up to the
crash, both pilots, Captain Cerea Beal, 58, and First Officer Shanda Fanning, 37,
had complained of being overworked. Beal told a colleague, “These schedules over
the past several years are killing me.” And when the plane’s cockpit voice recorder
was recovered the day after the crash, both pilots could be heard talking about their
demanding work schedules, about how tired they were—and even implying that
UPS was more interested in saving money than in pilot safety. “These people,” Beal
said, “have no clue.” (Nobody at UPS Airlines was disciplined for the crash, but the
NTSB required the airline to update their fatigue management plans.)

Human Factors Industry News 17
Industry Asks FAA To Clear Up Drug-testing Confusion

A group of aviation organizations and

businesses are asking the U.S. FAA to
clarify the applicability of drug and
alcohol testing requirements to
workers who are involved in receiving
items for stock. Sixteen organizations
wrote the FAA on February 15 for a
legal interpretation after reports
surfaced that some FAA auditors
viewed receiving responsibilities as
safety-sensitive functions and thus
covered under drug and alcohol testing requirements.

“A receiving process simply verifies that incoming parts or materials are what they
purport to be and that there are no obvious reasons to question a previous
determination of airworthiness,” said the letter, which was signed by organizations
such as the Aeronautical Repair Station Association, National Air Transportation
Association and General Aviation Manufacturers Association, as well as companies
such as Honeywell and Gulfstream.

The letter adds that receiving activities do not require the creation of a maintenance
record. “Therefore, they are not safety-sensitive functions under [the drug and
alcohol testing requirements of 14 CFR] Part 120.” Historically, agency guidance has
not included either distributing or receiving parts in maintenance or preventive
maintenance duties, the organizations agreed.

But the letter noted auditors who “have informally opined that personnel conducting
tasks associated solely with receiving items for stock are performing maintenance
and are therefore engaged in safety-sensitive functions,” and added, “This
expansive interpretation would result in the misclassification of employees, thereby
diluting random testing pools with non-safety-sensitive personnel.”

Human Factors Industry News 18
Aviation Maintenance Technician Handbook - General

Addendum Human Factors

https://www.faa.gov/regulations_policies/handbooks_manuals/aircraft/media/
AMT_Handbook_Addendum_Human_Factors.pdf

https://www.faa.gov/regulations_policies/handbooks_manuals/aircraft/
amt_handbook/

Human Factors Industry News 19
An-12 fire inquiry reveals doubts over APU maintenance

German investigators have been unable to

determine the precise cause of an
uncontained auxiliary power unit fire which
destroyed an Antonov An-12 freighter
preparing for departure from Leipzig.

But doubts have emerged over the

maintenance record of the APU at the time
of the accident on 9 August 2013.

Investigation authority BFU says the crew had started the APU and both outboard
engines of the Ukraine Air Alliance transport, which was parked on stand 207, when
they were alerted by a “dull bang” and the APU fire-warning indicator.

The APU was mounted behind the left main landing-gear. BFU’s inquiry found the
fire originated in the APU and was not contained, propagating rapidly to the cargo
compartment.

It says the severity of the fire was exacerbated by fuel, which had leaked from
fuselage-floor tanks and pooled near the left main landing-gear, as well as burning
light metal alloy components from the APU.

The fuselage forward of the empennage was completely consumed by the blaze.

“Due to the high degree of destruction it was not possible to determine the exact
cause of the fire,” says BFU.

Human Factors Industry News 20
But it reconstructed the APU gas turbine and its gearbox assembly and says there is
evidence of a burst compressor wheel, given the nature of damage to air intakes
and other components.

“Flying fragments of the compressor wheel could have penetrated the APU chamber
and severed fuel pipes,” the inquiry adds. The damage would have provided a
propagation path to the cargo compartment, which was loaded with nearly 49,000
day-old chicks.

The cargo door had been left open, because of the live cargo, and the inquiry
suggests the blaze would have been strengthened by the available oxygen.

Although the crew had activated the APU extinguisher, the extent of the damage
from the initial event would explain why this was ineffective in controlling the fire.

It states that the area of the APU fire was “not sufficiently isolated” from the rest of
the aircraft (UR-CAG).

Investigators state that the APU, built in 1975, had a total operating time of 407h
and, according to the operator, had undergone three overhauls in 1983, 1996 and
2007.

But Russia’s Interstate Aviation Committee says the APU manufacturer, Aviamotor,
had stopped maintenance of the equipment around 2000, and there is “some doubt”
that the claimed 2007 overhaul took place. In formal comments to the inquiry, it says
it believes the logbook entry on this overhaul was “fabricated”.

It adds that the “non-fulfilment” of this overhaul could have contributed to the APU’s
extensive damage, although BFU says it is unable to determine whether this was a
factor. The APU was fitted to the aircraft in 2012.

Human Factors Industry News 21
BFU says the flight-data recorder tape had been inserted the wrong way, although it
had registered the An-12’s arrival at Leipzig, while recovery of the two cockpit-voice
recorders revealed one was empty and the other contained an 11min recording
which was not captured at Leipzig.

AOPA Opens Up To Drone Pilots

Consumer drones have attracted millions

of users, and created a conundrum for
general aviation — are they friend or foe?
On the one hand, many pilots have
embraced the technology and enjoy it; on
the other hand, the small flying machines
can pose a threat to aircraft if operated
irresponsibly. AOPA recently took a step to
embrace the drone-flying community,
announcing a new line of membership
options for drone pilots. The idea, the
organization said in a news release, is to “unite manned and unmanned pilots for the
common purpose of safe integration of all users.”

“Dividing manned from unmanned aviators would rob both of many benefits, and
create unnecessary conflict,” said AOPA President Mark Baker. “We believe we are
stronger as a united community, and welcome these new pilots with hope that our
common goals of safety and freedom to fly will be achieved together.” The FAA
estimates it will certify 1.3 million drone pilots by 2020, AOPA said. Within just a few
years, they will outnumber pilots of manned aircraft by 2 to 1. AOPA said it will offer
an online drone-pilot training course to prepare applicants for the FAA knowledge
test, and will feature drone demos and seminars at its regional fly-ins.

Human Factors Industry News 22