Thoughts on Human Error

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  • Businessmen Beware the Air

    George’s Point of View

    Most business jet fatal accidents happen on approach. I suppose this means that it is fine for businessmen to fly but not to land. (Conclusions like this are why they never have me on any study committees.)

    But seriously, the latest Aviation study came out with these figures:

    • The fatal accident rate for air taxis is 3.49 per million flying hours
    • For corporate operations it is 0.24 per million
    • For owner-operated business jets it is 1.28 per million
    • The overall figure for all business jets flying civil operations is 1.45 per million flying hours.

      The fifty-nine fatal accidents under study show twenty-one occurred on ferry flights, seventeen on “private/business”, six carried cargo, five carried passengers, four were air ambulance flights, and three were training.

      Whether the problem is fatigue, pilot (or crew) training, plane maintenance, air traffic control, bureaucratic red tape, or gas-squeezing political policies, when the consensus is that more than half of these accidents are preventable, this is an indication that something is seriously wrong with Business Aviation.

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  • Seat Belts: Airplanes AND BUSES

    George’s Point of View

    Yesterday we posted the NTSB’s safety recommendation that each person who is less than 2 years of age to be restrained in a separate seat position by an appropriate child restraint system during takeoff, landing, and turbulence.

    It does make sense that infants not be held during dangerous turbulence in a plane, but kept securely in a seat, just as it is required by law when in a car.

    With all of the accidents we see on buses, I would like to know why the NTSB has not mandated seatbelts aboard all buses. Not just for infants, of course, but for everyone.

    Out of NTSB’s own reports, “42% of the total (fatalities) are from side impact or non-collision (typically rollover) accidents. It is for this 42% of fatal accidents that seat belts have their greatest life saving potential”

    NTSB should also demand seat belts on all passenger buses and school buses.

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  • First Rate Planes Need First Rate Maintenance

    George’s Point of View

    I fly a certain carrier.

    I fly a lot of miles on this carrier.

    This carrier impresses me as a company. They got through a bankruptcy as a team, and that says something to me.

    Now let me tell you what I don’t like.

    A half-*** approach to maintenance.

    You fill in the blanks.

    What if the maintenance of this carrier’s fleet were as bad as the aesthetic condition of the interior and exterior of the planes? Within a couple of months even new and re-configured planes lose that “new plane” smell. I can live without the “new.” What I can’t live without is working parts. I don’t care how shiny the bells and whistles are, I just want the important parts (engine, hydraulics, on board computer systems, etc.) to function. When I board one of these planes, every single time, I send a little prayer skyward that the maintenance has been done, perfectly.

    There’s no margin for error. I know I’ve said this before but it bears repeating. It’s not like a car–when you get a lemon, and you have to keep pulling over to the side of the road and calling road service. It’s not like a ship, where at least the passengers can get into a lifeboat and have a fighting chance at survival. There’s no soft shoulder or lifeboat for a plane. There’s only straight down, and certain termination. Every pilot, every crew member, every passenger puts their very lives into the hands of those mechanics. And if they’re American mechanics, I can be relatively confident that they’re well-paid, well-fed, and well-educated. Do I have that assurance if the mechanic is in some other country? No, I cannot.

    How can any passenger feel confident when the mechanics can’t read the plane’s manual? When I board a plane, I have every intention of getting where I am bound. With an American maintenance team, I am assured that if there were the slightest inkling that the maintenance were not up to par, I still can be confident that the parameters of maintenance are overseen by the FAA and the NTSB, and prescribed by American standards of excellence; and any default of or deviation from that standard of excellence is proscribed by and accountable thru the massive engine of our legal system. Can I say that when maintenance is farmed out to some obscure third world entity? Of course not.

    I had one emergency landing one hour out of Sao Paulo and was forced to stay the night, and wait 24 hours for the dubious right to depart on what turned out to be the same plane. Instead of taking off as expected, we rolled to a complete stop out on the runway. The captain came on the PA system stating that he was just not comfortable with the smell in the cockpit, and we were going back to the terminal.

    The pilot knew better to trust his own senses over dubious maintenance practices. So for that flight, it was back to the terminal for more waiting.

    I do have some cause to worry about maintenance. If there is belt tightening that must be done, by all means do it. But not if it means sacrificing safety standards in favor of a third world discount.

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    No Mayday, then Gone

    I could speculate here about what caused the disappearance of Malaysia Airlines Flight MH370, but that is all it would be: speculation. One can look at the type of plane, the weather, and various circumstances, but the truth is that the devil is in the details, and we just don’t know the details. The investigation will turn them up; the investigation can be a long road down a circular path.

    It makes it more difficult when there was no distress call. No mayday. Think of this: if something happens and you’re on a plane rapidly losing altitude—or with catastrophic issues which could be anything on a plane from a drunk grandpa to a bomb on board to a bad repair failing, to a sudden system failure due to frozen pitot tubes, what is the first thing that you are going to do if you’re part of the flight crew? That’s right—the first thing will be to fix the issue, and stay in the air. The last thing to do after the crisis is handled is to call ATC and let them know what’s going on.

    But because there was no distress call, we can assume that whatever happened happened fast. And now the wildest speculation of all is that the two people with fake passports were terrorists carrying a bomb. Do we need to go down that thought path? There are plenty of things that could have gone wrong although the 777 has a a stellar safety record.

    Now too, there is even speculation where the plane went down, apparently. There’s an oil slick approximately where the teams are searching. Maybe they’re right. Maybe under that slick, there’s a beacon to hear.

    Still, I keep hoping there’s a raft somewhere full of survivors.

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    The Delaminating 787: Causing Problems and Recalls


    The Boeing 787’s composite skin is under the eye now, with the carbon fiber structure deconstructing after improperly joined structural stiffeners fail. Longerons are installed on a wound carbon fibre barrel, frames and longerons are secured to the skin to strengthen the structure, and reinforced by shims. Without shims making a tight fit, damage incurs to the carbon fiber.

    The problem has been located on an All Nippon Airways (56), and two Qatar Airways airframes (57 and 58), all of which originate in Everett Washington.

    More 787s are expected to turn up with the same problem.

    The structural stiffeners are failing in the location of the Alenia Aeronotica-built horizontal stabiliser.

    Boeing confirms that the problem is a “straightforward repair that should cause no short-term safety concern.”

    Inspections are already underway, and strategic plans for repairs are on the drawing board. A 2010 problem involved the teardown and reinstallation of some Alenia Aeronautica-built horizontal stabilisers which had been assembled without adequate shims.

    In George’s Point of View

    updated


    According to a Reuters article, Boeing is saying publicly that this will not affect production.

    It SHOULD affect production.

    Boeing needs to slow down and get it right. Thousands of souls will fly in these “things.” Boeing’s got to have it right. Instead of ramping up, slow down production. What good is an ambitious target rate if the planes come out needing SAFOs (Safety Alerts for Operators)?

    Too fast reminds me of Airbus.

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    Spain Punishes Officers for Body Misidentification

    George’s Point of View

    After 30 bodies were misidentified and sent to the wrong grieving families, General Vicente Navarro received a three year sentence; and Commander Jose Ramirez and Captain Miguel Saez received 18-month sentences.

    Some of the bodies had to be exhumed so that the misidentification could be verified.

    Sixty-two soldiers died in the Yak-42 crash in Turkey on May 26, 2003. Imagine how the families felt. First they have to suffer the deaths. Then almost half of the victims were misidentified. And remember to the families, these weren’t random victims. They were husbands and sons.

    Imagine how the families felt when they had to dig up their husbands and sons and have the remains crosschecked with dental records and DNA samples. It probably wasn’t limted to 30, either; they probably exhumed all the victims except for whichever ones might have been visually recognizable by family members.

    One wonders if the buck stopped in the right place. Was the decision not to perform DNA/Dental verification really made by General Vicente Navarro or was it a decision that was passed down to him from defence minister Federico Trillo? Isn’t there a public policy of aviation procedure in cases such as this? My question is not whether the sentence is just, but whether the right individual was sentenced.

    Carelessness of this profundity goes beyond cruelty.

    If I were a Spanish lawyer or on the Ministerio de Fomento, Civil Aviation, I’d be going through policies with a fine toothed comb. I’d love to hear from Madrid to find out just exactly what they’ve done in the past three years to prevent this kind of inhuman treatment in the future.

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