23 OCT 2008 _______________________________________ *Human error stubborn snag in airline safety *Safety slip in Madrid crash also seen in U.S. *AFRAA: African airline industry is safer *Polar Air Cargo Worldwide Achieves Globally Recognized Safety Benchmark *2 small planes collide in air in Colo; no injuries *NTSB Chairman Cites Three Safety Areas to Reduce Accidents in Business Aviation *************************************** Human error stubborn snag in airline safety An incident in May 2005 at Washington Reagan National Airport,is similar to the crash last month in Madrid that killed 154 people. By Alan Levin, USA TODAY As the jet roared toward takeoff, it seemed "sluggish" and struggled to lift off, the captain said later. It climbed only 100 feet before the control column started shaking violently, a warning that the jet was on the verge of plummeting to the ground. Only then did the crew of the Boeing 737-800 head off tragedy. The co-pilot pulled a lever to extend flaps and slats, critical devices that add lift to the wings and must be used on takeoff. The pilots had forgotten to set them, the captain said. This incident in May 2005 at Reagan Washington National Airport, recounted in a NASA database of pilot reports, is eerily similar to a crash in August in Madrid that killed 154 people. The pilots of a Spanair Boeing MD-80 filled with holiday travelers also did not extend the flaps, according to a preliminary report by Spanish investigators. The jet lifted off briefly before striking the ground tail-first and bursting into flames. Just as in the Washington flight, the warning horn designed to prevent such accidents did not sound, according to the report. The captain on the Washington flight said a circuit breaker on the warning horn had tripped, preventing it from working. Despite a string of fatal crashes because of failure to set flaps, including two in the USA in the late 1980s, such incidents continue, according to the NASA Aviation Safety Reporting System. From 2000 to the present, pilots reported 55 cases in which they attempted to take off without properly extending the flaps, according to the data. In nearly all cases, the warning horn functioned normally and prevented tragedy. But pilots - many surprised that they made such a critical error - say that stress, fatigue or interruptions to their routines caused them to make big mistakes. "The cause of this potentially dangerous situation was a breakdown in checklist discipline attributable to cockpit disruptions," said the captain in the Washington incident. Pilots and airlines are not identified in the reports. Pilots thrown off track Safety has improved dramatically in the airline industry in recent decades. But the human mind remains a stubborn impediment to wiping out crashes altogether. "You'll do the same thing correctly 1 million times and then not do it correctly one time," says Ben Berman, a former National Transportation Safety Board (NTSB) investigator who has studied human behavior for NASA. "Things like a moment of stress, a spike in workload, a change in routine - all these things can throw humans off track." Distractions played a role in fatal accidents in Detroit and Dallas blamed on flaps and slats, the NTSB ruled. They were often cited in the NASA reports. "It's a good reminder for crews to understand that you've got to be following your procedures," says Terry McVenes, an accident investigator, safety expert and airline pilot. "And if there are interruptions while you are doing your checklists, you've got to stop and be vigilant to make sure you don't miss anything." Some specific cases Distractions similar to those documented in previous accidents - including a handful of cases in which pilots also may have sidestepped procedures intentionally - dominated the cases in the NASA data: . In September 2003, an airline pilot riding in a jet's passenger section noticed that the 737-200 did not have flaps extended as the jet reached the runway at Cincinnati/Northern Kentucky International Airport. Only when the jet accelerated toward takeoff did the flaps begin to come down, the pilot said. "Obviously, the takeoff warning horn saved all aboard from a terrible mishap," the pilot said. "It's pretty difficult to believe an event like this would take place." . In October 2000, a captain of a flight in St. Louis acknowledged forgetting to set the flaps until the warning horn sounded. The captain said that issues with congestion at the airport, restarting an engine and dealing with an unruly passenger caused the crew to forget a checklist. "It is very sobering to realize that only a small warning horn kept my flight from being a replay of the . MD-80 crash (in Detroit in 1978)," the pilot said. . In January 2007, a co-pilot recalled having to repeatedly shout at the captain before the senior pilot ordered flaps extended after they had reached the runway - a violation of the airline's procedures. http://www.usatoday.com/news/nation/2008-10-22-insidecrash_N.htm ************** Safety slip in Madrid crash also seen in U.S. FLAP AND SLAT POSITIONS The same failure by pilots to do a routine but critical task that likely led to a fatal crash in Madrid last summer has happened dozens of times in the United States since 2000, according to government data analyzed by USA TODAY. Spanair Flight JK5022 never got more than a few feet off the ground on Aug. 20 after its pilots failed to set the wing flaps and slats before the flight, according to a preliminary report by Spanish investigators. The crash killed 154 people. Since 2000, pilots in the USA have reported a failure to properly set the wings for takeoff 55 times, according to reports filed with a NASA aviation safety database. The flaps and slats expand the size of the wing, giving a plane more lift. Without them, aircraft face severe danger trying to take off. In most cases, the mistakes were caught by a warning system that serves as a last defense against accidents. (The warning horn did not sound in the Madrid crash.) Several U.S. cases were nearly catastrophic, including a 2005 incident at Washington Reagan National Airport in which pilots lifted off without flaps and nearly plunged to the ground, pilots told NASA. The agency does not identify pilots or airlines. "This represents a disturbing trend," says Bill Voss, president of the non-profit Flight Safety Foundation. "There are obvious human errors that are being made that take away . layers of safety." The instances are few compared with the more than 10 million airline flights each year, but Voss and others say the potential for fatal crashes means airlines and regulators need to pay closer attention. Human errors are one of the most stubborn remaining safety risks in aviation. Errors by pilots or maintenance workers caused all nine fatal airline accidents in the U.S. since 2000, according to National Transportation Safety Board data. In 1987 and 1988, two U.S. crashes that were caused by pilot failures to set the flaps claimed 170 lives. Since then, changes have been made to ensure pilots do not forget the task. Distractions occasionally foil those protections, according to the NASA reports. In October 2006, the crew of a Boeing 757 forgot to set flaps and slats in Orlando. The co-pilot said they were distracted by a runway change, said the NASA report. "Event could have been catastrophic," the pilot said, "had it not been for (the) takeoff warning horn." http://www.usatoday.com/travel/flights/2008-10-22-madridcrash_N.htm ************** AFRAA: African airline industry is safer APA-Maputo (Mozambique) The Secretary General of the African Airlines Association (AFRAA), Christian Folly-Kossi, said on Thursday that safety and security in the African airline industry is not a matter of concern or a threat. The Kenyan-based official, whose 40-year continental organisation has more than 40 registered national airline carriers as members, told APA in an interview that Africa\'s air safety record should not be judged on pirate private air companies operating in war-torn countries such as the Democratic Republic of Congo and the Sudan. "We need to give a clear message to the world. There is confusion in the sense that Africa's bad image on air safety is of concern. But it is not caused by the known scheduled carriers. This bad image is there because of the stern image put by unknown carriers of war-torn countries such as the DRC and the Sudan who are not meeting any of the safety requirements," he said. Folly-Kossi said the recent Kenyan Airways plane crash, whose 114 people on board had all died, is not enough proof to raise airline safety concern in Africa. "If you can recall, you don't know of many African airlines around that have caused accidents in the recent years, but yet their record is associated with the record of AFRAA and the International Air Transport Association (IATA) and Africa is painted black", he said. He said what is needed is for Africa's aviation industries to upgrade the safety, security, search and rescue capabilities and appealed for routine conduction of mock rescue exercises as a way of assessing the aviation industries' preparedness to respond to disasters. Folly-Kossi warned that brain drain, globalisation, poor financial resources, among other challenges, continue to rock the aviation industry in Africa and accused Asian and Gulf carries of poaching pilots, engineers, air traffic controllers and cabin crews from Africa. "Brain drain is seriously depleting our industry of its most experienced and qualified human resources", he said. He called on African governments' vigorous political and diplomatic interventions to help stem the haemorrhage. http://www.apanews.net/apa.php?page=show_article_eng&id_article=78553 ************** Polar Air Cargo Worldwide Achieves Globally Recognized Safety Benchmark PURCHASE, N.Y., Oct 22, 2008 (BUSINESS WIRE) -- Atlas Air Worldwide Holdings, Inc. (AAWW) (AAWW:atlas air worldwide hldgs in com new, a leading provider of global air cargo assets and services, today announced that its majority-owned subsidiary, Polar Air Cargo Worldwide, Inc. (Polar), has achieved a globally recognized safety and quality standard following a stringent audit of its operational standards and procedures. By completing the International Air Transport Association's Operational Safety Audit (IOSA), Polar, like its recently accredited sister company, Atlas Air, Inc. (Atlas), continues to demonstrate an international and industry-leading commitment to safety. "We are very pleased to join the IOSA registry," said William J. Flynn, President and Chief Executive Officer of Polar and of AAWW. "We are initiating a landmark, 20-year blocked-space agreement with DHL Express on October 27 under which Polar will provide trans-Pacific network service for DHL, and this is a further acknowledgement that our operations rank with those of the best air carriers in the world. It also affirms our dedication to providing strong value to our customers through safe, highly reliable, cost-efficient scheduled freight and express network service." Polar received the IOSA registration following a series of stringent audits by an IATA-accredited auditor. It is valid until November 2009, and is renewable thereafter every two years subject to future audits. The audit covered key areas of Polar's operations: corporate organization and management structure; flight operations; flight dispatch; aircraft engineering and maintenance; ground handling; cargo operations; and airline security. About Atlas Air Worldwide Holdings, Inc.: AAWW is the parent company of Atlas and the majority shareholder of Polar. Through Atlas and Polar, AAWW operates the world's largest fleet of Boeing 747 freighter aircraft. Atlas and Polar offer a range of air cargo services that include ACMI aircraft leasing -- in which customers receive a dedicated aircraft, crew, maintenance and insurance on a long-term lease basis -- military charters, commercial cargo charters, scheduled air cargo service (including express network service for DHL Express beginning October 27, 2008), and dry leasing of aircraft. AAWW's press releases, SEC filings and other information may be accessed through the Company's home page, www.atlasair.com. SOURCE: Atlas Air Worldwide Holdings, Inc. ************** 2 small planes collide in air in Colo; no injuries DENVER (AP) - A sheriff's department plane carrying inmates collided with another small craft in the air over western Colorado on Wednesday, but both landed safely and no injuries were reported, authorities said. "This is truly one of those miracles," said Allen Kenitzer of the Federal Aviation Administration. "Usually with a midair collision you have very serious damage and very serious injuries, if you have survivors at all." One of the planes was a Mesa County Sheriff's Department single-engine Cessna 210 carrying two inmates, a deputy and a pilot. The other was a single-engine Cessna 180 with two people aboard. Authorities could not say which parts of the planes came in contact, describing it only as a collision. The cause is being investigated. The 180 is registered to Miel del Rio Grande Inc. in Monte Vista. Kat Siglinger, an employee, said she spoke after the crash with company owners John Haefeli and Thomas Haefeli, who were on the plane. "They told me the collision tore off their tail," she said. "And that was at 10,000 feet in the air. They were pretty relieved." FAA spokesman Mike Fergus said he could not release radar records indicating how high the planes were flying because they are part of the investigation. The planes collided about 15 miles southeast of Grand Junction and 190 miles west of Denver, Fergus said. The sheriff's plane landed at Grand Junction Regional Airport and the other in a remote area about 10 miles south of the airport. Sheriff's officials said a federal inmate and a state inmate were being flown to the Canon City area, home to state and federal prison complexes. That plane made a hard landing back at the airport and suffered front-end damage, either from the collision or the landing, the sheriff's office said. Sheriff's officials identified the pilot as Andy Gordon, a pilot since 1962, and Mesa County Sheriff's Deputy Lisa McCammon. The other plane came to rest on its top amid sagebrush and scrub oak at the foot of the towering Grand Mesa. A medical helicopter crew spotted it, landed and determined that both people were all right, sheriff's spokesman Chuck Warner said. That flight originated in southern Colorado, though it was unclear where it was headed, said sheriff's spokeswoman Heather Benjamin. The plane did not have a vertical stabilizer - the tail fin on the back - but it was unclear whether it was lost in the air or while crash landing, Benjamin said. Kenitzer and National Transportation Safety Board spokesman Terry Williams both said they did not have any additional information. The plane was made in 1955, according to registration records. A call to National Transportation Safety Board spokesman Terry Williams was not immediately returned. ************** NTSB Chairman Cites Three Safety Areas to Reduce Accidents in Business Aviation National Transportation Safety Board Washington, DC - National Transportation Safety Board Chairman Mark V. Rosenker said today that improving runway safety, crew resource management, and addressing human fatigue will enhance safety in business aviation. In an address to the 2008 Bombardier Safety Standdown in Kansas City, Missouri, Rosenker cited the NTSB's review of accident trends and the potential for human error in emphasizing the importance of these safety areas. Rosenker outlined the following areas as "critical" to reducing aviation accidents and saving lives: -- Improving Runway Safety by requiring landing distance assessment with an adequate safety margin for every landing, and to give immediate warnings of probable collisions/incursions directly to flight crews in the cockpit. -- Improving Crew Resource Management by requiring on-demand air taxi flight crews to receive crew resource management training. -- Reducing Accidents Caused by Human Fatigue by setting work hour limits for flight crews, aviation mechanics and air traffic controllers based on fatigue research, circadian rhythms, and sleep and rest requirements. While advocating the adoption of measures designed to address these issues, Rosenker also indicated that regulation is not the only way to improve safety. "I believe that voluntary action by industry, in partnership with the government, is one of the most effective ways to decrease accidents," said Rosenker. Each of the safety areas Rosenker cited are on the NTSB's Most Wanted List of Safety Improvements, which is available on the Board's website at http://www.ntsb.gov/Recs/mostwanted/index.htm. The complete text of the speech is available at http://www.ntsb.gov/speeches/rosenker/mvr081021.html http://news.thomasnet.com/companystory/551091 **************