08 APR 2009 _______________________________________ *Winds force Reno-bound passenger jet to land in Sacramento *CAUSE OF MD-80 ENGINE FIRE LINKED TO MAINTENANCE AND FLAWED SAFETY MANAGEMENT SYSTEM, NTSB SAYS *NTSB: Cause of MD-80 engine fire linked to maintenance and flawed SMS *NTSB Says MD-80 Engine Fire Tied To Improper Manual Start Procedures *Manila chopper with Arroyo aides crashes, no survivors *Eclipse Jet Announces Formation Of US Service Network *FAA Inspectors skipped over evidence in air-safety case *OSHA rules against Norwalk-based air carrier *AIG's aircraft leasing unit gets $5-billion line of credit from Fed *QUALITY: Health Reformers Learn From Airline Safety Initiatives *Bellview, Virgin Nigeria pass IATA/IOSA safety audit **************************************** Winds force Reno-bound passenger jet to land in Sacramento Severe turbulence forced a Horizon Air passenger jet traveling from Los Angeles to Reno to make an emergency landing in Sacramento on Tuesday night. No serious injuries were reported. Five passengers and a flight attendant were treated at the Sacramento airport and released. They reported "being shaken up and bumped around a little bit so we immediately diverted to Sacramento," said Jen Boyer, a spokeswoman for Horizon Air. "You don't take any chances when it comes to severe turbulence. You immediately get on the ground, and get any passengers who might have been hurt, as well as the aircraft looked at." Sacramento airport fire/paramedics responded. Forty people were on board the plane, a 76-passenger Bombardier Q400 , a turboprop. The airplane, a 76-passenger, encountered heavy winds between 6:30 p.m. and 6:40 p.m. The passengers were scheduled to arrive in Reno later Tuesday on board another flight. "They have all been re-accommodated," Boyer said. No damage was reported to the plane that was diverted to Sacramento. http://www.rgj.com/article/20090407/NEWS18/90407071/1321/NEWS ************** CAUSE OF MD-80 ENGINE FIRE LINKED TO MAINTENANCE AND FLAWED SAFETY MANAGEMENT SYSTEM, NTSB SAYS The National Transportation Safety Board determined today that an engine fire on an American Airlines jetliner was probably due to an unapproved and improper procedure used by mechanics to manually start one of the engines. The fire was prolonged and the safety of the aircraft further jeopardized by how the flight crew handled the emergency. A flawed internal safety management system, which could have identified the maintenance issues that led to the accident, was cited as a contributing factor. On September 28, 2007, at 1:13 p.m. CDT, American Airlines flight 1400, a McDonnell Douglas DC-9-82 (MD-82), N454AA, experienced an in-flight left engine fire during departure climb from the Lambert-St. Louis International Airport (STL). During the return to STL, the nose landing gear failed to extend, and a go-around was executed. The flight crew conducted an emergency landing, and the two flight crewmembers, three flight attendants, and 138 passengers deplaned on the runway. No occupant injuries were reported, but the airplane sustained substantial damage. The investigation revealed that a component in the manual start mechanism of the engine was damaged when a mechanic used an unapproved tool to initiate the start of the #1 (left) engine while the aircraft was parked at the gate at STL. The deformed mechanism led to a sequence of events that resulted in the engine fire, to which the flight crew was alerted shortly after take-off. The Board examined how the flight crew handled the in-flight emergency and found their performance to be lacking. The captain did not adequately allocate the numerous tasks between himself and the first officer to most efficiently and effectively deal with the emergency in a timely manner. The Board was particularly concerned with how the crew repeatedly interrupted their completion of the emergency checklist items with lower priority tasks. "Here is an accident where things got very complicated very quickly and where flight crew performance was very important," said NTSB Acting Chairman Mark V. Rosenker. "Unfortunately, the lack of adherence to procedures ultimately led to many of this crew's in-flight challenges." In examining the maintenance issues, investigators found that in the 13 days prior to the accident flight, the aircraft's left engine air turbine starter valve had been replaced a total of six times in an effort to address an ongoing problem with starting the engine using normal procedures. None of valve replacements solved the engine start problem and the repeated failures to address the issue were not recognized or discovered by the airline's Continuing Analysis and Surveillance System (CASS). "The airline's own internal maintenance system, the purpose of which is to catch maintenance and mechanical issues that could lead to an incident or accident, failed to do what it was designed to do," said Rosenker. "And that allowed this sequence of events to get rolling, which ultimately resulted in the accident. Following the appropriate maintenance procedures would have gone a long way toward preventing this mishap." As a result of the investigation, the Safety Board issued a total of nine safety recommendations. The Board asked the Federal Aviation Administration (FAA) to 1) evaluate the history of air start-related malfunctions in MD-80 airplanes to determine if changes to the cockpit warning system are warranted; 2) ensure that pilots are trained to refrain from interrupting the completion of emergency checklists with nonessential tasks; 3) ensure that MD-80 operators train crews on the interaction of systems involved in engine fire suppression; 4) and 5) ensure that crews are trained to handle multiple emergencies simultaneously; 6) require that crews be trained to prepare the aircraft for an emergency evacuation after a significant event away from the gate; 7) provide flight and cabin crews with the latest guidance on effective communications during emergencies; and 8) require Boeing to establish an interval for servicing an engine component. The Board also recommended that American Airlines evaluate and correct deficiencies in its CASS program. A synopsis of the Board's report, including the probable cause, conclusions, and recommendations, is available on the NTSB's website, at http://ntsb.gov/events/Boardmeeting.htm . The Board's full report will be available on the website in several weeks. www.ntsb.gov *************** NTSB: Cause of MD-80 engine fire linked to maintenance and flawed SMS The National Transportation Safety Board determined that an engine fire on an American Airlines jetliner was probably due to an unapproved and improper procedure used by mechanics to manually start one of the engines. The fire was prolonged and the safety of the aircraft further jeopardized by how the flight crew handled the emergency. A flawed internal safety management system, which could have identified the maintenance issues that led to the accident, was cited as a contributing factor. On September 28, 2007, American Airlines flight 1400, a McDonnell Douglas DC-9-82 (MD-82), N454AA, experienced an in-flight left engine fire during departure climb from the Lambert-St. Louis International Airport (STL). During the return to STL, the nose landing gear failed to extend, and a go-around was executed. The flight crew conducted an emergency landing, and the two flight crewmembers, three flight attendants, and 138 passengers deplaned on the runway. No occupant injuries were reported, but the airplane sustained substantial damage. The investigation revealed that a component in the manual start mechanism of the engine was damaged when a mechanic used an unapproved tool to initiate the start of the #1 (left) engine while the aircraft was parked at the gate at STL. The deformed mechanism led to a sequence of events that resulted in the engine fire, to which the flight crew was alerted shortly after take-off. The Board examined how the flight crew handled the in-flight emergency and found their performance to be lacking. The captain did not adequately allocate the numerous tasks between himself and the first officer to most efficiently and effectively deal with the emergency in a timely manner. The Board was particularly concerned with how the crew repeatedly interrupted their completion of the emergency checklist items with lower priority tasks. In examining the maintenance issues, investigators found that in the 13 days prior to the accident flight, the aircraft's left engine air turbine starter valve had been replaced a total of six times in an effort to address an ongoing problem with starting the engine using normal procedures. None of valve replacements solved the engine start problem and the repeated failures to address the issue were not recognized or discovered by the airline's Continuing Analysis and Surveillance System (CASS). As a result of the investigation, the Safety Board issued a total of nine safety recommendations. The Board asked the Federal Aviation Administration (FAA) to 1) evaluate the history of air start-related malfunctions in MD-80 airplanes to determine if changes to the cockpit warning system are warranted; 2) ensure that pilots are trained to refrain from interrupting the completion of emergency checklists with nonessential tasks; 3) ensure that MD-80 operators train crews on the interaction of systems involved in engine fire suppression; 4) and 5) ensure that crews are trained to handle multiple emergencies simultaneously; 6) require that crews be trained to prepare the aircraft for an emergency evacuation after a significant event away from the gate; 7) provide flight and cabin crews with the latest guidance on effective communications during emergencies; and 8) require Boeing to establish an interval for servicing an engine component. (NTSB) (aviation-safety.net) *************** NTSB Says MD-80 Engine Fire Tied To Improper Manual Start Procedures Also Cites "Flawed Internal Safety Management System" At AAL The National Transportation Safety Board determined Tuesday a September 2007 engine fire on an American Airlines jetliner was probably due to an unapproved and improper procedure used by mechanics to manually start one of the engines. The fire was prolonged and the safety of the aircraft further jeopardized by how the flight crew handled the emergency. A flawed internal safety management system, which could have identified the maintenance issues that led to the accident, was cited as a contributing factor by the Board. As ANN reported, on the afternoon of September 28, 2007 American Airlines flight 1400, a McDonnell Douglas DC-9-82 (MD-82), experienced an in-flight left engine fire during departure climb from the Lambert-St. Louis International Airport (STL). During the return to STL, the nose landing gear failed to extend, and a go-around was executed. The flight crew conducted an emergency landing, and the two flight crewmembers, three flight attendants, and 138 passengers deplaned on the runway. No occupant injuries were reported, but the airplane sustained substantial damage. The investigation revealed that a component in the manual start mechanism of the engine was damaged when a mechanic used an unapproved tool to initiate the start of the #1 (left) engine while the aircraft was parked at the gate at STL. The deformed mechanism led to a sequence of events that resulted in the engine fire, to which the flight crew was alerted shortly after take-off. The Board examined how the flight crew handled the in-flight emergency and found their performance to be lacking. The captain did not adequately allocate the numerous tasks between himself and the first officer to most efficiently and effectively deal with the emergency in a timely manner. The Board was particularly concerned with how the crew repeatedly interrupted their completion of the emergency checklist items with lower priority tasks. "Here is an accident where things got very complicated very quickly and where flight crew performance was very important," said NTSB Acting Chairman Mark V. Rosenker. "Unfortunately, the lack of adherence to procedures ultimately led to many of this crew's in-flight challenges." In examining the maintenance issues, investigators found that in the 13 days prior to the accident flight, the aircraft's left engine air turbine starter valve had been replaced a total of six times in an effort to address an ongoing problem with starting the engine using normal procedures. None of valve replacements solved the engine start problem and the repeated failures to address the issue were not recognized or discovered by the airline's Continuing Analysis and Surveillance System (CASS). As a result of the investigation, the Safety Board issued a total of nine safety recommendations. The Board asked the Federal Aviation Administration (FAA) to 1) evaluate the history of air start-related malfunctions in MD-80 airplanes to determine if changes to the cockpit warning system are warranted; 2) ensure that pilots are trained to refrain from interrupting the completion of emergency checklists with nonessential tasks; 3) ensure that MD-80 operators train crews on the interaction of systems involved in engine fire suppression; 4) and 5) ensure that crews are trained to handle multiple emergencies simultaneously; 6) require that crews be trained to prepare the aircraft for an emergency evacuation after a significant event away from the gate; 7) provide flight and cabin crews with the latest guidance on effective communications during emergencies; and 8) require Boeing to establish an interval for servicing an engine component. The Board also recommended that American Airlines evaluate and correct deficiencies in its CASS program. FMI: http://ntsb.gov/events/Boardmeeting.htm, www.aa.com aero-news.net *************** Manila chopper with Arroyo aides crashes, no survivors MANILA (Reuters) - A helicopter ferrying aides of Philippine President Gloria Macapagal Arroyo has crashed and there were no survivors among the eight passengers and crew, officials said on Wednesday. Rescue teams in the Philippines found the wreckage of the helicopter on Wednesday, almost 24 hours after it was reported missing near the Banawe rice terraces in the north of the country. The wreckage was found by a team of police officers and civilian volunteers in mountainous jungles about three hours hike from the nearest inhabitation, said Teodoro Baguilat, governor of the province of Ifugao. "We have found the wreckage," Baguilat told reporters. He said the bodies of the passengers and crew were found in and around the helicopter. Among the passengers were Brigadier-General Carlos Clet, the president's senior military aide; Press Undersecretary Jose Capadocia; the president's appointments secretary; and two other palace officials. Two pilots and another crew member were also on board. The helicopter left Baguio City late on Tuesday for a short flight to Banawe to inspect a road project that Arroyo was due to visit on Wednesday. Arroyo canceled her trip as the military mobilized its resources to locate the missing helicopter. ***************** Eclipse Jet Announces Formation Of US Service Network Brigadoon Aircraft Maintenance First 'Platinum' Center The battle to service the orphaned fleet of Eclipse 500 very light jets ramped up significantly Tuesday. On the same day Hawker Beechcraft announced a letter-of-intent to discuss a servicing partnership with Eclipse owners, a bidder for the defunct planemaker's assets also announced plans for a nationwide -- and, possibly, worldwide -- network of service centers to support the inaugural VLJ. Eclipse Jet LP announced Tuesday it has entered into an agreement with logistics and management organization Eclipse Service Network, LLC (ESN) to form a network of third-party Service Centers across the United States. Eclipse Jet also says it is in discussions with third-party service providers in Europe to start an ESN-Europe as soon as possible. Brigadoon Aircraft Maintenance, LLC, is the first Platinum Level Service Center under the Eclipse Service Network. Located near Chicago, IL, Brigadoon is staffed with a team of Eclipse trained mechanics and recently started FIKI modifications for the Eclipse 500 Jet. "With the help of Mike Press and Mason Holland and the entire Eclipse Jet team we have been able to identify and source all of the parts necessary to begin FIKI modifications, we will begin taking orders for service shortly," said Ken Ross, founder of ESN and CEO of North American Jet Charter Group, an early adopter of the Eclipse air taxi model. "We have Eclipse trained mechanics and are now ready to accelerate our Eclipse services. "We have sourced all of the parts needed for the FIKI upgrade so we are ready to start scheduling these, however, we are waiting for Eclipse Jet to secure the assets of Old Eclipse so we can finish the work needed to deliver ETT, Avio NG, and Garmin 1.5 upgrades at reasonable production levels," Ross added. "When we looked at the body of work Brigadoon had already accomplished to expedite the delivery of the modifications, we quickly realized the level of expertise and dedication to the Eclipse community was unparalleled. We looked at many options, but we quickly came to the conclusion that the ESN model was the only one with the ability to deliver FIKI to the fleet in the few remaining months before icing season," said Press. Organizers state further the number of ESN service facilities will be determined by aircraft population and location. Qualified independent repair facilities or fleet operators may be eligible to join the Eclipse Service Network after completing an application process and passing an audit to verify it can meet the service level standards set forth by ESN. The levels of ESN certified service facilities are Platinum, Gold, Silver and Fleet Manager. Incidentally, if the word "Brigadoon" sounds familiar... perhaps that's because, in addition to being a suburb of Perth, Australia... Brigadoon is also the name of a Broadway musical based around the Scottish legend of a mythical village. A village that appears for one day in our realm, every 100 years. Reassuring? FMI: www.eclipseaviation.com, www.spjets.com, www.eclipse500club.org, www.najets.com aero-news.net **************** FAA Inspectors skipped over evidence in air-safety case, official says Federal Aviation Administration inspectors overlooked potential evidence before clearing an Alaska Airlines contractor of air-safety violations alleged by a whistle-blower, according to newly disclosed government records. Whistle-blower to be paid $30,000 by American Power Federal Aviation Administration (FAA) inspectors overlooked potential evidence before clearing an Alaska Airlines contractor of air-safety violations alleged by a whistle-blower, according to newly disclosed government records. Some people with additional information were not interviewed by the FAA during the 2007 investigation, prompting an investigator for the federal Occupational Safety & Health Administration (OSHA), who separately examined the whistle-blower's case, to write a pointed letter to FAA officials. The letter identified broader safety allegations against the repair contractor, American Power, than those raised by the whistle-blower. OSHA, after its investigation, found American Power retaliated against the whistle-blower by laying her off, leading to a settlement in October of nearly $30,000. The Auburn tool-supply and repair company went out of business about Jan. 1. FAA officials declined to comment on the case, but the agency recently released copies of the OSHA investigator's letter and other records to The Seattle Times under a Freedom of Information Act request. The FAA began investigating the allegations against American Power in late 2007, when former employee Melodee Nixon alleged she was laid off after accusing the company of ignoring federal air-safety standards. Nixon said she warned superiors the company was providing false data to Alaska Airlines relating to the recalibration of gauges on oxygen and nitrogen regulators. The regulators are used by the airline, among other things, during maintenance of oxygen masks, tires and struts. American Power's work for Alaska was done by a subcontractor, Hansen & Miller Service Center of Seattle. Nixon told the FAA that American Power was receiving incomplete information from Hansen & Miller certifying how each regulator was calibrated, FAA records show. "Ms. Nixon stated she was instead asked to cut and paste the calibration information from a previous invoice and paste it into the current invoice," an FAA inspector wrote. Even if work is done correctly, the FAA requires strict record-keeping to catch errors before they lead to major problems and to trace the maintenance history after a crash or other mishap. FAA inspectors determined American Power had asked its employees to cut and paste previous data relating to Hansen & Miller's work, according to FAA records. But the FAA concluded American's action wasn't falsification because the company believed the practice was acceptable, based on the data it was receiving from Hansen & Miller. American Power acknowledged shortcomings, agreed to bolster its procedures and stopped doing business with Hansen & Miller, the records show. The FAA considered opening a preliminary investigation of Alaska Airlines, which is responsible for its contractors. But the airline was ultimately found to be not at fault after producing adequate paperwork. The FAA investigation consisted of interviewing Nixon, Alaska officials and the president of American Power, but no other company employees, according to the records. OSHA gets involved Nixon then went to OSHA, which investigated her layoff under a law designed to protect aviation-industry whistle-blowers. After a lengthy investigation, OSHA determined American Power had retaliated against Nixon after she raised a valid safety issue. She received nearly $30,000 in lost wages and medical benefits from American, which denied any wrongdoing. OSHA said it did not determine whether safety violations occurred because that is the FAA's job. But during its inquiry, OSHA investigator Rebecca Phelps wrote a letter to the FAA, dated April 2, 2008, that raised questions about other work done by American Power for Alaska. "Another American Power employee, other than Ms. Nixon, indicated that in-house calibration of tools and hoists at American Power are being 'fabricated' or falsified," Phelps wrote. "The employee stated that calibrations in the morning when the shop is cold are basically 'fixed' so that the tools and hoists can pass calibration." For some tools, environmentally controlled rooms are required if called for by the original equipment's manufacturer for the tool's calibration, according to Alaska. The employee also reported that calibration work on devices called transducers had been shortened to save time, leading to false results, Phelps wrote. Transducers transfer power from one system and supply power usually in another form to a second system. Phelps informed the FAA that the employee knew about an FAA visit to American Power in November 2007 during its investigation of Nixon's complaint. "According to this employee, the FAA Inspector did not go into the shop or talk with employees working in the shop," Phelps wrote. Phelps also informed the FAA that Hansen & Miller "told us that they were instructed by American Power to calibrate and/or repair the Alaska regulators, but were not instructed to provide certification paperwork to American Power." Hansen & Miller indicated it had not been questioned by the FAA, Phelps wrote. Harold Heia, the owner of Hansen & Miller, confirmed part of Phelps' account, telling The Times that American Power didn't ask his company for certification information. However, he said an FAA official might have been part of a telephone conversation involving him, American Power and Alaska, but he wasn't sure. No response to letter Phelps, who was a new employee when she wrote the letter, acted within bounds, said Dean Ikeda, OSHA's deputy regional administrator in Seattle. She was counseled about the letter's tone because it went beyond factual allegations and implied the FAA wasn't doing its job, Ikeda said. The FAA didn't respond to the letter, Ikeda said. FAA officials in Renton, SeaTac and Washington, D.C., declined to comment on the letter or the agency's investigation of American Power. The FAA came under intense criticism last year when it was revealed that Southwest Airlines was allowed to fly at least 117 aircraft past mandatory inspection deadlines. U.S. Rep. James Oberstar, chairman of the House Transportation and Infrastructure Committee, said at the time that the FAA should "clean house from top to bottom" and had too cozy a relationship with airlines. Alaska stopped using American Power for calibration work in 2007 when it became aware of the FAA investigation, and it halted other repair work last year when it learned of OSHA's inquiry. Nixon said Phelps' letter confirms what she related to one of the FAA inspectors. "You did not want to find anything wrong," Nixon said she told the inspector. http://seattletimes.nwsource.com/html/localnews/2009003725_faaprobe08m0.html **************** OSHA rules against Norwalk-based air carrier The U.S. Department of Labor's Occupational Safety and Health Administration (OSHA) has ordered Norwalk-based air cargo carrier Southern Air to withdraw a lawsuit it filed against nine former employees and pay them more than $7.9 million in wages, damages and legal fees. Southern Air filed a defamation lawsuit against the former employees in Connecticut Superior Court in May 2008 after some of the workers raised air carrier safety concerns with Southern Air, OSHA and the Federal Aviation Administration (FAA). The workers, all former flight crew members, subsequently filed a whistleblower complaint with OSHA. OSHA's investigation found that the company's lawsuit was filed in retaliation for the workers' protected activities under the whistleblower provisions of the Wendell H. Ford Aviation Investment and Reform Act for the 21st Century (AIR21). "This order sends a strong and clear message that these and other workers have the right to raise safety issues with their employers and regulatory agencies without fear of retaliation and intimidation," U.S. Secretary of Labor Hilda L. Solis said. Southern Air said that it would "vigorously refute the findings," and it will appeal the findings and seek a hearing through the appropriate channels within the Department of Labor. "We strongly disagree with these findings and believe the underlying claims on which the OSHA Northeast Region based its decision are completely without merit," Brian Neff, Southern Air president, said. OSHA has directed Southern Air to: withdraw its lawsuit; pay the complainants $6,004,000 in lost future earnings, $1,800,000 in compensatory damages and $129,789 in legal fees and costs; purge each complainant's personnel file; and refrain from mentioning the complainants' protected whistleblower activity. or conveying any damaging information in response to third party inquiries. * Provide all Southern Air crew members with copies of the FAA Whistleblower Protection Program poster and OSHA's notice to employees, and post these in each Southern Air facility. The complainants and the airline have 30 days from receipt of the findings to file an appeal with the Labor Department's Office of Administrative Law Judges. Neff added: "We are also disappointed that OSHA's investigators chose to release these findings without first performing a thorough investigation into the matter, including notifying Southern Air of any facts upon which they were relying to support their findings and providing Southern Air with a full opportunity to respond. It is our strong belief that we will prevail in our appeal once we have had the opportunity to present all the facts in the matter. "The Federal Aviation Administration has conducted numerous safety inspections over the past 12 months, and Southern Air has been found to be fully compliant with all applicable FAA regulations." The Connecticut Superior Court recently upheld the Company's position in a ruling issued on February 17 in a related state court action. This state court action was the genesis for the litigation involving former Southern Air employees that is the subject of the findings OSHA released today. http://www.thehour.com/story/467629 *************** AIG's aircraft leasing unit gets $5-billion line of credit from Fed The financing will help the bailed-out insurance giant find a buyer for L.A.-based International Lease Finance. American International Group Inc.'s aircraft-leasing unit, which has been shut off from its usual sources of funding, will get a $5-billion line of credit from the Federal Reserve to help prepare it for sale, according to three people with knowledge of the matter. The Fed, which along with the U.S. Treasury has committed $182.5 billion to the bailout of AIG since September, is working to help the insurer sell divisions to repay some of its loans. The credit facility may reassure potential buyers of Los Angeles-based International Lease Finance Corp., the largest customer of Airbus and Boeing Co., that its business is sustainable outside of the AIG umbrella, the people said. International Lease Finance, run by founder Steven Udvar-Hazy, has attracted interest from at least three rival groups of investors, including private equity firms, one source said. The company's book value, or assets minus liabilities, was $7.6 billion as of Dec. 31. Paula Reynolds, AIG's restructuring chief, has said that the Fed agreed to offer "some form of backstop financing" to "facilitate that sale and carry the new owners with some secured financing over at least an interim basis." http://www.latimes.com/business/la-fi-ilfc8-2009apr08,0,420612.story ************** QUALITY: Health Reformers Learn From Airline Safety Initiatives For many of us, a mistake at work means a typo on a report. But for health care professionals, even a small mistake can put the life of a patient at risk. An industry with similarly catastrophic risks associated with even the tiniest of mistakes is the aviation industry. In an article published recently in Health Affairs, well-known health care safety expert Dr. Peter Pronovost, compares the slow progress of quality and safety initiatives in the health care industry to the success of similar initiatives in the airline industry. He encourages the health care industry to create a safety alliance similar to the public-private Commercial Aviation Safety Team (CAST). After a technical error in communications caused an American Airlines flight from Miami to Columbia to crash in 1995, the government took action. The following year, the White House and Congress worked together to assemble CAST, a broad coalition of private interests, including the entire aviation industry, major manufacturers, airlines, and labor organizations, and public interests, such as the FAA, NASA, and the Department of Defense. CAST has been successful-between 1994 and 2006, the average rate of fatal accidents decreased from 0.05 to 0.022 per 100,000 departures. The health care industry, on the other hand, has seen an increase in preventable errors, injuries, and deaths over the years. In a press release for the article, Pronovost said: Because it involves all the major stakeholders, CAST provides the resources to do in-depth investigations of accidents and near-misses, to develop and implement strong interventions that can prevent the problem from recurring, and to evaluate the effectiveness of those interventions. In contrast, the individual institutions that typically investigate medical errors often lack resources to conduct frequent and intensive investigations, and they lack the ability to implement strong interventions such as redesigning widely used medical equipment in ways that would make error impossible. Pronovost and his colleagues call for the establishment of a CAST type alliance for health care, the Public Private Partnership to Promote Patient Safety (P5S). With the help of a grant from the Robert Wood Johnson Foundation, they are working on a plan to describe the purpose, structure, and function of the P5S. Health care stakeholders including the Agency for Healthcare Research and Quality (AHRQ), the Food and Drug Administration (FDA), the Joint Commission, the ECRI Institute, and more than 15 large health systems have all agreed to participate. As we've discussed previously, Dr. Pronovost has plenty of experience with quality and patient safety initiatives. His strategies to control hospital acquired infections, which are estimated to cost thousands of lives per year, are as simple as increased hand washing, the full draping of patients, and limiting the time that patients spend using catheters. The House Oversight Committee found that if all state hospitals implemented Pronovost's simple safety checklist, more than 15,000 lives and 1.3 billion dollars would be saved each year. The success of the airline industry is a great example for health reformers-demonstrating that public and private interests can work together to save lives, save money, and improve the quality of care that everyone receives. http://www.newamerica.net/blog/new-health-dialogue/2009/quality-health-refor mers-learn-airline-safety-initiatives-11010 *************** Bellview, Virgin Nigeria pass IATA/IOSA safety audit Two Nigerian flag carriers, Bellview Airlines and Virgin Nigeria Airways are among 224-member airlines of the International Air Transport Association (IATA) listed as having scaled its international operational safety audit (IOSA). Industry sources confirmed to BusinessDay that only the two airlines from Nigeria were successful in the audit in December 2008. As it is known worldwide, IOSA is the global industry standard for airline operational safety management. The IOSA registry now consists of 308 airlines, 224 of which are IATA members. IOSA's 900+ standards, developed in cooperation with the world's leading airlines and regulators, including FAA, CASA, JAA, Transport Canada, represent industry best practice in all aspects of operational safety. In announcing the development in Geneva, IATA's director general, Giovanni Bisignani, said "Today is a momentous day for aviation safety, our number one priority. IATA membership is now synonymous with best practice in airline safety. This is a great achievement and an important mark of quality for all IATA airlines. This in turn is a reassurance for travellers everywhere of aviation's serious commitment to safety." The success of the two Nigerian carriers was undoubtedly due to the insistence and assistance of the Nigerian Civil Aviation Authority in ensuring that all the airlines flying the Nigerian flag compulsorily meet up with the highest safety standards. http://www.businessdayonline.com/index.php?option=com_content&view=article&i d=4368:bellview-virgin-nigeria-pass-iataiosa-safety-audit&catid=95:aviation& Itemid=284 **************** Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC