Flight Safety Information October 11, 2018 - No. 207 In This Issue Incident: Indigo A320 at Hyderabad on Oct 9th 2018, rejected takeoff due to runway incursion Incident: Korean B748 at Chicago on Oct 10th 2018, could not retract landing gear Incident: United B739 near Denver on Oct 9th 2018, engine shut down in flight Cessna 208B Grand Caravan EX suffered runway excursion at Beoga Airstrip, Indonesia Astronauts make emergency landing after Russian rocket carrying them to International Space Station ATSB issues final report on in-flight loss of propeller involving Saab 340B LIBIK Fire Suppression Kits for the Cabin and Flight Deck Last call: It's time for airlines to limit in-flight alcohol sales TSA officials find two grenades in bags at Wichita's ICT airport on the same day FAA orders engine software upgrade after aborted takeoffs Lufthansa Group Orders New Generation Aircraft Air Force hopes to train 1,500 new pilots each year by 2022 to help solve shortage GRADUATE RESEARCH SURVEY NTSB Accident Site Photography Course New HFACS workshop...Las Vegas, NV...December 18th & 19th, 2018 Medallion Foundation - PROVIDING ASSURANCE IN YOUR SYSTEMS MITRE SMS December Courses '2018 International Aviation Safety and Education Summit HIGH ALTITUDE FLYING: WHAT EVERY PILOT NEEDS TO KNOW - Course Incident: Indigo A320 at Hyderabad on Oct 9th 2018, rejected takeoff due to runway incursion A Indigo Airbus A320-200, registration VT-IHN performing flight 6E-743 from Hyderabad to Goa (India) with 80 people on board, was accelerating for takeoff from Hyderabad's runway 09R when the crew rejected takeoff at high speed after the crew spotted a vehicle on the runway. The aircraft slowed safely and came to a stop about 1900 meters down the runway (about mid point of the runway). The aircraft returned to the apron. The aircraft remained on the ground for about 80 minutes, then departed again and reached Goa with a delay of 75 minutes. http://avherald.com/h?article=4becbd03&opt=0 Back to Top Incident: Korean B748 at Chicago on Oct 10th 2018, could not retract landing gear A Korean Airlines Boeing 747-800 freighter, registration HL7624 performing flight KE-271 from Chicago O'Hare,IL to Atlanta,GA (USA), was climbing out of Chicago when the crew requested to level off at 5000 feet due to a technical issue they were working on. After working the checklists the crew advised, they could not retract the landing gear and needed to return to Chicago. The aircraft landed safely back on Chicago's runway 28C about 30 minutes after departure. The aircraft is still on the ground in Chicago about 12 hours after landing back. https://flightaware.com/live/flight/KAL271/history/20181010/0745Z/KORD/KATL http://avherald.com/h?article=4becb5c4&opt=0 Back to Top Incident: United B739 near Denver on Oct 9th 2018, engine shut down in flight A United Boeing 737-900, registration N36444 performing flight UA-1192 from Denver,CO to Houston Intercontinental,TX (USA), was climbing out of Denver's runway 08 when the crew stopped the climb at FL190 reporting the failure of the left hand engine (CFM56). The aircraft returned to Denver for a safe landing on runway 34R about 25 minutes after departure. A replacement Boeing 737-900 registration N69840 reached Houston with a delay of about 4 hours. https://flightaware.com/live/flight/UAL1192/history/20181009/1140Z/KDEN/KIAH http://avherald.com/h?article=4bec9986&opt=0 Back to Top Cessna 208B Grand Caravan EX suffered runway excursion at Beoga Airstrip, Indonesia Status: Preliminary Date: Wednesday 10 October 2018 Time: 06:20 Type: Cessna 208B Grand Caravan EX Operator: Jhonlin Air Transport Registration: PK-JBR C/n / msn: 208B5163 First flight: 2014 Engines: 1 Pratt & Whitney Canada PT6A-140 Crew: Fatalities: 0 / Occupants: 1 Passengers: Fatalities: 0 / Occupants: 1 Total: Fatalities: 0 / Occupants: 2 Aircraft damage: Substantial Location: Beoga Airstrip ( Indonesia) Phase: Landing (LDG) Nature: Unknown Departure airport: Timika-Moses Kilangin (Tembagapura) Airport (TIM/WABP), Indonesia Destination airport: Beoga Airstrip, Indonesia Narrative: A Cessna 208B Grand Caravan of Jhonlin Air Transport collided with an embankment during landing at Beoga Airstrip, Papua, Indonesia. https://aviation-safety.net/database/record.php?id=20181010-1 Back to Top Astronauts make emergency landing after Russian rocket carrying them to International Space Station fails Two astronauts from the US and Russia were forced to make an emergency landing after a Russian booster rocket carrying them into orbit to the International Space Station failed after launch. NASA astronaut Nick Hague and Roscosmos' Alexei Ovchinin lifted off as scheduled at 2.40pmThursday from the Russia-leased Baikonur cosmodrome in Kazakhstan atop a Soyuz booster rocket. They were to dock at the orbiting outpost six hours later, but the booster suffered a failure minutes after the launch. Russian and US space officials said the crew had to make an emergency landing in Kazakhstan, and primed search and rescue crews ready to reach the expected landing site. Soyuz-FG rocket booster blasts off from the Baikonur Cosmodrome carrying the Soyuz MS-10 spacecraft with Roscosmos cosmonaut Alexei Ovchinin and NASA astronaut Nick Hague of the ISS Expedition 57/58 prime crew aboard to the International Space Station (ISS) - Credit: Donat Sorokin/TASS Four helicopters were involved in the scramble, and the astronauts were found safe and well, not in need of medical treatment. https://www.yahoo.com/news/astronauts-making-emergency-landing-russian-091428702.html Back to Top ATSB issues final report on in-flight loss of propeller involving Saab 340B The Saab 340 propeller as found in bushland by PolAir (ATSB) The Australian Transport Safety Bureau's (ATSB) investigation into the in-flight propeller loss involving a Saab 340B was the result of a fracture of the propeller shaft on the right engine propeller gearbox (PGB). The right propeller separated from the aircraft, with 16 passengers and three crew on board, while it was on approach to Sydney Airport from the south-west on 17 March 2017. The ATSB found the fracture was due to a fatigue crack that originated in a propeller shaft flange dowel hole and spread through the shaft until it could no longer transmit the loads required to maintain the propeller on the aircraft. The NSW Police Aviation Support Branch undertook a search operation for the propeller four days later. The propeller was located in dense bushland at Revesby, and airlifted out. The ATSB was unable to determine, conclusively, what caused the fatigue crack to occur. Following the incident, the engine manufacturer, General Electric, and the airline, undertook a number of proactive safety actions, such as the release of new service bulletins and airworthiness directives, and changes to their maintenance regime, to reduce the risk of this event from occurring again. More info: Investigation report, AO-2017-032 https://news.aviation-safety.net/2018/10/10/atsb-issues-final-report-on-in-flight-loss-of-propeller-involving-saab-340b/ Back to Top Back to Top Last call: It's time for airlines to limit in-flight alcohol sales In-flight alcohol sales are a big moneymaker for airlines. Humor me. Have a look at some of these aviation headlines from 2018 and tell me if you can find a common denominator. • "Drunk woman giving lap dances allegedly sparks mass brawl on flight." • "Drunk man arrested for urinating on passenger." • "Boozy passenger brawls on flight after he's cut off." • "Three boozy lap dancers brawl at 30,000 feet." • "Drunk passenger's rampage forced flight to land." The latest intoxicating disruption came earlier this month on a flight from Phoenix to Boston when a boozy bro decided to turn a plane into a gym and began performing pull-ups on the overhead bin. He refused to stop, became violent, and the flight was diverted to Kansas City so the man could be ejected from the plane. Every week a new viral video or horror story arrives courtesy of a passenger who gets crazy drunk (that's "crunk" in the parlance of those under 30) and makes a mess of what should be a simple trip. Common sense would dictate that the motivating factor - in this case alcohol - be removed from flights. If airlines stopped serving alcohol, the number of fights and inappropriate acts would drop off dramatically. According the International Air Transit Association, which represents 280 airlines around the world, 9,837 passenger disruptions were reported in 2016, which was the last time numbers were released. A third of those disruptions were a result of alcohol abuse. "Since it is a voluntary reporting system, we think it may actually understate the number of such incidents," said Perry Flint, a spokesman for the organization. Although airlines are beset by drunk, brawling passengers who grope and urinate in a lot of places they shouldn't, it's unlikely they'll ever take booze off the menu because it's a cash cow. It also means they're unlikely to put standards in place to limit the number of drinks served per passenger on a flight. It wasn't always this way. Up until the late 1980s, most airlines had a two-drink limit per passenger, per flight, according to airline industry analyst Henry Harteveldt of Atmospheric Research Group. Perhaps that, and the lack of cellphones, is why we never witnessed the frequency and nastiness of brawls during the golden age of aviation. I'm about to become the most unpopular travel writer in Boston by suggesting this, but it's time that airlines reinstate a two-drink limit per passenger. Not only will it make flights safer and more comfortable, it will also save hundreds of thousands of dollars in re-routed planes each year. It would also mean fewer dudes yelling on flights to Las Vegas. "I like the idea of a two-drink limit for passengers," said flight attendant and blogger Joe Thomas . "People on airplanes follow rules - well, most of them do. The rules are in place because something bad once happened and they became necessary. Smoking is prohibited because an Air Canada plane burst into flames when someone threw their cigarette into the lavatory. I think we've seen plenty of times that too much alcohol has led to bad things. It's a rule that makes sense." But a two-drink limit would likely never fly at the corporate level because it would cut into the bottom line. The onboard technology company GuestLogix found that passengers spend more on alcohol than food or any other in-flight purchases. The five major airlines brought in $43 million in alcohol sales over a four-month period during 2013 and 2014, which is the last time the numbers were released (airlines are not required to share revenue from alcohol sales). That means airlines could pull in $130 million annually from alcohol sales. In the years since the GuestLogix study, airlines have upped the prices on many drinks. Given the disruptive behavior still flooding the news, those higher prices don't appear to have deterred passengers from overindulging. Still, many frequent fliers said they couldn't fathom making it through a flight without their calming cocktails, even if it means dealing with belligerent drunkards. "For me it's a tradition," said Cambridge-based medical sales representative Ann De Silva, who estimates she's in the air about 10 times a month. "I get on, relax, have a gin and tonic, and then watch a movie." "I walk onto the plane and I'm handed a glass of champagne," said investment banker and frequent flier David Waxman. "I don't think that should stop because there are a few people who cause problems." Eliminating or reducing alcohol consumption on planes would minimize the number of incidents, however it's unlikely to eliminate them altogether. Airport bars and lounges are where many begin their journey with the devil's nectar. Passengers arrive early to clear security, and then wait for flights, sometimes with long delays. By the time they board, they could easily be stewed. In the United Kingdom, Ryanair requested that airports stop serving alcohol before 10 a.m. and that airport bars and restaurants begin enforcing a two-drink-per-passenger policy following several incidents of partiers boarding flights already drunk this summer. Ryanair doesn't sell alcohol on its European flights so the passengers became lit waiting for their plane. In July, airports and airlines in the UK introduced the "One too many" campaign, reminding passengers that drunken behavior on planes could result in prison time and tens of thousands of pounds in fines. There hasn't been a similar campaign among US airports. With no regulations or rules about alcohol limits in place - aside from asking passengers not to get drunk and violent - gate agents and flight attendants are the ones who are generally left to police passenger behavior and alcohol consumption in the air. "We do our best to spot them before the flight takes off, but sometimes you can't always tell," said Thomas. "I've had people taken off the flight and I've had someone arrested after they were belligerent and verbally abusive for the entire flight." The Transportation Security Administration is not charged with determining if someone is drunk, only what they bring on a plane. The responsibility therefore falls upon the gate agent and flight attendants. "It's not the TSA's responsibility to screen for sobriety," Harteveldt said. "If a gate agent suspects that a passenger is inebriated, they generally have the right to stop the customer and make sure they don't get on a plane, but gate agents often don't want to get into an argument with a passenger and they don't want to be making a decision that could be considered arbitrary and lead to anything from a simple disagreement to a lawsuit." The Association of Flight Attendants, a union representing workers on more than 20 airlines, does not have official guidelines for alcohol service, those are set by airlines, but spokeswoman Taylor Garland offered an important piece of advice for thirsty travelers. "The call button is not the drink service button," Garland said. "Wait for the cart to come through the cabin and order a drink if you'd like one. That's a good way to pace yourself." https://www.bostonglobe.com/lifestyle/travel/2018/10/10/last-call-time-for-airlines-limit-flight-alcohol-sales/TCEA2zDaMKIAAxT4AZIFEK/story.html Back to Top TSA officials find two grenades in bags at Wichita's ICT airport on the same day Security officials found two grenades in bags at Wichita's ICT airport on the same day last month. The inert grenades were discovered at the Dwight D. Eisenhower National Airport in September, Transportation Security Administration officials said in a weekly blog. They were discovered in a carry-on bag and a checked bag on the same day. "We don't know if replica or inert items are live until our explosives professionals take a closer look and eventually open the bag," TSA officials said in the blog. "That takes time and slows down the line. It can even lead to a complete shutdown and evacuation. Real, inert, or anything resembling an explosive item is prohibited in both carry-on and checked baggage." https://www.kansas.com/news/local/crime/article219823490.html Back to Top FAA orders engine software upgrade after aborted takeoffs The engines were built by CFM International for Airbus A320neo and A321neo jets. Safety regulators are ordering that engine software be replaced on some Airbus passenger jets because of a problem that has caused pilots to abort several takeoffs in cold weather. The order covers 82 engines on planes registered in the United States. The engines were built by CFM International, a joint venture of General Electric, and France's Safran, for Airbus A320neo and A321neo jets. The Federal Aviation Administration and European Aviation Safety Agency said this week operators will have until late January to replace electronic-control software. The regulators say water can accumulate and freeze in pressure-sensor lines, preventing the fan blades from reaching takeoff speed. The FAA says the problem caused six aborted takeoffs. It says CFM has improved the software to better detect freezing in sensor lines. https://www.heraldnet.com/business/faa-orders-engine-software-upgrade-after-aborted-takeoffs/ Back to Top Lufthansa Group Orders New Generation Aircraft The Lufthansa Group is investing in the modernization of its fleet as the Supervisory Board of Deutsche Lufthansa AG recently approved the purchase of 27 short- and medium-haul aircraft. More specifically, purchase options for 24 Airbus A320neo and three A321neo will be converted into firm orders. The total investment of this order amounts to a list price of about $3 billion. "With this decision, the Lufthansa Group is reacting to the positive market and earnings development and thus ensuring the necessary fleet size in the coming years," the company said in an announcement. This increases the total number of A320neo and A321neo orders to 149 for the Group. Thirteen of them are already operating with Lufthansa. The A320neo and A321neo (short for "New Engine Option") are scheduled for delivery in 2023 and 2024. Ten of the 27 new aircraft are intended for SWISS, while the remaining aircraft will be in service by other flight operations within the aviation group. One part of the order will be equipped with Pratt & Whitney engines (PW1100G), the other with LEAP-1A engines from CFM International. This means that both engine types will continue to be available to the Lufthansa Group in roughly equal proportions for the "neo" family. The innovative engine technologies developed by Pratt & Whitney and CFM International as well as the aerodynamic wingtips (sharklets) with which the aircraft are equipped reduce fuel consumption significantly by up to 20 percent per seat kilometer. As all Lufthansa A320 family aircraft, the A320neo and A321neo are serially equipped with noise-reducing vortex generators. An A320neo taking off has a noise carpet that is around 50 percent smaller than that of other aircraft of this type. https://news.gtp.gr/2018/10/10/lufthansa-group-orders-new-generation-aircraft/ Back to Top Air Force hopes to train 1,500 new pilots each year by 2022 to help solve shortage Air Force Airman 1st Class Tyler Haselden, left, Pilot Training Next student, and Maj. Rachel Rehurek, PTN instructor pilot, prepare for a training flight at Austin-Bergstrom International Airport in Austin, Texas June 22. The Air Force hopes to increase its annual pilot training capacity from 1,160 in 2017 to 1,500 by 2022. (Sean Worrell/Air Force) The Air Force hopes to be able to train 1,500 new pilots each year by fiscal 2022 as part of its effort to solve its troubling shortage of aviators. Air Force Secretary Heather Wilson said at a Senate Armed Services readiness and management support subcommittee hearing Wednesday that the Air Force trained 1,160 new pilots in fiscal 2017, and expects to train 1,311 in fiscal 2019, before expanding further. The Air Force has taken several steps to try to improve air crew's quality of life and quality of service, and solve problems that might be leading some to choose to leave the Air Force. Wilson highlighted efforts to reduce operating tempos, revitalize squadrons and restore support staffs so air crew can concentrate on flying, as well as generous incentive pay and bonuses. The Air Force is also working on testing a "fly-only" technical track for interested airmen, and giving air crew greater input on assignments. But, Wilson said, "retention efforts alone will not solve the aircrew shortage," leading the Air Force to beef up its training capacity. Increased pilot training capacity could become even more important as the Air Force seeks to increase its number of operational squadrons from 312 to 386 by the end of 2030. Wilson told lawmakers that restoring readiness must be a top priority of the Air Force. The service is focusing on fixing readiness in the 204 operational squadrons that would be most important in a high-end fight. By the end of 2020, she said the Air Force hopes 80 percent of those units will have the right number of properly trained and equipped airmen. And two years after that, Wilson hopes 80 percent of all 312 operational squadrons will be ready. The Air Force has already made significant progress in cutting the maintainer shortage, Wilson said. Two years ago, the Air Force was short 4,000 maintainers, but by December, that gap is expected to be completely eliminated. But the Air Force's work on maintenance isn't done. Wilson said these new, green maintainers must be seasoned until they have enough experience to do more complicated or unsupervised work. The order, handed down by Defense Secretary Jim Mattis, is a lofty one, considering the current readiness rates of America's fighter fleets. The focus on maintenance and readiness is especially acute, given Defense Secretary Jim Mattis' order to have the F-35, F-22 and F-16 fighter jets, as well as the Navy's F-18, up to 80 percent mission-capable by the end of next September. Sen. Dan Sullivan, R-Arkansas, expressed concern that about one-third of F-35s are not available, even though it's the Air Force's newest aircraft. Wilson said the a lack of spare parts is a major factor limiting F-35s readiness, which varies greatly by squadron. John Pendleton, director of defense capabilities and management for the Government Accountability Office, said that the Air Force "focused on production, and not enough on sustaining the aircraft ... and it's causing problems now." The service has "high confidence" that an oxygen concentration problem was causing a series of physiological episodes in the service's T-6 training aircraft during certain maneuvers, Air Force Chief of Staff Gen. Dave Goldfein told senators. Now that the Air Force has zeroed in on the problem, Goldfein said, it is changing its maintenance procedures to minimize any oxygen level issues. In the long term, Goldfein said, the Air Force is planning to redesign the oxygen system in the T-6 to prevent it from becoming a problem again. A team is now drawing up plans for the redesign, and Goldfein said it will be a top priority when they're finished. https://www.airforcetimes.com/news/your-air-force/2018/10/10/air-force-hopes-to-train-1500-new-pilots-each-year-by-2022-to-help-solve-shortage/ Back to Top GRADUATE RESEARCH SURVEY I am a grad student at City University of London and am completing work on my Masters in Aviation Safety. In my thesis I am trying to determine what the competencies are for being an airline Captain. This is to complement the 9 competencies That ICAO identifies for training pilots. My ultimate goal is to identify the relevant competencies and determine if they are trainable from a flight education standpoint. The first step is to determine the state of Captain/Command training in the United States. The link provided for a survey via survey monkey that hopefully will help me establish a baseline of where we are at in the industry in the US. Thank you for your consideration. Regards, Captain Jeff Kilmer FDX 901-651-6070 https://www.surveymonkey.com/r/58SMR3B Back to Top NTSB Accident Site Photography Course Title Accident Site Photography Description Three courses in one training event - two days of photography instruction and practical exercises in addition to one day of digital image processing. Day One - Technical Photography The principles of digital imaging will be explained and demonstrated. Participants will create images to apply techniques discussed in class. Participants should be familiar with the operation of their digital camera prior to attending the course. Day Two - Advanced Accident Site Photography Participants learn how to capture the most important and useful images to document any accident site. Through the use of methods described in this course, participants will expose their own images in various photographic disciplines and then share in critique sessions offering constructive observations for improvement. This session will include interactive instruction and demonstration, as well as practical exercises. Day Three -Digital Image Processing Processing and storing of images for current and archival use in a variety of electronic formats will be discussed. Generally accepted protocols for processing of images to enhance image clarity will be presented, as well as information for retaining authenticity crucial for use as documentary evidence. ID Code IM300S Dates and Tuition November 6 - 8, 2018 $1,198 early registration by October 6, 2018 $1,248 late registration between October 7, 2018 and November 1, 2018. Times Day 1 & 3: 8am - 4:30pm Day 2: 8am-1pm and 5pm - 8pm (night documentation exercise) Location NTSB Training Center * 45065 Riverside Parkway * Ashburn, Virginia 20147 Status OPEN. Applications are now being accepted. Apply to Attend SIGN UP FOR THIS COURSE HERE CEUs 1.8 Program Agenda Day One - Technical Photography • Digital photography - how a digital image is formed, processed and stored; digital vs. analog imaging; adjusting resolution & file sizes for particular purposes • Camera usage and care - holding, focusing, light metering, batteries, moisture and cleaning • Elements of exposure - shutter speeds, lens apertures, depth-of-field and exposure vs. noise • Lighting: sources and techniques • Close-up and macro-photography - use of flash, filtration and polarization • Troubleshooting - Resolving difficulties by understanding the basics of digital hardware • Photographer safety and camera care • Digital imaging media, techniques and cautions Day Two - Advanced Accident Site Photography • Project environment - preparing for assignments under any conditions • Documenting the scene - protocols for documentation of any type of accident/incident site • Size, color and positional references - GPS capabilities and animation • Storytelling - capturing images to maximize informational content • Quantitative scene data - virtual reality, photomontage • Authenticity - ensuring image authenticity through use of specific procedures • Photo Reality - taking advantage of contrast, perspective, proper lens focal length and color reproduction • Exercise: Documentation of simulated aircraft accident site Day Three -Digital Image Processing • Workflow process - from image capture to archival storage • Scanning - converting traditional prints into digital images • File types - determining optimal file formats for various image types and usages • Image size - Guidelines for best file sizes for a range of storage and electronic transmission considerations • Compression - balancing the benefits and drawbacks of various modes of image compression • Image Correction - using imaging programs to correct for deficiencies in overall image quality: o Enhancing detail o Adjusting luminosity o Cropping out distracting/irrelevant elements o Correcting distorted color o Improving contrast Authenticity protocols - practices and procedures to ensure that the integrity and accuracy of the documentary digital image is not compromised at any point in the workflow process Equipment In addition, it is recommended and encouraged that you bring to class all equipment and accessories that you may use on the job, such as scales, mirrors, memory, and tripods. Students should be prepared to photograph at a simulated scene outdoors. Please be prepared for local weather and outdoor working conditions. Who May Attend • NTSB investigators • Federal, state & local investigators, including those outside the field of transportation, who would like to build or enhance photographic skills • Potential participants in an NTSB investigation • Law Enforcement Officers • Safety and Private Investigators • Enforcement Inspectors • Others who would like to build or enhance photographic skills Accommodations Area hotels and restaurants Airports Washington Dulles International (IAD): 10 miles Washington Ronald Reagan National (DCA): 30 miles Baltimore/Washington International (BWI): 60 miles More Information Email StudentServices@ntsb.gov or call (571) 223-3900 Courses, forums and symposia are added to the schedule throughout the year. Subscribe to the e-newsletter to learn about upcoming events and new programs: https://app.ntsb.gov/trainingcenter/list/list_mw020207.htm Back to Top New HFACS workshop Las Vegas, NV December 18th & 19th, 2018 HFACS, Inc. offers professional development training on our innovative HFACS/HFIX methodologies. Our intensive, two-day workshops teach updated cutting-edge techniques to help your organization identify the causes of errors and develop preventative measures to lower your risk and improve performance. You have been included in our new email database as we begin using this important tool for communication on upcoming workshops as well as being the first to hear about any special offers. Please forward this to any interested co-workers so they may also stay connected. How to register: To register email dnlmccnn@gmail.com, or info@hfacs.com or call 800-320-0833 or visit hfacs.com Attendees of the workshop will learn how to: • Integrate human factors and system safety concepts into the root cause analysis (RCA) process • Utilize the Human Factors Analysis & Classification System (HFACS®) to identify systemic causes of human error during accidents, incidents, and/or near misses. • Integrate HFACS into traditional RCA tools like the fishbone diagram, fault trees, and link analysis using HFACS • Implement the Human Factors Intervention matriX (HFIX®) to develop innovative corrective action programs Develop a human error database and tracking system for monitoring and evaluating performance improvement efforts All attendees of the workshop will receive: • HFACS Textbook • HFACS-RCA Handbook (including HFACS Interview Guide & HFACS/HFIX Checklists) • Complimentary Associate HFACS Professional (AHP) Certification • Opportunity to join the largest Listserv catering to human factors accident investigation and error management Already attended a 2-day workshop? Don't miss out on our special offers! • Our workshops have been updated to feature the newest information • If you have already attended our 2-day HFACS course, don't miss out on the opportunity to attend another workshop as a "refresher" for a discounted rate of $200 • Or bring a full-paying customer with you and receive free refresher course registration For any additional questions and information, contact dnlmccnn@gmail.com, or info@hfacs.com or call 800-320-0833 HURRY AND SAVE THE DATE SEATS GO FAST Register Here Phone: (231)720-0930 (9-6 EST) Curt Lewis