Awst Series On Aviation Safety

[BoeingBoy]

Face to Face With Former NTSB Member John Goglia
Aviation Week & Space Technology
08/23/2004, page 74


Former NTSB member--plain talking, never dull--looks back . . . and forward

Back to Basics

Think of aviation maintenance, think of John J. Goglia. Think of safety, think of John J. Goglia. In 1995, he became the first licensed mechanic to become an NTSB member. Since then, the outspoken Goglia's voice has been heard above the others in safety board probes, doggedly raising industry awareness of the role of maintenance in accidents. Anyone who's attended an NTSB accident hearing is familiar with how he sizzles witnesses in the quest to find out what went wrong and how to make it right again.

Maintenance-related investigations marked his arrival and departure from the NTSB. He presided over the ValuJet Airlines Flight 592 hearing. The DC-9 crashed in the Florida Everglades in 1996. The airline's failure to oversee its contract maintenance program was cited as a contributing factor. In May, Goglia formally stepped down from the board at the final hearing into the crash of Air Midwest Flight 5481 at Charlotte, N.C. The loss of pitch control that caused the January 2003 accident that killed 21 people was the result of incorrect rigging of the elevator control system.

For all his toughness, Goglia is a man who's not afraid to openly express the more tender emotions--especially for the families of accident victims. He has worked assiduously to win them more compassionate treatment from industry.

Goglia met with Transport Editor Frances Fiorino to talk about his post-NTSB life, which, no surprise, is devoted to building aviation safety.

Aviation Week & Space Technology: Financially strapped air carriers are cutting costs, but are they cutting corners in maintenance and thereby compromising the safety of passengers?

John Goglia: I'd say there's a lot of pressure on people within the airline community to deliver the product much cheaper, much quicker than they ever have in the past. And that kind of pressure often results in substandard work.

Not long after I arrived at the NTSB in 1995, I realized my concerns about maintenance were far greater than I had anticipated. Since then, the industry has gone through several periods of right-sizing, down-sizing--and all the fancy words we use for working faster, better, cheaper. It all means the same thing: doing more work with fewer people. But sometimes, under certain circumstances, there is no substitute for people. And when you cut your operation down to the bare bone, or maybe into the bone, you get an off-standard operation and find yourself behind the curve.

AW&ST: How has industry changed since you joined the NTSB?

JG: The aviation business is integrated. We are supposed to fit like a hand in a glove--but we are no longer fitting into the glove. We are turning into vertical silos and we don't talk very much, or very efficiently, across those silos.

AW&ST: What's the reason for that?

JG: The culture has shifted, in particular, the way we're managing the workforce. When I started this business, everyone helped each other. I was a maintenance person, but I'd also help ramp guys struggling to load an aircraft. It was like that across the board. You don't see that happening anymore; it's one simple example of the disconnects in industry.

AW&ST: How would industry reconnect?

JG: All I hear at meetings are grandiose plans on how we are going to fix the system. What we really need to do is go back to basics.

Managers aren't managing our workforce. One of the manager's responsibilities is to remove obstacles to getting a task done. But for whatever reason, managers instead have been driven down too close to, or become part of, the operation. They are more part of the crew trying to get the job done. We must make certain they develop the personal skills and have the tools to handle the workforce.

AW&ST: What skills and tools do you think are necessary?

JG: First, they need people skills to work with employees and they need whatever tools are available--knowledge about their job and the workplace, for instance--to perform effectively.

AW&ST: What is the quality of maintenance training out there?

JG: Training has been thin for maintenance employees. On the air transport side, there's been a big shift toward contracting out heavy maintenance. During the course of investigations, the NTSB found the vast majority of people who work on the airplane are unlicensed. Because the turnover rate is as high as 50% a year, there's a reluctance to invest money in training them.

Where does that leave the traveling public? Where does that leave the airline? The airline is paying good money to have this work done. Based upon what I've seen lately for warranty claims and such, carriers are not getting their money's worth as far as quality is concerned.

AW&ST: You've been very vocal about the need for improved oversight of repair stations. Are airlines meeting the challenge?

JG: There are a number of airlines with good programs. I've been particularly impressed with the efforts of America West Airlines and FedEx (see p. 76). Each of these airlines has taken a different approach, but the end result is a much higher quality product when the airplane goes out the door.

And remember, repair stations are staffed by humans. When you measure performance, it's amazing how much better the product is improved.

AW&ST: You are a proponent of infusing human factors into maintenance. What progress has been made?

JG: Human factors is not applied very well now in commercial aviation. A number of operators have portions of a good program but no one has embraced it fully. Human factors is mainly about teaching people how to communicate. In the maintenance environment, "communicating" doesn't necessarily mean you and I conversing while we're turning wrenches. It means learning how to accurately pass on job information to the guy on the next shift.

It also means management's sharing important job information in open dialogue with all crewmembers and workers being able to voice opinions without retribution. Closed dialogue is more common. That's how the grease problems on Alaska Airlines Flight 261 never saw the light of day. Imagine losing 88 people because of grease? That made me mad.

[Editor's note: Alaska Airlines Flight 261 crashed Jan. 31, 2000, killing 88 people. The NTSB determined that insufficient lubrication of the jackscrew assembly contributed to the probable cause of the crash: loss of pitch control resulting from inflight failure of the horizontal stabilizer trim system assembly's acme nut threads.]

AW&ST: You'd expressed anger at a number of hearings. Looking back over your years at the NTSB, what's angered you the most?

JG: I rattled a number of people . . . because I ask the questions that nobody wants to ask, and no one wants to answer. But they need to be put on, not under, the table: "Are you embarrassed, Mr. Maintenance Manager?--then do something about it!"

One of the things that got to me most has been fixed: The treatment of family members of accident victims. The Family Assistance Plan for Aviation Disasters Act, which was passed following the TWA Flight 800 accident, improved the situation. Families are now kept well-informed. Prior to that, the accident airline dealt with the families, and with rare exception, did not do a very good job. Their focus wasn't 100% on making certain the families understood the facts.

AW&ST: The NTSB has been criticized for not having board members with an aviation background. How much of a problem does that create in investigations?

JG: It can be a problem. When an accident report comes to the board, the board's job is to balance out the recommendations. We do that by probing members of the [investigative] staff. If you don't have the technical background--and nine out of 10 accidents we see are very technical in nature--then you do not have the ability to ask appropriate questions. Or if you do ask a question, you might not grasp the answer, or don't know if the answer is complete. So that leads to a little disconnect, and the scales between the board and staff are then out of balance.

But consider the system is not even 40 years old. And if you look at what's happened in 37 years, we have made tremendous improvements--in the airplanes, in the material we use in the airplanes, aircraft systems, and now we have been focusing on people issues. So the system really has served us well.

AW&ST: You are a workaholic, putting in 70-90 hr. a week at the NTSB. What's on your agenda now?

JG: I'm planning to do some government affairs work with the Professional Aviation Maintenance Assn. and represent a portion of industry--general aviation and some repair stations--that has no voice. Also, I've joined the faculty of St. Louis University as professor of aviation science in the Parks College of Engineering, Aviation and Technology. They've asked me to help develop a Center for Emergency Response, not just for aviation, but for all disasters. I plan a model that would build skills through education; for example, for students in bachelor/master's programs and certificate programs for those already in the field. Some aviation safety consulting work is also part of the plan.

AW&ST: Do you have a message for industry?

JG: There are pieces of our operation that are not functioning very well today. But they can be made to function much better--if we go back to the basics. We don't have to spend millions of dollars. We don't have to design new computer systems. We have in place all the bits and pieces we need.

We have a wonderful industry that has always responded to problems. And the industry will respond in a cost-effective way to get the job done. What we need to do is make certain we can stay focused to get that done. This is not rocket science. It's paying attention to detail.

 

[BoeingBoy]

Safety Experts Work To Take the Error Out of Being Human
Aviation Week & Space Technology
08/23/2004, page 76

Frances Fiorino
Washington

Aviation is unforgiving of mistakes, and safety experts are working to take the error out of being human

Eliminating the 'Dirty Dozen'

Regulators and researchers continue the drive to infuse human factors training into the maintenance arena--in a climate where cash-strapped carriers are reluctant to devote dollars to training.

The FAA defines human factors as "the study of the interaction between humans and machines" and includes what can go wrong, and why.

The need for such training is never more apparent than when an accident involving maintenance issues occurs, such as the January 2003 crash of Air Midwest Flight 5481, a Beech 1900, that killed 21 people. A contributing factor was incorrect rigging of the elevator control system that led to loss of pitch control on takeoff.

System Improvement Inc.'s TapRooT System software is designed to help determine the root causes of errors. The user inputs event data at incident editor screen (above). A flowchart is produced, which leads to identification of contributing factors and analysis of root causes.

Human error was a key factor in 80% of all accidents, from the first powered flight in 1903 to the present--and 12% were maintenance/inspection related, according to FAA data. The agency's research shows what goes wrong: Most often, the causes are incorrect installation of components; fitting of wrong parts; electrical wiring discrepancies; loose objects (tools left in the aircraft); inadequate lubricant; unsecured cowlings, access panels and fairings or fuel/oil caps; and failure to remove landing gear ground-lock pins before departures.

Maintenance errors are costly to carriers, too. The FAA estimates the cost of an engine shutdown at $500,000; one flight cancellation, $50,000; and a return to gate, $15,000. The Air Transport Assn. estimates an annual loss of $850 million to industry in ground damage.

The FAA refers to the 12 main causes of human error as "The Dirty Dozen": Lack of communication, complacency, lack of knowledge, distraction, lack of teamwork, fatigue, lack of resources, pressure, lack of assertiveness, stress, lack of situational awareness and "norms" (behavior that's not required, but expected, at the workplace).

Researchers continue analyzing the causes, with the goal in mind of creating error-fighting solutions that can be "implemented on the hangar floor by the mechanics," says the FAA's Dave Cann, manager of the aircraft maintenance division-flight standards.

Cann points out that in the last few years the agency has undergone a major culture shift. "We now always consider the human factors element in everything we're doing in maintenance, whether it's policy guidance or regulations."

Following the Air Midwest accident, for example, the FAA revised FAR Part 145, requiring repair stations to adopt an approved training program. Cann says the agency is now working on an advisory circular that will likely contain guidance on human factors training to be included in those programs.

The agency has also issued guidance on maintenance resource management (MRM) training (AC 120-72), a hangar-floor counterpart of crew resource management (CRM), with its focus on building situational awareness, communication skills, teamwork, task allocation and decision-making. Another advisory circular (AC 120-66B) contains guidelines for the implementation of the Aviation Safety Action Program (ASAP) for Aircraft Maintenance Organizations--the counterpart of the self-reporting program on the flight operations side of the business.

Cann notes that MRM is not new; the concept was introduced in the 1990s. It's more classroom-based training and is not structured, as is ASAP. "I wouldn't be surprised if in the future the FAA issued more guidance and more requirements for approved [MRM] training programs."

MRM presents a unique challenge, notes Barbara Kanki, human factors research psychologist and manager of maintenance-human factors in the Aviation Safety and Security Program at NASA Ames Research Center. "Although the concept is the same as CRM, it's applied in a very different domain. There are many, many different maintenance tasks and many organizations involved. There's no such thing as a maintenance simulator. Further, you want to be able to integrate it into everyday operations."

NASA-Ames human factors research focuses on five areas of evaluation: maintenance error baselines, task/risk analysis tools, maintenance procedure upgrades, augmented/virtual reality displays, and MRM skills and training. "Finding what errors exist out there is the foundation piece. We can then start efficiently going after the kinds of interventions you want to develop. Aviation Safety Reporting System (ASRS) data help us target problem areas," Kanki added.

FedEx Express plans to expand current human-factors-based training to include all mechanics at all facilities.

Alan Hobbs, senior research associate, who works with Kanki, is now analyzing 2,500 maintenance reports collected from the ASRS database since 1996. He's studying, among other factors, the types of errors reported, the aircraft involved and circumstances under which errors occurred. Hobbs notes that maintenance errors have a long lifespan, and implications of an error may not become apparent until many years after the event.

Some of the main issues the research has already uncovered include forgetting to perform a key function, deviation from procedures, and documentation issues (unclear instructions).

"Airline management has generally been very receptive to implementation of human-factors-maintenance training," says Kanki. "We had a lot of progress, until Sept. 11, 2001. Now, we are dealing with a lot of economic constraints."

"Companies are working to more effectively to use their resources, asking how can we do things smarter, simpler better," says Allyson Freyre, director of quality assurance at Alaska Airlines.

Given the economy and carriers shifting to the outsourcing of heavy maintenance, plus a nearly 50% worker-turnover rate at repair stations, there's a reluctance to invest scarce resources on maintenance training, says John J. Goglia, former NTSB member and maintenance safety advocate.

Even so, many airlines have adopted oversight programs and implemented human factors maintenance training and tools into everyday operations:

*Alaska Airlines, which outsources about half of heavy maintenance work, made ASAP available to both certified mechanics and to management personnel. In addition, all new employees in the maintenance and engineering division receive human factors training, although the airline does not offer recurrent training. Alaska uses TapRooT, a diagnostic tool that helps workers discover causal factors behind errors, according to Freyre.

*FedEx Express, with a 675-aircraft fleet, outsources about 80% of its airframe heavy maintenance. The division employs 2,500 mechanics and 1,600 professionals, of which 60% or 900 are maintenance staff. The company has "statistically significant surveillance of aircraft," with about 90-110 people employed in on-site teams, says Robert Rachor, FedEx Express vice president of safety and airworthiness.

The teams sample work to ensure it's performed in accordance with the repair certificate. The airline also meets with leadership and reviews work from both a quality and safety perspective. An aircraft coming out of heavy maintenance has to go through a release process. "We have a flight test crew that goes out with the aircraft before it returns to revenue service to make certain it's fully functioning and has no outstanding discrepancies," says Rachor.

FedEx continues to push human factors training on the maintenance side of the house. However, "We haven't rolled it out entirely," Rachor says. "The training is now given to our quality assurance and quality control management, and at internal base maintenance facilities. In the future, we will work it into all base and line maintenance."

*America West employs about 750 mechanics, as well as 38 quality control, 27 quality assurance and 85 maintenance supervisors, says Hal Heule, senior vice president of technical operations. The airline's outsourcing mainly goes to Timco Aviation Services facilities at Lake City, Fla., and Macon, Ga. What's unique about America West's outsourcing is that the Macon facility is dedicated to the airline. "It's closest to doing the work yourself without doing it yourself," Heule says.

America West has established a clear expectation of the relationship up-front and worked to build mutual goals. The airline controls the task cards, pays for actual work accomplished, as opposed to a fixed price. "Another unique element is that we have an open-book policy," says Rachor. America West knows the financial condition of the facility, its job standards, actual work times, the amount of wages they are paying workers and the turnover rate of mechanics. In addition, leaders meet quarterly to discuss mutual concerns.

"The payoff? Gaining predictability in terms of what we need in skills and tools months in advance," says Rick Oehme, vice president of engineering and quality.

In 1995-96, the airline lost track of the tasks and skills required and the length of time an aircraft would be in maintenance, Oehme explained. "We lost control because we believed our vendors would have the same level of interest we had--but we didn't give them the tools or resources to perform the task we asked them to perform. As a low-cost carrier, we really needed to gain more efficient use of the airplanes.

"We now have a high level of certainty in forecasting when an airplane is going in or out of checks. America West improved its C-check dispatch reliability 5% from the summer of 2000 to the present, and our completion factor increased to 99% this year from 95% in summer 2000," Oehme added.

 

[BoeingBoy]

Safety Ramps Up
Aviation Week & Space Technology
08/23/2004, page 78

Frances Fiorino
Washington

The airport apron, rife with aircraft, fuel trucks, baggage containers, workers . . . and danger?

A group of aviation safety experts is raising industry awareness to a growing threat to safety: airport ramp operations.

The group, the Airport Operations Safety Panel (AOSP), meets next month at the Airports Council International (ACI) Conference in Houston to better define risks and find ways of raising the bar on ramp safety. Based on preliminary findings, AOSP is recommending that industry:

*Set minimum standards for ramp operations as well as the licensing, training and certification for safe vehicle operations. AOSP proposes airports set the model and dictate procedures.

*Work with the FAA to develop regulations that would require airports to install a runway incursion program. Such programs are now only recommended.

*Adopt an industry-wide fuel facility design standard as well as a system operator certification program.

Safety experts say airport ramp congestion will increase and surface maneuverability decrease, as airlines set more frequent services and strive to speed up turnaround times. Credit: GEORGE HAMLIN

The AOSP panel was formed at the request of airlines seeking an independent body to voice concerns, which are worldwide, according to panelist John J. Goglia, former NTSB member. The panel also includes James Crites, executive vice president of DFW International Airport; John Denman, manager infrastructure safety, International Air Transportation Assn.; John H. Armbrust, president of Armbrust Aviation Group aviation consultancy; and Robert Vandel, executive vice president of Flight Safety Foundation (FSF).

What's happening? AOSP's initial report, issued in June, notes the FSF found that nearly 14 of every 100 ramp workers are injured yearly and the Occupational Safety & Health Administration (OSHA) reports 8.8 injuries per 200,000 hr. in commercial air transport in 2002.

In addition, data gathered by ACI indicates the injuries caused by ground accidents and incidents increased from .04 injuries per 1,000 aircraft movements in 1996 to nearly 12 per 1,000 in 2001. Further, the majority of ground accidents and incidents in that period involved equipment-to-equipment damage.

In February 2003, FSF launched the Ground Accident Prevention (GAP) project to analyze the risk of ground accidents. According to Vandel in the FSF report, one of the project's goals is to uncover the magnitude of the problem. He adds that a conservative estimate indicates annual costs of aircraft damage alone are $4 billion for air carriers and $1 billion for business aircraft operators.

IATA points out that human/operator error was the primary cause in 92% of accidents involving ramp damage to aircraft or terminals. Inadequate training and supervision were among the primary causes of operator error. Further, the AOSP report notes that airlines "self-insure" damages, meaning that with the average cost of an event listed as $250,000, most incidents fail to meet average deductibles: $1 million for wide-body aircraft; $750,000 for narrowbodies.

AOSP's report says ramp real estate will get more crowded as airlines increase regional jet services and as carriers in general push for higher utilization rates, which in turn mean higher demand for quick turnarounds. Aircraft are often maneuvering around each other and parking close together. This could hamper fire and rescue vehicles from reaching an accident site, according to the report.

Jack Kreckie of Massport Fire Rescue noted that there are ramp personnel driving tankers, deicing equipment and tugs that push $250-million aircraft. Outside the airport environment, those same personnel would be required to obtain special licenses, and medicals, yet there is no requirement for certification for ramp operations.

The report also states: ". . . a potentially lethal mix of ill-trained poorly paid workers, limited equipment maintenance and in some cases, management malaise, have made the airport ramp area a hazard with enormously expensive consequences." It goes on to note that the current financial distress of most U.S. carriers may have stymied efforts to make improvements through training.

FACTOR IN THE FUELING industry's astonishing rate of turnover--70% or more--with very high attrition rates occurring only a few weeks or months on the job, adds the AOSP. "We can't expect more from a person charged with driving highly flammable liquid through a congested area while being compensated with paltry wages."

The AOSP's preliminary data indicates "significant" cost savings can be achieved through adoption of the recommendations, and notes that quantitative data is not now available. If automatic positioning technology, for instance, was more widely applied to ramp vehicles it could yield industry savings of $1.4 billion annually, according to FSF's Vandel.

 

[aerosmith]

You go Gogo!!!

 

[E-TRONS]

How can this be?? Everyone knows that 3rd party providers are wonderful and quality oriented <_< <_< <_< .

The NTSB will miss you John Goglia. Not bad for a MECHANIC!!!