Category Archives: errors

Pilots forget to lower landing gear after cell phone distraction

This is back from May, but it’s worth noting. A news story chock-full of the little events that can add up to disaster!

From the article:

Confused Jetstar pilots forgot to lower the wheels and had to abort a landing in Singapore just 150 metres above the ground, after the captain became distracted by his mobile phone, an investigation has found.

Major points:

  • Pilot forgets to turn off cell phone and receives distracting messages prior to landing.
  • Co-pilot is fatigued.
  •  They do not communicate with each other before taking action.
  •  Another distracting error occurred involving the flap settings on the wings.
  • They do not use the landing checklist.

I was most surprised by that last point – I didn’t know that was optional! Any pilots out there want to weigh in on how frequently checklists are skipped entirely?

 

 

Photo credit slasher-fun @ Flickr

Lack of human factors = more of your tax dollars at “work”

I live in Raleigh, NC. Our area code has always been a little problematic for the nationwide 911 emergency system – it is 919. But at least until now, dialing the 919 for a local call was optional. Looks like we’re finally big enough for ten digit dialing and we can expect to pay the price in our public safety system.  Check out this email from the Director of Emergency Communications, particularly the part about dispatching officers every 7.5 minutes to investigate hang-ups:

I am sure by now that you have seen or heard about some of the impact that the new 10 digit dialing requirement has made upon our 9-1-1 center. Unfortunately, we are almost three weeks downstream from this implementation, and are seeing few signs of improvement.

Neither the 9-1-1 center, the city, or the local telephone carriers are responsible for selecting area codes. They are distributed according to a national plan. “Overlays” are added when a region begins to run out of numbers in their original pool; in this case 9-1-9. Unfortunately, with the similarity between 9-1-9 and 9-1-1, our agency has seen this issue in the past, as some of our citizens have utilized 10 digit dialing for some time. The current impact on our staff – and on law enforcement – is that on our peak days we are dispatching officers to investigate hang up calls once every seven and a half minutes. Of course, this is a daily average, meaning that at peak times the impact is even more severe. Plus, we only dispatch calls that we can’t resolve another way. Many people who misdial don’t realize they have until we answer. Others hang-up, but answer when we call them back. In such cases sending an officer is not required, so the total number of calls we receive in error far exceeds those dispatched.

As Director of Emergency Communications, I am asking for your help. We have identified that a majority of such calls come from either senior citizens or business telephones. In the first case, confusion over the proper procedures seems to be the norm.  After 40 years, folks now have to dial 10 digits just to talk to their neighbor. We’ve had callers tell us they thought they had to now dial 9-1-1 before calling in our area, and others ask if they needed to dial 9-1-9 before they called 9-1-1. If you have an elderly friend, relative, or neighbor, I’d like to personally ask you to take the time to make sure they understand to carefully dial “9-1-9” when required. I believe that with some patience and understanding we can make significant inroads.

With regard to business telephones, the issue is a little more complex, and may in some cases even involve the need to dial “9” to get an outside line, followed by the unnecessary “1” before dialing the area code. Whatever the reason, it really boils down to just taking a few extra seconds to make sure of the numbers you’re dialing. Whether you work at a local business, or own one, can I please also count on you to assure that your co-workers use due care when calling? This is a very serious issue and takes resources away from dealing with actual emergencies.

So, to summarize:

  • There is a lack of understanding when to use 10-digit dialing.
  • Being “careful” is not going to fix this problem.
  • The added traditions for businesses to dial “9” to get out adds to the problem (NC State moved to a dial “7” system, presumably for this reason).
  • Those with a lifetime of 7-digit experience, and presumably the least likely to have numbers pre-programmed into a cell phone, make the most errors.

The issues here are fascinating, yet predictable. I don’t know if there is a perfect answer, since changing the long-term ill-chosen area code would be confusing (although my home town in Alabama has gone through 3 such changes in the last couple of decades – from 205 to 334 to 251!). But it is clear that we are penalized by the similarity of our numbers to a national standard for emergency calls. I applaud the tone of the email, which is not blameful – just desperate for a solution. However, I have great skepticism that advising “due care” in dialing will make any difference at all.

Bad Usability Causes Cranky Babies

I peripherally heard about another Tylenol recall and assumed the recall was prompted by tainted medicine or something.  Anne just sent me a link to the story and it is apparently usability related.  The syringe-based dosing system, called SimpleMeasure, seems to be difficult to use.  Here is what NPR says:

the “SimpleMeasure” dosing system that’s supposed to make it easier to fill a syringe with the right amount of the grapey painkiller and fever-reducer is too complicated for some parents.

Development of the ground proximity warning system for aviation

This article tells the story of inspiration for and creation of a “ground proximity warning” system for pilots, as well as multiple other types of cockpit warnings. Don’t miss the video embedded as a picture in the article! It has the best details!

Some choice excerpts:

About 3.5 miles out from the snow-covered rock face, a red light flashed on the instrument panel and a recorded voice squawked loudly from a speaker.

“Caution — Terrain. Caution — Terrain.”

The pilot ignored it. Just a minute away from hitting the peaks, he held a steady course.

Ten seconds later, the system erupted again, repeating the warning in a more urgent voice.

The pilot still flew on. Snow and rock loomed straight ahead.

Suddenly the loud command became insistent.

“Terrain. Pull up! Pull up! Pull up! Pull up! Pull up!”

Accidents involving controlled flight into terrain still happen, particularly in smaller turboprop aircraft. During the past five years, there have been 50 such accidents, according to Flight Safety Foundation data.

But since the 1990s, the foundation has logged just two in aircraft equipped with Bateman’s enhanced system — one in a British Aerospace BAe-146 cargo plane in Indonesia in 2009; one in an Airbus A321 passenger jet in Pakistan in 2010.

In both cases, the cockpit voice recorder showed the system gave the pilots more than 30 seconds of repeated warnings of the impending collisions, but for some reason the pilots ignored them until too late.

After a Turkish Airlines 737 crashed into the ground heading into Amsterdam in 2009, investigators discovered the pilots were unaware until too late that their air speed was dangerously low on approach. Honeywell added a “low-airspeed” warning to its system, now basic on new 737s.

For the past decade, Bateman has worked on ways of avoiding runway accidents by compiling precise location data on virtually every runway in the world.

Fun with confusing medication names!

Check out this post from The Consumerist about how unhappy the FDA is with Durezol and Durasal.

A hint: It’s ok if you accidentally use Durezol when you wanted Durasal, but the penalty is high for using Durasal instead of Durezol!*

This link contains an explanation of the names:

When drugs are submitted to the FDA for approval, the Agency carefully screens their proprietary names for similarities. However, Durasal (salicylic acid) is an OTC medication that did not undergo the approval process. That is why the two names exist side-by-side in the pharmacies.

Thus far, the FDA is asking pharmacists to “be vigilant.” I think we know how that usually plays out.

 

*Durezol is eye drops. Durasal is wart remover.

Excerpts from the NASA ASRS

One of my students last semester (thanks, Ronney!) turned me on the “Callback” publication from the NASA Aviation Safety Reporting System. These are almost all first person stories written as case studies of errors and accidents or near accidents. There aren’t so many that it falls under my list of neat databases, but it certainly is interesting reading.

I’ve collected a few below to give a taste of the stories that are included. These are just the top level descriptions – click through to read the first person accounts.

From Issue 381 Upside Down and Backwards

  1. “An aircraft Mode Selector Panel that “looks the same” whether right side up or upside down, and that can be readily installed either way, is a good example of a problematic design. Confronted with an inverted panel, this Cessna 560 Captain found out what happens when the wrong button is in the right place. “
  2. “Without detailed instructions and clear notation, nearly symmetrical parts can be installed incorrectly. Faced with the replacement of such a part, this CRJ 700 Maintenance Technician wound up with a case of component “misorientation.”

From Issue 383 When Practice Emergencies Go Bad

  1. “…a C182 pilot performed a simulated engine failure while undergoing a practical examination. It appears that both the examiner and the examinee were so engrossed in the simulated emergency that they both tuned BEEEEP out BEEEEP the BEEEEP gear BEEEEP warning BEEEEP horn.”
  2. “When faced with a real engine failure, performing the Engine Secure Checklist reduces the chance of a fire on landing. However, actually performing the steps in the Engine Secure Checklist when the engine failure is not real can lead to a real problem.”

From Issue 382 Fly the Airplane!

  1. “A review of recent ASRS reports indicates that failure to follow one of the most basic tenets of flight continues to be a concern when pilots are faced with distractions or abnormal situations.”

From Issue 376 The Fixation Factor

  1. “The ability to maintain the “big picture” while completing individual, discrete tasks is one of the most critical aspects of working in the aviation environment. Preoccupation with one particular task can degrade the ability to detect other important information. This month’s CALLBACK looks at examples of how fixation adversely affects overall task management.”
  2. “Advanced navigation equipment can provide a wealth of readily available information, but as this Cirrus SR20 pilot learned, sometimes too much information can be a distraction.”

From Issue 375 Motor Skills: Getting Off to a Good Start

  1. “The Captain of an air carrier jet experienced a very hot start when distractions and failure to follow normal flow patterns altered the engine start sequence.”
  2. “This pilot was familiar with the proper procedures for hand-propping, but despite a conscientious effort, one critical assumption led to a nose-to-nose encounter.”

Photo credit smartjunco @ Flickr

 

 

 

What values are pilots allowed to enter for the weight of the plane?

I’d assume when pilots enter a weight estimate for the plane prior to takeoff that there would be a decision aid to prevents gross miscalculation. It certainly seems like an undue load (no pun intended) on the pilot to require entering multiple components for weight correctly. From the article linked below I am no longer sure how much automation is involved. Apparently, the pilot forgot to account for the weight of the fuel. Doesn’t it seem as though that would be the easiest weight to automatically enter?

From the article:

Pilot Miscalculates Plane Weight, Avoids Disaster

“The weight of the plane dictates the speed required to take off and too little speed could have caused pilots to lose control of the aircraft. Luckily, the captain realized something was wrong and compensated before the plane ran off the runway.

According to the report there have been “a significant number of reported incidents and several accidents resulting from errors in take-off performance calculations around the world in recent years.”

On a side note, I’ve been on small planes where we all had to be weighed as well as our luggage prior to boarding. If the margins are that thin, I sure hope no one made any data entry mistakes!

 

Photo credit martinhartland @ Flickr

Learning to use a steering wheel with no vision or feedback

Here is a link to an enjoyable radioshow called “99% invisible,” about the “design, architecture & the 99% invisible activity that shapes our world.”*

99% Invisible-37- The Steering Wheel

This episode covers the difficulty people have in correctly miming use of a steering wheel (spoiler: they can’t!) and how they can learn to do so correctly with no visual feedback. The researcher interviewed was Steven Cloete, whose website can be found here with more information about research specifics.

99% invisible was recently featured on Radiolab, one of my favorite science podcasts.

*no relation to the 99%.

 

Image credit ryanready at Flickr

Paper isn’t so bad…

One thing that annoys me is the silly argument that paper is bad or paper kills. Such hollow arguments are used to encourage technology adoption in airplane cockpits, the class room, and hospitals. Usually they are associated with silly statistics about how much paper is saved or how much less weight is carried, or how much easier it will be to look through documents (I use an iPad to hold hundreds of articles and while I can *hold* more articles, it has not translated to more reading and it does not improve my reading comprehension at all).

We are now finally starting to see a more nuanced view of technology.  The NTSB recently proposed banning all distracting technology while driving and this NYT article discusses the downsides of blind technology adoption in hospitals.

Hospitals and doctors’ offices, hoping to curb medical error, have invested heavily to put computers, smartphones and other devices into the hands of medical staff for instant access to patient data, drug information and case studies.

But like many cures, this solution has come with an unintended side effect: doctors and nurses can be focused on the screen and not the patient, even during moments of critical care. And they are not always doing work; examples include a neurosurgeon making personal calls during an operation, a nurse checking airfares during surgery and a poll showing that half of technicians running bypass machines had admitted texting during a procedure.

I hope this brief period of common sense lasts.

Rudder knob in cockpit mistaken for door latch

Any aviation experts want to chime in about a knob turning a plane upside down? Also, please note this was characterized as “pilot error.”

Pilot error causes airliner to flip, fly upside down

From the article:

According to the safety board, an analysis of the aircraft’s digital flight recorder indicated the co-pilot, alone in the cockpit while the captain used a restroom, mistakenly turned the rudder trim knob twice to the left for a total of 10 seconds.

The co-pilot apparently mistook the knob for the cockpit door-lock switch as he tried to let the captain back in. The mistake is believed to have caused the airplane to tilt leftward and descend rapidly.