Category Archives: safety

Collection of Aviation Safety Articles & Student Activity Ideas

I recently came across an impressive collection of Human Factors related safety stories, mostly concerning aviation, from a the System Safety Services group in Canada. The summaries are written in an accessible way, so I recommend this site for good classroom examples. I was already thinking of a classroom activity, perhaps for an undergraduate course:

In class:
Please read the following excerpt (abridged) from Aviation Human Factors Industry News Volume VII. Issue 17. Provide a list of the pros and cons of allowing ATCs to take scheduled naps during their shifts. Put an * by each pro or con that is safety related. The full article is available via the link above.

…the FAA and the controllers union — with assistance from NASA and the Mitre Corp., among others — has come up with 12 recommendations for tackling sleep-inducing fatigue among controllers. Among those recommendations is that the FAA change its policies to give controllers on midnight shifts as much as two hours to sleep plus a half-hour to wake up. That would mark a profound change from current regulations that can make sleeping controllers subject to suspension or dismissal. Yet, at most air traffic facilities, it’s common for two controllers working together at night to engage in unsanctioned sleeping swaps whereby one controller works two jobs while the other controller naps and then they switch off…

More than two decades ago, NASA scientists concluded that airline pilots were more alert and performed better during landings when they were allowed to take turns napping during the cruise phase of flights. The FAA chose to ignore recommendations that U.S. pilots be allowed “controlled napping.” But other countries, using NASA’s research, have adopted such policies for their pilots. Several countries — including France, Germany, Canada and Australia — also permit napping by controllers during breaks in their work shifts, said Peter Gimbrere, who heads the controllers association’s fatigue mitigation effort. Germany even provides controllers sleep rooms with cots, he said. …fatigue affects human behavior much like alcohol, slowing reaction times and eroding judgment. People suffering from fatigue sometimes focus on a single task while ignoring other, more urgent needs.

One of the working group’s findings was that the level of fatigue created by several of the shift schedules worked by 70 percent of the FAA’s 15,700 controllers can have an impact on behavior equivalent to a blood-alcohol level of .04, Gimbrere said. That’s half the legal driving limit of .08. “There is a lot of acute fatigue in the controller work force,” he said. Controllers are often scheduled for a week of midnight shifts followed by a week of morning shifts and then a week swing shifts, a pattern that sleep scientists say interrupts the body’s natural sleep cycles.

At home:
Your homework assignment is to identify another work domain with similar characteristics where you believe fatigue is a safety concern. Write an argument for requiring rest during work hours or other solutions for fatigue. Again, specifically call out the pros and cons of your solution.

A list of all articles, in newsletter form, can be found here.

Photo credit mrmuskrat @ Flickr

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.

Looking down the barrel of a gun

Here is a design that requires disobedience of the fundamental rule in a sport: don’t point your gun at someone you don’t plan to shoot. Blogger Mark Shead posits it might be due to a lack of domain knowlege by the designer and extends the analogy to software design.

Mistakes in software design aren’t always as easy to spot, but often it comes down to the same thing. To design something you must have at least a basic level of domain knowledge.  That doesn’t means you have to be a world famous chef in order to write a recipe webapp, but you need to make sure you at least know the basics.

Read the full post discussing this design.

New automation will warn drivers of lane changes

Ford is introducing a system that first warns of a lane change, then actually changes the direction of the car if the warning is ignored. From the USA Today article:

When the system detects the car is approaching the edge of the lane without a turn signal activated, the lane marker in the icon turns yellow and the steering wheel vibrates to simulate driving over rumble strips. If the driver doesn’t respond and continues to drift, the lane icon turns red and EPAS will nudge the steering and the vehicle back toward the center of the lane. If the car continues to drift, the vibration is added again along with the nudge. The driver can overcome assistance and vibration at any time by turning the steering wheel, accelerating or braking.

Is this going to be as annoying as having Rich Pak’s phone beep every time I go over the speed limit (which is A LOT)? Just kidding – stopping a drifting car could be pretty great.

 

LOLcat photo credit to ClintCJL at Flickr.

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

 

 

 

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.

 

Verdict Reached for Air France Rio Crash

The BBC has reported the incident analysis of the Air France crash that killed 228 people was due to lack of pilot skill in dealing with a high altitude stall.

Here is a link to the BEA Report from the Bureau d’Enquetes et d’Analyses. It’s a frightening read, as they give a moment by moment analysis of the last minutes in the cockpit. No emergency was ever noted and there did not appear to be any mechanical failures. It appeared that the flight crew thought events were under control the entire time (despite the alarms.)

 

 

Photo credit Vin Crosbie at Flickr.

Failure to Design Out, Guard, or even Warn Results in Worker Pulled Through 5-inch Opening

The story of a UK man who was pulled through a small opening meant for steel poles is in the news again as the companies involved pleaded guilty to not having safety measures in place. Read the article here (with a picture of the machine).

I’ve excerpted the reported accident factors below:

“His clothing snagged on the machine and he was forced though an opening just 125mm wide on the machine head, suffering injuries that have caused lasting physical and psychological damage…. The HSE investigation into the incident on 19 December 2008 found there was no guarding in place to protect the worker from dangerous moving parts …  HSE investigators also established that Matthew, then aged 23, was inexperienced in operating the machinery after being moved from a different line at the factory because of a lull in his regular workload.  However, it was the lack of guarding that was deemed the decisive factor.”

And from another article:

Prosecuting, Chris Chambers said: “The machine could start, stop and restart without warning to the operator. As Matthew leaned through the hatch he was struck on the back of the shoulder and pulled through. Shoulder to feet he was pulled through the opening…the width of a CD case.”

Summary: Clothing entanglement, lack of guards, lack of warning, and inexperience. I think it is interesting that the tone of the article seems to try and reduce the potential effects of inexperience, perhaps because it sounds like “blaming the victim.” I don’t think inexperience should have that overtone — one would classify re-assigning a worker without proper training to a dangerous task as an organizational problem with the company, not due to fault on Matthew’s part for performing the job he was assigned.