Flight Safety Information - July 13, 2023 No. 134 In This Issue : Incident: Canada B763 near Barranquilla on Jul 11th 2023, unreliable airspeed and altitude : Incident: LATAM A321 at Florianopolis on Jul 12th 2023, "dancing in the rain" : Accident: Air China A333 enroute on Jul 10th 2023, clear air turbulence injures two : Unresolved Citation jet’s air-data fault preceded serious airprox with E170 : Missing a small part on a landing gear, FedEx pilots were forced to make an emergency landing : NCAA suspends Max Air Boeing 737 planes over safety concerns : Some Allegiant Air passengers and crew are injured in a turbulent Florida-bound flight, officials say : Airplane emergency exit seats to be assigned to uniformed personnel first (S. Korea) : Frontier Airlines kicks 2 women off Las Vegas-bound plane for fighting, disrupting flight : Hawaiian Airlines set to add free Starlink WiFi : Runway Lighting Stolen From Lagos Airport : The Dirty Dozen: Common human error factors in aircraft maintenance mishaps : Jet engines so Reliable : Roman Abramovich: A Look At His Private Jet Collection : Kazakhstan’s Civil Aviation Reaches 82% Compliance with ICAO Requirements Incident: Canada B763 near Barranquilla on Jul 11th 2023, unreliable airspeed and altitude An Air Canada Boeing 767-300, registration C-GHLV performing flight AC-7263 from Bogota (Colombia) to Punta Cana (Dominican Republic), was enroute at FL380 about 170nm east of Barranquilla (Colombia) when the aircraft began to seemingly climb and descend. The crew reported they had unreliable airspeed indications, requested a block altitude and decided to divert to Barranquilla. The aircraft landed safely on Barranquilla's runway 05 about 55 minutes after the first larger altitude deviation (+250 feet) according to the aircraft's Mode-S transmitter. The aircraft is still on the ground in Barranquilla about 21 hours after landing. A listener on frequency reported the crew declared Mayday reporting unreliable airspeed, they needed a block altitude and requested to divert to Barranquilla. https://avherald.com/h?article=50bafbe0&opt=0 Incident: LATAM A321 at Florianopolis on Jul 12th 2023, "dancing in the rain" A LATAM Brasil Airbus A321-200, registration PT-MXM performing flight LA-3300 from Sao Paulo Guarulhos,SP to Florianopolis,SC (Brazil) with 172 passengers and 7 crew, landed on Florianopolis' runway 32 in heavy rain at 09:18L (12:18Z) but lost directional control, began to turn while drifting along the runway sideways and ran off the left runway edge before coming to a stop with the nose gear on soft ground and the main gear on asphalt of the runway shoulder. The right main gear broke through the asphalt and became stuck in the surface, the right hand engine (V2533) pod seems to barely touch the surface. There were no injuries, the aircraft received damage to tyres, wheels and possibly engine pod. The airline reported their A321-200 registration PT-MXM exceeded the runway limits at landing of flight LA-3300 in Florianopolis. The airline mobilized their recovery team to remove the aircraft as soon as possible. https://avherald.com/h?article=50baee51&opt=0 Accident: Air China A333 enroute on Jul 10th 2023, clear air turbulence injures two An Air China Airbus A330-300, registration B-5916 performing flight CA-1524 from Shanghai Hongqiao to Beijing (China) with 240 people on board, was enroute when the aircraft encountered clear air turbulence causing minor injuries to a flight attendant and a passenger. The aircraft continued to Beijing for a safe landing about 110 minutes after departure. The aircraft remained on the ground in Beijing for about 15 hours before returning to service. The worst moment during turbulence, a flight attendant and a passenger out of their seats thrown against the cabin ceiling. https://avherald.com/h?article=50baf36b&opt=0 Unresolved Citation jet’s air-data fault preceded serious airprox with E170 French investigators have revealed that a Cessna Citation 525 crew’s uncertainty over the jet’s altitude, owing to an air data problem, preceded a serious airprox incident involving a Hop Embraer 170 early last year. The inquiry found that a fault in the captain’s air-data system had occurred three times over the course of about four years – including a month before the airprox – but it had not been properly addressed. After the Valljet aircraft departed Paris Le Bourget on 12 January 2022 it climbed towards 27,000ft. But the captain, who was flying, and the first officer found that their altimeter readings disagreed – the first officer believed the aircraft had overshot its assigned altitude while the captain thought the aircraft was still beneath it. The standby altimeter was closer to the first officer’s display. The crew levelled the jet and asked the air traffic controller to provide an altitude reading, to which the controller responded with 26,300ft. This was consistent with the figure on the captain’s altimeter while the first officer’s altimeter was showing 28,000ft. French investigation authority BEA says this led to “confirmation bias” because the captain took the controller’s response as evidence that his altimeter was correct, when the controller was actually just reading back the inaccurate altitude data received from the aircraft. Pilots of the Citation 525 experienced a disagreement between their air-data systems The crew therefore continued the climb to 27,000ft, as indicated on the captain’s system, but the discrepancy meant jet was actually flying some 1,500ft higher. About 4min after supposedly reaching 27,000ft the captain informed the controller of an apparent problem with the altimeters, and said the aircraft might be higher than its transponder was transmitting. BEA says the crew “did not envisage” switching to the other transponder, which would have used the first officer’s indications. The controller advised the crew of traffic – the Hop E170 – directly ahead at 2nm distance, which was theoretically 1,000ft above. The E170 was actually some 660ft below. No collision-avoidance warning was issued because the systems were analysing the potential conflict based on erroneous data from the Cessna. BEA estimates the aircraft converged, a few seconds later, to a minimum horizontal and vertical separation of 1.5nm and 665ft. The aircraft, bound for Geneva, continued its flight after the controller asked the pilots to de-activate the Mode-C transponder and co-ordinated with military and Swiss control services to support its progress. No-one on board either aircraft was injured. Erroneous Citation air data meant the E170’s collision-avoidance system did not activate BEA says a fault on the captain’s air-data system had shown up in November 2017, after which maintenance work found pollution the left-hand airspeed indicator system. Another occurrence in February 2019 led to maintenance action which focused on a barometric fault. No air safety report was written. The system was the subject of a third incident in December 2021 but no air safety report was written and no fault was recorded in the technical log – only “informal verbal exchanges” took place, says BEA. BEA carried out a detailed examination of the aircraft (F-HGPG) and discovered that, just above the captain’s pedals, the left pitot hose formed an “elbow” which created a low point in the system – in which liquid water could potentially accumulate – whereas the hose should have followed a continuous slope from the air-data instruments to the pitot tube. The inquiry says the examination “did not identify with certitude” the cause of the air-data system fault. But it points out that the symptoms of the three incidents suggest the fault was probably an obstruction – likely to be water or ice – located in the hose on the captain’s side. BEA says the hose was reinstalled after the incident, eliminating the low point, and the aircraft was returned to service in March 2022. Up to mid-April this year, it states, no fault with the air-data system has recurred. https://www.flightglobal.com/safety/unresolved-citation-jets-air-data-fault-preceded-serious-airprox-with-e170/154084.article Missing a small part on a landing gear, FedEx pilots were forced to make an emergency landing WASHINGTON (AP) — Federal safety officials said Wednesday they were unable to determine why a pin in a landing gear of a FedEx plane came loose during a 2020 flight, disabling the gear and forcing pilots to make an emergency landing. The National Transportation Safety Board said they believe the pin, which helps secure one end of a rod to another part on the landing gear brake assembly, was in place when the plane took off from Newark, New Jersey. They said when it came loose during the flight to Los Angeles, it allowed the rod to become jammed in the landing gear. The NTSB said the mechanic who last worked on the brake assembly a month before the incident did not recall anything unusual about the job. Sparks flew when the cargo plane made a pre-dawn landing at Los Angeles International Airport. The three-year-old Boeing 767 came to rest on the engine housing under its left wing because the landing gear on that side never extended. The two pilots used a rope to escape the cockpit after getting an engine-fire warning — the plane was not required to have evacuation slides because of an exemption granted to FedEx by the Federal Aviation Administration. The co-pilot lost his grip on the rope and fell to the runway, suffering a fractured heel. https://www.rochesterfirst.com/news/business/ap-missing-a-small-part-on-a-landing-gear-fedex-pilots-were-forced-to-make-an-emergency-landing/ NCAA suspends Max Air Boeing 737 planes over safety concerns The Nigeria Civil Aviation Authority (NCAA) has suspended the operations of all the Boeing 737 aircraft in the fleet of Max Air over safety concerns after a series of incidents. The suspension conveyed in a letter with reference number, NCAA/DG/AIR/11/16/363, dated July 12, 2023, titled, ‘Suspension of Parts A3 and D43 of the Operations Specifications Issued to Max Air with Immediate Effect,’ The letter reads: “The Nigerian Civil Aviation Authority (NCAA) hereby suspends Parts A3 (Aircraft Authorization) and D43 (Aircraft Listing) of the Operations Specifications issued to Max Air Ltd. with regards to the operations of the Boeing B737 aircraft type in your fleet. “With the above suspension, you are to immediately suspend the operations of all Boeing B737 aircraft in your fleet. “The Authority’s action is due to the several occurrences that involved your Boeing B737 aircraft as listed hereunder: Power failure, poor maintenance caused Max Air's narrow crash — NSIB “Loss of Number 1 Main Landing Gear (MLG) wheel during the serious incident involving a Boeing 737-400 aircraft, registration marks 5N-MBD which occurred between Take-off at Yola Airport Adamawa State and on landing at Nnamdi Azikiwe International Airport, Abuja Nigeria on 7th May 2023. “Fuel Contamination of the main fuel tanks of aircraft B737-300, Registration Marks; 5N-MHM, leading to the Auxiliary Power Unit (APU) shutdown on ground Yola Airport on the 7th of July, 2023. “Aborted take-off of Boeing 737-400 aircraft, registration marks 5N-MBD, which occurred at the Mallam Aminu Kano International Airport (MAKIA) due to high Exhaust Gas Temperature (EGT) indication on the 11th of July, 2023. “An air return by aircraft B737-300, Registration Marks; 5N-MHM to Nnamdi Azikiwe International Airport (NAIA) due to duct overheat indication in the cockpit on the 11th of July, 2023. “The authority has constituted a team of inspectors to conduct an audit of your organization. The result of this audit, it said, must be found satisfactory by the Authority prior to considering the restoration of the privileges of the operations Specifications to your organisation to further operate the aircraft type.” https://punchng.com/just-in-ncaa-suspends-max-air-boeing-737-planes-over-safety-concerns/ Some Allegiant Air passengers and crew are injured in a turbulent Florida-bound flight, officials say Four people on a Florida-bound Allegiant Air flight were being examined for injuries after the flight encountered severe turbulence Wednesday afternoon, the airline said. Allegiant Air Flight 227, which had taken off from Asheville, North Carolina, “experienced severe turbulence before landing” at St. Pete-Clearwater International Airport, airline spokesperson Andrew Porrello said. The plane, carrying 179 passengers and six crew members, “landed normally and taxied to the gate under its own power,” Porrello said. Two passengers and two flight attendants were taken to a hospital for evaluation after airport paramedics assessed them for injuries, Porrello said, without describing the injuries or the conditions of the four. The injuries were believed to be relatively minor, St. Pete-Clearwater airport spokesperson Michele Routh told CNN. Lisa Spriggs, who was a passenger on the flight, said the turbulence was “petrifying.” “More than halfway through descending, and all of a sudden, we hit a small turbulence, and the stewardess beside us fell to the ground,” Spriggs told CNN affiliate WFTS. “And then we hit a major turbulence, which was petrifying. And she was literally like ‘Matrix.’ Watched her go up in the air and just land straight down,” Spriggs said. The crew of the Airbus A320 reported turbulence while on approach to the Florida airport around 3:45 p.m., the Federal Aviation Administration said. Neither the FAA – which said it would investigate the incident – nor Porrello released further details about what happened. Allegiant will investigate the incident in coordination with the FAA and the National Transportation Safety Board, Porrello said. https://www.cnn.com/2023/07/12/us/allegiant-air-plane-turbulence-injuries/index.html Airplane emergency exit seats to be assigned to uniformed personnel first (S. Korea) New seating scheme starts July 31 Airplane emergency exit seats of four Korean airlines will be initially assigned to uniformed personnel, including police officers and firefighters, in an effort to prevent the reoccurrence of an incident in which a passenger opened an emergency exit door before landing, the ruling party said Thursday. During a consultation meeting between the ruling People Power Party and the government, Rep. Park Dae-chul, the head of the party’s policy committee, said his party has agreed to introduce the new seating scheme starting July 31. “The purpose of the emergency exit is for the flight crew to quickly and safely help passengers get off the plane during emergencies,” Rep. Park told reporters after the meeting. The uniform personnel who would be prioritized for the exit row seats are firefighters, police officers, soldiers and airline employees, he added. The seating arrangement will be applied to 94 seats in 38 aircraft operated by the country’s four airliners -- Asiana Airlines, Air Seoul Co., Air Busan Co. and Aero K Airlines Co. With the new measure set to come into effect, airline companies will inform passengers about the revised seating chart to minimize confusion when they purchase tickets and select seats online. Staff at airport check-in counters will also verify the passengers’ identities. In addition, emergency exit seats will also be initially sold to uniform personnel buying tickets on site. The idea was floated after a series of mishaps where passengers had tried to open emergency exit doors in flight. In May, one passenger opened the emergency door minutes before landing. The door was reportedly opened for eight minutes until the plane reached the tarmac. In June, an 18-year-old attempted to open the door an hour after the plane took off. https://m.koreaherald.com/view.php?ud=20230713000756 Frontier Airlines kicks 2 women off Las Vegas-bound plane for fighting, disrupting flight LAS VEGAS (KLAS) — A planeful of Las Vegas-bound passengers ended up being diverted to Denver International Airport Tuesday night after a fight broke out involving some passengers. Frontier Airlines flight 2143 left Philadephia around 10:30 p.m. (ET) Tuesday and was scheduled to arrive in Las Vegas around 8:40 p.m. (PT) but was approximately an hour late because the plane deviated to Denver and two passengers traveling together were deplaned and met at the gate by Denver police officers, said Michael Konopasek, Frontier Airlines corporate communications manager. A Las Vegas resident on that plane, who was returning from a vacation, took video on the plane of the fight. The woman who asked not to be identified said two women began loudly arguing with each other and a flight attendant approached them three times to stop the argument and did end up moving one woman to a different seat. The passenger said the two women continued to verbally fight and swear loudly even after being separated. She said it appeared one of the women involved in the fight hit a male passenger on or near the head as she made her way to a bathroom. “It was fairly disruptive so passengers began to tell them to shut up because their behavior was escalating,” the woman told 8 News Now. The flight was diverted to Denver, Colorado so the women could be removed from the plane. According to the passenger, the two women were escorted off the plane. A few other passengers also left the plane to give police a witness statement. Upon returning to the plane, those passengers said the police had contacted the FBI. “Luckily the Vegas-based Frontier crew was great,” said the Las Vegas passenger who praised the crew for how it handled the situation. According to the FAA, it reports a surge in unruly passengers occurred during the post-pandemic travel surge, and the FAA called for stricter legal enforcement. FAA reports incidents of unruly passengers have decreased by 80% since a 2021 record high of nearly 6,000 incidents. Causing a disturbance on a plane is a federal crime. Unruly passengers can face criminal prosecution and charges. https://www.8newsnow.com/news/local-news/video-frontier-airlines-kicks-2-women-off-las-vegas-bound-plane-for-fighting-disrupting-flight/ Hawaiian Airlines set to add free Starlink WiFi HONOLULU (KHON2) — The airline industry — still struggling to recover from recent major disruptions that impacted big carriers including Hawaiian, Southwest, and United — is cautiously looking forward to a potentially transformative 2024 for Hawaiian Airlines. New offerings, such as Wi-Fi on long-haul flights and comfortable seating arrangements are part of the carrier’s future plan. Get Hawaii’s latest morning news delivered to your inbox, sign up for News 2 You Earlier this week, Peter Ingram, the President and CEO of Hawaiian Airlines, penned a letter to customers to apologize for recent issues, including delays stemming from runway construction at Honolulu’s airport, engine supply chain challenges and a recent technology upgrade that caused unexpected problems. Industry experts highlight that many airlines are currently battling with issues impacting their brand reputation with customers. Jerry Agrusa, a professor at the UH Manoa Shidler College of Business, commented, “Their brands need the help right now. Hawaiian Airlines has very loyal customers. And I think both of them really, really need to work on getting it down. And as you can see, it’s not just those airlines. United had this major crisis as well.” State data indicates that this month, Hawaii has averaged nearly 35,000 passengers a day, up 6% from last year. Moreover, spending this year has reached an all-time high of $243 per person per day. “Airlines have to do their job: get people from point A to point B and hopefully without a delay, and they can charge what they want. You can see the prices are higher. Everyone’s making more money,” added Agrusa. Hawaiian Airlines states that its reliability has improved now that the runway construction at Honolulu’s airport is complete and its IT systems are witnessing steady enhancements. Beginning in early 2024, Hawaiian Airlines plans to introduce free Wi-Fi on all flights, excluding neighbor island travel, boasting that they’ll become the first major airline to use SpaceX’s product Starlink. “It’s Starlink, which means that on all of our long-haul fleet, eventually, our guests will have access to fast, totally free Wi-Fi that you can connect to with a click of a button. So, it’s going to be very different, I think, than what people were used to experiencing in terms of in-flight Wi-Fi,” said Avi Mannis, the Chief Marketing Officer of Hawaiian Airlines. The airline is also set to debut its new 787 Dreamliner planes, featuring a new 3 by 3 by 3 seating chart. While the configuration may result in pairs or groups of four sitting next to a stranger, Hawaiian Airlines assures that the seats were designed with comfort in mind. “A brand new flagship aircraft. It is new in every sense. We have re-envisioned every cabin on the aircraft,” added Mannis. The Dreamliners are set to roll out in early 2024. As for securing good fares, Agrusa advises early booking to get some deals. However, if you procrastinate on booking a flight, you’ll likely pay premium prices. https://www.khon2.com/local-news/hawaiian-airlines-set-to-add-free-starlink-wifi/ Runway Lighting Stolen From Lagos Airport Sources claim top officials at the airport were involved. Thieves have made off with a lighting system on one of the runways at Lagos Airport. The lighting had only been installed in November 2022 and enabled planes to use the runway at night, a boost to airport operations. Lagos Airport runway lighting system stolen Murtala Muhammed International Airport (LOS) installed a new ground lighting system back in November 2022 to put an end to after-dusk restrictions on Runway 18/36L, located close to its domestic terminal. A spokesperson from the Federal Aviation Authority of Nigeria (FAAN), Abdullahi Yakubu-Funtua, confirmed to the BBC that the system has now been stolen. The runway had been undergoing maintenance over the past few months, giving the thieves a good opportunity to strike. One source told Punch, "The criminal took advantage of the closure to commit the crime. I cannot give the actual worth of the theft, but almost all the lighting was removed. The permanent secretary came around to see for himself the huge damage done." An inside job According to various local media sources, several airport workers were involved in the theft and conspired with "accomplices from the outside." Several officials at FAAN (Federal Airport Authority of Nigeria) have now been suspended on orders from Permanent Secretary of the Ministry of Aviation, Dr. Emmanuel Meribole, and an investigation has been launched to "arrest the criminals [and] recover what's missing." It is not clear exactly when the theft occurred. Arise News reports that the first set of lights were stolen back in May, and a directive to remove the remaining lights was ignored, raising suspicions of inside involvement. It seems incursions at the airport happen quite often, with an anonymous source claiming "the regular incursion and stealing of safety components at the airports are carried out by a syndicate," aided by workers on the inside. This wouldn't be the first instance of corruption from within the Nigerian aviation industry. There have been numerous instances of jet fuel theft, while one airline even alleged its planes were being deliberately sabotaged by ground workers. What exactly was stolen? As reported by One Mile At A Time, a NOTAM (Notice to Air Missions) indicates that it was the runway's PAPI (precision approach path indicator) lights that were stolen. PAPI lights are a visual aid that help pilots adjust their altitude position during landing. As for why exactly thieves would steal this highly specialized equipment, Group Captain John Ojikutu, a former Military Commandant at Lagos Airport, believes those responsible will try to resell the system back to the airport, essentially holding it ransom. Ojikutu commented, "This is not new at Lagos Airport. I wish the FAAN management could go back to 1990 when similar things happened in the airport. I was convinced that it was an ‘insider threat’. What did I do? I positioned soldiers on the runways and ensured that no FAAN maintenance staff went near the runways for anything without my approval; otherwise, it was shoot at first sight. It stopped completely." https://simpleflying.com/runway-lighting-stolen-lagos-airport/ The Dirty Dozen: Common human error factors in aircraft maintenance mishaps JOINT BASE SAN ANTONIO-RANDOLPH, Texas -- Aircraft maintenance saddles the worlds of occupational and aviation safety, which makes for a challenging combination of hazards. In the span of one shift, maintainers may encounter the risks of running a turbine engine at thousands of RPMs, falling from the potentially fatal height of wing, or losing a finger to a hydraulically actuated control surface. In the first half of 2023 alone, Air Education and Training Command experienced more than $23 million in aircraft damage costs associated with maintenance, according to Master Sgt. Clinton Gessler, AETC Safety Directorate flight safety NCO. In the mishaps that occurred, a common theme developed: shortfalls in “back-to-basics maintenance,” or as some would say, “Maintenance 101.” “In my 16-year career as a tactical aircraft maintenance technician, I can tell you aircraft maintenance isn’t a job that is going to get any less demanding,” Gessler stressed. “We will always have to deal with operational and fiscal constraints leading to aircraft availability challenges resulting in the all too familiar feeling of ‘do more with less.’ Additionally, dealing with an emerging near-peer threat and finding innovative ways to employ airpower will create challenges in both mishap prevention and aircraft maintenance’s mission success.” To better equip maintainers to combat the risks they encounter daily, AETC Safety is leveraging what one safety expert termed “The Dirty Dozen.” This list identifies 12 of the most common human error factors that lead to aircraft maintenance mishaps. This list is by no means all-inclusive, but it includes some of the most frequent elements that influence people in the maintenance community to make mistakes, and understanding these hazards will enable maintenance personnel to avoid costly and dangerous errors. Whether maintaining a legacy airframe with decades of “lessons learned” or a 5th generation aircraft with advanced automated aircraft health management and troubleshooting systems, The Dirty Dozen affects everyone. “When we choose to let these 12 human factors catalyze unnoticed, the probability and severity of mishaps will increase,” Gessler said. “However, when we deliberately allocate time and energy towards accomplishing the basics of maintenance — tool accountability, FOD (foreign object damage) walks, cleaning up spills, following tech data, and paying attention to details — we reduce the likelihood of a mishap occurring.” Drawing from SKYbrary (https://www.skybrary.aero/), an electronic repository of aviation safety knowledge, this article will identify and define The Dirty Dozen, and provide suggested countermeasures to reduce the risks posed by each of these hazards. The List: 1. Lack of communication 2. Distraction 3. Lack of resources 4. Stress 5. Complacency 6. Lack of teamwork 7. Pressure 8. Lack of awareness 9. Lack of knowledge 10. Fatigue 11. Lack of Assertiveness 12. Norms Lack of Communication Poor communication often appears at the top of contributing and causal factors in accident reports and is, therefore, one of the most critical human factor elements. Communication refers to the transmitter and the receiver, as well as the method of transmission. Transmitted instructions may be unclear or inaccessible. The receiver may make assumptions about the meaning of these instructions, and the transmitter may assume that the message has been received and understood. With verbal communication it is estimated that only 30 percent of a message is received and understood. Detailed information must be passed before, during and after any task, and especially across the handover of shifts. Therefore, when messages are complex, they should be written down, and organizations should encourage full use of logbooks, worksheets, checklists, etc. Verbal messages can be kept short, with the most critical elements emphasized at the beginning and repeated at the end. Assumptions should be avoided and opportunities for asking questions both given and taken. Furthermore, for critical operations such as towing or jacking an aircraft, or conducting an engine run, ensure all members of the team understand their roles, expectations and what to do if things go wrong. This extra communication may add time to tasks, but even one mishap will cost much more time to sort out, and it may cost someone his or her life. Complacency Complacency can be described as a feeling of familiarity with a task accompanied by a loss of awareness of potential dangers. Such a feeling often arises when conducting routine activities that have become habitual and which may be considered by an individual (sometimes by the whole organization) as easy and safe. With less vigilance, important warning signs can be missed, with the individual only seeing what he, or she, expects to see. Complacency can also occur following a highly intense activity such as recovering from a possible disaster. The relief felt at the time can result in physical relaxation and reduced mental vigilance and awareness. While too much pressure and demand cause over-stress and reduced human performance, too little results in under-stress, boredom, complacency and reduced human performance. It is therefore important when conducting simple, routine and habitual tasks, and when fatigued, to maintain an adequate, or optimum, level of stress through different stimulation. Always assume you can make a mistake if not careful. Following written instructions and adhering to procedures that increase vigilance, such as inspection routines, can provide suitable stimulus. It is important to avoid working from memory, assuming that something is okay when you haven’t checked it, and signing off work that you are unsure has been completed. Teamwork and mutual cross-checking will provide adequate stimulus when fatigued. If supervising, be actively involved in the activities of your subordinates in a positive, motivating way. Effective leadership is helping our Airmen stay actively engaged with their task by ensuring they perform with excellence, while also teaching them how to do so. Lack of Knowledge The regulatory requirements for training and qualification can be comprehensive, and organizations must enforce these requirements. Otherwise, lack of on-the-job experience and specific knowledge can lead workers into misjudging situations and making unsafe decisions. Aircraft systems are so complex and integrated that it is nearly impossible to perform many tasks without substantial technical training, current relevant experience and adequate reference documents. Furthermore, systems and procedures can change substantially, and employees’ knowledge can quickly become out-of-date. It is important for employees to undertake continuing professional development and for the most experienced workers to share their knowledge with colleagues. Part of this learning process should include the latest knowledge on human error and performance. It should not be taken as a sign of weakness to ask someone for help or for information; in fact, this should be encouraged. Checklists and publications should always be referred to and followed, and never make assumptions or work from memory. Finally, good leaders will help their subordinates see the value in investing in their own expertise. Encourage intellectual curiosity and independent study of the more technical subjects associated with aircraft maintenance. After all, wise investments in your knowledge of these subjects will better posture you for life after the Air Force as well, and there are many courses available for free such as those found here: https://www.faasafety.gov/gslac/ALC/course_catalog.aspx?view=AMT Distraction Distraction could be anything that draws a person’s attention away from the task on which they are employed. Some distractions in the workplace are unavoidable, such as loud noises, requests for assistance or advice, and day-to-day safety problems that require immediate solving. Other distractions can be avoided or delayed until more appropriate times, such as messages from home, management decisions concerning non-immediate work (i.e., shift patterns, leave entitlement, meeting dates, administrative tasks, etc.), and social conversations. Psychologists say that distraction is the number one cause of forgetting things, hence the need to avoid becoming distracted and to avoid distracting others. Humans tend to think ahead. Thus, when returning to a task following a distraction, we have a tendency to think we are further ahead than we actually are. To reduce errors from distraction, it is best to complete a task before responding. If the task cannot be completed without hurrying, then we can prominently mark (or “lock off”) the incomplete work as a reminder to ourselves and anyone else who may complete the work. When returning to work after being distracted, it is a good idea to commence at least three steps back, so that we retrace some steps before picking up the task again. If necessary, having someone else double-check our work using a checklist may be appropriate and useful. Management has a role to play in reducing the distractions placed on its employees. This may involve good workspace design, management of the environment, and procedures that create “safety zones,” “circles of safety” or “do not disturb areas” around workers engaged in critical tasks. Finally, when approached by a co-worker during a critical task, Airmen of all ranks are encouraged to respectfully communicate their need to complete the task before responding. If you need a minute to get to a logical pause in what you’re doing, say so. “Can I get back to you in 3 minutes? I’m on step 2 of 4 on this checklist, and I don’t want to miss anything.” “Sure! I didn’t realize you were in the middle of that. Just come see me when you’re done.” Lack of Teamwork In aviation many tasks and operations are team affairs. No single person (or organization) can be responsible for the safe outcomes of all tasks. However, if someone is not contributing to the team effort, this can lead to unsafe outcomes. This means that workers must rely on colleagues and other outside agencies, as well as give others their support. Teamwork consists of many skills that each team member will need to prove their competence. Some of the key teamwork skills include leadership, followership, effective communication, trust building, motivation of self and others, and praise giving. To create an effective team, it is necessary that the following issues, as appropriate, are discussed, clarified, agreed and understood by all team members: A clearly defined and maintained aim, or goal(s) Each team member’s roles and responsibilities Communication messages and methods Limitations and boundaries Emergency procedures Individual expectations and concerns What defines a successful outcome Debriefing arrangements Team dismissal arrangements Opportunities for questions and clarification A team’s effectiveness also can be improved through the selection of team members to reflect a broad range of experience and skill sets, as well as through practice and rehearsal. If you don’t understand how you fit into the team, or any of the key issues outlined above, speak up! Be that person who asks the obvious question everyone is thinking, and no one else is willing to ask. Good team players will ensure the team is all on the same page before any critical task. Fatigue Fatigue is a natural physiological reaction to prolonged physical and/or mental stress. We can become fatigued following long periods of work and following periods of hard work. When fatigue becomes a chronic condition, it may require medical attention; but workers should never self-medicate! As we become more fatigued, our ability to concentrate, remember and make decisions reduces. Therefore, we are more easily distracted, and we lose situational awareness. Fatigue will also affect a person’s mood, often making them more withdrawn and sometimes more irrational and angrier. It is a human problem that we tend to underestimate our level of fatigue and overestimate our ability to cope with it. Therefore, it is important that workers are aware of the signs and symptoms of fatigue – in themselves and others. Fatigue self-management involves a three-sided program of regular sleep, healthy diet (including reduced use of alcohol and other drugs), and exercise. Work of a critical and complex nature should not be programmed during the low point on the body’s circadian rhythm (usually 3 to 5 a.m.). Additionally, when fatigued, always get someone else to check your work. Moreover, it is estimated that 80 percent of the body’s calories are burned by the brain as it processes the complex problems we encounter on a daily basis. Some maintenance tasks are physically challenging, but just long hours of problem-solving and intense mental engagement can create fatigue as well. Finally, if you feel tired, the mission may demand you continue, but it doesn’t mean you don’t communicate it to your team and your supervisor. If your decision-making is suffering, or your fatigue is otherwise making your situation hazardous for you or your teammates, your supervisor needs to know. Unfortunately, manpower and resources are always challenging, so fatigue alone may not result in dismissal from your duties, but it may result in additional help to ensure you don’t hurt yourself or others while you complete a shift. Furthermore, it will enable your supervisor to begin working a plan to adjust your schedule if warranted. If they don’t know, it may not be apparent to them the risks they are asking you to assume by operating in a sleep-deprived state. Lack of Resources If all the parts are not available to complete a maintenance task, then there may be pressure on a technician to complete the task using old or inappropriate parts. Regardless of the task, resources also include personnel, time, data, tools, skill, experience, knowledge, etc. A lack of any of these resources can interfere with one’s ability to complete a task. It may also be the case that the resources available, including support, are of a low quality or inadequate for the task. When the proper resources are available and at hand, there is a greater chance that we will complete a task more effectively, correctly and efficiently. Therefore, forward planning to acquire, store and locate resources is essential. It also will be necessary to properly maintain the available resources. This includes the humans in the organization as well. Ensure that resource shortfalls are communicated to your supervisor, and if you are a supervisor, ensure they are passed up the chain of command. Commanders may have to assume risk to complete mission tasks without sufficient resources, but they are relying on you to ensure they’re aware of where those gaps are. Don’t assume that someone else has informed leadership about the problem, and guard against cutting corners to “make it happen” without the required resources to complete the mission without unnecessary risk. Pressure Pressure is to be expected when working in a dynamic environment, especially in combat. However, when the pressure to meet a deadline interferes with our ability to complete tasks correctly, then it has become too much. It is the old argument of quantity versus quality; and in aviation, we should never knowingly reduce the quality of our work. Pressure can be created by lack of resources, especially time, and from our own inability to cope with a situation. We may come under direct or indirect pressure from the organization/company, from clients and even our colleagues. However, one of the most common sources of pressure is within us. We put pressure on ourselves by taking on more work than we can handle, especially other people’s problems, by trying to save face and by positively promoting superpowers that we do not possess. These poor judgments are often the result of making assumptions about what is expected of us. Learning assertiveness skills will allow a worker to say “No! Stop!” and communicate concerns with colleagues, customers and the organization. These skills are essential. When deadlines are critical, then extra resources and help should always be obtained to ensure the task is completed to the required level of quality. The bottom line is that we need to generate airpower at the right time and place to achieve the desired effects in combat. However, a task done poorly may cause mission failure, and an on-time failure is still just that … failure. Lack of Assertiveness Being both unable to express our concerns and not allowing others to express their concerns creates ineffective communications and damages teamwork. Unassertive team members can be forced to go with a majority decision, even when they believe it is wrong and dangerous to do so. Assertiveness is a communication and behavioral style that allows us to express feelings, opinions, concerns, beliefs and needs in a positive and productive manner. When we are assertive, we also invite and allow others to assert themselves without feeling threatened, undermined or that we’ve lost face. Speaking one’s mind assertively is not to be confused with aggression. It is about communicating directly, honestly and appropriately, giving respect to the opinions and needs of others without compromising our own standards. Assertiveness techniques can be learned. They focus on keeping calm, being rational, using specific examples rather than generalizations, and inviting feedback. Most importantly, any criticisms should be directed at actions and their consequences rather than people and their personalities. This allows others to maintain their dignity and a productive conclusion to be reached. Any Airman is empowered to call “Knock it off!” before a mishap occurs. Better to stop, take a breath and ensure critical steps haven’t been overlooked before metal gets bent or people get hurt. Stress There are many types of stress. Typically, in the aviation environment, there are two distinct types — acute and chronic. Acute stress arises from real-time demands placed on our senses, mental processing and physical body, such as dealing with an emergency or working under time pressure with inadequate resources. Chronic stress is accumulated and results from long-term demands placed on the physiology by life’s demands, such as family relations, finances, illness, bereavement, divorce or even winning the lottery. When we suffer stress from these persistent and long-term life events, it can mean our threshold of reaction to demands and pressure at work can be lowered. Thus, at work, we may overreact inappropriately, too often and too easily. Some early visible signs of stress include changes in personality and moods, errors of judgment, lack of concentration and poor memory. Individuals may notice difficulty in sleeping and an increase in fatigue, as well as digestive problems. Longer-term signs of stress include susceptibility to infections, increased use of stimulants and self-medication, absence from work, illness, and depression. It is important to recognize the early signs of stress and to determine whether it is acute or chronic. Coping with daily demands at work can be achieved with simple breathing and relaxation techniques. However, perhaps more effective is having channels of communication readily available through which to discuss the issue and help to rationalize perceptions. It is entirely appropriate that some of these channels involve social interaction with peers. As with fatigue, sleep, diet and exercise are all important factors in helping to reduce stress and build resilience to stressors. If the stress is chronic, then definite lifestyle changes will be required. This must be achieved with support from the organization. Organizations should, therefore, have employee assistance (or wellbeing) policies that include stress reduction programs. As with many of these factors, communication is key. Let your supervisor know if your personal stressors are affecting you at work. They may not be aware of how factors external to what they see when you’re at work may be adding to your total stress. It may be that certain levels of stress on the job are unavoidable, but if it’s starting to increase the risk of a mishap, you need to let someone know so adjustments can be made wherever possible. Lack of Awareness Working in isolation and only considering one’s own responsibilities can lead to tunnel vision, a partial view, and a lack of awareness of how our actions can affect others and the wider task. Such lack of awareness may also result from other human factors, such as stress, fatigue, pressure and distraction. One problem with “channelized” attention is that it will prevent you from noticing key events happening around you that may affect your task. If you’re so focused on prepping for an engine run that you fail to notice someone else “borrowed” your fire bottle before the start, you may wish you had been aware what was happening so you could intervene at the time, rather than having to delay for 30 minutes to go find the required fire suppression. Additionally, you may lack awareness how the task you’re doing relates to everything that comes after it. Understanding the “why” will help you remember the “how” to do it correctly and “what” can result if you don’t. It is important to build experience throughout our careers, especially concerning the roles and responsibilities of those we work with and our own place in the wider team. Developing our foresight is essential in pre-empting the effects our actions may have on others. Furthermore, asking others to check our work and challenge our decisions is useful in gaining the relevant experience and expanding our awareness as well as theirs. Combat lack of awareness through good communication and asking questions. If you don’t know “why” you’re doing something, ask! If your supervisor doesn’t have time to explain it, then hold on to your question and follow up with them once the task at hand is complete. If you are the supervisor, anticipate “why” questions and answer them as thoroughly as time/opportunity will allow. At a minimum, commend your subordinates for their curiosity, and always take advantage of an opportunity to teach. If you don’t know the answer, admit that, ask your supervisor, and follow back up with your Airmen when you do. Norms Workplace practices develop over time, through experience, and often under the influence of a specific workplace culture. These practices can be both, good and bad, safe and unsafe. They are referred to as “the way we do things round here,” which become norms. Unfortunately, such practices follow unwritten rules or behaviors, which deviate from the required rules, procedures and instructions. These norms can then be enforced through peer pressure and force of habit. It is important to understand that most norms have not been designed to meet all circumstances and, therefore, are not adequately tested against potential threats. They also lack flexibility when the broader situation changes. Norms that were good enough on fourth generation fighters may not work for fifth generation aircraft, especially when every mistake costs much more to repair. Compliance with regulatory guidance should be the first norm in any maintenance organization. Rules and procedures have been designed and tested and, therefore, ought to be enforced and followed rigorously. Where workers feel pressure to deviate from a procedure, or work around it, then this information should be fed back so the procedure can be reviewed and amended, if necessary. Norms can be tough to challenge because they are often deeply entrenched in the culture of the organization. However, if a norm is creating a hazardous environment, don’t accept it. Study the written guidance and respectfully challenge the norm, using factual data wherever possible. This will require assertiveness and good communication, but if you’re new to the unit, you may be the only one who is still outside the culture enough to see the real risk the norm creates. This may mean you stay on the outside a little longer, which can be tough, but you may save a life. Change has to start somewhere with someone bold enough to ask tough questions. Ultimately, if you have alerted your chain of command to unsafe norms without success, changing norms may require you to go outside of your unit. Consider talking to wing safety or the wing IG if needed rather than accept a hazardous situation. NOTE: Below is a link to the Airman Safety App (ASAP), which provides Airmen the opportunity to report safety-related risks and close calls using the Airman Safety Action Report. Anyone, anywhere, with almost any device can quickly and easily report safety-related problems involving personnel, equipment or property. Remain anonymous if you wish. Reporting is the first step to obtaining a solution for improvement. Reporting is simple and only takes between 3 and 10 minutes. Click on the link below to start your report. It’s fast and easy! https://asap.safety.af.mil/#/ https://www.torch.aetc.af.mil/News/Article-Display/Article/3456436/the-dirty-dozen-common-human-error-factors-in-aircraft-maintenance-mishaps/ Jet engines so Reliable Jet engines are designed and manufactured with high-quality materials and precision engineering. The materials used in jet engines are specifically chosen for their ability to withstand high temperatures, pressures, and vibrations. Additionally, the manufacturing processes used to create jet engines are highly advanced, with strict quality control measures in place to ensure that each engine is built to exact standards. Jet engines are subject to rigorous testing and maintenance procedures throughout their lifespan. Before they even leave the factory, jet engines are put through a battery of tests to ensure that they meet performance and safety standards. Once in use, jet engines undergo regular inspections and maintenance to detect and fix any issues before they become more serious problems. So the aviation industry as a whole places a high priority on safety and reliability. This includes not only the manufacturers of jet engines, but also the airlines, pilots, and maintenance personnel who operate and maintain them. Safety is always the top priority, and there are strict regulations and guidelines in place to ensure that jet engines are operated and maintained in a safe and reliable manner. https://medium.com/@dk8321580/jet-engines-so-reliable-8924fe4f7324 Roman Abramovich: A Look At His Private Jet Collection Roman Abramovich, the Russian billionaire, has a remarkable collection of big and luxurious private jets. His latest addition is a Boeing 787 Dreamliner, one of the most expensive private jets in the world, equipped with luxurious amenities and top-of-the-line features. There are private aircraft collections; then there are those that really stand apart from the rest. Such is the case with Roman Abramovich, the Russian billionaire who loves his big jets. They are big in size and luxury. Let's take a look. The man behind the aircraft Abramovich is a successful man, noted for incredible financial wealth, a citizen of three countries (Russia, Israel, and Portugal), and a foray into politics. He is the former Chelsea football club owner and the primary owner of the private investment company Millhouse LLC. Constant travel to support this flurry of activity caused the oligarch to consider expanding his private jet collection. This became evident when he was governor of Chukotka Autonomous Okrug, a federal subject region of Russia with many inaccessible areas. The need for rapid and accessible travel was the impetus for his first jet, a Boeing Business Jet (VIP modification of Boeing 737-700). After becoming the governor, he discovered that regular flights between Moscow and Anadyr required a fuel stop in Igarka. His expanding jet collection would resolve that issue. Big money, big planes After the 737, Abramovich purchased a Boeing 767-33AER. Hawaiian Airlines had intended to operate it but canceled the order in 2004. It was then purchased by Abramovich, who had it registered in Aruba and the interior refitted. It was based in London Stansted Airport - part of Harrods Aviation. The 767 had a bright, easily recognizable livery with white, gray, and brown lines. The slanting black stripes near the side windows of the cockpit resembled a mask. These unique exterior markings gave the plane notoriety and the nickname “Bandit.” After flying in the 767 for some time, Abramovich opted to 'dream' big by purchasing his Boeing 787 Dreamliner. Aimed to replace the 767, this top-of-the-line jet is considered one of the most expensive private aircraft in the world. Its amenities include a large dining room, a movie-theater-style viewing space, private bedrooms, bathrooms, and walk-in closet space. This Dreamliner's open-cabin concept can comfortably carry up to 50 passengers via different seating configurations for security, on-board staff, and guests. The inside of the aircraft has been drastically modified from the standard version. The cabin is equipped with a banquet hall with accommodations for 30 people, a kitchen, an office, and a bedroom with a double bed. Precious metals and fine woods make up the lavish décor of the airplane’s interior. In addition, the aircraft has the newest communication and security systems, including Abramovich’s own anti-ballistic defense system, the cost of which exceeds two million dollars. Based on the inner furnishings and functionality of the Russian businessman’s aircraft, it rivals the airplanes of many world leaders. Abramovich enjoys flying in heavy jets that have comprised his fleet at one time or another. The aircraft he flies is determined by the purpose and distance of his trip. Shorter trips may utilize his $60 million Gulfstream G650ER, while the 18-hour endurance on the 787 provides an even more global reach. Whatever he is flying on, Roman Abramovich is undoubtedly enjoying the jet-setter life. https://simpleflying.com/roman-abramovich-private-jet-collection/ Kazakhstan’s Civil Aviation Reaches 82% Compliance with ICAO Requirements ASTANA – Kazakhstan achieved 82% compliance with the International Civil Aviation Organization (ICAO) flight safety standards, which is comparable to the average indicator of the European Aviation Safety Agency (EASA) member countries, the Kazakh Civil Aviation Committee reported on July 12. The committee published an electronic bulletin of an action plan for implementing the ICAO’s Universal Safety Oversight Audit Program (USOAP) on monitoring flight safety for the next year. It represents ICAO’s planned audits of member state aviation authorities for the forthcoming period. The selection of countries for audits by ICAO is based on the risk indicators, the results of previous audits, the extent of aviation activity in the country, and the progress made by states in addressing identified deficiencies. According to the plan, the ICAO is not planning to conduct the audit of Kazakhstan’s aviation authorities in 2023 and 2024. https://astanatimes.com/2023/07/kazakhstans-civil-aviation-reaches-82-compliance-with-icao-requirements/ Curt Lewis