Aviation Human Factors Industry News

Aviation Human Factors Industry News Volume VII. Issue 12, June 05, 2011 Hello all, To subscribe send an email to: [email protected] In thi...
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Aviation Human Factors Industry News Volume VII. Issue 12, June 05, 2011

Hello all, To subscribe send an email to: [email protected] In this weeks edition of Aviation Human Factors Industry News you will read the following stories:

★FAA Revises Schedule For Safety Systems Implementation ★Blame the Pilots of Air France 447? Not So Fast ★Stalled AF447 did not switch to abnormal attitude law

★Broken Wire = Live Magneto ★TORCH LEFT IN NOSE WHEEL STEERING CABLE RUN ★From The FAA: SMS: What It Means for the AMT ★Bad Parts

★Blue Angels Commander Quits ★Pilot error behind CAL 747 tailstrike incident

★And Much More

Human Factors Industry News 1

FAA Revises Schedule For Safety Systems Implementation  

The FAA has been forced by budget limitations to revise implementation of Safety Management Systems (SMS) procedures, as they apply to agency personnel. The revision, issued June 1, will enable FAA personnel assigned to review proposed airport projects to apply SMS procedures and documentation requirements to projects at the nation's 29 large airport hubs. The original SMS order of last August, which defined procedures for FAA personnel to follow, had envisioned application to all hubs-36 medium-size airports and 72 small hubs-by June 1. FAA personnel will follow formal SMS procedures, including the additional documentation, and will conduct demanding risk analyses required by SMS when reviewing large-hub projects that need FAA approval. The agency was forced to reduce the implementation schedule because it is operating at the 2010 funding level and is unable to undertake the planned workload without additional financial and staffing resources, says James White, deputy director, airport safety and standards. Separately, the FAA has issued a notice of proposed rulemaking to amend Part 139 and require airports to develop Safety Management Systems for their application on all projects and operations. The deadline for comments on that proposal is July 5.

Human Factors Industry News 2

Blame the Pilots of Air France 447? Not So Fast

With recent data release from the Air France 447 flight data recorders, it's an easy reflex to point the finger at the pilots for failing to avoid or solve the crisis on board the Airbus 330 that crashed in the Atlantic two years ago. But aviation experts tell Popular Mechanics (PM) that people shouldn't be so quick to assign blame: The increasingly automated nature of modern aircraft may mean that pilots don't have the information they need to save the plane when flight management fail. Last week, French accident investigators released a much-anticipated report on Air France 447—actually a dry recitation of the flight's final minutes. Many rushed to pin the blame squarely on the pilots. Indeed, as details of the document trickled out in the days after the recorder was pulled up from the depths of the Atlantic, the phrases "human error" and "pilot error" appeared frequently in headlines atop numerous news stories around the world. It is not hard to see what's behind the finger pointing. As the released partial transcript makes clear, the chain of events that led to the crash began when the A330's autopilot and autothrust disengaged more than 3 hours into the flight, and the co-pilots took control. (Investigators already knew about the failure of airspeed indicators that caused this to happen.) "I have the controls" the co-pilot was quoted as saying in the transcript. What he did after that is at the heart of the controversy over the crew's role. "The airplane began to roll to the right and the [co-pilot] made a left nose-up input," the report said. "The stall warning sounded twice in a row." After the stall warning was triggered again, the report said, the co-pilot continued to try to point the nose up. The "nose-up input" is contrary to established procedure. In fact, it's the exact opposite of what every beginning pilot is taught to do. (Pointing the nose down can help pull a plane out of a stall.) Questions about the pilots' performance were compounded by the news that the captain was not in the cockpit at the time, but was on a rest break instead—a routine occurrence in the cruising phase of a long flight.

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Safety experts say that it's premature and far too simplistic to assume there were no other factors involved. A major airline crash rarely has just one cause. Rather, it's a chain of multiple failures that have to line up, according to William Voss, chief executive of the Flight Safety Foundation. "We have to be careful we don't demonize the pilots here because that is not going to help us the next time," Voss says. There had been much speculation following the crash that the investigation might also implicate the plane's automated fly-by-wire technology. Other incidents involving faulty speed readings emerged just weeks after the Air France 447 crash. Then, in late June 2009, the National Transportation Safety Board revealed details from two other neardisasters that resembled what happened aboard Air France 447. In one, a TAM Airlines flight from Miami to São Paulo lost basic speed and altitude data from its flight management system, forcing the crew to rely on backup instruments. It took them 5 minutes to reboot the main computer. Around the same time, Northwest Airlines also experienced a similar failure on a flight between Hong Kong and Tokyo. Both flights landed safely and no one was injured. Voss takes issue with those singling out the Air France pilots for not pulling off a similar feat. "[They] seem to think that if you spend enough time behind the controls, in a situation like this you ought to just know how to point the airplane in the right direction and chill," he says. "That's unfair. They were in what must have been a rather noisy and chaotic environment... You've got multiple system failures; you've lost the air speed [indicators]; you have data computers going offline; there are beeps, bells and buzzers, all happening simultaneously." On top of that, the plane was flying through a heavy thunderstorm. The Air France crew was experienced, Voss says. His concern is whether pilots are getting enough training on how to deal with a crisis when automated systems fail. "What may be lacking is the ability to triage a sick aircraft," he says. "We have to get back to the focus on automation as a tool to manage the aircraft. It should be serving us, not the other way around." The NTSB is especially concerned because modern fly-by-wire technology relies on several layers of redundancy to ensure system failure doesn't happen, but on the rare occasions that it does, the pilots may not be prepared. "When there is a malfunction of these cockpit displays, pilots may be left without the critical information they need to fly the airplane," John DeLisi, the NTSB's deputy director of aviation safety, said in an earlier interview with PM. More details about the last moments of Air France 447—and what the pilots did and why they did it—could come later this summer, when French authorities release more data from the black boxes.

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Air France, for its part, released a statement Friday commending the pilots for their professionalism and claiming that the report showed they were trying to avoid the worst of the storm by turning the plane slightly—just before the systems failed.

The Final Minutes of Air France 447 >>> http://www.popularmechanics.com/technology/aviation/crashes/the-final-minutes-of-airfrance-447-5818470

Stalled AF447 did not switch to abnormal attitude law  

Investigation into the accident sequence of Air France flight AF447 has revealed that the Airbus A330 did not enter the abnormal attitude law after it stalled, despite its excessive angle of attack. The abnormal attitude law is a subset of alternate law on the aircraft and is triggered when the angle of attack exceeds 30° or when certain other inertial parameters - pitch and roll - become greater than threshold levels. Alternate law allowed AF447's horizontal stabilizer to trim automatically 13° nose-up as the aircraft initially climbed above its assigned cruising altitude of 35,000ft. The stabilizer remained in this nose-up trim position for the remainder of the flight, meaning that the aircraft would have had a tendency to pitch up under high engine thrust. Crucially the abnormal attitude law - if adopted - would have inhibited the autotrim function, requiring the crew to re-trim the aircraft manually. After stalling, the A330's angle of attack stayed above 35°. But while this exceeded the threshold for the abnormal attitude law, the flight control computers had already rejected all three air data reference units and all air data parameters owing to discrepancy in the airspeed measurements.

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Abnormal law could only have been triggered by an inertial upset, such as a 50° pitch-up or bank angle of more than 125°. "That never occurred," said French accident investigation agency Bureau d'Enquetes et d'Analyses. The BEA is still attempting to explain why AF447's crew failed to rescue the aircraft after it climbed to 38,000ft and stalled. The pilot's control inputs were primarily nose-up, despite the stall condition. There has been no indication that the aircraft switched into any other control law, other than alternate, during the accident - suggesting that auto-trim was available throughout the descent. Failure to realize a need for manual re-trim was central to the loss of an Airbus A320 over the Mediterranean Sea about six months before the AF447 crash. The auto-trim had adjusted the horizontal stabilizer fully nose-up but, during a flight envelope test involving near-stall, the aircraft switched control laws and inhibited the auto-trim. Without manual re-trimming, the aircraft pitched up sharply as the crew applied maximum thrust. It stalled and the crew lost control. In its conclusions over the accident the BEA highlighted the rarity of the need to trim manually, which created a "habit" of having auto-trim available made it "difficult to return to flying with manual trimming". "One of the only circumstances in which a pilot can be confronted with the manual utilization of the trim wheel is during simulator training," it said. "However, in this case, the exercises generally start in stabilized situations." In the wake of the A320 accident, near Perpignan in November 2008, the BEA recommended that safety regulators and manufacturers work to improve training and techniques for approach-to-stall situations, to ensure control of an aircraft in the pitch axis.

Human Factors Industry News 6

Blue Angels Commander Quits The commander of the Blue Angels has resigned and the team is back in Pensacola for training and practice after an unspecified maneuver was at too low an altitude during a show in Lynchburg VA on May 22. Navy Cmdr Dave Koss was "voluntarily relieved of duty" as the elite team's commander and will be replaced by Capt. Greg McWherter, whom Koss replaced as the team lead. "This maneuver, combined with other instances of not meeting the airborne standard that makes the Blue Angels the exceptional organization that it is, led to my decision to step down," Koss said in the statement. The No. 1 aircraft normally leads a flight of four or six F/A-18s through formation maneuvers but the formation breaks for some parts of the show, including the solo performances and the signature cross maneuver. It's not clear whether Koss alone busted the altitude or whether he took the others with him. It's also not been stated just how much too low the aircraft got. Clearly, the miscue got the attention of Navy brass because it led to the cancellation of at least seven shows. They won't resume the schedule until the Quad City Air Show in Davenport IA June 18-19.

Pilot error behind CAL 747 tailstrike incident

Taiwan's Aviation Safety Council has recommended for China Airlines (CAL) to improve and review its pilot training, following an investigation into a tailstrike incident involving a CAL Boeing 747-400 in 2010. Pilot error was found to be the cause behind the incident, which took place at Anchorage on 4 March 2010. During take-off roll, the pilot received a stick shaker warning, indicating that the aircraft was flying at an airspeed which was too low to sustain lift.

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The 747 continued on its flight to Taipei Taoyuan airport. After landing, inspections of the aircraft found that the belly suffered "substantial damage", said the council. In a report on the incident, the council said that the pilot had entered the incorrect gross weight value before the flight, resulting in a lower speed than required and the aircraft's belly making contact with the runway during take-off. While investigations found that the flight crew had sufficient rest hours required by the airline and Taiwan's civil aviation authority's regulations, pilot fatigue was identified as a contributing factor to the incident, said the council. In its safety recommendations, the council has advised CAL to enhance its flight operations training and ensure that steps are in place for flight crew to verify input values before take-off. It also recommended for the airline to pay greater awareness to fatigue management and to strengthen communication between pilots.

Broken Wire = Live Magneto AN investigation into the accident that killed a young Namibian pilot on Sunday has revealed that a wire in the ignition system was broken. "The prime suspect so far is that the left hand magneto wire was found broken," Erickson Nengola, head of the aircraft accident investigation team in the Ministry of Works and Transport, said yesterday. The investigation was launched early yesterday morning, after Tiaan Oberholzer (21), a pilot at Desert Air, died on Sunday night after he sustained a fatal head injury from a propeller. The unconscious Oberholzer was found by a Desert Air colleague shortly after he had fallen to the ground at the Hosea Kutako International Airport at around 14h00 on Sunday afternoon.

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Although there were no eyewitnesses, the question as to what Oberholzer had been doing so close to the propeller during his final round of checks after he had loaded his passengers, was on everyone's lips on Monday. One of the investigators yesterday said it was unlikely that Oberholzer was attempting to do a "hand start", and that he was in fact doing a routine propeller test. It was for this reason that he was caught unawares when the propeller "fired" on before it switched off again. Nengola said yesterday that the broken wire could explain why the propeller switched on for a few seconds, striking Oberholzer on the arm and head. Nengola said the investigating team suspects, from the evidence gathered so far, that Oberholzer "wanted to check if the propeller was rotating freely" shortly before take-off. Oberholzer was unaware that the magneto wire was broken, Nengola explained. "The magneto was still alive. The ignition was on inside the cockpit, and by turning the propeller, that triggered it to go fast and he was struck." Witnesses say Oberholzer did not regain consciousness after the accident. He was already in a critical condition when he was rushed by ambulance to the Roman Catholic Hospital, where he was put on life support. He was declared dead just after eight on Sunday night.

Learning From Experience TORCH LEFT IN NOSE WHEEL STEERING CABLE RUN Maintenance errors, as we know, can take various forms from panels being missinstalled to inadequate surveillance inspections. This incident relates to the consequences of not accounting for all tooling used after a task has been completed. During taxi-out to the runway for a return sector from Europe, the flight crew of a Boeing 737 found the aircraft difficult to control through the rudder pedals.

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The steering tiller would not return to the neutral (self centre) making rudder nose wheel steering “impossible”. Inspection of the nose wheel steering mechanism found a torch stuck in the cable run, causing damage to the cable guide wheel bracket and a pulley. Investigation identified that the nose wheel spin brake pads had been replaced the night before but why had the Engineers involved failed to remove the torch? An Engineer and two Technicians were tasked to work the B737 but prior to starting their assigned work for the night, they were involved in clearing late evening departure snags. The Engineer busied himself with researching a hydraulic leak on an Airbus whilst the technicians started the spin pad replacement on the B737 at approx. 3:30 am. In addition to the spin pad replacement, the B737 also had a toilet leak requiring the toilet dump valve to be replaced, so the technicians split the tasks. The technician arrived at the aircraft, which was parked remotely, in the mobile workshop and assessed the job. His original plan was to use separate lighting from the mobile workshop but when he opened the rear doors of the workshop there was a torch lying on the floor. He placed the torch on top of the nose leg and positioned it as best he could to illuminate the task in hand. During completion of the task, the technician inadvertently kicked over a bag of spanners and only after completing the replacement of the spin pads did he pick them up. In doing so, he was momentarily dazzled by the headlamps of the mobile workshop, which was enough to distract from the fact that the torch had not been removed. The technician then assisted his colleague in changing the toilet dump valve as past experience had told him it was a tricky job. After both technicians had completed their work on the B737, they proceeded to the Airbus and began work on a Hydraulic Pump change. They did not complete this job in the time available and eventually handed it over to the day shift. The Engineer never visited the B737 as he considered the technicians to be proficient and the assigned tasks relatively straightforward. The main contributory factors identified during the investigation were:

Time pressure; The technician was aware that work was still outstanding on the Airbus and he needed to give his colleague a hand with changing the toilet dump valve.

Tool control; There was inadequate control to ensure all tooling was accounted for.

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• Inspection; The Engineer failed to inspect the replacement of the spin pads prior to signing for the task in the Technical Log. It is worth noting that the ‘safety nets’ of an engineering pre-service check and two flight crew walk-round inspections failed to identify the torch, primarily due to the restricted visibility of the nose wheel area, with doors closed, on the B737. A fundamentally mundane task could have led to a far more serious incident

From The FAA: SMS: What It Means for the AMT?

Everyone should be monitoring the risk controls to ensure they remain effective One of the popular buzzwords today in aviation is SMS or safety management system. So what is SMS, what is its function, and more importantly, what does it mean for the maintenance technician? We will look at a basic overview of what the SMS initiatives are and how it concerns you, the maintenance technician. SMS is an evolving international effort to improve safety of the air transportation system. The FAA is actively engaged in all aspects of the SMS program development. Even though currently there is no SMS rule, guidance is in place to assist aviation organizations to develop and implement SMS-based processes and procedures to enhance their existing safety programs. A SMS provides a systematic method to control risks and to assure that the risk controls are effective in all aspects of flight and maintenance operations. The foundation of any SMS is defined by two important aspects. First, the responsibility for the management of the safety of aviation products and services firmly rests with the providers themselves. The FAA sets forth the safety regulations and system requirements necessary to control risks to acceptable levels. The individual providers of aviation services are expected to comply with the regulations to maintain effective control of risk rather than just to meet the administrative requirements of the regulations. The second aspect of a SMS is that aviation contains inherent risk. Aviation can never be entirely risk free. Risk can only be reduced to an acceptable level. But risk can be managed and the essence of a SMS is to establish a management system that maintains an acceptable level of safety to all aspects of our industry.

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Any SMS will contain four basic elements. They provide the overall approach and foundation for an organization to achieve the acceptable levels of safety risk. We will examine each element. Safety policy Safety policy is the first element of a SMS. The safety policy provides the requirements, processes, procedures, and expectations of the respective SMS. The policy also includes implementing those procedures and processes and supports the promotion of the safety culture inside the organization. For the maintenance technician, this will be the documents and procedures their organization puts in place for their SMS. Become familiar with these procedures as you have a valuable part in the SMS process. Safety risk management The second element of a complete SMS is safety risk management. This element is where the SMS identifies various hazards that exist or may exist within the organization and then provides the processes to analyze and control the risk created by the hazards. This could include anything from hazards associated with moving the aircraft on icy ramps to performing maintenance operations that are unfamiliar to the organization. The key here is to be aware of those items that increase risk to levels that may not be acceptable and then control them to an acceptable level. Risk management as it concerns the maintenance technician includes review of data from the equipment manufacturers, other operators, and any other sources that may assist in defining safety risks with the type of aircraft being maintained. We will discuss in greater detail the subject of risk management in the maintenance arena in a future article. Safety assurance Safety assurance is the third element in a successful SMS program. This function oversees the ongoing risk controls to ensure they are maintaining the risk to the desired levels. Safety assurance should be everyone’s responsibility within an organization. Everyone should be monitoring the risk controls to ensure they remain effective at controlling risk. For example, a control process is in place to ensure the safe operation and condition of maintenance equipment. A maintenance technician notices a piece of equipment that requires attention due to a problem that could create an accident. The maintenance technician must be able to effectively and quickly report it and be assured the situation is remedied before an accident occurs.

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Safety promotion And finally, the fourth element is safety promotion. This is really all about the safety culture within the organization. Every employee should be on the same page when it comes to safety. Encouragement of the safety culture should be promoted from the very top down with emphasis on safety driving all other functions in the organization. Every employee plays a part in the overall success of the system and each employee must realize that their participation is important. Maintenance personnel should not only be on the alert for safety concerns with the aircraft but the total environment in which the maintenance operations are conducted. Much of this sounds overwhelming and complex. One of the primary concerns with a SMS is that it has to be scalable. The SMS must fit the size of the organization. A SMS for a company with 4,000 employees and 100 aircraft is going to look and feel much different than for a company of 10 employees providing a specific service to the aviation system. And for a single person operating a single aircraft, they may well not even participate in a comprehensive SMS. Individuals are responsible for their primary safety management and it may be very informal and minimally, if at all, documented. So in looking at a SMS, it is evident that many of the elements discussed are already in place to some degree in most organizations. Any SMS strives to put all of the elements in a planned and organized manner. For most organizations, developing a SMS will consist of documenting and fine tuning the processes they already follow. Some processes will need improvement or require the development of a process to address new issues. In closing, remember, the operator or service provider has the legal and functional responsibility for safety management within the organization’s line of business. The FAA provides the appropriate oversight to ensure the capabilities of the organization are adequate to control the risk to acceptable levels. As maintenance technicians you have a very active role in your organization’s SMS program. Don’t take this responsibility lightly; it is a critical part of your job and your commitment to safe operation of aircraft on a daily basis. Familiarize yourself with the procedures and use them to improve the safe operation of all aspects of your organization.

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Bad Parts AeroSafety World April 2011 Issue reports that incidents of counterfeit parts in the electronics industry more than doubled between 2005 and 2008, according to the Aerospace Industries Association, which is urging action to reduce the associated risks in the aviation industry. The decreasing numbers of component manufacturers and issues involving shortages of materials also play a role in the production of counterfeit parts, the report said. [Download PDF 3 pages. 217K]

Alaska Airlines replacing paper manuals with iPads

Alaska Dispatch's Bush Pilot blog previously reported on the increasing popularity among private pilots of iPads and similar tablet computers as an alternative to the heavy paper manuals and charts that would typically clutter a cockpit. Now, the Seattle Times reports that Alaska Airlines will issue iPads to all of its pilots as a space-saving and hopefully injurypreventing measure, replacing the up to 50 pounds of paper manuals a pilot may be required to carry aboard a given flight. Pilots like the easeof-use and the aviation industry has responded with apps targeting specific airports, aviation-related weather reports, and flight-planning apps. According to the airline, pilots will be required to stow their company-issued iPads during takeoffs and landings, just as passengers are told to do -- and surely it's a small comfort to know that a pilot won't be playing Angry Birds while trying to conduct a landing in crosswinds.

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However, the possibility of the cockpit distraction represented by an app-enabled computer such as the iPad is still very real, as evidenced by incidents like the 2009 Northwest Airlines flight that missed its scheduled landing because the pilots were working on their personal laptop computers.

Sleep Problems Lead to Other Problems The National Institute of Health reports that studies show 75 percent of Americans have sleep problems more than once a week. About 50 million Americans suffer from chronic sleep disorders. Some tips from The Mayo Clinic for addressing sleep problems include: 1.

Cut out alcohol before bed. Alcohol, although a sedative, prevents deep sleep, which encourages light sleep.


If you do not fall asleep after 15 minutes, get back up, as stressing over sleep can prevent it.


Be wary of sleep aids, only using them as a last resort. Dependence on sleep aids could have negative side effects.


An alternative to sleeping aids is boosting vitamins and balancing hormones, which are natural options.

Going to bed and waking up at a consistent time throughout the week helps your body to become suited to a dependable routine. Finding a quiet sleep environment, exercising regularly and staying healthy are other great ways to make sure you won't encounter any disruptions of your sleep. From personal experience as a shift worker with sleep problems, these problems can lead to obesity, hypertension, irritability, depression, heart disease. Get regular checkups and discuss any sleep problems with your doctor. If you work rotating shifts or work at night, tell your doctor. A person who works rotating shifts does not have the option of going to bed and waking at a consistent time throughout the week. The recommendations from experts differ, and the tips and suggestions do not work well for every person. Some of the tips below are not practical, but at least consider them. Adapt them for your benefit. Employers have some responsibility for providing opportunities for adequate rest, but employees have responsibilities for taking advantages of the opportunities.

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Fatigue management is a shared responsibility of employers and employees. Sleep Tips for Shift Workers from the American Academy of Sleep Medicine 

If you work rotating shifts, ask your manager to schedule your shifts “clockwise.” This means that your new shift will have a start time that is later than your last shift.

Take a nap during a break in your shift or before reporting for a night shift. Even a nap of just 20 to 30 minutes can improve your alertness on the job.

Arrange for someone to pick you up after a night shift, or take a bus or cab home. Drowsy driving can put your life and the lives of other drivers at risk.

Try to keep the same schedule on work days and days off. Keeping a routine helps your body know when to be alert and when to sleep.

Plan ahead for a major change in a shift-work schedule. Begin to alter your sleep time a few days in advance. This will make it easier for your body to adjust.

Use moderate amounts of caffeine to help you stay alert on the job.

Ask your doctor if medications, melatonin or bright light therapy might help you.

Avoid exposure to sunlight if you need to sleep during the day.

Make sure others in your home are aware of your work schedule. They should keep the home quiet when they know that you need to sleep.

Talk to a sleep specialist if you have an ongoing sleep problem.

Night Owls at Risk for Weight Gain, Bad Diet

Staying up late every night and sleeping in is a habit that could put people at risk for gaining weight. People who go to bed late and sleep late eat more calories in the evening, more fast food, and fewer fruits and vegetables and weigh more than people who go to sleep earlier and wake up earlier, according to a new Northwestern Medicine study. Late sleepers consumed 248 more calories a day, twice as much fast food, and half as many fruits and vegetables as those with earlier sleep times, according to the study. They also drank more full-calorie sodas.

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The late sleepers consumed the extra calories during dinner and later in the evening when everyone else was asleep. They also had a higher body mass index, a measure of body weight, than normal sleepers. The study is one of the first in the United States to explore the relationship between the circadian timing of sleeping and waking, dietary behavior, and body mass index. The study was published online in the journal Obesity and is expected to appear in a late summer print issue. "The extra daily calories can mean a significant amount of weight gain—two pounds per month—if they are not balanced by more physical activity," said colead author Kelly Glazer Baron, a health psychologist and a neurology instructor at Northwestern University Feinberg School of Medicine. "We don't know if late sleepers consume the extra calories because they prefer more high-calorie foods or because there are less healthful options at night," said co-lead author Kathryn Reid, research assistant professor in neurology at the Feinberg School. The study shows not only are the number of calories you eat important, but also when you eat them—and that's linked to when you sleep and when you wake up, noted senior author Phyllis Zee, MD, professor of neurology and director of the Sleep and Circadian Rhythms Research Program at Feinberg and medical director of the Sleep Disorders Center at Feinberg and Northwestern Memorial Hospital.

NIOSH Releases Lockout/Tagout Tip Sheet

Workers are at risk of severe injury and death during machine maintenance and servicing if proper lockout/tagout procedures are not followed. NIOSH has released a document highlighting best practices for employers, workers, and manufacturers to follow during machine maintenance. Workers are at risk of severe injury and death during machine maintenance and servicing if proper lockout/tagout procedures are not followed. NIOSH recommends developing and implementing a hazardous energy control program including lockout/tagout procedures and worker training to prevent such incidents. Lockout/tagout procedures apply in the following circumstances:

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Workers are servicing and maintaining equipment and unexpected startup of the machine or release of stored energy could occur.

When, during normal production, workers must remove or bypass a guard or safety device.

When, during normal production, workers place any part of their body into the danger zone or near the machine’s point of operation.

During all set up activities.

NIOSH recommends that employers comply with the OSHA regulations outlined in 29 CFR* 1910.147, the control of hazardous energy (lockout/tagout). Results of NIOSH fatality investigations indicate that the following steps are particularly important: •

Develop and implement a written hazardous energy control program, including lockout/tagout procedures, employee training, and inspections before any maintenance or service work is done.

Be sure that workers have a clear understanding of when hazardous energy control procedures apply and training on how to properly apply the procedures.

Ensure that procedures on lockout/tagout are developed that are specific to each machine.

Provide training to production workers in addition to maintenance workers in methods of energy isolation and control.


Follow the regulations contained in your employer’s hazardous energy control program.

Complete all employer-provided training on hazardous energy control procedures.

Before beginning machine adjustment, maintenance, or servicing work, deenergize all sources of hazardous energy: o

Disconnect or shut down engines or motors.


De-energize electrical circuits.


Block fluid (gas or liquid) flow in hydraulic or pneumatic systems.


Block machine parts against motion.

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Manufacturers: •

Consider designing equipment that requires fewer and more easily accessible disconnect points to facilitate the use of safe lockout/tagout procedures for maintenance and repair.

Go to http://www.cdc.gov/niosh/docs/wp-solutions/2011-156/pdfs/2011-156.pdf to view the entire document.


The first book written entirely about America's earliest aircraft mechanics

Director Of Maintenance magazine columnist, Giacinta Bradley Koontz (Gia), has written an excellent book about the unsung heroes of aircraft maintenance. illustrated with vintage photographs and aviation advertisements, this paperback contains more than 20 fact-filled stories of aircraft mechanics prior to WWII. This is a must-have book for anyone in the aircraft maintenance industry.

http://r20.rs6.net/tn.jsp? llr=zjwqasdab&et=1105687269613&s=2780&e=001Dl5Rw9OlWf2tbRpSrLgBGVf6Oju3P5x0ZXZfgpD 9xohIwczIHR7UzMk4qMRxugsWSr3oIIVWX1EMBkMGOLTGFh7uiDtQ_urvr8sYJ0enblRrecvA_wH3Guk8 B-re5pNhCawmRo_vtr_Ztu0homAJA==

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What every leader can learn from “The King’s Speech” In the movie “The King’s Speech,” England’s King George VI turns to Lionel Logue, an unorthodox Australian speech therapist, to overcome his stammer. The two men become friends as they work together, and after his brother abdicates the British throne, the reluctant king relies on Logue to help him make a radio broadcast at the beginning of World War II.We also see the movie as a parable — a story about a leader healing from the wounds of broken trust. King George VI had to heal from childhood betrayal before he could “find his voice” and become the leader his country needed at the brink of war. The king, however, found it extremely hard to ask for — and accept — support that he, as that would-be leader, needed. If you’re like most leaders, you, too, struggle with asking for, and accepting, support — support you might need to perform, such as King George VI, to your most powerful potential. You probably think you should be able to go it alone, to have all of the answers. Yet, in failing to receive support, odds are you are depriving yourself — and your organization — of your true greatness. Accepting support isn’t a sign of weakness; it’s a sign of courage and strength. Only strong, self-aware leaders can size up a situation and see, realistically, what they can or cannot face alone. Working with leaders, we find that there are at least three common, instinctive reactions to the idea of receiving support. Here is advice and insight for how to deal with them: “I’m the leader here. I can’t let on that I need help.” Sure, you can. People expect you to lead, and if accepting support from others will help you be an even better leader, it’s your best course of action. What’s more, by example, you’re letting your leadership team, among others, know that it’s OK to receive support, embrace their human-ness and to learn and grow through and with other people. That awareness can deepen their connection and commitment to one another and to the organization. It also builds trust and respect.

Human Factors Industry News 20

“I don’t know whom I can trust. I don’t want to open myself up to be vulnerable.” Make a wise choice — and take the risk. Playing it close to the vest might be your default, but that doesn’t mean it’s the smartest thing to do. Also, ask yourself whether you’re really concerned about trust or, more likely, about letting others in. During highly stressful periods, you might unreasonably question everyone’s intentions. Resist those doubts and fears. They can — and will — hold you back. “I want to be the best leader I can be for my organization. That has nothing to do with my personal life.” Really? You’re a whole person, and your success comes from the sum of your experiences. Additionally, as a leader, your ability to build and rebuild trust with others has a lot to do with how you’ve dealt with — or haven’t dealt with — situations of broken trust in your life. If you don’t want to “go there” with someone within your organization, look for someone on the outside — your Lionel Logue.

Picture This Don’t Worry, I’m Not Inhaling

Human Factors Industry News 21