Submitted by: Roger Hughes, Human Factors Practitioner President, Decoding Human Factors, Inc. 3 Sarah Kathryn Way
Waldwick, NJ 07463

646

- 773

- 2808 rhughes@humanfactorsedu.com

Date: July 30, 2010

Preliminary Assessment and Recommendations Regarding Potential Bird Strike Hazards to Aviation from the Proposed North Shore Marine Transfer Station, Queens, New York.

The North Shore Marine Transfer Station (NSMTS) in College Point, Queens, New York, should not be constructed at the above location. It will cause a threat to aviation safety and the public that cannot be managed to
an accepta ble risk level. The belief that mitigating strategies will reduce the collision risk with bird/s for departing and arriving aircraft to an acceptable risk level at LaGuardia Airport, runway 31 is naïve.

The NSMTS will never be safe enough even with the b est crafted mitigating strategies. No human has designed and implemented the perfect defense or safety net (mitigating strategies) to preclude human error (also known as system error) from eliminating unacceptable risk. The building and operation of the NS MTS is no exception. The risk will always remain unacceptable as humans are in control of evaluating, designing and implementing the NSMTS mitigating strategies. If the facility is constructed over the mountain of concerns for flight and residential safety

, it is imperative that all mitigation procedures described and implied be fully enacted with additional considerations listed below. I base my position on

the science of human factors.

Brief Description Of Human Factors

Human factors are a sc ience base discipline. It is the study of people in their working and living environment and how they interact with machines, polices procedures, guidelines, regulations, the environment, and other humans. It includes what can go wrong and why.

To err is human. There are impediments in the intellect and our skill.

Human error is unintentional circumstances in which planned actions fail to achieve the desired outcome. Errors leading up to an incident or accident formed by contributing factors are known a s an error chain. These are usually latent errors (undetected) that lay dormant, accumulating until theprecise moment when they are released by another human or mechanical

action (active failure.) This releases energy into the chain allowing a negative co nsequence to occur. Since humans design, construct, manage and operate within the system they work, it is imperative that the system be robust enough to mitigate and recover from these events. A successful mitigation and recovery process will be predicate d on the defenses

- in

depth or safety nets that are in play when the error chain was released.

Dr. James Reason is a Professor of Psychology who has published extensively on the nature of human error. Reason proposed the “Swiss Cheese Model” of system fai lure. Every step in a process has the potential for failure, to varying degrees. The ideal system is compared to a stack of slices of Swiss cheese. Consider the holes to be opportunities for a process to fail, and each of the slices as “defensive layers” i n the process. An error may allow a problem to pass a hole in one layer, but in the next layer the holes are in different places, and the problem should be caught. Each layer is a defense against potential error impacting the outcome. If

these defenses are breached because one or more of the safety nets were bypassed, then the risk of an accident, incident or injury is greatly increased. For a catastrophic error to occur, the holes need to align for each step in the process allowing all defenses to be defea ted and resulting in an error. If the layers are set up with all the holes lined up, it is an inherently flawed system, it will allow a problem to progress all the way through to adversely affect the outcome. Each slice of cheese is an opportunity to stop an error. The more defenses you put up, the better. Also, if the holes are fewer and smaller, you are more likely to catch/stop errors that may occur.

Through human factors education, all employees are made aware of their human limitations and capabiliti es. This educational tool has shown to

influences the attitudes and behaviors of individual workers towards reducing human and system error, a major cause of incidents, accidents and injuries.

The NYC DOS Part 360 Permit Application Did Not Fully Disclos e Or Address Human Factors Awareness Training For Employees working

At The NSMTS

.

The reality is we put humans in charge of assessing threats, risk and mitigating strategies knowing that there will be flaws in their endeavor.

These flaws are also known a s latent errors. In organizations that have embraced human factors training, worker awareness is heightened to recognize contributing factors to human performance shortcomings. Thecourse content should include but not limited to the Dirty Dozen, twelve

fa ctors that impact human performance. They are: Lack of Communication, Lack of Teamwork, Lack of Knowledge, Lack of Resources, Lack of Assertiveness, Lack of Awareness, Distractions, Complacency, Work Place Norms, Fatigue, Individual Stress and Pressure. Ar med with this knowledge the „safety culture‟ is strengthened and employees are encouraged to report errors and near misses to their leadership for

immediate corrective action.

If the NSMTS becomes operational with a flawed goal of low or no

- impact qualit y escapes, then human factors‟ training is essential. Unfortunately this training program was not mentioned in the permit application.

The Absence Of A Robust Continual Analysis And Surveillance Audit Program In The NYC DOS Part 360 Permit Application.

In all human endeavors, humans will drift from what they have been taught. Drifting applies to a term that applies to our behavioral choices we make that unknowingly create unjustifiable risk. Becoming complacent and

over

- confident when performing work t asks, leads to behavioral drift. Short cuts from established policies and procedures are adopted not realizing the consequence of this new at

- risk

- behavior. A broken organization safety culture where negative norms are allowed to take root will reinforce e rrant behavioral drift. It‟s the unwritten rule that “ I know what the manual says, but this is the way we do things around here.” It becomes the new norm.

The motto is: ”no blood no foul.” Non

- compliant behavior is witnessed by supervision but as long as the work gets done and no one is injured, then carry on business as usual. If this behavior is allowed to continue unchecked, then the organization and surrounding community is at risk of experiencing a tragic event. We measure what we consider to be impo rtant. One standard of measurement is frequent scheduled and unscheduled audits. Reviewing the NYC DOS Part 360 Permit Application, page 73. Paragraph 3.9.1 Entitled „Record Keeping,‟ indicates that inspection of the NSMTS will occur on a routine basis. Th ere is no specificity on the audit schedule (scheduled and unscheduled), audit checklist, audit report and repository database, audit trend analysis review, stakeholder corrective action report and a means of communicating audit findings and best practices back to the NSMTS employees. Who will be held accountable when the operation is degrading to unacceptable level? Of particular note, there is no mention of independent oversight or enforcement of compliance by the regulatory agency to ensure regulatory

a nd local policies are in compliance. If human behavioral drift is to bemeasured and corrected ensuring the organization is not stepping over the

margins of safety, a continuing analysis and surveillance program is
paramount.

Building Maintenance Is A Re active, Not A Proactive Program As Stated In The NYC DOS Part 360 Permit Application.

Page 62, paragraph 2.6 addresses the policy and procedure for building

maintenance on an as

- need basis . The process calls for the Bureau of Building Maintenance (BBM) t o be notified by the NSMTS supervisor who completes a repair order and forwards it to the BBM for action. There is no mention of a preventative maintenance program or building maintenance

technicians on

- site 24/7 to address mechanical and electrical breakd owns. There is no time to wait for the BBM technician‟s arrival to resolve a quick roll up entry or exit door anomaly which is designed to prevent birds for accessing portions of the waste transfer operation.

Waste Container Serviceability Inspection Pr ogram Not Covered In The NYC DOS Part 360 Permit Application.

To ensure waste container serviceable to receive their prescribed payload, a NSMTS employee must conduct a thorough visual integrity inspection of the fitted gaskets and seals that provide the leak

- proof and watertight seal. This is equivalent to a flight officer of a pre

- departing airliner conducting a

walk

- around to ensure the aircraft is airworthy. If the waste container is deemed unserviceable, there‟s no mention in the permit application a s to where to stage the unserviceable containers and who will perform the repairs.

The FAA/USDA Evaluation Of The NSMTS And Its Compatibility With Respect To Bird Strikes And Safe Air Operations At LaGuardia Airport Report.

Page 23, Paragraph entitled „ Recommendations‟ states:

“Reduction of hazards to aviation safety posed by birds that might be attracted to the proposed North Shore MTS can be accomplished through the incorporation of building design modifications, adherence to strict operational proce dures, and the development and implementation of an integrated wildlife hazard management plan and program. The FAA, USDA, and members of the technical panel of experts conclude that the recommendations provided will achieve compatibility between the North Shore Marine Transfer Station and LaGuardia Airport with respect to birdstrikes and safe air operations.”

This raises various questions; “What are the strict operational procedures that employees are to adhere to and how will they be enforced? Has any agency outside of the NYDS reviewed the operational procedures for thoroughness and compatibility against the NSMTS? What is included in the training curriculum and does each employee have to pass a proficiency examination before being deemed qualified to work in his or her assigned position?

Did The Design Engineering Firm Of The NSMTS Incorporate A Human Factors Design Specialist Into Their Design Team?

A human factors design specialist working with the design team would suggest ideas to mitigate the effects of our human limitations and capabilities in the workplace. This added measure of human factors insight and safety would be invaluable by ensuring the system that the employee works in has not set them up for failure. The vast majority of human err or is caused by deficiencies within the system and not within the human. Boeing Aircraft Co. developed an investigation audit tool entitled: Maintenance Error and Decision Aid (MEDA). This document is used during event investigations to capture the contrib uting factors and to identify mitigation strategies to prevent a re

- occurrence. In my use of this tool I‟ve discovered the major causes of incident and accidents were due to disturbances within the system (structure, culture, policy/procedures, leadership, resources, etc.) We cannot change the human condition but we can change the conditions that the human works in. Has the NSMTS facility been designed using the most current scientific human factors design principles?

Catastrophic industrial accidents ca used by latent error were: The Gulf Oil Spill and destruction of the Deepwater Horizon oil rig, the Exxon Valdez, the Columbia space shuttle accident, the Chernobyl Nuclear Power Plant meltdown and the escape of poison gas in Bhopal, India.

If the NSMTS becomes operational, one day the world will sadly read about an airliner, crew, customers and other innocent bystanders being killed due to engine/s failure caused by a bird strike in the landing or takeoff path of runway 31 at LaGuardia airport. When the Board of Investigation presents their findings, the probability that one of many contributing factors will be the approval to build the NSMTS, as it did became a magnet attraction for birds, an unmitigated risk that jeopardized aviation safety. Unfortunat ely some of the error links have already joined as construction of the NSMTS progresses. The mitigation strategiesplanned to address the threats and risks will never be comprehensive

enough to advert a future catastrophy. We have an obligation to break th e error chain before another link is allowed to be formed.

Roger Hughes President, Decoding Human Factors, Inc.

Reference:

Gordon Dupont: Authored the “Dirty Dozen” and is a human factors practitioner. Dr. James Reason, author of Human Error

D avid Marx founder of Outcome Engineering and author of The Just Culture Community Workbook : Boeing: Maintenance Error and Decision Aid

Biography:

Roger Hughes is president of Decoding Human Factors, Inc., a consulting firm that provides human factors training and consulting to aviation organizations to reduce human and system error. Roger volunteers his time and talent as an FAA FASTeam Lead Representative to speak on the topic of human factors to Part 147 aviation schools, IA renewal seminars and FAA safety seminar.

Prior to forming a consulting business in 2010 Roger was employed with JetBlue Airways from October 2000 to 2008 in positions of Manager of Human Factors and Director Quality for technical operations. As Manager

of Human Factors he was responsible for developing and delivering human factors educational courses and fostering a strong human factors organizational culture. He managed the line station Human Factors Working Group Delegates who promoted human factors educational

initiativ es. He conducted event investigations for technical operations using the Maintenance Error Decision Aid process to identify human and system contributing factors.

Roger was employed with American Airlines from May 1967 to October 2000 serving as: Aviat ion Maintenance Technician, Avionics Technician, Supervisor or Maintenance Training, Technical Foreman, Manger of Quality Assurance.From 1962 to 1966, Roger served in the U.S. Navy as an Aircraft

Structures Technician Second Class (AMS2).