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 acceptable 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 best 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 NSMTS 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 science 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 as an error chain. These are 

usually latent errors (undetected) that lay dormant, accumulating until the 
precise moment when they are released by another human or mechanical 

action (active failure.) This releases energy into the chain allowing a 

negative consequence 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 predicated on the defenses-indepth 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 failure. 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” in 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 defeated 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 capabilities. 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 Disclose 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 as latent errors. In organizations that have 

embraced human factors training, worker awareness is heightened to 

recognize contributing factors to human performance shortcomings. The 
course content should include but not limited to the Dirty Dozen, twelve 

factors 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. Armed 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 

quality 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 tasks, 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 errant 

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 

important. 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. There 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 

and local policies are in compliance. If human behavioral drift is to be 
measured 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 Reactive, 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) to 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 breakdowns. 

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 Program 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 as 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 procedures, 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 bird 
strikes 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 error 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 contributing 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 caused 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. Unfortunately some of the error links have already joined 

as construction of the NSMTS progresses. The mitigation strategies 
planned to address the threats and risks will never be comprehensive 

enough to advert a future catastrophy. We have an obligation to break the 

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 

David 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 

initiatives. 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: Aviation 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).