Report highlights Chicago air traffic controller fatigue

Air traffic controllers at Chicago O'Hare International Airport have too little time off between shifts, according to a federal audit released Thursday. The report by the U.S. Department of Transportation criticised the Federal Aviation Administration for not acting sooner to alleviate air traffic controller fatigue at three of the country's busiest air traffic control facilities and recommended immediate changes. The audit showed most controllers at the three Chicago ATC facilities have had fewer than 10 hours rest between some shifts, progressively earlier start times on consecutive shifts and increased overtime hours. "This type of work schedule offers minimal opportunity for sleep when the time required for commuting, eating and other necessary daily activities is taken into account," the report said. The report stated that the FAA has failed to act on earlier National Transportation Safety Board recommendations on controller fatigue and that the agency "does not consistently address human factors issues, such as fatigue and situational awareness" in incident investigations. Source: Associated Press, 2 July 2009. tinyurl.com/neesfg

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From input error to near disaster at Melbourne airport

An Emirates flight EK-407 from Melbourne to Dubai narrowly avoided disaster, with 275 people on the Airbus jet. On the flight deck, the first officer and the captain fed routine information, including the plane's weight and fuel load, into a computer. The procedure was for them to check each other's work to avoid mistakes. The first officer opened the throttles and headed down runway. As the first officer tried to ease the aircraft off the runway, the jet stayed grounded. On a second attempt, the nose came up — but the jet's rear repeatedly hit and dragged along runway, puncturing the skin of the jet, tearing off a panel and breaching the air pressurisation. Eventually, at the end of the runway, the jet began climbing. But it was still too low, hitting a runway light, then antenna equipment on the ground, and scraping the grass. With seconds to spare, the jet climbed and finally reached a safe height. The pilots dumped most of their fuel over the bay and, with smoke in the cabin, the plane was given emergency clearance to land. When the pilots checked their instruments they spotted the potentially fatal mistake. Before take-off, their fuelled-up jet weighed 362 tonnes. But they had accidentally keyed in 262 tonnes, resulting in too little engine power. Only the captain's rapid reactions averted a disaster. Source: Sydney Morning Herald, 01 May 2009. tinyurl.com/kjd3r2
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Intensive care errors ‘frequent’

Errors in the administration of injected medication occur frequently in intensive care units, a study of 113 units across 27 countries suggests. Over a 24-hour period, 441 patients out of 1,300 were subject to errors, and seven suffered permanent harm. Nearly half of the affected patients suffered more than one mistake. The most frequent errors related to the wrong time of administration and missing doses. Stress, tiredness, recent changes in the drug’s name, poor communication, and protocol violations were cited as contributing factors. Lead researcher Dr Andreas Valentin recommended error reporting systems and routine checks at shift changes. The Intensive Care Society said many units had developed patient safety training programmes, including measures to learn from ‘near misses’. Work was also under way to standardise concentrations of some drugs for critically ill patients, refine the use of antibiotics and minimise the risk of adverse drug reactions. Source: BBC, 13 March 2009. http://tinyurl.com/b9cqz6

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