This year’s annual safety standdown– sponsored by Bombardier Aerospace, NBAA, the FAA and the NTSB, focused on more than procedure and technique. The three-day event (one day longer than in previous years) emphasized the need to initiate and sustain positive changes in behavior and cultural norms. To that end, presenters focused attention on recognizing and dealing with attitudes and predispositions–of individuals and organizations– that compromise safety.
Optional one-day workshops on subjects such as CPR and crewmember medical training, ditching/underwater egress and water survival training, international procedures, human factors for maintenance managers and behavioral accountability preceded the event.
Created by Bombardier to improve aviation safety by “combining skill and knowledge-based training,” Safety Standdown was free to the 534 attendees. NBAA president and CEO Ed Bolen opened the general session by remarking, “While we are the safest mode of transportation,” it is necessary to get even better. “Our goal must be not only to be safe but to be perceived as safe” by the media and the public.
NTSB chairman Mark Rosenker noted, “It’s not often that the NTSB takes a significant role in these external activities, but this seminar has caught our attention over the past few years, and I wanted our agency to be a part of it.” This is the first year his agency has cosponsored the event. He complimented salaried crews flying corporate jets under Part 91 for accident rates comparable with those of scheduled airlines but added, “There is always room for improvement.”
Rosenker acknowledged that the NTSB has no regulatory authority but pointed out that a high percentage of NTSB recommendations are adopted as law or regulations. “We believe it’s not necessary to regulate if the industry comes up with a better, safer way,” he continued, endorsing voluntary assumption of personal responsibility, which he called “more effective than any possible regulation.”
Rosenker identified common factors of “unprofessional pilot behavior and deviation from standard operating procedures” in several accident findings, among them the Comair crash at Lexington, Ky., and the Circuit City Citation 560 accident at Pueblo, Colo. The NTSB found a root cause of the Comair mishap to be “failure to positively confirm and cross-check the exact location of the aircraft…” while the Circuit City jet fell victim to deviation from prescribed anti-ice activation procedures.
Recognizing that aviation safety stems from more than just aircraft and pilots, the NTSB is pushing for duty-time limits for both flight crews and mechanics. Rosenker pointed to the 2004 crash of an emergency medical service King Air whose pilot had been awake for 21 hours as evidence of the need for duty-time regulations.
“Operators who short-cut maintenance,” either through under-staffing or failure to comply with established standards, “come to the NTSB’s attention,” he said, adding, “We strive for perfection…and work our way up from there.”
Behavior Changes Can Improve Safety
Bob Agostino, Bombardier’s flight operations director and organizer of Safety Standdown 2007, introduced his new look at Safety Standdown fundamentals with a quote from the Roman philosopher Epicurus: “It is impossible for a man to learn what he thinks he already knows.” He continued, “Looking within ourselves is the hardest thing we can do. We have undervalued the effect of behavior on safety, [and] our interpersonal relationships need work.” He went on to discuss factors comprising the “environment,” not only weather, air traffic and the equipment being flown but fatigue and an organization’s internal political atmosphere.
Agostino outlined an airmanship model that he called the path to total situational awareness, both in the air and within the organization. He defined airmanship as based upon a high state of situational awareness obtained through knowledge of one’s self, team, aircraft, environment, mission and risk. “This is the whole basis of Safety Standdown,” Agostino stated. The model, he said, provides a shared vision of excellence that fosters continuous organization-wide improvement. It includes a common language and objectives and establishes a starting point for professionalism and uncompromising personal discipline.
He continued, “We need to get beyond one-dimensional skill-based training. Some things must be lived to be learned. Development of the human half of the man-
machine equation has not kept pace with… technology…in either formal training or regulatory oversight.” Agostino discussed fallacies about human error, based on the fact that skill, vigilance and conscientiousness are not sufficient in themselves to prevent error, as evidenced by experts periodically erring due to subtle variations in task demands, information available and cognitive processing impaired by “tunnel vision” under stress.
Safety Board North Central Region director Carl Dinwiddie discussed recent jet accidents rooted in unprofessional behavior, improper decision-making, poor CRM and bad corporate culture. He said these mishaps show that “accidents happen to anybody at any time. I say ‘anyone’ because we had company presidents, chief pilots, check airmen and pilots with 10,000, 15,000, even 20,000 flight hours involved.”
He said at least one instance was a case of “you know better but you do it anyway,” and cited corporate cultures as accident contributors by ignoring or condoning deviations from standard operating practice and violations of regulations. The former naval aviator and air traffic controller presented three case histories of “when bad things happen to good people.”
In the first, on July 19, 2006, at Cresco, Iowa, a Cessna 560 used up all 2,949 feet of runway attempting to land in VMC and continued off the end into a cornfield. Both pilots died and their two passengers were seriously injured. The cockpit recorder revealed that the copilot had convinced the PIC to attempt a landing after misjudging the runway’s length, perhaps because of its unusually narrow 50-foot width. This was an unplanned diversion for weather to an airport about which the crew had not obtained information.
The next example was a Dassault Falcon ditching in a river due to fuel starvation after ATC terminated the airplane’s first approach to the destination airport. Both engines flamed out during the second approach after the pilot elected not to proceed to another airport 14 miles away. No alternate had been filed in the flight plan. The NTSB determined the probable cause to be “the pilot-in-command’s improper
in-flight decision not to divert…and his failure to relay his low fuel state to air traffic control in a timely manner.”
And finally, on Nov. 30, 2004, a Hansa 320 turbojet crashed into a river two miles from Spirit of St. Louis airport due to misrigged flight controls following maintenance to comply with an AD during which the pitch trim cable had been reversed. Neither maintenance personnel nor the flight crew performed a functional check of the flight controls before the aircraft took off.
Unmasking the Rogue Pilot
So-called rogue pilots have been around as long as aviation itself, from the daredevils of powered flight’s first decade, World War I fighter pilots and the barnstormers and air mail pilots of the 1920s. Then they were indispensable and considered heroes, as Tony Kern, CEO of Convergent Knowledge Solutions in Memphis, explains in his book Darker Shades of Blue: The Rogue Pilot. (Each standdown attendee received a copy.) But now an attitude of “Complete the mission regardless of risk, and the hell with regulations and procedures” creates an unacceptable hazard.
Kern told the audience that identifying and dealing with this type of aviator is a key component in error prevention. He noted that cockpit resource management (CRM) and safety management systems (SMS), while essential, “are not the be-all and end-all. Most accidents wind up being failures in self-management.”
He asserted that toleration or even reinforcement of rogue pilot behavior can be both institutional and individual. Such reinforcement includes the perception that rules must be bent to get the job done; belief that the violator has the
skill and stature to do the job better outside the boundaries; perception that the violation is unlikely to be detected by anyone in authority; lack of adequate planning time or depth, resulting in “free styling” during execution; and leaders who practice or are known to condone procedural non-compliance.
Kern pointed out the irony that many who practice or are likely to practice unsafe behavior outside the envelope are high achievers who are admired by their colleagues and valued by management. He pointed out that good policy and procedures are organizational cornerstones, while compliance is an individual cornerstone. He added, “Over-proceduralization breeds non-compliance in a mission-oriented culture.” On the other hand, “There are actually rogue organizations that encourage undisciplined behaviors [in] a culture of noncompliance that develops over time.”
Kern advocates and conducts personal error training within a framework of individually developed personal operating procedures. He stated, “It has been long assumed that when you train people to do something right you simultaneously train them not to do it wrong. This is grossly in error.” Kern said the cornerstones of personal error training as the key to individual responsibility for safety are to “Recognize your personal vulnerabilities, sense the event as it approaches, and prep yourself with a pre-packaged response.”
Gene Cernan, Apollo 17 astronaut and the last man to walk on the moon, capped the first day session by summing up Safety Standdown 2007: “It’s not about our aircraft. It’s about you and it’s about me. Are we prepared for the unanticipated? The focus here is the depth of our commitment to the discipline to do the right thing at the right time. Do we have enough passion to be the very best?”
The former Navy A-4 aviator and high-time Learjet pilot advised his fellow aviators to “prepare for the unknown, unexpected and inconceivable. Sharing experiences can help us to prepare. Personally, after 50 years of flying I’m still learning every time I fly.” He added, “You are among the aviation elite. You are the professionals. Professionalism is no more or no less required to land on the moon, or for a night trap [carrier landing], or a 200-and-a-half night approach in IMC.”
Cernan noted that 80 percent of accidents originate in the cockpit, and said, “The real goal of Safety Standdown? Get that number down to zero. Can zero be achieved? Probably not, but we can reduce it significantly.” He concluded by observing, “The Wright brothers’ great gift to us wasn’t the airplane but inspiration. I call it ‘passion.’ Let’s each of us harness that passion to a commitment to be a professional aviator, the best that we can be.”
Sean Roberts, director of the National Test Pilot School at Mojave, Calif., pointed out that while test pilots are probing the edge of the performance envelope, most ordinary flight is conducted right in the middle of the envelope, the “comfort zone.”
“But,” he went on, “there’s an upset…then what?”
Roberts explained that at 2.5g stall occurs at Va, but at zero g stall speed is 0. “So…push! Unload for control. Pushing is an unnatural act, but that’s what it takes.” He explained that the procedure is simple because FAR Part 23 stall requirements call for “recovery without an exceptional degree of skill by an average pilot.”
His summary of lessons learned about stall/departure recovery began with “Unload for control.” One of his several departures from FAA standard procedures was that “Power degrades stall characteristics. The FAA training requirement to add power at stall warning is a recipe for disaster.” He added, “Preconceived ideas and attitude about general aviation aircraft can kill.”
A Review of Real-world Skills
During a lively question and answer session following Roberts’ lecture he counseled that when flying at very high altitudes, “leave the throttles alone.”
Later, Sam Harris, president of V1 Aviation Safety Training, explained why balanced field length is often not enough to stop safely after a rejected takeoff. Balanced field length, noted Harris, a Naval Air Reserve selectee for captain with two Iraq combat tours in his logbook, is based on performance by test pilots under ideal conditions. A rejected takeoff in the normal, real world involves several factors that erode response time and lengthen the runway requirement.
“Every second you spend talking about this stuff is making you and your passengers safer,” Harris advised. He recommended lowering SOP V1 speed by five knots to allow for reaction time, and to consider all aspects of the rejected takeoff scenario beforehand. He pointed out that a rejected takeoff initiated at just four knots above V1 will create a runway end overrun at 50 knots.
Statistics show that one in 14 crews will have a rejected takeoff near V1 during a 25-year career, but that in 55 percent of cases continuing the takeoff was successful in avoiding a rejected takeoff, while another 16 percent could have been avoided with correct stopping techniques. “In nearly three-quarters of all rejected-takeoff accident cases, full takeoff power was available,” Harris noted.
Dr. Jerry Berlin provided a wide-ranging and entertaining presentation on aviation psychology in general and pilot attitudes–both desirable and not–in particular. The aviation human factors guru recalled that until about 1960 accidents unexplained by material causes were chalked up to “pilot error.” When researchers began to examine the why, said Berlin, aviation psychology–the parent of CRM–was born.
“Early results were less than spectacular,” he recalled, “but for the first time, this year I can tell you we are creating small amounts of change. We have come to the realization that learning best takes place when people have fun. Now we’re looking at ‘What behaviors do you wish to change?’”
Berlin’s other observations included, “It’s a given that pilots are not a microcosm of society. As a group we are different. Pilots tend to be significantly brighter than others in our culture, but they don’t look it. Pilots like simple definitions and simple explanations based on logic. We do better with simple concepts. We tend to be narrow in our interests and focus. We differ from most components of society in how we deal with feelings, the single most critical variable.”
Why this is so, Berlin stated, is because “teaching leadership, management and interpersonal relationships is effective only when there are feelings involved. At United Airlines we tried experiments to get new hires to express feelings about various subjects. We never got a feeling back, only ideas. Pilots can’t tell the difference between feelings and ideas. Of a possible 40,000 words to denote anger pilots use eight, of which the most common are ‘I’m pissed.’ My job was to develop ways of training that include feelings.”
Berlin called the concept of authority the root of all conduct in the cockpit, specifically the captain’s ability to take and maintain command and control. He said the task is to define the behavior we want in CRM, then to seek those with high authority and secure personalities.
He said the goal is authority with participation through assertiveness and the ability and willingness of subordinates to show initiative. Teaching assertiveness requires that it be done respectfully, Berlin stated. “There’s a healthy way to teach it and do it. When they really feel it, that’s when learning takes place.” He said successful CRM training will bring out feelings in normally stoic pilots and facilitate communication on the flight deck, especially at critical moments.