By all accounts, the 1996 genesis of Bombardier’s Safety Standdown, an event that now regularly draws nearly 500 aviators to Wichita annually, was rather humble. Bob Agostino, director of Bombardier’s Flight Operations at the time and a trained accident investigator, asked his pilots for their thoughts after a particularly difficult accident investigation. One of them, Air Force veteran Dave Sullivan, explained how the military dealt with similar issues. “We’d stand down until we figured out the cause.” Agostino wondered, “Why wait for another accident before we look into what causes them?” A few months later the first standdown was launched as an internal training tool for Bombardier’s seven-pilot Wichita flight department.
Rick Rowe, manager of safety standdown programs for Bombardier today, picks up the timeline. “That first event included a theatrical smoke generator in a Lear 31 to demonstrate emergency evacuations realistically. Then we brought over the fire department and everyone got a chance to try putting out an actual fire with an extinguisher.” In 1997 Bombardier invited its research and development, as well as its production test pilots, to the standdown. “By 1999 we were inviting Bombardier customers to what had officially become the Safety Standdown. In 2000 we opened the doors to other flight departments,” Rowe explained. By 2005, FAA, NTSB and NBAA support solidified the Safety Standdown brand.
Attendance has grown each year since. In 2008 it nudged 600 when the event was held in Kansas City. Safety Standdown returned to its Wichita roots the next year, however, because people felt it lost some of its original flavor with such inflated attendance. “At first we thought bigger would be better, but we came to realize that 475, right here in Wichita, is just right,” said Puja Mahajan, Bombardier’s manager of flight operations. “This number is intimate enough to make an impact, but not so large that we lose the message in the vastness of a big room,” she added.
This year, as usual, the topics all integrated around the “Learn, Apply, Share” philosophy for which the Safety Standdown has been noted since it began. The idea endures that meeting the minimums of the regulations is simply not good enough for anyone in this industry. Registration for Safety Standdown remains free.
Leadership Must Focus on Safety
Forget the constant back and forth about whether or not there will be a pilot shortage and how leaders will deal with the mismatch of cockpit experience levels that’s about to hit. Dr. Tony Kern, CEO of Convergent Performance, spelled it all out in the Standdown keynote.
“Want to focus on safety over the next ten years?” Kern asked. “Find the right people and figure out how to hold on to them,” he said. “Competition for recruiting and selecting well qualified pilots will increase, so the fight is on. If you don’t stay in step you’ll get the leftovers. And if the economy picks up this change is going to come at us very, very fast.” The writing is on the wall for leaders: Change or get out of the way. While “leaders will need to learn how to train,” new hires will also need to learn how to teach themselves “because there won’t be enough training dollars to make up the difference between the experience levels. We’ll have to take quality assurance and standardization much more seriously, too. And [leaders] will need to come to grips with continuous turnover.”
Reflecting on the 2009 Colgan accident in Buffalo, Kern said, “Clearly there was a lack of discipline, proficiency and skill. And all these failures occurred above the regulatory line, despite what it looked like. Eight or nine years from now, this might be your best crew. [It does not matter who] we put in which airplane. Those pilots can’t just meet minimums. They must perform at a level of holistic excellence.” Kern said the industry can’t survive with the eroding levels of professionalism being displayed today. “Aren’t we all professionals though? If the answer is yes, then we’ve set the bar too low. We’ve dumbed ourselves down with what is an acceptable performance. But how do we raise it without angering some people enough to fight against it?”
Kern asked, “Are there times when pilots must perform nearly perfectly to survive? Absolutely. So training only to a level of effectiveness is [related] more to simply keeping your job. Perfection might be what keeps you alive. But how can we be ready [for anything] when we don’t train like we fly every day? We need to demand more [from pilots]. But being better is above the minimums outlined on the regulatory line.”
Kern believes in personalizing professionalism. His theory: “A level-one pilot has a job. By level two he meets all the standards. But at level three [where we need to be] he is doing all he can to be the best and help his peers do the same. That’s the competitive advantage of better safety improvements.” Kern said, “It’s vitally important that you realize you are capable of so much more.”
Runway Incursions and Excursions
Al Gorthy, a former Navy carrier pilot, works in the FAA’s Runway Safety Group. He said runway incursions and excursions are still on the NTSB’s Top 10 Most Wanted List. “In the past thirty-five years, more than 1,100 people have died in ground collisions. All those accidents were preventable,” he said. When it comes to determining causes, Gorthy said, “We’re good, but only after the fact. We need to get much better at connecting the dots before an excursion or incursion. Most causes point to human error. It is easy to blame and difficult to look at ourselves. We must remember that arrival at an airport means you’re operating in a hostile environment populated with well meaning people who sometimes underperform. One person underperforming can create a threat.”
He pointed out that despite today’s technology–airports with state-of-the-art signs and electronics, aircraft and pilots with sophisticated simulators and training–human error remains a constant. Today’s pilots are making “the same errors we made 40 years ago. How do we fix this?” He said 70 to 80 percent of the time pilots admit that their mistakes stem from simply not paying attention. “If you focus too much on what has happened, though, you may lose focus on what might happen. Focus too much on what might happen and you might miss what is happening. It is simple to understand, but difficult to manage.”
Runway incursions are categorized from “D” to “A,” with “A” the most serious. The only difference between a “C,” a “B” and an “A” is time, and often just seconds. The total number of incursions has remained relatively flat for the past four years, about three each day at towered airports. We’ve made tremendous progress on “A” and “B” until this year, according to Gorthy. The numbers are climbing and, he said, “We don’t know why right now, but we’ll find out. That’s a close call every 17 days, with controllers [responsible for] 20 percent, vehicles 20 percent and pilots 80 percent, although business aviation is only a small portion of those incursions. Most are general aviation. Are we going to settle for this?” Gorthy asked. “Is this really the best we can hope for?”
Runway excursions are the most common type of fatal runway accident, with 80 percent occurring during landing. Between 1995 and 2010 there were 650 runway excursion accidents worldwide, 65 of which were fatal and taking 1,121 lives. Failure to execute a timely go-around is the top reason for runway excursions, and business aviation pilots are nearly twice as likely as an airliner crew not to execute a go-around when needed. Precursors to both incursions and excursions include airport construction, pilot’s unfamiliarity with the airport, shortened runways, land and hold-short operations, intersection departures and operations on crossing runways. “We need to start connecting these dots much better,” Gorthy said.
A Little Apollo Guidance
Safety Standdown’s unofficial ambassador is Capt. Gene Cernan, Apollo 17 Commander and the last man to walk on the moon. As a pilot type-rated in the Learjet 45, Cernan understands and appreciates business aviation. He handles personal transportation with the Cessna 421 he still flies.
It’s the thinking that happens at the standdown that makes the event useful, Cernan said. “I was a naval aviator, a carrier guy,” he said. “Years ago, Bob Agostino asked me to do more than just tell the Standdown what I’ve done. So I told them all the dumb things I’ve done. Just because you’ve gone to the moon doesn’t mean you’re exempt from making stupid decisions. I’ve made a lot of them in my life. I think when guys heard I was vulnerable they realized they could be too.” He worries about the complacency technology is imposing on pilots. “We tend to become overwhelmed with all the lights on these glass panels and forget we still have a responsibility to fly the airplane,” he told attendees.
His 421 now has a glass PFD and MFD and terrain avoidance technology that’s “supposed to keep me from killing myself. But if that technology fails, I still need to fly the airplane and miss that mountaintop.” He said Safety Standdown forces him to be more introspective when he flies. “It’s easy to preach and a little more difficult to do,” Cernan said. “I always feel a little guilty now if I take a shortcut I told someone else not to try. I call it the standdown effect.”
Bombardier’s Rick Rowe said, “I used to think we had the wrong people in the room at Standdown listening, because those people already get it. But then someone said no, we have just the right people in the room, the right people to take the ‘learn, apply and share’ message back to people who were not here. They also need to tell others that simple compliance with minimums will not keep us safe. There are plenty of dead people out there who met minimums.”
Cernan concluded, “You must be committed to the belief that you can be a better pilot. Just good in our profession is never going to be good enough. That’s not a regulation; that’s a commitment that each individual must make to himself.”
Nine Principles of Glass-cockpit Airmanship
Within four months of the Air France 447 crash–May through October 2009–three more A330s suffered a total loss of air data in convective weather above FL370. Why did these three crews recover while the Air France crew did not?
Chris Lutat, an MD-11 check airman and a member of the Convergent Performance team, said, “Those three events have become just a footnote. Why aren’t we looking at what those pilots did correctly to interpret what they saw [in the cockpit]?”
On glass-cockpit aircraft, Lutat said, “After almost two full decades of flight training on these airplanes we finally have a repository of expert knowledge on glass cockpits. Training was pretty much absent when we began operating these aircraft. Good judgment and safe practices do not come packaged with new technology.” Lutat echoed the NTSB’s John Lauber, who urged that we must define the relationship between people and technology and not let it define us. “Glass-cockpit airplanes are still just airplanes. The elements of discipline, skill and proficiency remain unchallenged as the foundation of professional airmanship. The technology has simply given us a new lens through which to view how the aircraft performs.”
Why is glass operational excellence so important? “Expert performance is required right after initial training,” Lutat said. “Complex systems fail in complex ways. Few training and evaluation programs provide [much of] a balance in developing proficiency flying with degraded automation.” Recalling Qantas 32’s uncontained engine failure, Lutat explained why automation competence has become a frontline skill. “That incident left the A380 crew with information they didn’t know what to do with, information they didn’t need and necessary information they couldn’t find.”
Lutat shared his nine principles of automation airmanship, reminding the audience never to forget that “you are way smarter than the technology.”
1. Planning The PIC conducts a thorough pre-flight briefing ensuring each crewmember understands the aircraft’s technology and assigns specific crewmembers responsibilities for specific automation duties.
2. Briefing and De-briefing Specific flight-deck briefings on FMS, autoflight mode configurations, unanticipated automation behavior and timely resolution of discrepancies. Brief from the FMS, not the flight plan, to ensure the crew understands what the aircraft is planning to do next.
3. Data Entry Use of strict data entry and verification routines that compare intentions with aircraft performance. Ambiguous data entries are challenged and corrected before being entered into the airplane’s systems.
4. Communicating Concise, bold person-to-person communications between crewmembers, including the intent of all pilot actions.
5. Monitoring The PIC maintains authority over crew and automation, ensuring that the crew, not the aircraft, makes flight-path changes. Humans can focus on only one task at a time but must learn to switch quickly between tasks.
6. Situational and Mode Awareness Crewmembers must thoroughly understand all autoflight, flight guidance and system sensors to maintain accurate mental pictures of the flight.
7. Workload Management Flight crews must smoothly alternate between automated and manual flight, with all cockpit crewmembers aware of the changes.
8. Positive Flight-path Control Aircraft control is never compromised when automation fails. Flying the airplane first is always key.
9. Logic Knowledge Pilots accurately apply knowledge of automated systems in all operations.
“Automation Airmanship is accessible, learnable, teachable and observable,” Lutat emphasized. “Pilots must learn to apply automation system knowledge to their decision-making and understand expected and anticipated automation actions. Most of all, eliminate discussions that begin with “What’s it doing now?”
Piloting Good Cardiovascular Health
It’s tough to talk about how airmen should interact with their aircraft, its technology and the world around them without discussing how pilots can keep their bodies, specifically their hearts, healthy enough to fly.
Dr. James Smith, a Wichita-based cardiovascular disease specialist, said treating cardiovascular health means treating systemic health as well because the heart is a muscle that needs stimulation to stay healthy. “Cardiovascular disease essentially means circulatory trouble often triggered by high cholesterol, high blood sugar, infections, abdominal obesity and, of course, smoking.” Cardiovascular disease also affects the brain, lungs, kidneys, blood vessels and blood pressure.
Smith compared a number of controllable versus uncontrollable heart risk factors. “Pilots can control their diet, exercise, weight, smoking and alcohol intake, but they can’t control their age, genetics, diseases, environment or stress.” He reminded pilots they’re also great candidates for deep-vein thrombosis (blood clots in the legs) from extended periods of sitting idle at high altitudes. Dehydration exacerbates the problem. Frequent sips of water and movement every hour or 90 minutes work well.
Smoking, however, remains the most damaging risk to the heart, Smith said. Smoke contains toxic chemicals that damage the vascular lining, increase blood clots and raise bad cholesterol levels.
Smith ended with a discussion of the relationship among diet, exercise and weight control. “Each factor affects the other two. Maintaining a good diet and exercising regularly will help with weight control, while weight control and a good diet will make exercising easier.”