Feedback on my safety management system article in AIN’s March 2011 issue exhibits the mixed feelings that business aviation users continue to have on the subject of SMS. One of the elements of the article that readers didn't like is the photo of the Citation CJ2 that ran off the runway at Atlantic City's Bader Field on May 15, 2005. The obvious conclusion, these readers say, is that no SMS would have prevented that accident.
"Right on page 36," wrote pilot Terry Walby, “there is a picture of a Citation jet that overran the runway with the caption that reads, ‘…could have benefited from a Safety Management System.’ Really? Tell me what steps in the SMS risk assessment procedure would have prevented that accident?”
I wasn’t involved with the selection of artwork for this story, although I did have an opportunity to veto that photo. I did think that the photo was appropriate the first time I saw it.
But after hearing from Terry and another reader, I thought they had a point. After all, the pilot in this accident seemed to exhibit questionable judgment (see the amazing video of the accident on YouTube). Bader Field was then closed to jets and is now closed permanently; that accident probably hastened its demise. An airport diagram clipped to the pilot’s yoke had this notation: “airport closed to jet aircraft.” Runway 11 was only 2,948 feet long, and calculations showed that at the CJ2's 11,4000-pound landing weight, it would have a landing distance of 3,000 feet.
There was another factor: a 10-knot tailwind, which increased the landing distance to 3,570 feet. If the pilot had landed into the wind, he might have succeeded. Oddly, the NTSB report doesn’t ask or answer a key question: whether this pilot had accomplished this flight in the past, thus setting him up for the expectation of being able to do it again.
Now, would an SMS have helped this pilot? Perhaps not. From reading the NTSB report, this pilot appears to have exhibited some strange characteristics. If the pilot had flown an ordinary stabilized approach to the runway, one might give him the benefit of the doubt and conclude that he simply picked the wrong direction to land yet still tried his best to salvage the situation. This happens. I’ve done it, more than once.
But this was no stabilized approach. After being cleared for the visual approach, the pilot descended to 800 feet while heading 220 degrees. One minute later, he made a 360-degree turn, rolled out on 220 degrees, then crossed abeam Runway 11 at 100 feet. He climbed to 300 feet and flew downwind adjacent to Runway 11, then turned right toward the runway at about 200 feet at a groundspeed of 180 knots. Approaching Runway 11, the CJ2 was at 200 feet and 155 knots 1.25 nm from the end of the runway. Then the CJ2 descended to zero feet at 140 knots, with the last radar return logged at 1,000 feet beyond the approach end of the runway at 128 knots, according to the NTSB. The CJ2 touched down about two-thirds along the runway.
It seems pretty obvious that no amount of skill could have prevented that CJ2 from overrunning that runway at those speeds and even without the tailwind.
But to the question posed by the readers: would an SMS have prevented this accident?
After considering this some more, I think it could have. First, because an SMS, to be successful, must be adopted by the entire organization and supported by top management, and presumably this pilot would have been part of the SMS process. The NTSB report doesn’t say if he was the owner of the company, but it seems likely that he was in the executive level and would have been intimately involved with SMS development.
Second, because part of the SMS process is assessing risk before flying. We all are familiar with taking off without thinking too much about what’s coming. This is a terrible habit, yet I learned it from my flight instructors. We never calculated weight and balance or runway requirements before our flights, except for when tests were imminent. Consequently, I got in the habit of ignoring many preflight planning considerations, all of which now fall into the risk-assessment category.
I wonder how the CJ2 pilot was trained. Wouldn’t it be better for all pilots to learn and adhere to good risk-assessment practices from day one of their training? Isn’t this how the military trains its pilots? And isn’t that a key part of an SMS?
Third, no SMS can prevent all accidents. But nurturing an attitude of consideration of risk and how to minimize it can’t hurt. If the CJ2 pilot had spent even a few minutes looking over the charts for Bader Field, assessing the CJ2’s runway performance and then considering more suitable alternatives, he might have thought that Bader Field wasn’t the appropriate choice. Then again, given his odd high-speed flying close to the ground, one may wonder whether safety was a high priority for this pilot.
The readers raise another important question. SMS may be beneficial, but does it need to be law?
On this point, I remain unconvinced. There are more than enough regulations covering every aspect of flying as it is, and if we all complied with every one of them, maybe there would be fewer accidents. The FAA, in fact, is completely unable to marshal the resources to enforce all of its regulations and leaves it up to the industry to comply. And for the most part, we do comply.
Turning the SMS into a regulation, however, is a big step towards carving in stone some squishy concepts, and it raises innumerable questions.
How, for example, is the FAA going to enforce an SMS requirement?
Will SMS documents eventually require FAA approval, thus creating an even larger bureaucracy supported by more third-party auditors?
How does the FAA determine that an operator is violating an SMS regulation? If SMS is such a good idea, why not require it of all pilots, mechanics, flight attendants, charter operators, airlines, repair stations and so on?
And if this happens, how will we ever get our work done, because we will be spending so much time assessing risk before we can even climb in an airplane or open a toolbox.
The FAA seems to think that writing more regulations will improve safety and that SMSs will make us all stop and think before we take off and do something like land downwind on too short a runway. Ultimately, it’s impossible to regulate people into making the right decision. And while SMSs may help, especially if the concept is introduced early in pilots’ careers, I believe that there is no need to make SMS a regulation.
Instead, the FAA should encourage operators to adopt SMSs where it makes sense and reward them for doing so voluntarily. But the rush to make SMSs mandatory is going to have less of a safety benefit than regulators expect and will increase costs of operation yet again (which may improve safety because people will fly less).
The FAA would see better safety results by working closely with the industry to incentivize safety practices and not by enacting more punitive regulations. SMS is a safety practice and is not amendable to regulatory treatment.