AINsight: Time Out for Safety

 - August 29, 2019, 4:02 PM

A spate of business aviation accidents has discussion boards and Facebook pilot groups asking the question: why have there been so many in recent months, a notable turnabout from last year’s far better record? It’s not uncommon in the military for organizations to take a break when safety issues rise to a high level, called a “safety standdown.” Bombardier’s annual Safety Standdown sort-of replicates that concept.

During my career, there have been a few instances where, in retrospect, I should have applied more consideration toward the safety of what I was doing. In thinking about that, I came up with a concept that I named “Time Out for Safety.” The idea is that anyone involved in the operation can at any time raise a hand and say, “Time Out!” This stops the clock, halts whatever steps are underway, and forces those involved to rethink the plan.

There are times I should have invoked the time out before it was too late and there are times I did, and I can easily say I feel much better about the latter.

In one case, we had finished preparing a complex piston single for its first flight after an engine change. For some reason, I allowed group pressure to take over and let a bunch of our mechanics go along for a ride with the owner during the first flight. As it took off, my heart was in my throat as I willed the engine not to hiccup. Obviously turning a first flight after an engine change into a joy flight wasn’t a good idea, and I learned from that.

Twice I eventually made the right decision while in flight. The first involved a flight to test a single-engine piston airplane that can fly well into the flight levels. It wasn’t until after we took off that the demo pilot revealed that we had only two oxygen masks for the three people on board, so we would have to share the oxygen. As we climbed into the teen altitudes, I finally decided to say something about this being an unsafe operation, that we shouldn’t risk climbing into the flight levels without proper masks for each of us. The demo pilot and my boss reluctantly agreed, and we descended.

Another time, while flying to visit relatives with family on board, we thought we were having a problem extending the landing gear in a Piper Arrow. It turned out to be a failure of the dim lighting side of the landing gear position lights, and when I finally wised up and asked my wife to read the emergency checklist, I switched on the interior lights, which caused the bright side of the position lights to illuminate. I should have invoked crew resource management earlier, but at least I finally did so.

I have plenty of examples where I should have used a time out, and some are embarrassing, but informative nevertheless. While test flying a business jet, I accidentally switched off the audio on my side while manipulating the nosewheel steering tiller, just as I was taxiing into position for takeoff. I should have stopped the takeoff and taxied off the runway and fixed the problem, but I continued taking off, which was the wrong decision.

Time Out for Safety works in many circumstances, and not just aviation. An offer by a friend to take a powerboat ride to an island about 15 miles offshore sounded great. The weather was perfect, the sea calm, and it would have been a fun trip for our spouses and children. However, before this trip, someone had stolen all the boat’s emergency equipment, including the life vests. I decided that we weren’t going to go, which disappointed the kids and my friend, but it wasn’t worth the risk.

It’s easy to get caught up in the vortex of an activity and go along with events without stopping to think about consequences. This is really what tools such as flight-risk assessment and safety management systems are all about: considering consequences, assessing the risk, and making an intelligent decision as how to mitigate, but ultimately accept, the risk.

Looking at the accidents that have happened this year, it’s not hard to think about when a time out might have helped. None of the investigations are done yet, so we have to wait to find out what actually happened. But it never hurts if when that little voice on your shoulder starts to raise some questions, take a deep breath, ask whether it makes sense to call a time out, and if so, stop the clock (on the ground) or do a go-around or slow down or hold (if in the air) and step back and talk through the situation before making an irrevocable decision.