The Air Charter Safety Foundation’s (ACSF) recent annual safety symposium, held March 7 and 8 in Ashburn, Va., carried the theme “Safety is a choice you make,” and proceedings underscored an intended double meaning. The message: while adopting safety-enhancement initiatives is a choice, it is not enough. Operators must also elect to put forth the effort required to ensure these programs deliver measurable results beyond preventing accidents.
Put another way, it is not enough for business aviation to sign on to safety efforts such as an Aviation Safety Action Program (Asap). The success of such programs depends on operators’ treating implementation as an early step on the risk-management journey, rather than a box-checking exercise. And a safe operation in macro terms—zero accidents or major incidents—might make an unaware operator even more susceptible to risk escalation.
“Success, in my view, is something that breeds complacency,” said Joe Salata, chairman and v-p of the ACSF and v-p for flight operations at Flight Options.
The good news is that more operators appear to be embracing risk-management programs. ACSF, an FAA-designated third-party Asap manager, counts 65 companies in its four-year-old program and has 20 more in the queue. Participants are roughly split between Part 135 and Part 91 operators. Among the program’s extra benefits: ACSF handles 90 percent of the administrative burden, removing one potential obstacle for smaller operations concerned about manpower.
While initiatives such as Asap and corporate flight operations quality assurance (C-FOQA)—flight data-monitoring—programs help identify risk areas, they are of little value if the lessons they teach are not applied.
Pattern of Noncompliance
Investigators probing the May 2014 accident that killed all seven people on board a Gulfstream IV attempting to take off at Hanscom Field in Bedford, Mass., gained significant insight about the flight crew’s tendencies from 303 hours of quick-access recorder (QAR) data. Among the patterns discovered: a habit of skipping full pre-flight checks of the flight controls. The NTSB’s final report on the accident listed this “intentional noncompliance” in the series of errors that caused the crew to attempt to take off with the GIV’s gust lock engaged, leading to an attempted rejected takeoff and high-speed runway overrun.
The GIV’s operator was enrolled in C-FOQA, Tom Huff, Gulfstream’s director of safety, told symposium attendees. “What we don’t know is how they were using the information,” he added. The operator’s only employees—two pilots and a flight attendant—were killed in the accident, leaving the Safety Board with few leads for gaining insight into the operation’s inner workings.
A study last fall in response to an NTSB recommendation generated by the Bedford accident suggests that many operators participating in data-monitoring programs are missing clues. An NBAA-led group analyzed business aviation FOQA program data from 144,000 flights between 2013 and 2015, looking specifically at pre-flight checks. Their findings: on 16 out of every 100 flights, crews performed partial checks but were not in full compliance with manufacturer recommendations. On two out of 100, no checks were done.
“That’s [3,000] flights where the crew did no flight control sweep at all, and that’s disturbing,” Huff said. “And these are just people who participate in a FOQA program. This is a small percentage of the operators worldwide.”
Evidence of such habitual noncompliance exposes another weak link in the safety-program chain: the value of industry ratings and related audits.
The Bedford GIV’s operator passed International Standard for Business Aircraft Operations (IS-BAO) in 2010 and 2012. The second, a Stage 2 audit, recognized several notable achievements, including “demonstration of an effective [safety management system],” the NTSB report noted. Passing an IS-BAO Stage 1 or 2 audit does not require a check ride, and the GIV operator’s 2012 audit report noted that flight operations were not observed because no flights were scheduled during the audit period,” the NTSB report said.
While an audit check ride might not uncover issues such as pre-flight checklist noncompliance, the NTSB argued in its report that “audit standards could have included a provision indicating that company policies and procedures should specify preferred methods for checklist execution.” While not guaranteeing flight-crew compliance, the existence of such standards “would have provided a clear message to the flight crew about best practices regarding checklist execution,” the Board continued.
The NTSB recommended that the International Business Aviation Council, IS-BAO’s steward, change its standards. The group did, telling the board in February last year that a new standard calling for operators to “comply with best practices for checklist execution,” and providing examples, is now part of IS-BAO.
While such changes may create tools that flight departments can use to hold themselves accountable, ultimately, meaningful execution of a safety program comes down to internal commitment.
“I think this is an organization that fooled itself,” NTSB member Robert Sumwalt said of the Bedford GIV’s operator, citing the IS-BAO audit results. “You can fool the auditors, but never fool yourself.”