Bombardier hosts its annual safety session

Ask any flight department manager his top operational priority and the number-one answer is running a safe operation. But today, we still face a dilemma that’s been with us for decades. Dr. Jerome Berlin, a consulting aviation psychologist says, “Twenty-five years ago, we started to see changes to the causes of accidents. The technology and reliability of the aircraft improved, but the numbers of accidents caused by humans increased.” Nearly 70 percent of all accidents today are attributed to pilot error.

Citing pilot error as a cause, however, is as simplistic as using the often-ambiguous “human factors” tag. No crew wants to fly a perfectly good aircraft into the ground. The “why” behind the crew’s part in these accidents is the wild card that has kept experts scratching their heads for years. The real answers behind the “why” remain elusive.

For the most part, pilots are chosen for their technical expertise, the amount of time they’ve spent in command and their ability to maneuver an aircraft with the smoothness of an autopilot. And although much of modern business aviation hiring is now often turned over to headhunters capable of psychologically sophisticated emotional testing, there is still no clear-cut barometer to accurately gauge how well a crew will work together in day-to day-cockpit operations, much less explain their working styles in a crisis. Only time on the job seems to allow for a real shakeout, and then it is sometimes too late.

In 1996, a Gulfstream IV crashed on takeoff near Chicago when the captain lost directional control of the aircraft in a strong crosswind shortly before V1 speed on takeoff. This was the first trip this highly experienced cockpit crew flew together and each pilot displayed a different cockpit style. The left-seater tended to defer to the other pilot, while the co-captain in the right seat was the opposite. Both pilots were employees of different companies that had loaned a crewmember to the flight.

Despite findings by a jury of a number of extenuating circumstances leading to the eventual crash off the departure end of the runway and the deaths off all four people on board in the post-crash fire, the primary cause of the crash was clear to anyone who heard the cockpit voice recorder; the Gulfstream began to leave the hard-surfaced runway as the two pilots argued about what action to take. One pilot could clearly be heard yelling for an abort of the takeoff, while the other demanded they continue and get the airplane in the air.

Both airmen had sufficient experience in the aircraft to command the left seat on their own company’s aircraft. But in this situation, the discipline each had honed over many years of flying evaporated as the two tried to find the solution to a flight-critical situation they’d each demonstrated dozens of times in the simulator.

Reinventing a Standdown
Eight years ago, Learjet’s flight department manager, Bob Agostino, decided it was time to ensure that no one in the Learjet factory demonstration team suffered an injury because of the cultural failures of cockpit discipline. The first Safety Standdown–a military term–was born in Wichita in 1996.

The military employs a standdown from operations after a series of accidents shines a light on a problem in serious need of a solution. Civil aviation has never quite embraced the budget necessary to offer this kind of military-like solution after the fact. That’s why Agostino believes a military-type standdown before an accident is prudent. When the Bombardier Safety Standdowns began, there were few attendees and the group included only Learjet personnel. The goal was to engage in a new form of scenario-based training that might break a few of the old molds with which most pilots have grown up in multi-pilot operations.

Early critiques gave the standdown the thumbs up, and word of Bombardier’s success began to spread quickly. Learjet customers began to ask questions about how it all worked and whether they could participate. The standdown was also viewed as a way for pilots to become aware of the need to stand up for themselves under cockpit stress and that anything less may cost them much more than their jobs.

Agostino said, “The standdown calls attention to many of the topics we all take for granted and is not product- or model-specific. The key, though, is to transfer what people learn here into the real world.” Without a positive transfer, those standdown efforts are for naught.

Bombardier Learjet eventually opened the standdown doors to anyone interested and the numbers have swelled. This year, the seminar’s headquarters at the Hyatt Regency Hotel in Wichita ran out of rooms as the roster grew to 420 pilots, flight department managers and interested parties, nearly 25 percent more than last year.

The standdown curriculum revolves around one problem…that most business aviation departments operate aircraft more sophisticated than the human factors training anyone offers the crews.

Seasoned astronauts have become a part of the landscape at Safety Standdowns of the past, and this year’s was no exception. In fact, the astronaut population increased by 200 percent over last year’s event with the inclusion of Apollo 7’s Wally Schirra and Shuttle Atlantis Commander Steven Nagel. Some might question the connection between flying in space at 25,000 mph and at Vref on short final into Aspen, a question for which Agostino had an answer at the ready.

“Think about this,” he said. “There have been only a few hundred pilots who have ever reached the rank of astronaut, and only a dozen of those have visited the moon. It took the U.S. and these pilots an incredible amount of discipline and skill to achieve that objective. It calls attention to the fact that nothing in our control is impossible to accomplish. With this level of skill and intelligence, if they can make a mistake, we should be able to accept the reality that it can happen to us. These guys make fighter pilots look like Boy Scouts. They are the ultimate Alpha dogs. What better teachers can you ask for?”

Another Alpha dog adding considerable flavor to the standdown was a pilot with decades of close calls to share. R.A. “Bob” Hoover is a pilot Chuck Yeager described in his book as “a fabulous stick-and-rudder man.” A former USAF test pilot, Hoover is better known for his thousands of airshow performances around the world in the North American P-51, Sabreliner and Shrike Commander. At airshows, Hoover offered the ultimate in energy management routines by shutting down both engines on the Shrike and still having enough momentum to carry the aircraft through a series of aerobatic maneuvers, landing dead stick and parking the aircraft right in front of the crowd.

The standdown begins with an optional extra day of emergency procedures training, with topics ranging from in-flight emergency medical training, to OSHA bloodborne pathogen training, CPR and defibrillation, and emergency landing evacuations training provided through the use of Facts/Air Care International’s aircrew emergency procedures simulators that replicate the cabin of an aircraft the size of a GIV, complete with emergency exits.

New simulator technology brings immense realism to the training, like the rock and roll necessary to feign turbulence or a crash landing and the ability to create non-toxic smoke in the cabin and cockpit to create the “illusion of confusion” closer to what crews might realistically face during an airborne fire. While simulators have a long history of capturing an airman’s attention rather benignly, the startle element of the emergency procedures training makes the entire training program considerably more valuable.

Training covers emergency water ditching and evacuation practice, including the use of full-size multi-occupant life rafts, vests and survival equipment in the hotel pool for those who don’t mind getting wet. The last element of survival training employs the Air Care inverted underwater dunkers, which realistically simulate the confusion of an upside-down submersion after a crash.

Much contemporary training is becoming scenario-based simply because the knowledge transfer is more effective than that of traditional standards-based education. Some of the more interesting Air Care sessions offered included:

Scenario One–A 35-year-old aircraft technician is working at the bench when she is accidentally electrocuted. You witness the incident, disconnect the electricity and begin CPR while yelling for help. After a witness calls 911, a co-worker retrieves the defibrillator from the aircraft parked in the hangar and brings it to you and the victim. Do you know what to do next?

Scenario Two–A few hours into a transcontinental flight, a frantic passenger calls the cockpit because the passenger next to her has suddenly slumped over in his seat. You leave the cockpit and assess the patient and find him completely unresponsive, with no respiration or pulse. You ask the passenger to tell the PIC while you pull out the emergency equipment from the drawer underneath one of the cabin seats. Now you wish you’d finished reading the defibrillator manual during your last recurrent training session.

If you’d attended the standdown in Wichita, you would have had an opportunity to work through both of these types of emergency with hands-on training and the chance to talk to someone who would be certain you understood not simply the concept, but how to apply the knowledge under stress.

Fatigue Countermeasures
Dr. Mark Rosekind, president and chief scientist of Alertness Solutions, speaks to the standdown group each year, and even pilots who have heard his program before walk away with new knowledge about fatigue as well as the knowledge that being well rested is one of the greatest advantages we can offer ourselves to complete a flight safely.

“We live in a 24/7 world today,” he says. “And while the technology of our world has changed, people have not. Technology was, in fact, seen early on as the solution. But
it has introduced boredom and complacency to the equation. Fatigue is more prominent today, but again, we haven’t changed, yet our jobs are more demanding than ever. You’ll pay for a lack of sleep…somewhere.”

A primary symptom of fatigue is the inability to challenge a potentially dangerous situation. Some of the management staff at NASA had been up for 20 to 30 hours when they made the decision to launch the Challenger in 1986. That poor decision, tied directly to a lack of sleep, set in motion a series of events that cost the lives of all aboard the spacecraft.

Sleep debt is a lot like a good bank account. You should use only what you’ve squirreled away. Most people can cope with being overdrawn on sleep from time to time. Repeating that behavior leads to a cumulative sleep debt, a problem that cannot be erased with one good night’s rest. If your body requires eight hours’ rest and receives only six, your sleep debt is two hours.

“A two-hour sleep loss equates to the same performance reduction that might be expected of someone who has had a couple of beers,” Rosekind said.
Pilot performance with a six-hour sleep debt, something quite possible on a long international trip, is equivalent to downing a six-pack.

Aging is also another prime cause of sleep problems, which can intensify when an individual reaches the age of 50. “You have more awakenings at night and the sleep you do have is not nearly as deep,” he adds.

Factor in sleep apnea, for which only about 10 percent of the estimated 20 million people afflicted are diagnosed, and sleep quality is even less effective. Sleep apnea sufferers actually stop breathing. Sleep apneas can occur hundreds of times per night so that even eight hours of sleep is not enough to offer relief from fatigue. People who live with untreated sleep apnea perform as if they had a blood alcohol level of .08, enough to charge most drivers with DUI.

According to Rosekind, regulations do not reflect current technologies and knowledge about the effects of sleep deprivation. “We can’t eliminate fatigue from the workplace, but we can manage it better,” he said, suggesting that pilots make a list of their personal fatigue symptoms and share them with fellow pilots.

Reducing the effects of sleepiness requires a regular reality check. No matter how much sleep a pilot has had before a flight, alertness is at its lowest between 3 a.m. and 5 a.m. and 3 p.m. and 5 p.m. People are programmed for alertness between 9 a.m. and 11 a.m. and 9 p.m. and 11 p.m. Traveling west you fly with the clock and sleep will improve. Flying eastward, however, your body fights the clock and serious performance consequences should be expected. Rosekind says, “Sleep is part of a good safety culture and requires change.” And that’s not easy for anyone. It must begin at the top to be effective.

International Procedures
No one begins a session quite like Dave Stohr, president of Air Training International. Stohr’s mood was gloomy as he began his talk about international emergency contingency procedures in Wichita this year. “Someone just handed me a note,” he began. “I can’t believe this is happening today, but a 777 and a business jet were involved in a midair collision just a few hours ago. We have no word yet on casualties.”

No one breathed as Stohr attempted to pull it together. It took 10 minutes for everyone to realize the fictional message was part of his talk, one designed to reinforce the disastrous consequences of not taking international procedures seriously enough. It is not like flying from New York to Atlanta under radar control.

“Why don’t airplanes run together out over the Atlantic and Pacific?” he asked. “It’s simple. They have separation.” Because the oceanic areas are non-radar, three types of separation are employed… a routing offers lateral guidance, a cruise Mach number delivers longitudinal and altitude gives the vertical component.”

While Stohr’s presentation certainly got everyone’s attention, the fact that an increasing number of operators of business aircraft still don’t understand oceanic crossing procedures was eye opening. “Last year, there were 18 gross navigational errors (GNEs).” There were also 70 interventions by air traffic control necessary to prevent collisions last year, according to Stohr.

Approximately 1,000 aircraft cross the North Atlantic each day, so 18 may not sound like a great many. But what makes the problem even more difficult is that “four of the 18 aircraft were business jets.” Forty-eight of those interventions involved altitude deviations, an issue that is almost unheard of in the continental U.S.
Through September of this year, there have already been 22 GNEs across the Atlantic region. Business aviation makes up only 5 percent of the traffic, yet we’ve accounted for nearly 30 percent of the GNEs.”

Stohr offered listeners ideas about how to avoid becoming the first business aircraft actually involved in a midair over the ocean. Not surprisingly, much of what he said was common sense, or at least what most attendees believed was common sense. If this is so simple, however, why are business pilots continuing to mess up? Much appears to come from not paying close enough attention.

“It is critical that you understand the capabilities of the equipment you are flying,” Stohr said. A cursory review to meet recurrency is simply not enough. “Have you actually tried to engage the autopilot for a track offset in the simulator to see what happens or do you brief for an engine failure while you’re in the tracks? If you do lose an engine and must descend, get off the track.”

How Do You Feel about That?
Pilots and shrinks mix as well as oil and water. As soon as Berlin, an aviation psychologist and pilot, mentioned aviators talking about their feelings, half the room seemed to sigh. “We did some research on pilots and feelings. We don’t do well with that, I’m afraid.”
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Berlin can draw conclusions like no other mental health professional around. Early on he spoke to the process of researching aviation and smiled as he explained the results. “I was so sure that the pilots we were interviewing were really into the entire process. I learned that no one can lie like a pilot!”

He learned that most pilots use the same eight words to describe their feelings although literally thousands exist. “We don’t feel like the rest of the world feels. We are on and off switches. These are great impediments to our learning. Pilots are essentially dishonest. We love to cheat and get that little bit extra. We also don’t actually see what is often in front of us. When a pilot takes in data, he comes to a conclusion and then that conclusion becomes concrete proof of his decision.”

Assertiveness is a major focus of Berlin’s. “Assertiveness with respect is critical in the cockpit. Assertiveness will not come without respect. Pilots are willing to give their lives so long as it’s not their fault. When we asked 24 new captains if they’ve had the experience of needing to take an aircraft away from a captain, between a third and a half said they were in situations where they should have taken the aircraft but did not. Only one-third actually made the effort to take the aircraft. The others simply could not bring themselves to do it, they said. We had to train them that they should feel obliged to take the aircraft.” There was one caveat, however: “The worst enemy in our careers is ambiguity, which in assertiveness is a problem. How critical is it at that moment? At altitude it works, but not down low. You’d better be sure you are right. We are unforgiving of mutiny.”

Scenario-based Training
If a picture is worth a thousand words, scenario-based training is worth a considerable amount. Berlin played a couple of videos, one a re-creation that left the room quiet. Then he played back the last 20 minutes of a 747 flight in Indonesia.
The freighter crew had jumped many times zones in just a few days although it had 30 hours off before the short flight to Kuala Lumpur. Destination weather was down and early on it was clear the first officer–the flying pilot–and the captain did not agree. ATC was offering a straight-in NDB approach almost to minimums. The first officer kept asking the captain to request an ILS to the opposite end of the runway, but the captain never did and the first officer did not push the issue further.

When the controller’s accent caused the captain to misunderstand a clearance, no one in the cockpit thought it odd that the controller was asking them to descend to 400 feet above the ground for the initial approach. Many who had not heard the tape before kept wondering when the crew would realize their error. In the last 10 seconds, the electronic, “Whoop-whoop…pull up,” was unmistakable.

But what was impossible for almost anyone to understand was the pilot error, the human factors experience or whatever label might be placed on what caused two experienced pilots to take no action whatsoever, despite seven warning calls from the GPWS about approaching terrain. The 747 crashed five miles short of the runway, killing all aboard. Berlin’s earlier words about a pilot’s willingness to die rather than confront authority were on everyone’s mind.

Landing Accident Insights
Although flying in space reduces the chances of hitting terra firma, Nagel still finds the topic of landing accidents on Earth of intense interest. He spent an hour at this year’s standdown talking about the statistics of business aviation. “While we are all professionally trained, the Flight Safety Foundation says business jets were involved in 251 accidents–67 of which were fatal–between 1991 and 2002. Of the 67 fatals, 27 (40 percent) involved controlled flight into terrain (CFIT). Of those 251 accidents, 104 occurred during the approach and landing phase, with 57 percent being runway overruns and 13 percent being undershoots.”

Nothing Nagel spoke to illustrated the mistakes that even experienced airmen can make quite like the Southwest Airlines Boeing 737 overrun accident at Burbank in March 2000. As with every accident, there was no single issue that caused the incident, but there certainly was an identifiable chain of events that continued unbroken until the aircraft stopped.

Southwest Airlines requires the aircraft to be configured in the slot at 1,000 feet agl, with flaps five and airspeed 170 to 180 knots. At 500 feet, the aircraft should be within five knots of target airspeed with a rate of descent of less than 1,000 fpm.
This night, however, the crew was told to keep their speed up and did indeed maintain 230 knots and 3,000 feet altitude until over Van Nuys, about five miles west of Burbank, where they were cleared for a visual to Runway 8. At the time, the 6,000-foot runway was wet, with a light wind out of the west. On final approach, the flight never slowed below 180 knots, although ref speed was 132 kias. The vertical velocity on final averaged 2,200 fpm. The 737 crossed the runway threshold at 182 kias and touched down 2,150 feet beyond the threshold. The remaining 3,850 feet was not enough to stop the Boeing and it slid off the end of the runway and crashed into a gas station. Luckily, there were only minor injuries.

As with all elements of scenarios presented at the standdown, the question is the same: why would experienced pilots commit such a monumental blunder? Certainly contributing to the accident was the fact that the crew was two hours behind schedule. Later, Nagel said, “The captain said he fixated on the runway and simply could not give any reason why he did not go around. There was of course another pilot in the cockpit who also did not command a go-around.” Nagel’s comments dovetailed nicely with those of Berlin’s earlier mention of assertiveness and how pilots can become fixated on a solution once they believe they see one.
Looking Back at Standdown 2004

Steve Reed, who operates a Learjet 60, said, “I attended one of the first standdown seminars open to the public. It was quite a different program four years ago. It has grown in every respect.”

One pilot who did not wish to be identified said, “I think it was clear early on during the standdown that pilots in general are not tolerant of the diversity of issues we face in our operations. Despite that, this was hands down the best safety conference ever. You are constantly learning. You never really graduate from this sort of thing. You can’t.”

Another said, “I would like to try to talk the president of my company into attending at least one day of the program, and I think he might be interested enough to set aside one day. It would be great to include him in the least technical part of the program. I think that would be a good connection for the executive level.”
Other pilots also mentioned Agostino’s suggestion of inviting some management-level participants for an abbreviated version of the standdown next year.

The Road Ahead
The focus for future standdowns remains the same as it was at the end of last year’s event. Obviously, as we search for the answers to questions like “Why do pilots continue to fly perfectly good aircraft into the ground?” citing human factors is simply not enough. Clearly these pilots had no idea of where they were in time and space. So the jury is still out on whether technology helps or hurts us today.

The standdown should be a must for all flight crews. But there are monumental cultural issues yet to be overcome within that realm of human factors development the standdown or any similar seminar tackles. Pilots are not risk-takers or rule-busters. It is simply not in their nature. They are, in fact, risk-mitigators, professionals paid to avoid heading down a road with no clearly marked exits.

To move past the interpersonal summits pilots face in the cockpit, the risk of embarrassment or being fired should never outweigh the effect of speaking up, a situation most today still believe will get them fired.

Most successful flight-department managers will confirm their top goal is safety, all the time. But until we devise an immunity system for pilots to speak up about cultural and operational problems within their company, without fear of retribution–much like the NASA Aviation Safety Reporting System does for the industry at large (see story on page 8)–the fine education we see in Wichita will never be enough to break through the barriers that keep those accident chains intact. And the culture of job protection, short of negligence, must come from the top…not from the aviation department manager, but from the CEO.