Spurred by the popularity of Bombardier’s blockbuster annual standdown in Wichita, safety stand- downs are becoming regional one- day events. The Greater Washington Business Aviation Association recently hosted its own one-day safety and security standdown at Signature Flight Support’s FBO at Ronald Reagan Washington National Airport.
These business aviation-focused safety meetings aren’t a reaction to a dire series of occurrences, as is sometimes the case with military-oriented standdowns. “First of all, the sky is not falling,” said Bob Agostino, Bombardier director of flight operations, creator of that company’s annual standdown and speaker at the Washington event. Professionally flown corporate aircraft have a safety record as good as or better than that of the airlines, he said, and airlines have reached a Six Sigma level of safety, which equates to not more than 3.4 defects per million.
The purpose of a standdown, said Agostino, is to “provoke a little thought.” Airplanes have grown ever more sophisticated, but he worries that pilots have not kept up with airplane developments. Training focuses almost exclusively on skills-based activities, where pilots learn systems, then get tested on those during checkrides, over and over again. “A lot of things have changed,” he said, “but I’m not sure we have.”
Agostino gave attendees more sobering subjects to think about when he said, “None of us can believe we can have an accident. No one ever imagines their face going through an instrument panel.” In a Boeing study, he added, 95 percent of flight crews who had to execute an emergency procedure did it incorrectly. “Did you think about the abort before you stood the throttles up?”
Much of Agostino’s presentation focused on fundamental pilot skills, which he worries might be emphasized less as airplanes become more automated. “We might be losing some of our flying skills,” he said. The risk for the aviation industry is that pilots could be replaced by automation. The technology to do so already exists, Agostino noted, citing the X-45 fully autonomous unmanned combat air vehicle, which requires human intervention only when it needs permission to fire a weapon.
Some train systems already run without human operators, and airplanes might not be far behind if the industry doesn’t fix the human-error problem that causes accidents. “Why don’t we really fly much anymore?” Agostino wondered. “I’m absolutely amazed that we think automation can fly better than we can. It is our handmaiden, not our master.”
Greg Feith, safety consultant and former NTSB investigator, is not convinced that humans will ever be replaced completely by automation. “Twenty five years ago humans used to drive the automation,” he said. He pointed out that NASA engineers solved the problem with the CO2 scrubber that enabled the Apollo 13 astronauts to make it back to Earth alive, adding, “no computer in the world could have solved that.”
What automation has done, however, is increase pilots’ mental workload. And that workload adds to stress in the cockpit. During training, which is a sterile environment, the stress comes from being watched by the instructor and check airman. “The stress level changes when you’re in the airplane,” Feith said. “And no matter how good your training is, you just don’t know what’s going to happen on the line. You don’t want to train to proficiency, you want to train to a level of knowledge.”
Building a Safety Net
Former airline pilot Ben Winfree, an instructor pilot at SimCom Training Center in Orlando, Fla., has studied fatigue issues and is a partner in fatigue management training firm Alertness and Performance Management. Winfree’s presentation explained how fatigue management can be incorporated into a flight operation’s safety management system (SMS), something that many companies are implementing or already using.
As part of an SMS, a fatigue-management program addresses human factors, scheduling issues, education about fatigue problems and relies on commitment of senior management. “Fatigue is a workplace hazard that leads to error vulnerability,” Winfree said. “The degree of performance reduction matches the amount of fatigue.”
Safety nets are the solution to errors that occur in aircraft maintenance, explained John Byrd, director of aviation at Coosa Valley Technical College, of Roma, Ga., and a pilot and A&P with Inspection Authorization. Byrd outlined the famous “dirty dozen” (see box) human factors and identified the safety nets that help prevent each of the problems caused by those factors.
It’s normal for humans to make mistakes, Byrd said, but we can reduce errors by knowing our limits and learning to recognize the human factors that lead to errors.
“There is always risk,” said Robert Francis, former vice chairman of the NTSB and a member of the board of governors of the Flight Safety Foundation. What we need to do, he explained, is study the risk that we are exposed to and figure out how to spend resources to minimize risk effectively. “We’ve dealt in the last 20 years with some of the big issues,” he said. “But humans always have the ability to screw it up somehow.
“Our challenge is to build error-tolerant systems,” Francis said. And this includes promoting corporate cultures whose leaders encourage safety efforts and communication about safety. Francis also recommends that flight departments consider using safety tools that airlines have been using for years, such as the aviation safety action program, which helps people report safety problems without punishment, and flight operational quality assurance (FOQA), a method of tapping recorded flight data to assess adherence to standard operating procedures. These should be used as preemptive tools, Francis said. “These are the tools that are going to enable us to have a safer system. It beats a hole in the ground.”
Jim Burin, director of safety programs for the Flight Safety Foundation, summarized the safety challenge that corporate aviation is facing. “Accidents are becoming almost random events,” he said. However, there is something consistent among these random events: human error was a primary cause in 55 percent of accidents from 1996 through 2005, according to a Boeing study. The challenge is to learn who made the errors, why and how to prevent them.
The Flight Safety Foundation launched a FOQA program for business aviation five years ago, and two flight departments have been participating for the past year. FOQA, which airlines have been using for many years, is an effective method of measuring performance against a set of standards like SOPs. So far, in the business aviation FOQA demonstration program, “the operators are absolutely thrilled with the results,” Burin said. The foundation is expanding business aviation FOQA into phase II, working to sign up more corporate flight departments and fleet operators to help lower the cost of participation.
The GWBAA safety standdown also addressed security issues, an increasingly important facet of corporate aviation. “If security is not part of your culture,” said GWBAA president Bob Blouin, “you need to have it.”
The dozens of attendees who came to Signature Flight Support’s FBO for the safety standdown on March 8 likely accounted for the most activity the facility has seen since the 9/11 terrorist attacks. A few operators are now flying to Ronald Reagan Washington National under the Transportation Security Administration’s DCA access plan, but since that went into effect, fewer than 100 operations have taken place.
“We have a couple of operators who have broken the code,” Blouin said. “Is it perfect? Is it easy? It’s a start. The TSA has been good about opening new airports. If your home base is not on the list [of approved DCA gateway airports], talk to us.”
Rob Rottman, a general aviation expert from the Department of Homeland Security, assured standdown attendees that the TSA is getting better at understanding general aviation and how corporate aviation fits in. “DHS takes a broad approach to general aviation,” he said, “and you get lumped in with crop dusters and recreational aircraft. They don’t always [understand] the impact on you folks.”
Rottman said that he recognizes the efforts that corporate operators make to take security matters seriously. But at the same time, operators should codify their security procedures. “Make [security] a part of your processes,” he said.
“You are the primary source for preventing accidents,” Feith concluded. “We have done an amazing job at reducing certain types of accident, but you can’t take the harm or risk out of everything.”