Business Aviation Safety Summit 2016

Loss of control in flight (LOC-I), unstable approaches and fitness for duty were among the issues addressed at the recent Business Aviation Safety Summit (BASS). Organized and hosted by the Flight Safety Foundation (FSF) in partnership with NBAA, the event drew 225 pilots, aviation safety experts, medical specialists and support providers to Austin, Texas. The 17 presentations delivered over the two days illustrated how far the art and science of safety have advanced, and how much more complex the safety challenges facing business aviation have become in the 70 years since the FSF was founded.

Fitness for Duty

In years past many flight departments addressed fitness for duty, a prerequisite for safe operations, simply by asking pilots, “How are you feeling?” said Dr. Daniel Mollicone, president of Pulsar Informatics. Now it’s “a science with quantitative assessment,” allowing measurement of fatigue-induced impairment and the development of mitigation strategies. Pulsar provides fatigue-mitigation services to airlines and flight departments, and effective plans can be relatively simple, Mollicone said in discussing “Fitness for Duty: How Much Fatigue is Too Much?” In developing a solution for Delta Air Lines, Pulsar found only 3 percent of its flights created fatigue issues, which could be mitigated by providing crewmembers with hotel rooms for a 90-minute nap. “The risk reduction, for a total cost of a few hundred dollars, is dramatic,” he said. 

Mollicone recommends always starting a trip rested, and using caffeine (“the second most highly traded commodity on earth after oil,” he noted of coffee). “Everything you do, you do better with caffeine. Overuse is the main problem,” he said. Limit consumption to 300 mg (three cups) per day.

Yet “there’s a lack of guidance or data,” on what constitutes fitness for duty, said Dr. Quay Snyder, president and CEO of Aviation Medicine Advisory Service (Amas). “The FAA medical certification standards are worthless, training vendors have different philosophies, and there’s no standard evaluation system,” he said in “Losing the Right Stuff.” But, he stressed, “It is not fit or unfit; there’s a gradation.”

Today over-the-counter medications and prescription and illicit drugs have replaced alcohol as the focus of pilot impairment concerns. Snyder noted that a single dose of Benadryl can be as impairing as a blood alcohol level of 0.08 percent–legally drunk–and may require as much as 60 hours before a person would be fit for duty.

Amas offers assessment and treatment programs for pilots who exhibit fitness-for-duty issues. Of the 48 pilots who’ve received treatment from Amas, 55 percent returned to flying, 25 percent retired voluntarily and 20 percent were terminated. Snyder said the assessments can identify which pilots “can be safely returned to the cockpit with treatment and those who are not safe to fly.”

Fitness for duty also involves attitudes and performance unaffected by fatigue levels. That was the subtext of William Bramble’s account of “Human Factors Issues in the 2014 GIV Crash at Hanscom Field” in Massachusetts, an accident that claimed seven lives following an aborted departure after the crew attempted to take off with the gust locks engaged. Bramble, the NTSB’s human performance investigator on the scene, said the flight crew’s failure to perform a flight-control check before takeoff and their delayed rejection of the takeoff–along with failure to disengage the gust lock–were the accident’s probable causes. He also pointed to the crew’s habitual non-compliance with preflight checklists, with their longtime pairing leading to a “normalization of deviance” from standard procedures, allowing the accident to happen. In the airline industry, “by-the-book standardization is needed because you’re randomly paired with other crewmembers,” Bramble said, and procedural compliance is more likely between crewmembers who do not work together frequently. “You don’t know how a new partner will react to not doing it by the book.”

For checklists, research indicates NASA’s “challenge-verification-response” method is best, Bramble said. He also noted the GIV’s operator had received IS-BAO certification before the accident, but “the audit standards didn’t say how the crew should handle the checklist.” Nor can such audits identify whether the crew adheres to standards when no one is watching.

The Line Operations Safety Audit (Losa), an open-source method covered in the ICAO Manual and FAA Advisory Circular, is an audit-by-peer “diagnostic safety tool” developed to get rawer views of cockpit behaviors than formal audits provide, said Dr. James Klinect, CEO of Losa Collaborative. Losa’s goal is to identify compromising behaviors and practices so they can be addressed before an accident happens. An outgrowth of more than a decade of research Klinect conducted at the University of Texas on Losa and threat and error management, the Collaborative has implemented some 130 Losa programs, mostly in Part 121 operations, worldwide. A show of hands revealed few attendees had first-hand experience with Losa. But, Klinect acknowledged, even during what’s supposed to be an informal and anonymous process, “there are times when I see [crews] doing things they don’t normally do because they’re being watched.” Cameras in the cockpit would work no better, he said, as they miss potentially important non-verbal cues. “For Losa to work, we need real-world data,” said Klinect. “Low pilot trust equals low hope for Losa.”

Fitness for duty certainly includes possessing the piloting skills required to deal with unusual attitudes and other deviations from the normal flight path, and LOC-I– which accounts for 2 percent of accidents–is now the leading cause of fatalities in both general and commercial aviation. In addressing “Effective Improvement of Pilot-airplane State Awareness,” Paul Ransbury, president of Aviation Performance Solutions, which provides upset prevention and recovery training (UPRT) in aircraft, said definitions of LOC-I vary–listing as examples flying unintentionally at an attitude of 25 degrees pitch up or 10 degrees down, a bank angle in excess of 45 degrees, or an inappropriate airspeed. LOC-I may be pilot induced, result from a system anomaly (such as flight control failure) or be environmentally induced, as in wake turbulence, but distraction plays a role in all LOC-I events and accidents, Ransbury said. Furthermore, unprepared pilots usually intervene in exactly the wrong way, as correct control responses are counterintuitive, he said. Ransbury advocates in-aircraft, rather than simulator-based, UPRT because pilots “have to be exposed to the psycho-physiological stimulus,” of real upsets to overcome natural reactions and master recovery (“habituation”). That typically requires “three to four flights. In the first, they recognize their need for training; the second flight they’re overwhelmed by trying to deal with the situation; by the third and fourth flights they’re taking effective action.”

Safety experts are now grappling with a danger that defies traditional mitigation strategies: pilot murder-suicide. In “Human Factors in Extremis: The Rogue Pilot Phenomenon,” Thomas Anthony, director of USC’s aviation safety and security program, said that should Malaysia Airlines MH370 join the identified cases of last year’s German Wings Flight 9525 and Air Mozambique’s LAM 470 in 2013, “then you would have three [pilot murder-suicide] primary causes of fatal commercial accidents in three successive years.”

Unlike “accidents based on wreckage, this brings us into an area of the profiler of criminal behavior, and the psychology of murder suicide, a very different area of inquiry,” Anthony said. He believes “the anonymity in today’s large carriers where you don’t fly with the same people” puts airlines at more risk for these crimes than business aviation, where “we fly with the same people, and that allows us to keep an eye on people in our organization.” He also emphasized that “murder-suicide is premeditated; it’s not out of the blue.’”

Organizational Issues

Organizational or group “culture” also shapes safety attitudes and behavior. In “Avoiding Human, Organizational and Cultural Accidents at NASA,” Dr. Charles Justiz, now a principal of JFA, recounted his experience directing NASA’s flight safety program after the loss of Columbia. While the public knows the agency for its spaceships, it also operates a disparate fleet that includes T-38 jet trainers, the Super Guppy, a 747 that ferried the Space Shuttle from its landing to launch site, and a pair of “Vomit Comets” used for weightlessness training. “Our challenge,” Justiz said, “was how do you fly these aircraft and do it safely?”

The space agency had many skilled pilots, but its can-do, stick-to-schedule ethos was an impediment to safe operations, Justiz said. NASA “changed the organizational responsibilities, opened lines of communication and empowered workers to raise issues,” after its shuttle losses, “but it didn’t change the culture,” Justiz said. “How many people want to recognize a risk [knowing], ‘If I change this part, I’m going to have to postpone launch,’” he asked. “They’re not lying; they’re biasing.”

Justiz ultimately concluded the only way to change organizational culture is to hire people with the right cultural attitudes; those supportive of or inculcated with the status quo will not change. Justiz implemented SMS, Losa to complement line and proficiency checks, and Flight Operations Quality Assessment (Foqa) protocols. “We went from four reportable incidents per 100,000 hours to zero reportables in 350,000 hours,” Justiz said.

Organizations can also be complicit in normalizing deviance from SOPs, and non-compliance with approach go-around criteria for commercial and business aviation operations is a glaring example. Only 3 percent of airline pilots comply with SOPs mandating go-arounds if not on a stabilized approach at or below 1,000 feet agl. Corporate pilots are believed to be equally non-observant. FSF commissioned Presage, a risk-management consultancy, to study the situation and recommend fixes. In his presentation, “Understanding the Psychology of Non-Compliance in Go-Around Decision Making,” Dr. Martin Smith, Presage’s founder, said compliance could eliminate 54 percent of accidents, but most pilots believe the standard is unrealistic and have little incentive to observe it. Managers were either unaware of the problem or never mentioned it. Non-compliant pilots score lower on all measures of situational awareness and are less communicative with other crewmembers than compliant pilots, Smith said. Yet the estimated 330 airline go-arounds per day that compliance would entail create risks of their own. Presage recommends making 300 feet, rather than 1,000 feet, the go-around height for unstable approaches, and the study recommends installing stable approach and alerting systems on aircraft and ensuring flight crews actively communicate during approach and landing.

Crisis Management

Despite best efforts, accidents will still happen, and organizations should prepare for the worst, several safety and crisis management experts said. “The story is going to run, not just in the media but also on social media, with or without you,” said Adam Konowe, vice president for client strategy at TMP Worldwide in “Crisis Communications: Theory Meets Reality.” Organizations should establish a process to handle a crisis before a calamity strikes, and recognize that they’ll have to keep their businesses functioning while dealing with the disaster, Konowe said. “If you’re waiting until an aircraft accident, it’s too late. If you’re an FBO, explain why you’re important to the local economy. Build relationships. Understand who your allies are and who are potential adversaries.”

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{{Head:}} The Accident: Now What?

A familiar face from NTSB investigation press conferences, NTSB member Robert Sumwalt used CNN footage of press conferences to illustrate how leaders should and shouldn’t respond in the aftermath of an accident. Among his recommendations:

• Control the press conference environment. Have some physical barrier between you and the media.

• Know the facts and your talking points.

• Have a “murder board,” a small group of people to pepper the principal with tough questions, in preparation for meeting the press. “You need to have those questions ahead of time,” Sumwalt said.

If your organization is a party to an NTSB investigation and you’re unsure what you can or can’t say publicly, the general rule is that if you can make the statement the day before an accident, you can make it the day after, Sumwalt said, citing disclosing an aircraft’s service history as an example.

Low-level Ops

While flight departments might face safety challenges ranging from non-compliance to crisis management, Pete Agur, chairman of VanAllen Group, noted companies can get a handle on business aviation’s most common mishaps: ground events. In “Raise your Standard of Safety: Address Non-Catastrophic Threats,” Agur noted that operators are 3,800 times more likely to experience a ground event than a fatal accident, with the cost averaging $62,000 per event; ground event insurance claims exceed any other category “by far,” Agur said. A survey of flight departments VanAllen conducted found half of reported events resulted from “hangar rash,” damage while moving aircraft in a hangar. About one-third happened during towing, 10 percent from ground vehicle collisions and 7 percent while taxiing. A ground event occurs once every 4,000 flight hours, suggesting that on average, “an aircraft will have a ground event once every eight years,” Agur said.

VanAllen’s recommendations:

• Equip all personnel with whistles or horns, so they can alert others if they see an unsafe situation.

• Use three wing walkers (one at each wingtip and the tail) for any hangar movements.

• When the aircraft is hangared, have brightly colored cones at all four corners and maintain a five-foot buffer zone.

• Directly supervise all movement operations, and when away from home base, directly supervise all de-icing and refueling operations.

• If the aircraft is tied down on a ramp, don’t park it next to a roadway.