Bizav Experts Highlight Need for Safety Data

Drilling down to trend lines, preparing for change, filtering out the “noise” of substantial data collection, and learning more about employees personally were among the lessons provided to attendees at recent the 2018 Bombardier Safety Standdown. In a workshop entitled "Safety, Education, and Experience Talks," top business aviation executives, many of them NBAA Dr. Tony Kern Professionalism in Aviation Award winners, told tales of safety issues they encountered or initiatives they have undertaken in their continual quest to build safety cultures.

Dan Boedigheimer, CEO of Advanced Aircrew Academy, noted the belief that all the low-hanging fruit for safety improvements have been addressed to drive the accident rate down to a low level. “But what if we had a system that in the next 90 days you could reduce your own error rate by 50 percent?” he asked. Boedigheimer described his own effort to manage personal errors through a certification program that involved a tally sheet to track every time a small error would crop up. Tracking personal patterns is important because everyone has different issues—“everyone is weird”—he said.

These errors involved mostly minor issues, such as initially forgetting to turn on a rotating beacon light, and on the surface looked random. But looking closely he saw a thread connecting many of them: self-induced time pressure. “I am always trying to cram 90 minutes into every hour,” he said, and this pressure led to 50 percent of his errors. This realization allowed him to step back and write personal standard operating procedures (SOPs) to address those occurrences. He was able to reduce those errors in half.

Jeff Wofford, chief pilot and director of aviation, CommScope, highlighted efforts his company went through to upgrade to a larger aircraft, a Challenger 300, and effectively managing change. This involved extensive planning and list-making that started with a single spreadsheet and soon spread to several sheets. Everybody in the flight department was involved, from the pilots to the maintenance technicians.

The change-management process, he said, is just like other parts of safety management systems, looking at risk, mitigation, and then assurance of the risk-mitigation efforts. This is a continual cycle, he said and applies to any change, whether hiring a new pilot, accommodating a change in leadership, or adding an aircraft.

Managing Information

James Slabaugh, pilot and safety chairman at Kiewit Corp., provided guidance of how to “filter out noise” from the vast amount of information that has begun to flow in through all the safety programs and data-collection efforts. His organization noticed a higher level of events reported on arrival procedures and he realized this was an issue that needed to be addressed. “The difficult part was figuring out how to solve [the issue],” he said.

Slabaugh's organization sorted through the different reports and came up with 13 corrective actions based on the data. These actions were all “legitimate things” representing best practices, but they were disjointed, not really taking into account the full picture, he said.

Instead, his group took a step back, filtering out excess noise to determine root causes, he said, and they discovered three most common triggers that were beyond the control of the pilots and might have led to increased pilot workload: being vectored off the arrival and then cleared to rejoin; a runway change that occurs after arrival procedures begin; and being given an unpublished restriction by ATC.

The pilots then were aware of those triggers and could make sure they follow through with proper procedures. The result has been notable, he said, “definitely better than before.”

“Beware of what you don’t know,” was the message of Don Wade, director of safety at Pinnacle Aviation, discussing fatigue management. “Fatigue is everywhere,” he said, noting that his organization, which is IS-BAO Stage 3 certified, has tried to address this with policies, training, and reference materials from top fatigue experts. But it was what they didn’t know about their pilots that would lead to fatigue issues.

He cited as an example two pilots dealing with health issues involving family members. This was keeping those pilots up at night, resulting in fatigue. Another pilot had a caffeine addiction, which was resulting in loss of sleep and thus leading to fatigue. Because the organization wasn’t aware of issues such as these, it created the possibility of two such pilots being paired on a mission. This underscored the need to learn as much as possible about factors that could play into fatigue among its pilots.

Automation errors also were highlighted. Jim Weaver, vice president of operations with Advanced Aircrew Academy, discussed his experience with a Part 135 operation, which learned through a two-year-old Aviation Safety Action Program that automation management errors were causal in 24 percent of the operation’s altitude deviations and 37 percent of course deviations.

Looking at policies and procedures, the organization realized automation management procedures were spread over many places, often “bolted on” over time. The organization streamlined and simplified its procedures. A feedback loop was incorporated to enable discussion with pilots, and the organization began conducting pilot briefings. “We had a great reduction in our deviations following this,” he said.

FBI supervisory special agent Troy Smith discussed how his organization’s flight department began factoring in ground support equipment in its preventative maintenance program. “If you are not looking at this stuff, it is going to come back and hurt you. There are little gremlins in every one of these things,” he said, citing data that eight employees are killed annually while using scissor lifts.

In an effort to develop checklists that apply to ground support equipment, the FBI realized that much of the equipment came with maintenance manuals, but not all. The agency then went to equipment providers for preventative maintenance programs.

Another story relayed by Erika Armstrong, director of instructional design for Advanced Aircrew Academy, involved an instance where a Citation X crew learned of poor runway braking conditions just before touchdown, essentially too late to go around. The aircraft skidded off the runway on landing. While everyone on the flight survived, the pilots were shaken by the event and in the moment they froze. They were unable to figure out how to retrieve the emergency response plan in their iPads. The lesson here, she said, is that while the use of electronic devices can be positive, it may be worthwhile also having a laminated emergency procedure checklist available.

Marty Grier, senior manager for aircraft maintenance for Home Depot, discussed the importance of having measurables, saying, “If you can’t measure it, you can’t improve it.” He outlined a series of data points—such as near misses or other incidents and errors—that come from safety reports. The reports must be easy for employees to file, he said. Grier cited a change effected from a report that came in a few years ago involving a pilot who injured his back while helping a passenger board with a manual lift chair. That touched off a series of questions of how it happened and ultimately why he was using a manual lift chair. That led to the discovery of the availability of an automated chair that could protect against such injuries and the subsequent acquisition of the chair.

Home Depot has a mantra, he said, adding, “You take care of the associates, they take care of the customers, and the rest takes care of itself.”