At the Air Charter Safety Foundation (ACSF) Safety Symposium held in early April, speakers and participants shared important safety information, lessons learned, and opportunities for improvement. The symposium began with an acknowledgment that the business aviation industry hasn’t gotten off to a good start in the first quarter, with three fatal business jet accidents and nine fatalities occurring in the U.S., up from two accidents and two fatalities during the same period last year.
Held at Embry-Riddle Aeronautical University, not only was the ACSF Symposium an opportunity for business aviation operators to share safety ideas, but the organization also welcomed Embry-Riddle students to participate and learn more about business aviation safety. The event began on April 1 with a panel of industry experts sharing their career experiences, and this was well-attended by Embry-Riddle students who are interested in business aviation opportunities.
Business Aviation Career Panel
Embry-Riddle students Turueno Garcia and Trevor Simoneau moderated the panel session, which featured Richard Meikle, FlightSafety International executive v-p of operations and safety; Joan Sullivan Garrett, MedAire founder and chairman; Megha Bhatia, chief science and chief marketing officer at JSSI; and Greg Johnson, COO of Tuvoli.
The panelists shared experiences from their careers, responding to questions from Garcia and Simoneau, such as what they learned in college that they expected and didn’t expect to learn; who they learned the most from early in their careers; the most impactful advice they received; what makes them leave fear of failure behind and try to bring their ideas into being; what they are excited about; problems they are trying to solve; and what they think about the new generations entering the aerospace industry.
“Something I learned going through college was what's my next immediate threat,” said Meikle. “Every morning I'm looking at my calendar and saying what's my next threat, knowing that the day’s probably going to shuffle. Obviously, academic stuff is really important as well. But the other thing I think college teaches you is how to interact with other humans. And that is something that I think we are losing a little bit as a society because you walk into the student common and you watch them and probably 80 percent are on a headset or some device.”
Bhatia emphasized sales skills as a key learning opportunity. “You may be the smartest person in the room, but if you can't get the point across clearly, effectively, and in a way that the audience can consume it, then it's not getting across. You do not have to be in a sales job. And it may not be the core thing you want to do. But if you can do the sales job even for two hours ever in your life, do it. Their resilience, their rejection, get used to it. It's a part of the process and knowing that, you’re going to come out on top.”
Discussing the role of mentors helping her build MedAire over the past 40 years, Garrett said, “There have always been people, women in the industry that I saw that were so successful, and I said, ‘If she can do it, I can do it.’ And so I'm going to tell you, if I can do it, you can do it. You just have to have the vision. You just have to have the dream. You just have to have the desire to do what it takes to get to where you want to be.”
Johnson credited mentors with believing in him but also highlighted his willingness as a young new entrant to aviation to take a risk and submit a business plan for an aircraft management operation, even though he had little experience in the field. “You’ve got to make those leaps,” he said. "I'm a big believer in that saying: luck is the intersection of opportunity and preparation.”
Accidental Inspiration
Scott Griffith, founder and managing partner of SG Collaborative Solutions, shared two stories about events that shaped his career and led to the development of the aviation safety action programs (ASAP) that have helped make commercial aviation the safest mode of transportation.
At age 17, Griffith was logging time toward his private pilot license and took off one day for a short flight to another airport. Not realizing that a front had gone through, he ended up landing with a tailwind and, while standing on the brakes and screeching to a halt at the end of the runway, his airplane’s wingtip scraped the airport’s wind tetrahedron. “The plane spun around and I came to a stop,” he recalled.
“This old man came running out and yelled at me. ‘What are you doing? Don't you know you can't land with a tailwind?’ And he looked at me and he said, ‘Are you okay?’”
After Griffith assured him that he was okay, the man said, “‘Well, let me help you paint that tip of your wing, and nobody has to know about it.’ And I thought, oh my gosh, he just saved my entire career.”
Griffith could have kept this a secret, but he admitted, “I went back and told the owner of the flight school what happened. And he said, ‘Since you came forward, there will be no repercussions.’ Had I not done that, I would carry that secret with me for the rest of my life. So flash forward about 20-some-odd years. When I went into the airline industry, I created a program for pilots that come forward and disclose not only the risks outside their cockpit but also the risks coming from themselves. And that was transformative for the airline industry.”
The other formative event was when Griffith witnessed an iconic, tragic accident, the Delta Flight 191 L-1011 crash at DFW Airport in Texas on Aug. 2, 1985, which was due to a powerful microburst downdraft.
While doing a walkaround of the Boeing 727 he was flying, Griffith saw the L-1011 burst out of the clouds, lower than he’d ever seen such a large airplane. After hitting a building, the Tristar bounced back into the air, then crashed onto Highway 114, killing the occupant of a car and 136 passengers and crew.
As Griffith stood there with the sun shining on the tarmac, he recalled, “Everything’s just normal.” Then the wind from the microburst struck the 727, followed by a torrent of rain. Some passengers inside the 727 saw the fire, heard the sirens from the crash, and started heading for the exit, and some were panicking. After helping the passengers back into the terminal, he said, “My brain couldn't get wrapped around what I had just seen.”
The event spurred Griffith into working on a laser-prediction system and his master’s degree thesis. What struck him and still raises questions is that a well-equipped airplane piloted by a skilled crew with the best training in the world “couldn't see…nor understand the risk environment” because the microburst essentially was invisible.
The important issue is that accidents and incidents are what he characterized as “the tip of the iceberg” that we can see sticking above the water. What organizations like ACSF are doing by creating a mechanism for members to share safety information is helping identify those invisible risks, the ones that live below the surface. “These are risks that live in your system and with your people,” he said.
SG Collaborative Solutions helps companies develop systems to mitigate these risks, by setting up a collaborative culture run by a reliability management team. “I took the words from the ACSF call to action,” he said. Before setting up a safety management system (SMS), he recommends developing a collaborative just culture program. “Build on that with your ASAP programs or FOQA [flight operations quality assurance] programs, align everything, and then integrate that into something called SMS.
“But we've introduced a term called RMS, which means reliability management system. And what is collaborative high reliability? It's comprised of a collaborative just culture program, a reliability management team, and a reliability management system. It’s evidence-producing because no one has done it until recently. We've had three organizations achieve it. [The RMS] is documented, monitored, measured, aligned, and integrated, and it's the first integrated approach to get independently audited by a third party.
“Reliable organizations involve more attributes than just safety.”
Flexjet’s Just Culture
“Why do we do what we do?” asked Kent Stauffer, v-p of safety at fractional-share operator Flexjet. Characterizing his presentation as “observations from an operator that has access to lots of mistakes,” he explained, “I’m going to talk about how people fit into this model, why we do what we do, and what contributes to our errors. What are we trying to accomplish? We’re trying to get to a high-reliability organization."
“We all don’t have enough people,” he acknowledged. While pilots have been an issue, “Did you know the maintenance shortage is worse? The pilot gap is being shortened and will be solved quicker than maintenance.” But there are also not enough people in air traffic control, at the regulators, and at companies that supply aviation, work at FBOs fueling aircraft, and teach.
The latter is critical because so many new people are starting aviation careers and “now you have a knowledge gap,” he said. Another gap is cultural, with people from different backgrounds coming together. “You still have not solved the issue yet to get to your high-reliability organization. It’s not only not about people, not enough education, and what I see is not enough of the organizational structure to understand and compensate for that.”
Stauffer listed four attributes that Flexjet communicates to its people to help inculcate the company’s safety goals.
The first is to be fit for duty, and part of this means getting adequate sleep. Flexjet is developing its own fatigue management software to manage this critical issue because existing tools didn’t meet the company’s needs. “We’ve found that when our pilots call in fatigued,” Stauffer said, “a high percentage of the time it involves something that's absolutely uncontrollable, like the fire alarm went off in the hotel. Undiagnosed sleep issues are a problem.”
Next is acknowledging your limitations. It’s okay to say, “'I’m not okay.' You can tell others about it. Don’t be a martyr,” he emphasized. Flexjet also teaches new-hire pilots to be willing to use tools like the go-around and saying “unable” to air traffic controllers. “We tell them, if you need to go around, you will not be penalized. We will reward you when you do: ‘Phenomenal job, thank you very much.’” Controllers frequently give instructions that a flight crew might feel aren’t suitable but, in the spirit of being helpful, will not refuse. “The answer should be ‘No, we’re not going to do that.’ It’s okay to acknowledge this.”
Third is integrity. “Do the right thing every time. You have to define it in your organization. That means that everybody has to understand what that is.”
Being accountable is fourth on the list. Stauffer pointed out that pilots more often provide reports to Flexjet’s ASAP, so it might be necessary to encourage other groups such as mechanics to participate more. “Radically embrace a just culture. You have to define it. If we don’t define, measure, and audit, do we really have one? You’ve got to have something to define what it is you’re expecting in your just culture.”
Stauffer is well aware of human limitations and offered some tips to overcoming these. Communication is key, but “first by listening” then by using standard terminology; “turning our brain on” instead of tuning out; not being accusatory; and avoiding emotions in written communications. We also need to recognize other people’s strengths and understand the people we work with. Culture is key, he explained. “If you’re blaming people, you’re not learning anything. Just culture is exceptionally valuable, and the information you’re getting from it is valuable.” Finally, we must have empathy. “You can't fire people who make mistakes, otherwise none of us would have jobs. You can’t get to the root of it until you truly understand and care about when they make a mistake.”
In response to a question from the audience about the most outstanding learning that Flexjet has from its FOQA program, Stauffer said the company receives hundreds of reports to its ASAP per month. “It’s invaluable.” Many of the reports would never have come to light without the ASAP, and they have driven improvements such as new trip notes for specific airports. More importantly, the data from ASAP enables sharing within and outside Flexjet. “Data helps us get to where we need to go,” he said. “Sharing is important.”
Excursions and Incursions
Retired NTSB air safety investigator Roger Cox highlighted the risks of runway excursions and incursions, citing a number of accidents and takeaways from each that could have eliminated the risk factors that led to the accident.
“The most popular way to wreck a corporate airplane is an excursion,” he said. Pointing to what seems like an increase in the number of such accidents, he explained, “We have to look at the risk factors, and how to figure out as operators what they are and what we can do about [them].”
One important takeaway from studying these accidents: “You can make your own commit-to-stop policy. It can be in the air but written in advance so that everyone knows and agrees to it and everybody understands what’s going to happen. [An excursion with] low energy is better than high.”
Cox also recommends that pilots and operators take the time to study accidents without waiting for the final NTSB report, which is usually released up to two years later. “Look at the accident database for your airplane. See how many times the crew misunderstood their own braking system. If you’re not on speed in the touchdown zone, you’re asking for it.”
Inspiration from Tragedy
The second day of the ACSF Safety Symposium featured Scott and Terry Maurer, parents of Colgan Flight 3407 victim Lorin Maurer, highlighting issues facing families when accidents happen, especially given the poor business aviation record during the first quarter. Their presentation focused not just on the tragic accident that took the life of their daughter and the other 49 victims but on tools that they believe can help prevent accidents.
“This is a tough subject,” Scott Maurer said. “I want all of you to know we’ve done this many times, we want to do it for you, and it’s also a way of us honoring those loved ones we’ve lost.”
“We’re so pleased yesterday that you started by recognizing the people who lost their lives [in the first quarter],” said Terry Maurer. “Remember them, say their names. If you can confront someone who has had a loss, they just want to talk about their loved one, so ask them.”
After detailing the painful circumstances of the accident and the initial poorly handled assistance given to the victims’ families, Scott Maurer outlined his recommendations to the symposium attendees. “If an accident were to happen, or if something bad were to happen, one of the takeaways Terry and I think would be beneficial to you, number one, be a good listener. Information is critical. If somebody says, ‘This is what I’m looking for, I would like an answer,’ you’ve got to get them the right answer…in a timely manner.
“You need to communicate with compassion. Yes, you have a business to run. I use the phrase, ‘There’s a difference between no and hell no.’ The attorney’s going to be whispering in your ear saying, ‘You shouldn’t do this, you can’t do that, no, no, no.’ When I talk to CEOs and executives, my comment to them is, ‘What would you do if it was your son or daughter, wife, cousin? Would you be wondering what your bottom line is going to be? Whether you’re going to get sued? Heck no. You’d do the right thing.
“Be compassionate. Make sure you’re providing those basic needs. Terry and I didn’t know it was time to go to bed; we didn’t know it was time to eat. You’ve got to help people survive those first couple of days.
“I always like to say, empower them, let them make some decisions because that’s empowering. What would you like? What are you looking for? Allow them to get back into getting to some control.
He concluded: “Put the families first, do not be defensive, do not impede the message, and I can’t say enough, communicate, communicate, communicate.”
For the Maurers, whose daughter Lorin adopted the motto “It’s a beautiful day and it’s great to be alive,” Scott said, "Every day is not a beautiful day and it doesn’t always feel great to be alive. But I’m so proud to put that message out here because it meant enough to my daughter that she put it here, she put it there. And it gives you an alternative. You have a choice when you get out of bed in the morning, you can smile or you can frown. My daughter attempted to put a smile on every day and say it’s a beautiful day and it’s great to be alive and live life. And what we have found from so many people, as they share stories with us about their experiences with our daughter, is in 30 short years she led a pretty full life and we’re so thankful for all the people who engaged with her and gave her a good life.
“One thing I do want to say to all of you: I want to challenge you. You had this conference for a good reason; you gathered here for a good reason. You got a lot of good tools. In two days you’re going to go back to your old world, and by next week, maybe this didn’t happen. Don’t let that be the case. Please leave this conference and take a tool and something you got from this conference and maybe next year, [the organizers] can ask them to report back, ‘What did you take away from last year that you put into your business to make it better?' That’s my ask.”
Content Rich Conference
The two-day ACSF Safety Symposium included many more presentations from industry experts, including a fascinating summary by Bryan Willows on Bristow’s plans to field advanced air mobility aircraft; Convergent Performance’s Jermaine Cadogan on building a just culture; system theoretical analysis by Shem Malmquist of Florida Institute of Technology; Cabin Mastery Consulting’s Sharon Lipinski on “The Biological Basis of Complacency;” and “Clear as Mud, the Confusing Side of Safety” by Flexjet’s Tim Wade. The PowerPoint presentations of all the speakers are available at www.acsf.aero/2024-acsf-safety-symposium/speakers/.