A Part 135 operator case study serves as a cautionary “could have gone terribly wrong” tale for aircraft operators to develop better internal communications, documentation, and operating procedures, Aviation Safety Solutions CEO Amanda Ferraro said this week at Bombardier’s Safety Standdown during her “Into the Danger Zone” presentation.
Kenny Loggins’ “Danger Zone” played during a drone light show and faded as Ferraro took the stage. “We all love the song,” she said. “I don't know what pilot, what aviator, what mechanic doesn't like that song. But when it comes to safety, the danger zone is a place that we don't want to be.”
Ferraro began with a personal anecdote about pushing herself too hard during a Civil Air Patrol training exercise when she was 17. She fainted while on a ropes tower and sustained injuries when she fell, which led to six reconstructive surgeries at Mayo Clinic.
Reflecting on her choices that day and the consequences in her life has strongly influenced what she characterizes as her calling in aviation safety. Ferraro segued from her personal close call to the close call illustrated in the Part 135 operator/aircraft management case study and what lessons the operator gleaned from the experience—and what the broader aviation community can learn from it.
The unnamed operator failed to document in writing a maintenance light issue on a smoke detector system for an airplane newly managed by the company, leading to eight subsequent flights with inoperative equipment. The maintenance team determined that the smoke detector was operative, but the maintenance light continued to light up, which made it difficult for flight crews to determine if there was or was not an immediate problem. There was no minimum equipment list (MEL) approved for the aircraft to defer the maintenance temporarily. Multiple flight crews at the company flew the airplane with the maintenance light illuminated.
Ferraro was called in to help investigate the issue when FAA scrutiny heated up. “When we got on the call with the FAA, who do you think they were holding responsible for this event?” she asked the audience. “The PIC, the pilot in command, is responsible to ensure the airworthiness of the aircraft, is he not or she not? So the FAA was squarely looking down the railroad track at the pilot in command, and they wanted answers. So they said, ‘You guys have an SMS, don't you?’ And the operator goes, ‘Well, yeah, we have an SMS.’ ‘We want a full-fledged investigation. In this event, we want this completely run through the SMS, and we want you to report back a full investigation report to us.’
“I helped them through this process, but…I think the most interesting part of the story, in talking to the pilot in command…this individual didn't want to take any responsibility for what happened. This individual didn't believe that he did anything wrong, and this individual placed the blame on the maintenance vendor,” she said.
The FAA interviewed the maintenance vendor, flight crew, chief inspector, contractor, and chief pilot of the operating certificate. The maintenance vendor indicated that the crew had a habit of dropping off airplanes without providing written documentation of discrepancies.
The investigation further revealed systemic issues, including a culture of verbal reports of discrepancies and a lack of proper documentation. Rather than take a punitive approach, the agency asked the operator to update its training and policies to prevent similar situations in the future. Mitigations included strengthening MEL training, updating procedures, and ensuring written discrepancies. The case underscored the importance of a robust safety management system (SMS) and continuous improvement, and the operator began using it for annual training.
As for the PIC in the story, “what the accountability executive decided to do was essentially provide counseling to this pilot in a very strict manner and remedial training, and ensure that it was very clear that” the company’s expectations included adhering to its SOPs, Ferraro said. “And I agree with that, because I do feel… it was fair to give this gentleman a chance.”
“The FAA expects a couple of things,” she continued. “First off, they expect you to look at all the ways in which a hazard touches your operation and to extract additional hazards that have been present. But in addition to that, they want you to come up with your mitigation or risk control plan.”
“So let's talk about, based on the system analysis and going through the entire operation and looking at the entire envelope, how did we ensure that this never ever happened again to anybody in the organization? And that's the question when you are dealing with safety and events like this that you need to ask yourself, how do we ensure this never happens again? Not, how do I ensure this never happens to Amanda or this captain, but how do we ensure [that] across the organization, it doesn't ever happen to anybody else?”
The solution is not a one-track option, Ferraro said. “I think our industry right now, we do lots of one-track ways like, okay, we have a hazard that comes in, and I write down one mitigation. That's not what the FAA is looking for. They're looking for you to extract this out and really deep dive into your root cause for these types of events and say, ‘We have more mitigations here than just one item. We need to change maybe several things within our operation to get this right, to make sure we don't have an escape again.’”
The Safety Standdown event and webcast, which marked its 28th year, was held in person and online from November 12 to 14. Bombardier does not charge for attendance.
A Part 135 operator case study serves as a cautionary “could have gone terribly wrong” tale for aircraft operators to develop better internal communications, documentation, and operating procedures, Aviation Safety Solutions CEO Amanda Ferraro said at Bombardier’s Safety Standdown during her “Into the Danger Zone” presentation.
Kenny Loggins’ “Danger Zone” played during a drone light show and faded as Ferraro took the stage. “We all love the song,” she said. “I don't know what pilot, what aviator, what mechanic doesn't like that song. But when it comes to safety, the danger zone is a place that we don't want to be.”
Ferraro pointed to the close call illustrated in a Part 135 operator/aircraft management case study and what lessons that could be gleaned from the experience.
The unnamed operator failed to document in writing a maintenance light issue on a smoke detector system for an airplane newly managed by the company, leading to eight subsequent flights with inoperative equipment.
The maintenance team determined that the smoke detector was operative, but the maintenance light continued to light up, which made it difficult for flight crews to determine if there was or was not an immediate problem. There was no minimum equipment list (MEL) approved for the aircraft to defer the maintenance temporarily. Multiple flight crews at the company flew the airplane with the maintenance light illuminated.
Ferraro was called in to help investigate the issue when FAA scrutiny heated up. “When we got on the call with the FAA, who do you think they were holding responsible for this event?” she asked the audience. “The PIC, the pilot in command, is responsible to ensure the airworthiness of the aircraft, is he not or she not? So, the FAA was squarely looking down the railroad track at the pilot in command, and they wanted answers. They said, ‘You guys have an SMS [safety management system], don't you?’ And the operator goes, ‘Well, yeah, we have an SMS.’ ‘We want a full-fledged investigation. In this event, we want this completely run through the SMS, and we want you to report back a full investigation report to us.’
“I helped them through this process, but…I think the most interesting part of the story, in talking to the pilot in command…this individual didn't want to take any responsibility for what happened. This individual didn't believe that he did anything wrong, and this individual placed the blame on the maintenance vendor,” she said.
The FAA interviewed the maintenance vendor, flight crew, chief inspector, contractor, and chief pilot of the operating certificate. The maintenance vendor indicated that the crew had a habit of dropping off airplanes without providing written documentation of discrepancies.
The investigation further revealed systemic issues, including a culture of verbal reports of discrepancies and a lack of proper documentation. Rather than take a punitive approach, the agency asked the operator to update its training and policies to prevent similar situations in the future. Mitigations included strengthening MEL training, updating procedures, and ensuring written discrepancies. The case underscored the importance of SMS and continuous improvement, and the operator began using it for annual training.
As for the PIC in the story, “what the accountability executive decided to do was essentially provide counseling to this pilot in a very strict manner and remedial training, and ensure that it was very clear that” the company’s expectations included adhering to its SOPs, Ferraro said.
“The FAA expects a couple of things,” she continued. “First off, they expect you to look at all the ways in which a hazard touches your operation and to extract additional hazards that have been present. But in addition to that, they want you to come up with your mitigation or risk control plan.”
The solution is not a one-track option, Ferraro said. “I think our industry right now, we do lots of one-track ways like, okay, we have a hazard that comes in, and I write down one mitigation. That's not what the FAA is looking for. They're looking for you to extract this out and really deep dive into your root cause for these types of events and say, ‘We have more mitigations here than just one item. We need to change maybe several things within our operation to get this right, to make sure we don't have an escape again.’”