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Colgan in Buffalo: Pilot error or Inadequate Training?

Can Commercial Airlines Achieve ‘One Level Of Safety’
By Embarking on a Program of ‘One Level of Training’:
What is the Relationship Between
Training and Safety in Commercial Air Operations?

By Captain Paul Miller and Captain David Williams

The paper looks at the relationship between training and safety at commercial airlines with a high level of training and finds several important aspects. First the paper finds that the training program and the safety program are integrated. In other words, safety program data feeds directly into the training program. The training program has numerous mechanisms prepared to use what is being developed, discovered and reported in the safety program

Secondly, the paper finds that the level of training is related to the level of safety. In other words, as safety risks are evaluated by the safety program manager, risks both experienced and expected, the risks and their resolutions are integrated into training at that equivalent level of importance and emphasis. The response of the safety manager to systemic as well as individual and specific risks, results in a further response by the training manager in flight crew education, in the updating and flow of safety data, in standard operating procedures, practices and techniques, and finally in simulator and academic training syllabi. This results in training at a level much higher than the minimum required by regulation. The airline addresses training requirements of the regulator but also establishes a current and valid list of safety concerns that then can become additional curricula requirements of the airline’s training sayllabus.

Thirdly, the paper finds looks at methods that training and safety departments use to integrate training and safety, programs and develop training at a level much higher than the minimum required by regulation.

The paper next examines National Transportation Safety Board Aviation Accident Reports for commercial airlines and finds numerous references to flight crewmember training deficiencies or shortfalls. The paper then offers the postulation that the achievement of safe commercial airline operations may be related to the integration of a safety program with the training program.

The paper next looks at the relationship between training and safety at commercial airlines which subscribe to minimal training requirements and determines the differences in the process of integration between the training and safety programs, from those observed at airlines that integrate safety data into training and train at a higher level. A correlation is suggested between the achievement of safe operations and training by the NTSB reports.

Lastly the paper examines the question, “If you are seeking one level of safety amongst all commercial airline operations, would you not also need to seek one level of training amongst all commercial airline operations?” This is not to ask or suggest that all training syllabi be identical, but it is to ask the question, “Would all training at least have to be of the same level, that is at a level equivalent with the risks experienced and expected?” The paper looks at ways to measure training levels of proficiency, substance and sophistication. The measurement is then used to compare training in this way at a minimum level with training at a higher level and evaluate the differences.

The paper concludes with the postulation that the FAA policy of One Level of Safety may become achievable when the industry embarks on a policy of One Level of Training. The paper seeks to examine if this One Level of Safety through One Level of Training is possible and if so, what are some of the important details of such an effort?

[The paper would be of interest to commercial air operators, and in specific persons involved in safety management and flight training. It would be of specific interest to organizations that are tasked with regulation of and promotion of the commercial airline industry as well as manufacturers of aircraft and those offering training products and services.]

CV: Captain Paul Miller is currently an international captain with a major global commercial airline. In pursuing the goal of flight operations with zero mishaps, he has served on the pilot association safety committee and on the joint safety forum of the association and the airline. He helped to compose the first rough draft of the FAA Advisory Circular on the joint FAA, airline and pilot association aviation safety action partnership. He served as a safety program manager previously in the US Navy managing safety at two major air installations and a carrier based passenger and logistics squadron. He serves on the European Advisory Committee, Flight Safety Foundation. He has presented papers on safety program management, safety forecasting and planning and response based safety programs. He holds a degree in engineering from Rensselaer Polytechnic Institute, a minor degree in Humanities from Saint Leo University and is attending The College of William and Mary, Masters of Business Administration program.

CV: Captain David Williams served as an FAA designated check airman at a regional airline and as a line and training captain. He served as an aircraft mishap board member and as a pilot association safety representative. A US Navy career veteran from the maritime and antisubmarine patrol community, he served in numerous capacities in training, flight instruction and standards, including as a fleet pilot evaluator and check airman. His goals have always been to train to the particular characteristics of each individual so that the pilot group as a whole is standardized and competent. He holds a degree in science. Now retired, Captain Williams remains active in safety and training consulting.

Comair Layoffs

Comair Expects Furloughs of up to 100 Pilots Starting in September in Wake of Service Cuts (AP, July 9)

Comair expects to furlough up to 100 additional pilots between September and the end of the year in the wake Delta’s decision to make service cuts.
The airline placed 295 pilots on furlough in October.
A Comair spokeswoman said Thursday that the regional airline is working with ALPA to explore ways to lessen the impact. She says the number of furloughs could be reduced through voluntary options.
The pilots union says the company has indicated those options could include unpaid leaves, early buyouts or reduced work schedules.

Comair employs about 1,380 pilots.

Safety is Local

Why is being local an important aspect of any safety program?

The answer is quite simple: the owner of an asset has the most vested interest in preserving the assets by a safety program. Government and other organizations do have safety programs and they are important to aviation, especially commercial aviation. But the local program has the ability to address every threat to the preservation of assets, even those which might not initially alarm or get the attention of a government program.
Here is an example: Several years ago, the FAA and the City of Sacramento opened a previously closed former military airfield as an additional city airport. The airport was not crowded, but late night noise was an issue for the main airport neighbors. So air express cargo and package airlines were moved to the new field.

But neither the FAA nor the companies were alarmed by the airfield being put into operation without an air traffic control towner, without a crash fire and rescue crew and equipment, and without approach lighting and radar.

The pilot association was alarmed and raised the safety concern locally at the company, the city and the FAA. It was the local concern expressed by the pilot group which led the FAA, the city and the company to install a working tower, crash crew, approach lighting and radar.

Local input in safety programs is critical to safety. The upshot is that the company has suffered no aviation mishaps, in what initially was a high risk operation.

Air France 447, Airbus 330, Rio to Paris 1 June

First Published 1 June, but inadvertently deleted. It has been edited and re-posted today along with the accompanying comments. Thanx. Paul Miller

The Weather Channel displayed an inter-tropical convergence zone (ITCZ) satellite shot of the area at the time of AF447 passage through the area. The Sat shot showed large areas of high cloud tops. This suggests ongoing convective activity. Routine meteorological knowledge of the troposphere in the tropics places the trop layer at about FL600.

In laymen terms, the thunder-boomers were likely topping out at 60,000 feet. The coverage for the area looked as if a flight would have to pick its way though and might not be able to “stay on the track of the course.”

If this metro estimation is relatively correct, the violent convection turbulence, hail, lightning and precipitation would make the transit of any cell or area of cells on this track or this course to be extremely hazardous.

Additionally, one other hazardous character of convection in the tropics is very rapid cell growth. Cells can grow at rates in excess of 6000 feet per minute. This means that a cell could literally grow right up in front of you in what may have appeared on radar to be a clear area. Pilots who fly to South America from various Miami airline domiciles can verify this amazing metro phenomenon when in the tropical inter convergence zone.

Three other safety things are troubling to me though: If the Weather Channel can have this data available for presentation to me, while I am sitting in my den in my house on my TV, why doesn’t airline’s flight control dispatch have this current data available for presentation to the flightcrew in the cockpit real time, while in flight? Remember that the preflight briefing occurred about 5 hours prior to the thunderstorm area transit, the transit was at night and this ITCZ is extremely dynamic both vertically and horizontally.

Why are Convective Sigments merely passed to flight crew, without flight control route hazard analysis, on the presumption that only the flight crew in flight, are to plot each weather report and compare it to the flight path to determine the hazard? Is not the company a stake holder in this issue? Should not flight control determine if the activity is in the flight’s path and recommend the safest path around the severe convection?

Why isn’t this done on the ground where more resources are available?

Next, does Air France have a procedure whereby flight crew are required to avoid convective cells by 20-30 miles? Do Air France flight crews actually comply with such a procedure? Is it a procedure or is it a policy? At your airline, is this avoidance a policy or a procedure?

Can an airborne radar with perhaps a good 80 mile range be expected to be sufficient equipment to circumnavigate an area 200 to 300 miles in width? Once in clouds, how capable is an airborne radar, in comparison to ground based hourly sat photos and infra red cloud top imaging?

Lastly, I suspect that there were other flights in the area at the time, heading to Europe and other points. What did they see in terms of weather? What did the official weather agencies report? Did any coordination transpire to assist the flight crews? Was there any chance of weather radar from Brazil being transmitted to flights in the area?

Let’s see, Antoine De Saint Exupery wrote about this in his 1931 novel “Night Flight.” ISBN 9780156656054

[Opps, I forgot, The Patagonian Weather services set up in the mid 1920’s, may not have changed much. I wonder if the same guy may still be working there with a sandwich, thermos of coffee, pack of cigarettes and a sharp pencil.]

How many times have pilots heard some version of this statement? “It is not our job to advise pilots about what they are supposed to do. It is our job only to observe and report the weather, the cloud covering and rain.”

Initially Posted by Paul Miller at 9:25 AM, June 1, 2009
Edited and re-posted 2 June.

Expensive Investigation? Better Operating Alternatives?

What are the costs now being incurred by Brazil, France, Air France, Airbus and all other parties to the AF447 disaster? Ever thought of that? My estimation is that more than $500 million will be spent in the next 2-3 years in operations related to this mishap.

I wonder what would be the costs for Air France and other airlines of keeping the requested and cleared flight paths for scheduled flights clear of areas of massive convective thunderstorms, by using real time satellite photos, dispatch reroutes and various satellite and HF communications? By the way all of the technology is on board the airplane and in flight control dispatch offices.

Safety Riddle

Safety Riddle: Does the mishap cause the hazard to occur or does the hazard cause the mishap to occur?
According to the FAA, Congress and airline transport associations safety experts, every thing is fine, until every thing is not fine. Read this case below:

Crash Puts Focus on Air Safety-Senate Panel Plans Further Hearings (Washington Post, May 15)

A U.S. Senate committee is planning to hold a series of hearings next month looking into the safety practices of commercial airlines, following revelations of a number of safety lapses from the crash of Continental Connection Flight 3407.

The announcement came on the final day of public hearings by the NTSB into the Feb. 12 crash near, which killed 50 people. The crash was the first fatal commercial aviation accident in two years and has been described by the NTSB as the worst transportation accident in seven years.

In an interview yesterday, Sen. Byron L. Dorgan (D-N.D.), chairman of the Senate subcommittee that oversees aviation, said he was “stunned by what I’ve seen and heard on the evidence” from the safety board hearings.

“There are issues of training, crew rest, exam failures, acquaintance with icing,” Dorgan said.

“There are so many things that are troublesome. It calls for a real serious investigation.”

Dorgan said he met yesterday with families of victims of Flight 3407. He said his committee’s hearings will examine the safety practices of the regional airline industry, which has grown as major airlines contract out service to smaller cities. Colgan Air, which is the Manassas-based unit of Pinnacle Airlines, was operating the Buffalo flight as a regional partner of Continental Airlines. The hearing will also focus on the development of safety standards for the airlines by the Federal Aviation Administration. “We’ve had a remarkably good record [in aviation safety],” Dorgan said. “But it’s my understanding that those commercial airline crashes in recent years have overwhelmingly been commuter carriers.

My question is this. Didn’t the safety hazard issues exist before the crash occurred? Why is Congress, FAA and other safety experts looking at these issues after the crash occurred? Why didn’t they look at them before the crash occurred?
Do they believe that the crash caused the hazards to occur? Is that why they are looking at them now? But in contrast, wouldn’t the average person believe that the hazards were there all along, waiting for a challenging situation to bring them out? Any pilot can fly on a fair day. But does it not take a well trained pilot to fly on a dark and stormy night?

Would you agree that the hazard occurred before the mishap and in fact was directly related to the cause of the mishap?

So what is Congress doing? Here is the answer. Congress are lawyers. In tort law, you have to have an offense before you can go to court. You have hearings also before you go to court, to determine if a court proceeding is justified. So these hearing and the Congressional action is related to finding blame for the damage done. That is why the hearings are taking place after the mishap occurred, That is what lawyers do. They take injured parties to court and try to get recompense from the parties that injured them. That is what is going on here.

This is not safety.It is too late to practice safety when the mishap has already occurred. This is just tort law proceedings under the guise of Congressional hearings. The goal may be legislation, but to do what: To make the FAA live up to their own policy of “ONE LEVEL OF SAFETY”?


Well Paul, a worthy initiative for sure. At least you got me curious, particularly about how we aregoing to get to a useful forecast. And also about how we will get investments in effort (andperhaps even money) going in anticipation of future threats. (This is a bit of an achilles-heel for initiatives such as FAST as well). This would seem to me to be some of the challenges here. And as challenges make life interesting, this is not a bad thing. Do you have some ideas already ?

Michel Piers
NLR Netherlands