Tag Archives: Aviation Safety

How Good is your Ability to Observe?

A person I knew stated,  “We learn on how to prevent mishaps by deriving from the investigations stemming from mishaps.”

I agree that we learn by observing the mistakes that are made. That being said, I would add that we actually have a more superior ability to observe these mistakes as they are made on the line and before they contribute to a mishap.

Did you know for example that Safety Theory tells us that flight crew will make 1000 errors which could lead to 100 reportable events, which could lead to 10 incidents and which could lead to 1 major mishap.

Many people do not believe that or do not understand this very valuable nugget of safety information. This is the key to succeeding in the safety profession and I will tell you this from my own 43 years of experience. You can achieve zero mishaps, you can prevent mishaps at your airline.

Here is how to do it. You must have a reporting system that allows flight crew members to speak about and report their errors and those that they observe. Next the safety person has to investigate these errors, figure out how they impact the operation and take steps to correct the organic reason for the errors. Most often in my experience this involved some adjustment, modification or addition to SOP. But the safety person has to be well versed in flight ops and SOP so that the changes to SOP make sense.

Unfortunately all too many people believe that until an event, incident or mishap occurs, that their operation doesn’t “have a problem.” However the problems are there because we are human. They will always be there. The key is to incorporate the error reporting process into day to day operations, to talk about them and fix them right then and there.

Allowing human errors to “fester,” to unreported and uncorrected is to set the operation up to failure. Can an operation be made error free? Of course not. But at the same time can an operation be made mishap free? Absolutely so, by finding and fixing errors as they occur.

But I believe that as humans we are constantly making errors

Flawless operation or a Mishap Free Operation: What Should You aim for?

It has been said, “You seem to be convinced that a flawed world can be actually made flawless.”

My response is this. Human error is part of our nature. However we can make our own flight operations mishap free by remembering Miller’s Rule for Safety Management: ALL SAFETY IS LOCAL.

Any one safety manager cannot make a “flawed world ….. flawless.” He or she can only affect the operation over which they have control.

I can personally recommend steps to each LOCAL Flight Operations Safety Manager that have worked extremely well to achieve mishap free flight operations.

One person commented, “In a process oriented investigation “human error” cannot be the ultimate root cause. You need to ask yourself, “Why did the humans make the errors?”

My response to this is, “True, but you also need to go further and ask what procedures can be put into the SOP and become part of the training program that will help flight crew members overcome their human errors.

For example, lets say that a very important system characteristic is buried on page 49 of a chapter in the Aircraft Operating Manual. Well, maybe if it is considered to be so important, should it be bold faced, underlined and not buried on page 49? In other words, humans make errors that can easily be corrected. Safety managers need to find ways to help the flight operation correct errors as they are occurring and are reported.

Some have also said, that crew selection and training criteria are often driven by both financial and safety level aspects. FAA and other civilian authorities have criteria set at minimal requirements. But one company may decide to exceed those.
For example, one company may decide to select pilots (1) which have a Commercial Pilots License from a school with a weak syllabus and accept those after a minimal medical and psychological selection process, accepting captains with only 3,000 flight hours. Another company may have require at least a masters degree in technical sciences and demand a very strict medical and psychological selection criteria and accept captains only after 30,000 hrs. The same could and often does apply to training. One set of training requirements are used for a Government operation and another set of training criteria are used for a major airline.”

But my response is this. You still have to train flight crew in the company SOP. You still have to check to the SOP and make your operation “procedure oriented” and not technique oriented. This way flight crew are performing procedures and not using their own techniques to operate.

Further, as the operation improves its control, it will develop a need to have more standardization in procedures just so that mixed crews can operate efficiently.

Should the FAA tolerate such a wide variance between airlines? It is the Topic for another day.

Just Culture: Why is Jailing Pilots a surprise?

Does not the person in charge of any vessel or organization bear some legal responsibility? If so, why would anyone be surprised to see a pilot jailed following an accident? Are we really just seeing the terribly weak legal profession just beginning to realize how much work has gone undone in the past 70 years.

If in an accident, lives are lost and property is destroyed, why wouldn’t victims, survivors and claimants seek some form of compensation?

Is it really the accident investigation profession which has been dropping the ball all these years? Has ICAO really taken all the action that it could to actually promote safety and promote learning from investigations?
Or has the case really been made year after year that it is the pilots who made the errors and that is all the blame that we need to know about?

So finally everyone is reading these atrociously poorly prepared and written accident reports and noting what was written so often.

For years airlines, the FAA and NTSB has been laying all blame on pilots, often those deceased in the mishap, and directing attention away from ATC, manufacturers, the weather guessers, airport operators, and everyone else. So here we are in 2011, surprised and complaining.

Yet even as we write this blog, the BEA has issued a scathing reproach of the AF447 pilots who could not decipher the cryptic puzzle presented before them, struggled to save their own lives for several minutes before perishing. Nowhere in the report is any mention made of the responsibility of the dispatch office to advise of foul weather, of the manufacturer to sell good equipment, of the airline to verify that the equipment works, of ICAO and other agencies to keep updating all technology for the benefit of the flight crew. A passenger sitting in row 24 on that airbus could have accessed the internet and obtained the most up to the minute satellite pix, but the flight crew had on board pix probably over 4 hours old.

How inaccurate a weather data process could anyone ever invent? Make a copy of the last satellite shot an hour before brief time, have it ready for the crew who show up an hour and a half before take off and give them one hour old data. By the time they take the runway, the data is 2 1/2 hours old. At three hours into the flight the data is 5 1/2 old.
But wait, isn’t the entire life cycle of convective weather defined as a matter of 30-45 minutes, may be an hour tops? Moreover, doesn’t convective weather around the tropics often build at 4000 to 6000 feet per minute?

So how could 4-5 hour old weather ever be considered accurate or useful data for safety purposes? Why wouldn’t the airline and their dispatch office know this? Why would the official weather forecasters not offer more accurate weather data, some form or method of updating that sat pix in flight to the flight crew?

Oh yes the passenger in 24E has the latest sat shot on his PC.

So I can easily see why ICAO and BEA and everyone else are so determined to blame the pilots and by that process, not give a second’s care about what might happen to passengers tomorrow who might be in similar jeopardy.

Do you not think that the same mishap cannot happen tomorrow? Think harder. It can and it most likely will.

Just Culture proposes the idea that when the injury and loss of people, the damage and destruction of property is the result of a commercial aviation mishap, that all charges of criminality be suspended so that a safety investigation of the mishap can be completed without interference. My suggestion is that the safety investigation and the investigations to determine who was at fault for the losses and who pays for the losses proceed simultaneously.  Real evidence can be shared but evidence based on crew and other witness testimony should be determined solely by the board doing that investigation. Each board can and therefore should gather their own testimony evidence.

In the past, aircraft mishap boards have taken real evidence away from the public, which I do not believe is right. Additionally, they have taken years, 2-3 and more years to come out with any kind of useful reports, in essence failing to do the safety task of a quick safety hazard identification.

So now we find ourselves in a position where parties want recompense and no longer are willing to wait 8-10 years. No surprise that pilots are being jailed when an aviation mishap occurs where people are hurt and property is damaged. Just Culture is a good idea and I support it. But an even better idea is to prevent mishaps so that a flight never experiences a mishap and the lawyers are left with nothing to do.

Captain Miller with US Supreme Court Justice Sandra Day OConnor

Flawed Investigations?

I cite a flawed investigation as the cause for re-occurrence because in aviation you have one chance to get it right.  You must gather the right facts, gather the right testimony, analyze the data, reach the correct conclusions and create recommendations for corrective actions. In the process you will find human error or human factors. This is where the mishap occurred. It was not the thunderstorm that caused the weather, it was the failure of the humans to avoid the thunderstorm that caused the mishaps, for example.

If you connect coincidental events together but then label them as “causation” you will fool all the people some of the time. An example is placing pilot error as the cause, when in reality when the pilot reported for work, was assigned the flight and climbed into the seat, he/she was “fully qualified” according to the FAA, the company and any other regulator. If that pilot made a pilot error as gross as stalling the aircraft on final and not recovering, the pilot, a product of the company and FAA training and qualification program to me, appears to be untrained and unqualified in this area. Since most would consider this area of flight procedures to be a skill critical to safe flight it would appear to me that the training and qualification program was deficient. Failing to correct the training and qualification program in my mind would be an example of a flawed investigation, wherein I would expect a same or similar mishap to occur at some time in the future at that airline, or to similarly trained and qualified airmen.

If you miss this opportunity to get the investigation right, then you can pretty much expect that the next pilot, similarly trained and qualified, facing similar circumstances to make the same mistakes. The purpose of the investigation is to find these flaws and recommend training to overcome this skill deficiency.

Look at how we all do windshear recovery training to proficiency now. Too bad the pilots at Kenner, Kennedy, DFW, Charlotte and other places did not have that training.

We are lucky that we had Dr. Fujita and the training that resulted from his models and those of NCAR in the 1980’s to inform us on how to react to inflight encounters with microbursts.


Grim Safety Forecast for Air France

The recommendation is contained in the latest BEA accident report investigating the loss of the Air France Flight 447, a document that outlines 10 new safety recommendations, including improved pilot stall-awareness training, the inclusion of cockpit cameras, and adding angle-of-attack readouts in the cockpit.
But it’s the inclusion of a call for mandatory data streaming technology that is sure to raise the biggest objections with airlines, who will have to pay for it.

This is a grim future for Air France if these are the BEA’s main plan to prevent this event from reoccurring.
I can agree with the angle of attack recommendation. I can agree with the stall awareness training.
But did not having the cameras cause the mishap? Of course not; this is just someone trying to get the camera in the cockpit nnd using thes dead people to do it.
Did not having data streaming from the acft cause the mishap? No, in fact it was not having weather data streaming TO THE AIRCRAFT that was in great part responsible for the mishap.

So, it is my opinion that AF will have a string of these mishaps, more of the same!